A recertification survey was initiated on 1/9/2024. The census was: LCHH-74 LHH-0 Total agency census: 74 The agency was in compliance with 42 CFR part 484.102, Emergency Preparedness Requirements for Home Health Agencies.
Every finding on record at Custom Care Healthcare Inc
Benbrook, Texas · CCN 458125
3 findings across 1 survey, in the inspector's own words.
The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.
Survey of January 17, 2024
3 findingsA recertification survey was initiated on 1/9/2024. The census was: LCHH-74 LHH-0 Total agency census: 74 Abbreviations: LCHH-Licensed and Certified Home Health LHH-Licensed Home Health
Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review and interviews, the agency failed to provide the patient and/or caregiver with written information outlining a visit schedule including frequency of visits by home health staff in 5 (Patients #1, #3, #4, #5, and #6) of 5 patients' home folders reviewed during home visits. This failure placed the patients at risk of missed visits by staff when visits were not scheduled and conflicted with other appointments and the availability of the patients. Findings include: An interview was conducted on 1/9/24 at 11:10 am with the Supervising Nurse. The surveyor asked the Supervising Nurse how the patient’s knew when a nurse or therapist would be making their home visits. The Supervising Nurse said, “they call them the day before.” The Surveyor asked the Supervising Nurse if the patients are provided with anything in writing of when the visits will be made. The Supervising Nurse said, “No.” Patient #3: Record review contained a plan of care for the period of 12/7/2023 through 2/4/2024 with a start of care of 12/7/2023. The frequency for the skilled nurse was ordered 1 time a week for 9 weeks. During a home visit with Patient #3 on 1/12/2024 at 8:45 am, the agency home folder provided to Patient #3 failed to contain a written schedule of visits. The Surveyor asked Patient #3 if anything had been removed from the home folder. Patient #3 said, no. Surveyor asked Patient #3 if anyone had given her anything in writing of when they would be making the home visits. Patient #3 said, “No.” Surveyor asked how she knew when the nurse would be making their visits. Patient #3 said, “They call me the day before.”. The agency failed to provide the patient with a written schedule of visits. Patient #5: Record review contained a plan of care for the period of 11/21/2023 through 1/19/2024 with a start of care of 9/222023. The frequency for the skilled nurse was ordered 1 time a week for 1 week: every other week times 4 weeks; 1 time a week for 1 week and every other week times 2 weeks and physical therapy 1 time a week for 1 week; 2 times a week for 2 weeks and 1 time a week for 1 week. During a home visit with Patient #5 on 1/12/2024 at 9:40 aam, the agency home folder provided to Patient #5 failed to contain a written schedule of visits. The Surveyor asked Patient #5 if anything had been removed from the home folder. Patient #5 said, no. Surveyor asked Patient #5 if anyone had given her anything in writing of when they would be making the home visits. Patient #5 said, “No, they don’t know til the week before.” Surveyor asked how she knew when the nurse or therapist would be making their visits. Patient #5 said, “They call me.” The agency failed to provide the patient with a written schedule of visits. Patient #4: Record review contained a plan of care for the period of 12/6/2023 through 2/3/2023 with a start of care of 12/6/2023. The frequency for the skilled nurse was ordered 1 time a week for 9 weeks and medical social services 1 time a week for 1 week. During a home visit with Patient #4 on 1/12/2024 1012/21/2023 at 10:40 aam, the agency home folder provided to Patient #4 failed to contain a written schedule of visits. The Surveyor asked Patient #4 if anything had been removed from the home folder. Patient #4 said, “No.” Surveyor asked Patient #4 if anyone had given her anything in writing of when they would be making the home visits. Patient #4 said, “No.” Surveyor asked how she knew when the nurse or social worker would be making their visits. Patient #4 said, “They call me.” The agency failed to provide the patient with a written schedule of visits.” Patient #6: Record review contained a plan of care for the period of 9/29/2023 through 11/27/2023 with a start of care of 9/29/2023. The frequency for the skilled nurse was ordered 1 time a week for 9 weeks. The record contained an order for a physical therapy evaluation on 10/11/2023. During a home visit with Patient #6 on 1/12/2024 at 11:35 am, the agency home folder provided to patient #6 failed to contain a written schedule of visits. The Surveyor asked patient #6 if anything had been removed from the home folder. Patient #6 said, “No.” The Surveyor asked Patient #6 if anyone had given her anything in writing of when they would be making the home visits. Patient #6 said, “No, they just call or text me.” The agency failed to provide the patient with a written schedule of visits.” Patient #1: Record review contained a plan of care for the period of 11/20/2023 through 1/18/2024 with a start of care of 11/20/2023. The frequency for the physical therapy was ordered 2 times a week for 1 week and 3 times a week for 4 weeks. During a home visit with Patient #1 on 1/12/2024 at 1:00 pm, the agency home folder provided to patient #1 failed to contain a written schedule of visits. The Surveyor asked Patient #1 if anything had been removed from the home folder. Patient #1 said, “No.” The Surveyor asked Patient #1 if anyone had given him anything in writing of when they would be making the home visits. Patient #1 said, “No, they call me the day before.” The agency failed to provide the patient with a written schedule of visits.” An interview was conducted on 1/17/2024 at 10:30 am with the Supervising Nurse. The surveyor reviewed the home visit findings of a written schedule not provided to the 5 patient’s the surveyor made home visits to on 1/12/2024. The Supervising Nurse said, “We weren’t doing that before you told us about it.” The agency failed to provide the patients with a written schedule of visits.
← Back to the Custom Care Healthcare Inc record
Federal survey findings only. State licensure findings for home health agencies are not shown.
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction