Every finding on record at Citica Home Health LLC

Purpose of Visit: Recertiication Entrance Conference: 5/23/22 at 8:20 a.m., with the Administrator and the Alternate Administrator Agency Census: Licensed and Certified (L&C) - 0 Licensed Home Health (LHH) - 0 Personal Assistance Services (PAS) - 164 An Exit Conference was conducted on 5/25/22 at 4:20 p.m., with the Administrator and the Alternate Administrator 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 receipt of the Statement of Deficiencies. THHS - Texas Health and Human Services ISP - Individual Service Plan Admin - Administrator

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to have a written emergency preparedness and response plan based on a risk assessment that thoroughly described its approach to dealing with a disaster that could or did affects its services, in that: The agency did not review their hazard risk assessment after its February, 2021 winter storm and May, 2021 flood evacuation response when the agency implemented its emergency preparedness plan as per policy. This deficient practice places the agency's PAS patients at risk when for not receiving services during or after a disaster when the agency does not plan or prepare for either a man-made disaster or a natural-disaster. The findings included: Review of the "All Hazards Facility/Community Based Hazard Risk Assessment" dated 1/4/21 revealed in part "Complete this assessment at least annually, and after each actual emergency response or drill, using an all hazard approach to determine areas of vulnerability for disaster response. Further review revealed floods and thunderstorms were listed under "natural hazards" Review of the agency "Flood Emergency" dated 5/19/21 revealed the agency implemented their emergency preparedness response plan due to floods and thunderstorms and possible evacuation of patients from their homes. Further review revealed there was no documented evidence that the agency reviewed or revised their hazards risk assessment after the emergency response according to their policy. During an interview on 5/25/22 at 2:30 p.m., with the Alternate Admin he stated that last time the agency implemented the emergency preparedness plan was 5/19/21 due to serve weather and that the agency did not reassess their hazard risk after that event and should have. He further stated that he did not realize that it was part of the form and did not review the hazard risk form after the 2/14/21 winter storm. He added that this could impact client care when the agency knows what disaster it needs to be prepared for to continue services to our clients after a disaster. Review of the agency's "Emergency Preparedness Policy (agency's plan) EC.02 revealed in part "Emergency plan 1. The agency will develop and maintain an emergency preparedness plan that ill be reviewed, and updated at least annually, and after each actual emergency response, to evaluate its effectiveness and to update the plan as needed. the plan will be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach to determine areas of vulnerability for disaster response..."

Purpose of Visit: Recertification Entrance Conference: 5/23/22 at 8:20 a.m., with the Administrator and the Alternate Administrator Agency Census: Licensed and Certified (L&C) - 0 Licensed Home Health (LHH) - 0 Personal Assistance Services (PAS) - 164 An Exit Conference was conducted on 5/25/22 at 4:20 p.m., with the Administrator and the Alternate Administrator 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 receipt of the Statement of Deficiencies. THHS - Texas Health and Human Services ISP - Individual Service Plan Admin - Administrator

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to have implemented and review a quality assessment and performance improvement program for 2021, in that: There was no analysis of client complaint and satisfaction survey data and negative client outcomes for 2021 for the L&C patients. This deficient practice places the agency's patients at risk of not receiving quality care and services due to the agency’s inability to improve weaknesses in service. The findings included: 1. During the entrance conference on 5/23/22 at 8:20 a.m., with the Admin and the Alternate Admin they stated that they did not provided skilled nursing or therapy services since Dec 9, 2021 and in 2021 and 2022 the agency provided PAS services. 2. Review of the QAPI Meeting Minutes Quarter 1 dated 1/31/22 revealed there were no active or inactive L&C clients and there were no no deficiencies noted. Review of QAPI Meeting Minutes Quarter 1 dated 4/27/21 (for certification period from 1/1/21 - 3/31/2021);QAPI Meeting Minutes Quarter 2 dated 8/1/21 (for certification period from 4/1/21 - 6/1/21); QAPI Meeting Minutes Quarter 3 dated 10/31/21 (for certification period from 7/1/21 - 9/30/21); QAPI Meeting Quarter 4 2021 dated 1/31/22 (for certification periods from 10/1/21 through 12/31/21); revealed no documented evidence that the agency analyzed client complaints and satisfaction survey data and negative client outcomes Review of the "National Patient Satisfaction Benchmark System from 1/2021 through 11/2021 revealed the agency performed a total of 11 client satisfaction surveys (L&C) clients. Further review revealed no documented evidence that the agency reviewed the L&C client satisfaction surveys at the QAPI meeting. Review of the binder titled "Incident Report" 2021 revealed there were 45 L&C clients that had a fall. Further review revealed there was no documented evidence that the QAPI committee reviewed negative client outcomes for the L&C services. 3. During an interview on 5/25/22 at 9:30 a.m., with the Admin and the Alternate Admin they stated that they had a system to track L&C client satisfaction through their medical record system but they did not report the results to the QAPI committee. They added that they did not discuss falls in the QAPI meeting and they should have. Finally, they stated that this could impact client care because the agency would loose out on trending data to make improvements in care and make all services meaningful, 4. Review of the agency's "QAPI Program" dated 5/22/17 revealed "The agency will maintain a QAPI program that is implemented by a QAPI committee. The QAPI program will be ongoing, focused on client outcomes, that are measurable, and have a written plan of implementation (measurable goals)...The Agency utilizes a system that measures significant outcomes for optimal care. The measures includes the following as appropriate for the scope of services provided by the agency: negative client care outcomes, complaints and incidents of unprofessional conduct by licensed staff and misconduct by unlicensed staff, infection control activities, medication administration and errors, effectiveness and safety of all services provided, competency of the agency's clinical staff, the promptness of service delivery and the appropriateness of the agency's response to client complaints and incidents, B. An analysis of a representative sample of services furnished to clients contained in both active and discharge clinical records will be reviewed, C. A determination that services have been performed as outlined in the Individual Service Plan (ISP), care plan, or plan of care and D. An analysis of client complaint and satisfaction survey data..."