Every finding on record at Capitol Home Health Inc

The purpose of the visit was for an intake investigation survey for intake numbers 1053398 and 1051772. The entrance conference was conducted on 12/22/25. The census was: L&CHHS: 686 LHHS: 0 PAS: 0 Acronyms & Abbreviations: FM: Family Member L&CHHS: Licensed and Certified Home Health Services LHHS: License Home Health Services PAS: Personal Assistance Services PTA: Physical Therapy Assistant VP: Vice President

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on observation , record review, and interview, the agency failed to respect the property of patients in the home in 1 out of 3 patients (Patient 1) reviewed in that PTA A was observed stealing pain medication from Patient 1. Failure of the agency to ensure the patient’s property was respected put all of PTA A’s patients at risk for stolen property and a risk to their health if medications were switched or stolen. Findings included: In a review of the video provided by the agency (originally sent from FM 1), PTA A was observed stealing Patient 1’s medications at Patient 1’s home on 11/20/25. There was no time or date on the video itself, but the Administrator confirmed the video was taken during PTA A’s visit to Patient 1 on 11/20/25. In the video, PTA A walked into an empty living room and approached a collection of medication bottles in the corner by the couch. PTA A grabbed a bottle, looked at the label, and emptied the pills into her scrub pocket, then took new pills out of a separate scrub pocket, refilled the bottle with the new pills, and returned the medication bottle to where she had taken it. In a phone interview with Detective A, at 1:05 PM on 12/22/25, he stated he was not onsite at the arrest but was leading the investigation. He confirmed that the police officers that responded to the call were shown the video FM 1 had captured and arrested PTA A. In an interview at 4:40 PM on 12/22/25, FM 1 stated that FM 2 could view the camera footage from their living room camera live from his computer at work, and that he just happened to catch PTA A stealing the medications as it was happening. FM 1 reported that FM 2 called her immediately to tell her what he saw. FM 1 stated that she had been upstairs at the time, and she went downstairs to confirm the medication bottle PTA A had emptied and refilled with other pills was Patient 1’s hydrocodone (prescription pain killer). She confirmed that it was, and then she called the police. She stated she tried to “stall” PTA A to prevent her from leaving before the police arrived. PTA A attempted to leave and FM 1 stated she followed her out to the driveway, where FM 1 then said to PTA A, “I have one more question for you. Those pills you took from [Patient 1], can I have them back?” She stated that PTA A confessed to taking the medication but claimed it was for “her other patients” who “were in a lot of pain”. FM 1 stated that the police arrived at that time and arrested PTA A. She stated that the police searched PTA A’s car and found other pills. In a phone interview with Patient 1 on 12/23/25 at 8:40 AM, Patient 1 confirmed that this had been her first visit from PTA A, and that PTA A went over all her medications with her first, and then walked her down the hallway and gave her an exercise to do laying down on the bed and said she would be right back. Patient 1 reported that PTA A was gone for a brief time and then returned with pictures of the exercises they were working on. She stated she did not realize until FM 1 showed her the video that it was during that time that PTA A had returned to living room to take the hydrocodone. In an interview with the Administrator and VP at 10:40 AM on 12/23/25, the Administrator stated that they train all staff on abuse, neglect, and exploitation, including misappropriation of property, and how to avoid compromising situations. They stated PTA A received this training on hire and annually. The Surveyor asked who is responsible for ensuring patient rights are respected. The Administrator stated that “everybody who walks in the home is responsible for that. But also, everyone on the team who is attached to the patients, even here at the office, because it is our role to educate the team to respect patient rights.” The surveyor asked the Administrator how not respecting patient rights could affect the care that patients receive. The Administrator stated in this case, it had a huge effect on patient care because patients “trust us to come in their homes” and it is a “violation of trust” to not respect their rights and property. The administrator stated that, in this case, there was the additional risk of the patient not receiving the medication that they were prescribed, which could be a safety risk and delay their healing. A review of the agency’s policy titled, “Patient Bill of Rights,” undated, revealed a documented which read in part, “The Patient Bill of Rights statement defines the right of the patient to: A. Have his or her property treated with respect, consideration, and recognition of patient dignity and individuality.” Further review of this document revealed a statement which read, under the same heading, “H. Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property.” A review of the agency’s policy titled, “Assessment of Possible Abuse/Neglect,” undated, defined “exploitation” as “Unexplained loss of social security or pension checks, any evidence that material goods are being taken in exchange for care, any evidence that personal belongings of patient (house, jewelry, car) are being taken without consent or approval of patient.”

An Entrance Conference was conducted on 8/30/2021 with the Administrator and Alternate Administrator/ Supervising Nurse at 10:35 a.m. The agency representatives were informed that the purpose of the visit was to conduct an investigation of Complaint TX # 00390252. The agency census was: Austin (Parent): L&C-395, LHH-0, PAS-0 An Exit Conference was conducted on 8/31/2021 with the Administrator and Alternate Administrator/ Supervising Nurse at 3:05 p.m. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Additional information was not received. Written instructions for submitting a plan of correction within 10 days of receipt of the Statement of Deficiencies was provided. Abbreviations: LVN- Licensed Vocational Nurse Rt.- Right Cm.- Centimeter SN- Skilled Nurse T.O.- Telephone Order d/t- Due to

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that orders were received prior to providing treatment for one of four patients (Patient #1) receiving wound care. This failure resulted in treatment being performed prior to review and approval of the physician. Findings Include: 1. Review of the clinical record of Patient #1 revealed the following documents which read in part: "Wound Care LVN" dated 7/15/2021 which read in part: "Patient wounds are healing well but has developed new wound on right plantar foot. MD was called and they are to have a virtual appointment with family next week. Wound #5- Rt. foot, open, onset date 7/15/2021, pressure ulcer, stage II, Length 4.5cm, Width 2cm, Depth 0.3cm, drainage purulent, odor strong. Treatment: Donned clean gloves and using aseptic technique, cleaned wound with wound wash, patted dry with gauze, applied hydra blue to wound bed, covered with foam bandage and secured with rolled gauze. Wound #6- Rt. foot plantar, open, onset date 7/15/2021, pressure ulcer, stage II, Length 1cm, Width 1cm, Depth 0.1cm, drainage purulent, odor strong. Treatment: Donned clean gloves and using aseptic technique, cleaned wound with wound wash, patted dry with gauze, applied hydra blue to wound bed, covered with foam bandage and secured with rolled gauze. Patient developed 2 new wounds on right plantar foot. Education done on weekly basis about cleaning patient well and floating feet. SN will call physician and write new orders for right foot. Patient has some pain with two new wounds and strong purulent odor." The document is signed by LVN B. "Wound Care LVN" dated 7/19/2021 which read in part: "Waiting on physician to assess two new wounds to get orders." The document is signed by LVN B. "Wound Care LVN" dated 7/23/2021 which read in part: "Wound #5- Rt. foot, open, onset date 7/15/2021, pressure ulcer, stage II, Length 4.5cm, Width 2cm, Depth 0.3cm, drainage purulent, odor strong. Treatment: Donned clean gloves and removed old dressing. Sanitized hands and donned clean gloves, using aseptic technique cleansed wound with wound wash, patted dry with gauze, applied hydrafera blue foam, covered with 4 x 4 gauze and secured with kerlix. Wound #6- Rt. foot plantar, open, onset date 7/15/2021, pressure ulcer, stage II, Length 1cm, Width 1cm, Depth 0.3cm, drainage purulent, odor strong. Treatment: Donned clean gloves and removed old dressing. Sanitized hands and donned clean gloves, using aseptic technique cleansed wound with wound wash, patted dry with gauze, applied hydrafera blue foam, covered with 4 x 4 gauze and secured with kerlix." The document is signed by LVN B. Physician Order dated 7/30/2021 which read in part: "TO/ LVN B on 7/29/2021 for frequency 3 times weekly for wound care d/t skin breakdown. With sterile supplies and aseptic technique, SN to cleanse wounds with wound wash, pat dry with gauze, apply hydrofera blue foam to wound bed, cover with 4 x 4 gauze and wrap with kerlix, secure with tape. Wounds to be addressed are right plantar foot, two wounds. Effective 7/30/21." The document is signed by LVN B. 2. During an interview with LVN B on 9/1/2021 at 4:50 pm, LVN B stated she treated wounds to right foot with hydra fera blue on 7/15/2021 and 7/23/2021 per the patient's (family member) request, and stated the (family member) told her they had always used that for wounds. LVN B stated the physician contacted her on 7/29/2021 with orders for hydra fera blue to wounds on right foot. 3. Review of the agency Policy and Procedure Manual revealed a policy entitled "Response/ Reporting to Physician." The policy read in part: "6. Based on the communication with the physician, a verbal order will be obtained for any change in the plan of care to ensure care is provided according to the revised plan of care."