Every finding on record at Dallas County Physician's Choice Homecare, LLC.

Purpose of visit: Recertification/Relicensure Survey Entrance: 01/03/2022 The agency's census was: Licensed and Certified HHS-7; LHHS-0; PAS-0 Exit: 01/05/2022 An entrance conference was conducted on 01/03/2022 at 10:55 AM with the Administrator. The agency was informed that the purpose of the survey was to conduct a Recertification/Re-licensure Survey. The "Home and Community Support Services Agencies (HCSSAs), What To Expect During Your Agency's Survey" was provided and explained. The information card giving instructions on how to complete the on-line comment survey was provided. An exit conference was conducted on 01/05/2022 at 2:01 PM with the Administrator. The preliminary findings of the survey were discussed, and a written copy provided. The agency was informed which records were duplicated. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Violation. Abbreviations: Quality Assessment Performance Improvement Plan (QAPI). Outcome and Assessment Information Set (OASIS)

Purpose of visit: Recertification/Relicensure Survey Entrance: 01/03/2022 The agency's census was: Licensed and Certified HHS-7; LHHS-0; PAS-0 Exit: 01/05/2022 An entrance conference was conducted on 01/03/2022 at 10:55 AM with the Administrator. The agency was informed that the purpose of the survey was to conduct a Recertification/Re-licensure Survey. The "Home and Community Support Services Agencies (HCSSAs), What To Expect During Your Agency's Survey" was provided and explained. The information card giving instructions on how to complete the on-line comment survey was provided. An exit conference was conducted on 01/05/2022 at 2:01 PM with the Administrator. The preliminary findings of the survey were discussed, and a written copy provided. The agency was informed which records were duplicated. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Violation. Abbreviations: Quality Assessment Performance Improvement Plan (QAPI). Outcome and Assessment Information Set (OASIS)

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure proper written notice was provided, in advance of terminating on-going care in five of five (patients #6, 7, 8, 9 and 10) inactive patient records reviewed. The agency failed to provide the Centers for Medicare and Medicaid form titled Notice of Medicare Non-Coverage. The failure could place the patients at risk of harm due to inadequate or inappropriate continuity of care in the patients' post-discharge needs and could prevent the patients from exercising the right to appeal the discharge decision, if desired. FINDINGS INCLUDED: Clinical Record # 6: Record review 01/04/2022. Record review of the electronic clinical record for Patient # 6 revealed a discharge Outcome and Assessment Information Set (OASIS) dated 11/16/2021 and showed a discharge date of 11/16/2021. The record included a written Notice of Medicare Non-Coverage signed and dated by the patient on 11/16/2021. The written Notice of Medicare Non-Coverage included an incorrect phone number Identifier D instead of Identifier E as the correct phone number for an immediate appeal. Patient # 6's clinical record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 11/16/2021. Clinical Record # 7: Record review 01/04/2022. Record review of the electronic clinical record for Patient # 7 revealed a discharge OASIS dated 12/28/2021 and showed a discharge date of 12/28/2021. The record included a written Notice of Medicare Non-Coverage signed and dated by the patient on 12/28/2021. The written Notice of Medicare Non-Coverage included an incorrect phone number Identifier D instead of Identifier E as the correct phone number for an immediate appeal. Patient # 6's clinical record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 12/28/2021. Clinical Record # 8: Record review 01/04/2022. Record review of the electronic clinical record for Patient # 8 revealed a discharge OASIS dated 11/30/2021 and showed a discharge date of 11/30/2021. The record included a written Notice of Medicare Non-Coverage signed and dated by the patient on 11/30/2021. The written Notice of Medicare Non-Coverage included an incorrect phone number Identifier D instead of Identifier E as the correct phone number for an immediate appeal. Patient # 6's clinical record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 11/30/2021. Clinical Record # 9: Record review 01/04/2022. Record review of the electronic clinical record for Patient # 9 revealed a discharge OASIS dated 12/22/2021 and showed a discharge date of 12/22/2021. The record included a written Notice of Medicare Non-Coverage signed and dated by the patient on 12/22/2021. The written Notice of Medicare Non-Coverage included an incorrect phone number Identifier D instead of Identifier E as the correct phone number for an immediate appeal. Patient # 9's clinical record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 12/22/2021. Clinical Record # 10: Record review 01/04/2022. Record review of the electronic clinical record for Patient # 9 revealed a discharge OASIS dated 11/092021 and showed a discharge date of 11/09/2021. The record included a written Notice of Medicare Non-Coverage signed and dated by the patient on 11/09/2021. The written Notice of Medicare Non-Coverage included an incorrect phone number Identifier D instead of Identifier E as the correct phone number for an immediate appeal. Patient # 10's clinical record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 11/09/2021. In an interview on 01/04/2022 at approximately 2:45 p.m. with the Administrator and DON, the surveyor discussed the above findings of why the agency had not provided written notice of the intent to discharge with the Notice of Medicare Non-Coverage form no later than two days in advance of terminating on-going care for Patients # 6, 7, 8, 9 and 10. The DON replied, "That was an oversight on my behalf." The surveyor discussed the phone number for an immediate appeal provided to the patient was incorrect and showed the administrator and DON how to access the correct phone number. The Administrator replied, “We will make sure to correct the form.” Review of agency policy titled "PE.6 Patient Discharge" dated 050616 read in part: "Policy...G. Agency will deliver the ...CMS notice NOMNC (Notice of Medicare Non-Coverage) ... to the patient (or authorized representative), no less than two (2) days prior to the day of anticipated discharge, or as soon as the provider determines coverage will end ..." According to §405.1200 - Notifying beneficiaries of provider service terminations: (a) (2) (b)(1) Timing of notice. A provider must notify the beneficiary of the decision to terminate covered services no later than 2 days before the proposed end of the services. If the beneficiary's services are expected to be fewer than 2 days in duration, the provider must notify the beneficiary at the time of admission to the provider. If, in a non-residential setting, the span of time between services exceeds 2 days, the notice must be given no later than the next to last time services are furnished.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure its QAPI committee met at least twice a year to address identified problems and concerns in service delivery in the years 2020 and 2021. This failure limits the agency's ability to review patient outcomes, identify and immediately rectify any problems that might threaten the care, services, and safety of patients. Findings Include: During an interview with the Adm and the DON on 01/05/2021 at 11:30 AM, the surveyor asked if the QAPI binder given to the surveyor included all QAPI documents for 2020 and 2021. The Administrator stated, "Yes." Record review of the agency's QAPI binder did not include any QAPI committee meetings held in 2020 and one meeting dated 1/4/2021. During an interview with the Adm on 01/05/20221 at 12:59 PM, the surveyor asked why the agency had not conducted QAPI meetings twice a year in 2020 and only one in 2021. The Adm stated, " It was an oversight ..." Surveyor asked without QAPI oversight how would the patients be affected? The DON stated, “We cannot improve on our processes.” Agency Policy read in part, "... Quality Assessment & Performance Improvement Plan...8.001.1...Procedure ...The QAPI Committee must meet at least quarterly and more often if needed ..."