Every finding on record at C & L Esperanza Home Health Inc

Purpose of visit: Recertification survey and investigation survey. Intake: 461206, 479711, 482738 Entrance conference date: 1/27/2025 The census was - 296 Licensed and Certified patients – 107 Licensed Home Health clients - 0 Personal Assistance Services clients – 189 No deficiencies cited. The agency is in compliance with the conditions of participation for emergency preparedness.

Purpose of visit: Recertification survey and investigation survey. Intake: 461206, 479711, 482738 Entrance conference date: 1/27/2024 The census was – 296 Licensed and Certified patients – 107 Licensed Home Health clients - 0 Personal Assistance Services clients – 189 Abbreviations: Adm- Administrator Alt Adm – Alternate Administrator CMS – Centers for Medicare and Medicaid Services DON- Director of Nurses IQIES- Internet Quality Improvement and Evaluation System OASIS – Outcome and assessment information set QA- Quality Assurance QAPI – Quality Assurance and Performance Improvement QIO - Quality Improvement Organization KEPRO - Keystone Peer Review Organization POC – Plan of Care CMS 485 - Home Health Certification and Plan of Care

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to encode and electronically transmit each completed OASIS assessment (a tool used by CMS to collect and report patient information for quality improvement and monitoring) to the CMS system within 30 days of completing the patient’s assessment for 418 OASIS assessments submitted from 1/15/2024 to 1/15/2025 for 418 patients. This failure prevented CMS from analyzing patient’s data and the agency’s performance in comparison to other agencies, which potentially placed patients at risk for substandard care due to inaccurate OASIS information. Findings: The surveyor reviewed the OASIS error report in IQIES (Internet Quality Improvement and Evaluation System) on 1/17/2025 for period 1/15/2024 to 1/15/2025. The report revealed late submissions greater than 30 days for 418 comprehensive patient assessments. The report included 418 patient names with late submissions. An interview was conducted on 1/27/2025 at 10:55am with the Alt Adm. The surveyor informed the Alt Adm of the 418 late submissions reported in IQIES for period 1/15/2024 to 1/15/2025 and asked about the late submissions. The Alt Adm stated the completed patient admissions were sent to coding then reviewed by QA before the Adm or Alt Adm transmitted the OASIS assessments to the CMS system. The Alt Adm stated the late completion of admissions by the nurses resulted in late submissions to the CMS system. The Alt Adm reported completed admissions were often submitted on the last day and did not make the time frame. An interview was conducted on 1/31/2025 at 11:58 am with the Adm. The surveyor informed the Adm of the 418 late submissions reported in IQIES for period 1/15/2024 to 1/15/2025 and asked about the late submissions. The Adm stated the nurses were submitting the admissions late. The surveyor asked the Adm if the agency had a Performance Improvement Project (a project to monitor and improve healthcare processes, safety, and patient outcomes) in place for the pattern of late OASIS submissions and were the OASIS submissions monitored by the agency's QAPI (Quality Assurance and Performance Improvement) program. The Adm reported the agency was not currently monitoring OASIS submissions through QAPI and the agency did not have a PIP in place. Review of agency’s policy “Oasis Data, Encoding, Locking and Reporting” Policy 4.25, revision December 2024 read in part “The agency uses software that meets federal specification for the encoding, locking and electronic reporting of OASIS data…OASIS data items are encoded, checked for errors, locked and submitted within 30 days of collection and made transmission ready… Procedures- All OASIS assessments are transmitted no later than 30 days from M0090 date. Agency is recommended to submit daily to ensure timelessness of OASIS data.”

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on observations, interviews, and record reviews the agency failed to provide the name, address and telephone numbers for the Agency on Aging location in Dallas and failed to provide the correct phone numbers for the Quality Improvement Organization (QIO) for 3 (Patients 1,2 and 4) of 4 patients. This failure resulted in patients having inaccurate contact numbers for the Quality Improvement Organization (QIO) and no knowledge of the Dallas location of the Agency on Aging which potentially placed patients at risk for not receiving information, referrals, and community services through federally funded and state funded agencies. Findings: Review of the Agency’s undated home health admission booklet, on 1/27/2025 at 2:15pm revealed on page 10, no listing for Dallas County under counties served by the Agency on Aging. Page 13 of the booklet listed two incorrect phone numbers for QIO Texas Kepro (Keystone Peer Review Organization -contracted by CMS to receive appeals from patients regarding home health discharge decisions) Area 3. The incorrect phone numbers were verified by the surveyor through the CMS website and phone calls to the numbers listed in the agency’s admission booklet. Observation of Patient #1’s undated home health admission booklet during a home visit on 1/28/25 at 1:10 pm revealed incorrect numbers for QIO Texas Kepro Area 3 and no listing for Dallas County under counties served by the Agency on Aging. Observation of Patient #2’s undated home health admission booklet during a home visit on 1/28/25 at 2:45 pm revealed incorrect numbers for QIO Texas Kepro Area 3 and no listing for Dallas County under counties served by the Agency on Aging. Observation of Patient #4’s undated home health admission booklet during a home visit on 1/28/25 at 3:50 pm revealed incorrect numbers for QIO Texas Kepro Area 3 and no listing for Dallas County under counties served by the Agency on Aging. An interview was conducted with the Adm on 1/31/2025 from 11:58am to 12:30pm. The surveyor informed the Adm that the undated agency’s home health admission booklets did not list Dallas County as counties served by the Agency of Aging and the phone numbers for QIO Texas Kepro Area 3 were incorrect. The Adm reviewed the agency’s undated admission booklet and stated she was unaware that Dallas County was not listed under the Agency of Aging resource section or of the incorrect numbers for QIO Texas Kepro Area 3 and agreed with the findings. Review of agency’s policy “Admission Process” Policy 4.5 revision December 2024 read in part “Upon admission and before the initiation of treatment clients are informed and given a written agreement for services, which includes but may not be limited to the following: Documentation of available community resources to meet patient’s needs.”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interviews and record reviews the agency failed to include in the plan of care an individualized description of the patient's risks for emergency department visits and hospital readmissions to address the underlying risk factors for 10 (Patients 1,2,3,4,5,6,7,8,9 and 10) of 10 patients' records reviewed. The failure to provide all required detailed information in an individualized plan of care subjected the patients to the risk for poor quality and unsafe care. Findings: Record review of Patient #1 revealed a POC for period 12/9/2024 to 2/6/2025 signed by RN A. The risk for emergent care and acute care hospitalization was entered as “moderate” with no individualized risks for hospitalization or emergency department visits listed on the POC. Record review of Patient #2 revealed a POC for period 1/2/2025 to 3/2/2025 signed by RN B. The risk for emergent care and acute care hospitalization was entered as “moderate” with no individualized risks for hospitalization or emergency department visits listed on the POC. Record review of Patient #3 revealed a POC for period 11/26/2024 to 1/24/2025 signed by RN B. The risk for emergent care and acute care hospitalization was entered as “moderate” with no individualized risks for hospitalization or emergency department visits listed on the POC. Record review of Patient #4 revealed a POC for period 1/18/2025 to 3/18/2025 signed by the DON. The risk for emergent care and acute care hospitalization was entered as “moderate” with no individualized risks for hospitalization or emergency department visits listed on the POC. Record review of Patient #5 revealed a POC for period 11/14/2024 to 1/12/2025 signed by RN B. The risk for emergent care and acute care hospitalization was entered as “moderate” with no individualized risks for hospitalization or emergency department visits listed on the POC. Record review of Patient #6 revealed a POC for period 12/29/2024 to 2/26/2025 signed by RN A. The risk for emergent care and acute care hospitalization was entered as “moderate” with no individualized risks for hospitalization or emergency department visits listed on the POC. Record review of Patient #7 revealed a POC for period 4/24/2024 to 6/22/2024 signed by the DON. The risk for emergent care and acute care hospitalization was entered as “moderate” with no individualized risks for hospitalization or emergency department visits listed on the POC. Record review of Patient #8 revealed a POC for period 12/03/2023 to 1/31/2024 signed by the DON. The risk for emergent care and acute care hospitalization was entered as “moderate” with no individualized risks for hospitalization or emergency department visits listed on the POC. Record review of Patient #9 revealed a POC for period 11/07/2024 to 1/05/2025 signed by RN C. The risk for emergent care and acute care hospitalization was entered as “high” with no individualized risks for hospitalization or emergency department visits listed on the POC. Record review of Patient #10 revealed a POC for period 10/29/2024 to 12/27/2024 signed by the DON. The risk for emergent care and acute care hospitalization was entered as “moderate” with no individualized risks for hospitalization or emergency department visits listed on the POC. An interview was conducted with RN A on 1/30/2025 from 3:22pm- 3:45pm. The surveyor asked about Patients #1, 6 and 10’s risks for hospitalizations and emergency department visits. RN A stated Patient #1’s risks for hospitalization were the reopening of a surgical wound due to walking outside and infection. RN A reported Patient #6’s risk for hospitalization was patient’s high risk for falls. RN A stated Patient #10’s risk for hospitalization were cellulitis (a bacterial infection of the skin and underlying tissue) and hypertension (a condition of high blood pressure). Surveyor asked RN A to describe the process of adding individual risks for hospitalizations and emergency room visits to the POC. RN A stated she documented risk factors in the patient’s admission, teaching, interventions and on the CMS 485 form (Home Health Certification and Plan of Care). RN A was unable to provide an explanation on why the patients’ risks entered in the admissions and form CMS 485 did not transfer to the section for risks for hospitalizations on the POC. An interview was conducted with RN B on 1/31/2025 from 9:30am-9:55am. The surveyor asked about Patients #2 and 5’s risks for hospitalizations and emergency department visits. RN B stated Patient #2’s risks for hospitalization were falls and infections. RN B reports Patient 5’s risks were infections, hypoxia (inadequate levels of oxygen to the human body tissues) and diabetes (a chronic disease in which the body does not control the amount of sugar in the blood). Surveyor asked RN B to describe the process of adding individual risks for hospitalizations and emergency room visits to the POC. RN B stated she added patients risks to the patients’ clinical notes and discussed with the patients the plan for prevention. RN B reported the patients’ risks were entered in the admissions and OASIS but did not transfer into the POC. RN B was unable to provide an explanation on why the patients’ risks entered in the admissions and OASIS did not transfer to the section for risks for hospitalizations on the POC. An interview was conducted with the Adm/DON on 1/31/2025 from 11:58am- 12:30pm. The surveyor informed the Adm/DON the patient’s individualized risk factors for hospitalization and emergency department visits were not listed in the POC for 10 of 10 records reviewed and the nurses interviewed reported the risks entered in the admission and OASIS were not transferring to the POC. The Adm/DON stated the “Moderate” and “High” listed under risks for hospitalization and emergency department visits generated from the patient’s assessment and the number of items checked. The Adm/DON reviewed a patient’s plan of care and confirmed that “Moderate” was listed under the patients risks for hospitalization and emergency department visits. The Adm/DON stated the patient’s risks were listed under the homebound statement and the agency’s current patient electronic medical record system was not user friendly. DON/Adm informed surveyor the agency was transitioning to a new electronic medical record system soon. Adm/DON reviewed the agency’s policy 4.13 revision December 2024 “Plan of Care” and agreed that the patient’s individualized risks were not listed under the risk for hospitalization. The Adm/DON could not provide an explanation on why the risk factors were not transferring from the admission and OASIS to the POC. Review of agency’s policy “Plan of Care” Policy 4.13, revision December 2024 reads in part “The POC is established by a physician in consultation with agency staff and covers the following: A description of the patient’s risk for emergency department visits and hospital readmissions…”