Every finding on record at Central Home Health Services of Texas LLC

An incident investigation (Intake#1007728) was conducted on 05/08/2025. The census was 337. 173- LHHS, 16- L&C, 148- PAS. Abbreviations used: Adm- Administrator AA- Alternate Administrator APRN- Advanced Practice Registered Nurse CMS- Centers for Medicare & Medicaid Services CNS- Clinical Nurse Specialist CR – Clinical Record DON- Director of Nursing Dr- Doctor Form 485- Home Health Certification and Plan of Care ADON- Alternate Director of Nursing HHA- Home Health Agency HIPPA- Health Insurance Portability and Accountability Act LBD_ Lewy Bodies Disorder L&C- Licensed and Certified LHHS- Licensed Home Health Services LVN- Licensed Vocational Nurse NP-Nurse Practitioner NOMNC- Notice of Non-Medicare Coverage OASIS- Outcome Assessment Information Set PA- Physician Assistant PAS- Personal Assistance Services PHI-Protected Health Information POC- Plan of Care SOC- Start of Care RN- Registered Nurse SN- Skilled nurse SNV-Skilled nurse visit

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure the confidentiality and protection of 11 of 17 active and discharged patients’ (#7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17) Protected health information in that an unauthorized individual had documents containing confidential medical and identifying information of the 11 patients without their knowledge or consent. This failure placed the patients at risk of identity theft/fraud as they had not consented to their medical and/or identifying information being used outside of the agency provision of care and services. Findings Include: Record review of complaint Intake #1007728 that was received 05/06/2025 @8:33 AM, included the name and information about 1 agency patient (Patient#4). Record review on 05/08/2025, of the agency's policy titled "HIPPA- Privacy Compliance" with a revised date of 01/03/2025 read in part: “Ensures protection of personal medical information shared with healthcare providers. Employees receive training on PHI handling and must sign off before accessing PHI.” Further review of the HIPAA policy revealed it did not include any information about the use of cell phones for the exchange of patient information, and no information about how the agency would retrieve or remove the information from the staff personal phones. On 05/08/2025 at 9:13 AM, during an interview with COM it was revealed that the individual had possession of confidential PHI - text conversations between CEE, Office Staff A, Office Staff B, and Office C for 4 current ( patients #10, #11, #15, #17), and 7 discharged (patients #7, #8, #9, #12, #13, #14, #16) and shared with the surveyor the PHI retained on a personal device as evidence. Review of the information showed it included start-of-care, diagnosis, demographic and discharge information. Surveyor asked COM why the confidential PHI of the agency’s patients was retained on the personal device. COM stated to make sure the evidence was retained when it was reported to Texas Health and Human Services, and to assist in the investigation process. COM stated that she wanted to ensure that no other patients get neglected because the agency was not doing right to the patients. Record review of electronic clinical record (ECR) for Patient #4 on 05/08/2025 revealed a plan of care (POC) with a start of care (SOC) dated 06/22/204 and certification period of 02/17/2025-04/17/2025. The POC included diagnosis of Unspecified Hypothyroidism ( An underactive thyroid, or hypothyroidism, occurs when the thyroid gland creates less than the normal amount of thyroid hormone), Essential (primary) hypertension (develops when blood flows through your arteries at higher-than-normal pressures), unspecified convulsions ( a general term used to describe uncontrollable muscle contractions), and shortness of breath ( the feeling of an inability to get enough air in your lungs). Orders for care included SN (skilled nurse) twice a week for eight weeks, then once a week for a week, and with two prn as needed visits for any overall health complications. Incidents that may occur during this certification period. Physical Therapy to evaluate and treat. SN to instruct PT/CG on disease process of hypertension, and measures to manage the disease. SN to instruct PT/CG on methods to recognize pulmonary dysfunction and relieve complications. On 05/08/2025 at 3:29 pm, COM provided surveyor with screenshots of patients #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17 confidential PHI. Surveyor received emails to include confidential PHI from COM. Record review on 05/09/2025 of CEE personnel file did not reveal specific training related to HIPPA compliance. On 05/13/2025 at 3:30 pm, during an interview with the Administrator, she stated that all employees had been trained on HIPPA compliance initially and on an annual basis and are expected to adhere to the policy and procedures of the agency. Administrator stated that the agency did not have a policy on using personal cell phones to conduct agency business. She stated that all office staff have a line in their office to communicate as needed. The Administrator stated that the office staff did at one time use an electronic application known as “WhatsApp” (A free messaging application for text, voice, and video communication), but no longer utilizes this platform. The Administrator was unable to provide surveyor dates of use for that software product. Administrator stated that she did not know that any of her agency’s PHI had been compromised. Administrator stated that she was ultimately responsible for ensuring that all policies and procedures are followed. Administrator stated that she was unsure why this happened and that she would work with her corporate office information technology team to prevent this from happening in the future. Administrator stated that this deficient practice affects the security and integrity of the health information of all patients whose records were not protected and places the agency at risk for regulatory and legal consequences. No further information was provided.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on clinical record review and interviews, the agency failed to notify 1 of 6 patients reviewed (Patient #4) , their representative (if any), the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional of Patient #4's discharge in that: The agency discharged patient #4 without prior written notice, and without documentation supporting an emergency or unplanned discharge, the same day insurance coverage was denied, . This failure placed the patient at risk of not having treatments continued routinely which could have led to decline in health status. Findings Include: Review of Intake #1007728 included information that Patient #4 was discharged on 04/18/2025 the same day the agency was informed that the Insurance company was no longer going to reimburse the agency for any of the patient services. Patient experienced a fall with injury requiring hospitalization within two weeks of her immediate discharge. Record review of the (ECR) for Patient #4 on 05/08/2025 revealed a plan of care (POC) with a start of care (SOC) dated 06/22/204 and certification period of 02/17/2025-04/17/2025. The POC included diagnosis of Unspecified Hypothyroidism ( An underactive thyroid, or hypothyroidism, occurs when the thyroid gland creates less than the normal amount of thyroid hormone), Essential (primary) hypertension (develops when blood flows through your arteries at higher-than-normal pressures), unspecified convulsions ( a general term used to describe uncontrollable muscle contractions), and shortness of breath ( the feeling of an inability to get enough air in your lungs). Orders for care included SN (skilled nurse) twice a week for eight weeks, then once a week for a week, and with two prn as needed visits for any overall health complications. Incidents that may occur during this certification period. Physical Therapy to evaluate and treat. SN to instruct PT/CG on disease process of hypertension, and measures to manage the disease. SN to instruct PT/CG on methods to recognize pulmonary dysfunction and relieve complications. The record revealed that a recertification OASIS ( A tool used by CMS to collect certain patient information) assessment was completed on 04/14/2025, with no documentation of impending discharge. Continued review of the CR revealed that four days later 4/18/25, the patient was discharged by the agency following notification of insurance denial for further services. The clinical record contained no discharge summary, no physician-ordered discharge plan, and no documentation indicating that the patient had been given written notice of discharge. Interview with Patient #4 on 05/09/2025, revealed she was contacted by phone on the same day by office staff, who informed her she had completed all her visits and that no additional services would be provided. Patient #4 stated that she is unable to recall the name of the person at the agency that she spoke with. Patient #4 also added that she thought she was still going to get therapy services until that call from the agency. Stated that she was still unsteady at that time. Patient #4 stated that she fell within a few weeks of being discharged from the agency and had to be hospitalized for hitting her head. During an interview on 05/09/2025 at 3:45 PM, the AA provided the surveyor with a NOMNC signed by the office staff C and dated 04/18/2025. The AA also stated that she thought if the agency informed the patient of the discharge the patient did not have to sign for it and that the date they were notified did not make a difference as long as they were told. Surveyor asked AA why the agency did not follow the policy related to discharges and she stated that she did not know about that policy and that it applied to licensed home health patients. The AA confirmed that a formal discharge notice was provided due to the immediate nature of the insurance denial, and no exception criteria (such as an emergency or patient refusal) was cited to justify same-day termination. The AA stated that the insurance denial was not documented in the clinical record. When asked what the risk to the patient this failure could cause the AA stated that the patient might not have known what was going on with her care and might have expected for services to continue. Review of the agency’s policy titled “Discharge/Transfer Procedure:” undated, read in part: “Upon termination of services, the agency will: 7. At least 2 days before the discharge (final) visit, the patient/ will receive the notice of discharge, with instructions on the purpose of the form. The patient will be required to sign the Notice of Medicare Non-Coverage (NOMNC).

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 interview and record review, the agency failed to ensure that services and treatments were administered as ordered by the physician or allowed practitioner for 1 of 6 patients (Patient #1) in that: The agency failed to document the physician orders for wound care to be provided to Patient #1 twice weekly by the agency. This failure placed all patients at risk of not receiving needed services to meet the patient's goals and healthcare problems. Recommend the specific risk to Patient #1 that was noted in the DON’s interview—the wound could get worse—be included in the outcome. Findings Include: Review of Patient #1’s clinical record revealed a Plan of Care for certification period 04/11/2025 to 06/09/2025 with a primary diagnosis of Other Complications of Procedures (an unexpected medical event that occurs during or after a procedure, treatment, or surgery, which alters the patient’s recovery or requires additional interventions), and secondary diagnoses of Neurocognitive disorder with Lewy bodies ( a complex and challenging brain disorder. LBD is characterized by the presence of Lewy bodies in the brain and cognitive decline that worsens over time). Continued review of Patient #1’s clinical record revealed a wound care order dated 04/25/2025, directing the agency to perform wound care two times per week. The order was signed and incorporated into the clinical documentation submitted by the wound care specialist. Review of the Plan of care for Patient #1 included the following orders for the SN: Review of the skilled nursing visit notes dated 04/14/2025, 04/21/2025, 04/28/2025, and 05/05/2025 showed that wound care was performed only once per week. There was no documented reason or physician communication authorizing the reduced frequency. During an interview conducted on 05/12/2025 at 1:15 PM, LVN A stated that she had been working for the agency since February 2025. She is currently assigned 3 patients that live near her. Stated that she had a very brief orientation, and she had some orientation with the DON/Admin on that morning related to wound care. LVN A stated that she had some wound care experience at the level of a Dr.’s office nurse would typically have. Surveyor asked LVN A did she demonstrate competency in wound care at the agency and she stated that she had not. Surveyor asked what type of wound care training the agency had provided her she stated that she had some training videos and verbal education broken up since hiring on to the company. LVN A stated that she had been seeing patients alone since her first visit. She did not go in the field with anyone. Stated that she does have a RN to consult with if needed. LVN A stated that she was assigned Patient #1 and sees him on weekly basis. Surveyor asked if she knew what the wound care orders were for Patient#1 and she stated that she could not recall them without looking them up, but she knows that she only goes once a week and does the wound care while she was there. During an interview conducted on 05/12/2025 at 1:53 PM, Family member #1 revealed that the wound care is done once a week with the agency nurse. FM#1 stated that she did the wound care and dressing changes when the nurse was there, and she looked at the wound to see if there were any problems with the wound. She stated that the wound care Dr. and or NP came on Fridays and looked at the wound as well. Stated that the agency came on a weekly basis and scheduled and that the last visit was on 05/12/2025. During an interview conducted on 05/12/2025 at 3:45 PM, the Director of Nursing/Administrator confirmed that the order for twice-weekly wound care had been received but was not transcribed onto the plan of care (Form CMS-485) or communicated effectively to the field staff responsible for implementation. DON stated that she was not aware of that order. DON stated that LVN A told her that she did not know how to read the orders or understand the charting software system. Surveyor asked if the policy was that the assigned skilled nurse should review orders and ask if the patient had been to a provider since her last visit, every visit, to ensure coordination was happening. DON replied “yes,” and she also stated that “I just missed this one. It should be done twice a week, and it should be on the 485.” Surveyor asked why this process did not occur with this patient and she stated that the wound care NPs are supposed to call and coordinate and when they don’t, things get missed like that. Surveyor asked what the risk to the patient was when things like this happened and the DON/Admin stated that the wound could get worse. Review of agency policy titled; “Coordination of Care” undated read in part: All personnel involved in the patient’s care are responsible for coordinating care effectively to support the objectives outlined in the patient’s plan of care. Responsibility of the agency: The agency coordinates care by 1.c. Integrating orders, from all physicians, or (PA, APRN CNS as state allows), involved in the plan of care, to ensure the coordination of all services, and interventions, provided to the patient, to ensure continuity of care.