Every finding on record at Coryell County Memorial Hospital Authority

An entrance conference was conducted for relicensure and recertification with the Administrator on 9/16/2024 at 12:45 p.m. The Administrator was informed of the purpose of the survey. Gatesville: Census: 83 Licensed and Certified Home Health: 27 Licensed Home Health: 0 Personal Assistant Services: 56 Hospice: The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. NO DEFICIENCIES WERE CITED

An entrance conference was conducted for relicensure and recertification with the Administrator on 9/16/2024 at 12:45 p.m. The Administrator was informed of the purpose of the survey. Gatesville: Census: 83 Licensed and Certified Home Health: 27 Licensed Home Health: 0 Personal Assistant Services: 56 Hospice: 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 Violations. Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services PAS - Personal Assistance Services CMS - Centers for Medicare & Medicaid Services OASIS - Outcome and Assessment Information Set iQIES - Internet Quality Improvement and Evaluation System HHA - Home Health Agency PT- Physical Therapist OT – Occupational Therapist

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 to the CMS system, within 30 days of completing the assessment of the patient for 3 of 297 assessments processed for the time period reviewed of 05/31/2023 - 12/31/2023. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare failing to be reported to CMS in the required time frame. Findings included: Record review of “The HHA Error Summary Report”, retrieved from the iQIES website for the time of 05/31/2023 - 12/31/2023 was reviewed. Review of the HHA Error Summary Report for the time-period of 05/31/2023 - 12/31/2023 identified Error #-3330. The description for Error #-3330 read in part, “Record Submitted Late: The submission date is more than 30 days after M0090 (Item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with this error was 3 assessments and the percentage of assessments with this error was 1.01 % of assessments completed by the Agency. A joint interview was conducted with the Administrator and Supervising Nurse on 9/18/2024 at 1:30 p.m. The HHA Error Summary Report was reviewed with the Administrator. The Administrator stated the Agency was aware of the late submissions of OASIS assessments due to the Agency using a third-party software company responsible for the error during 05/31/2023 - 12/31/2023. The Administrator further revealed that the Agency also frequently educates the Agency nurses on timely submission of documentation. Record review of an Agency policy titled, "Reporting of OASIS Information" no date, read in part, “The Agency will report, and safeguard required data collected for the OASIS items. The Agency will transmit accurate, completed, encoded, and locked OASIS data for each patient no later than the last day of each month.”

Services under arrangement CFR(s): 484.105(e)(1) The HHA must ensure that all services furnished under arrangement provided by other entities or individuals meet the requirements of this part and the requirements of section 1861(w) of the Act (42 U.S.C. 1395x (w)). This STANDARD is not met as evidenced by: Based on record review and interview, the Administrator failed to enforce a written agency policy consistent with state requirements for one of two contracted staff (OT A) whose records were reviewed, in that: The contract for Therapy services did not include OT. This failure could place agency clients at risk of harm or inadequate care from contracted employees. Findings include: Record review of the agency’s contracted staff policy titled, “Contractual Staff,” no date, read in part, “Contractual staff includes independent individuals who contract directly with the Agency on a…per visit to provide services to Agency patient according to a written agreement/contract…4. Any personnel under…per visit contracts used by the Agency, there shall be a written employment contract between those personnel the Agency that specifies the following: All services must be authorized by the Agency…delivered in accordance with the patient’s plan of care.” Record review revealed the agency’s therapy contract between the agency and the therapy contractor titled, “Professional Service Agreement,” dated 12/12/2008, revealed “Contractor employs professional practitioners...to furnish these services to agency’s patients: Physical Therapy.’’ Further record review of the agency’s therapy contract also revealed that the contract did not specify Occupational Therapy. Record review of the agency’s current Occupational Therapist, OT A, revealed a date of hire of 9/11/2017. During an interview with the Contracting company’s owner (PT A), PT A revealed during the drafting of the contract in 2008, the omission of the Occupational Therapist was an oversight. In a joint interview with the Administrator and the Administrator consultant on 9/16/2024 on 2:00 p.m., the Administrator stated that she was not aware that the Occupational Therapist was not indicated on the Agency’s current contractual therapy contract but will be corrected. The Administrator consultant further revealed that she drafted the contract at the time, and the Occupational Therapist omission on the contract was strictly an oversight.