Every finding on record at Cardiac Care of Texas P L Lc

A recertification survey entrance conference was conducted on 05/12/26. The agency was in compliance with no deficiencies cited. Census- 0 Licensed and Certified-0 Licensed Home Health-0 Personal Assistance Services- 0

A recertification survey and follow up to 5FB04-H1 (exit 05/4/23) entrance conference was conducted on 05/12/26. Census- 0 Licensed and Certified-0 Licensed Home Health-0 Personal Assistance Services- 0 Acronyms: OASIS- Outcome and Assessment Information Set CMS- Centers for Medicare and Medicaid Services IQIES- Internet Quality Improvement and Evaluation System RN- Registered Nurse

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 interview and record review, the agency failed to code and electronically transmit each completed OASIS (data collected as part of the comprehensive assessment) assessment to the CMS system within thirty days of completing the assessment of the beneficiary for 1 of 2 assessments submitted (50%). The agency did not code and electronically submit 1 patient’s OASIS data to IQIES (electronic system used to transmit quality measures from the OASIS data collected during comprehensive assessments) within 30 days to track and evaluate changes in the patient’s health while admitted to home health services to help ensure quality healthcare for patients. This failure prevented the agency’s patient OASIS data from being made available to CMS for analysis of patient care performance and could cause negative patient outcomes. Findings included: Record review of an IQIES Error Summary Report dated 05/12/25 to 05/12/26 generated by the surveyor during pre-survey on 05/12/26 indicated the agency failed to code and electronically transmit 1 of 2 OASIS assessments data to the CMS system within thirty days of completing the assessment of the beneficiary. During an interview on 05/12/26 at 10:40 a.m., the RN Administrator said the agency serviced 1 patient in the last 12 months, which was in December of 2025. She said the patient was on service for a couple of weeks. The RN Administrator said she did OASIS and submitted them to CMS in IQIES. She said there was an issue with getting the face to face [requirement by Medicare (health insurance program) of a face-to-face encounter between a patient and a physician (or authorized practitioner) to certify eligibility for home health services] back from the doctor, and that slowed things down for submission. She said this was her first OASIS to submit to IQIES/CMS. She said she did not know the timeframe, and she thought she submitted it timely. During an interview on 05/12/26 at 10:55 a.m., the RN Administrator said she submitted OASIS twice in IQIES. She said once was for admission and once for discharge. She said Patient #1 was the agency’s first and only patient and she was trying to learn how to do OASIS transmissions because it was her first time. She said the OASIS might have been a few days late because the agency didn’t get the face to face back on time from the doctor and that delayed everything. She said Patient #1 was on service for about 30 days and the agency had to fill in the face-to-face visit date on the OASIS to submit, and the agency didn’t have the face-to-face back. She said the agency kept notifying the doctor’s office that they needed the face to face and the agency couldn’t just put dates in on the OASIS. She said she thought the start of care OASIS was a few days late. During an interview on 05/13/26 at 10:58 a.m., the RN Administrator said the importance of submitting OASIS timely was for CMS to be aware of patients being admitted and gave CMS information about the patient. She said it was also important for the agency for billing. She said if CMS had to do a review, OASIS needed to be transmitted timely so CMS could do reviews on time. Record review of an Outcome and Assessment Information Set (OASIS) policy dated 01/01/26 indicated “…The Agency is required to submit all OASIS assessments to the national database specified by CMS within 30 days of the M0090 date…” Record review of a Timelines policy dated 01/01/26 indicated “…All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications and data dictionary, and that includes the required OASIS data set and the CMS assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with the Federal Information Processing Standard… from the agency or the Agency contractor to the CMS collection site within 30 days of the M0090 (date of completion) date…”

A Re-licensure Survey entrance conference was conducted on 05/02/2023 with Texas Cardiac Care at 11:10 a.m. Census 24 L&CHHS: 23 LHHS: 1 PAS: 0 Hospice:0 Exit conference was conducted on 5/4/2023 with the Administrator/ Owner/ Nurse at Texas Cardiac Care at 2:00 p.m. No deficiencies were cited.

A Recertification Survey entrance conference was conducted on 05/02/2023 with Texas Cardiac Care at 11:10 a.m. Census 24 L&CHHS: 23 LHHS: 1 PAS : 0 Hospice:0 Exit conference was conducted on 5/4/2023 with the Administrator/ Owner/ Nurse at Texas Cardiac Care at 2:00 p.m. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. EMR- Employee Misconduct Registry NAR- Nurse Aide Registry L&CHHS- Licensed and Certified Homecare Services LHHS- Licensed Home Health Services PAS- Personal Assistant Services HHSC- Health and Human Services TULIP- Texas Unified Licensing Information Portal

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to enforce its written policies to provide annual Bloodborne pathogen training as required by the OSHA, 29 CFR 1910.1030 and Appendix A relating to Bloodborne pathogens for five of the six employees (Alternate Administrator, Nurse A, Attendant A, Physical Therapist A, and Physical Therapy Assistant A) in 2022 whose records were reviewed. This failure could place staff and the agency's current clients at risk for exposure to communicable and/or infectious diseases. The findings included: Review of the agency's policy manual revealed a policy titled "Infection Control Program," dated 1/12/2018, read, in part: "H. Education of Employee 1. Staff are educated on minimizing the risk of spreading infection and communicable diseases include as a minimum: …g. Provide in-service infection control education for staff periodically but at least annually that is consistent with accepted standards of practice, such as: …h. In service include but are not limited to: i. OSHA Bloodborne Pathogen Training/Standard Precautions.” Review of Alternate Administrator’s personnel record revealed Alternate Administrator 's "Date of Hire" as 10/25/2016. Review of Nurse A’s personnel record revealed Nurse A’s "Date of Hire" as 5/8/2006. Review of Attendant A’s personnel record revealed Attendant A’s "Date of Hire" as 6/24/2021. Review of Physical Therapist A’s personnel record revealed Physical Therapist A’s "Date of Hire" as 8/5/2014. Review of Physical Therapy Assistant A’s personnel record revealed Physical Therapy Assistant A’s "Date of Hire" as 6/8/2017. Further review of the agency’s personnel record for the Alternate Administrator, Nurse A, Attendant A, Physical Therapist A, and Physical Therapy Assistant A failed to reveal of Bloodborne Pathogen training was conducted and completed in 2022 as required by agency policy and (OSHA), 29 Code of Federal Regulations Part 1910.1030 and Appendix A relating to Bloodborne Pathogens. During an interview with the Administrator on 5/4/2023 at 1:30 p.m., the surveyor presented the above findings and asked if the agency performed bloodborne pathogen training for Alternate Administrator, Nurse A, Attendant A, Physical Therapist A, and Physical Therapy Assistant A in 2022. The Administrator stated, "No, it was not. They have not completed the course online as of yet. Some of them have started the course." The Administrator also stated that the importance of the Bloodborne Pathogen course is because it teaches the staff ways to prevent infection when caring for clients.