Every finding on record at Dfw Consolidated Healthcare Services LLC

An entrance conference was conducted on 06/07/2022 at 12:55 p.m. with the Adm/DON. The Adm/DON was informed that the purpose of the survey was for a 36-month recertification inspection. L&C Census: 1 An exit conference was conducted on 06/13/2022 at 2:00 p.m. with the Adm/DON. The preliminary findings were discussed. The agency was given an opportunity to provide additional information. Additional information was provided. Written instructions were provided to the agency for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. Abbreviation List: Adm-Administrator Alt Adm-Alternate Administrator DON-Director of Nursing/Supervising Nurse ALT DON-Assistant Director of Nursing/Alternate Supervising Nurse L & C- Licensed and Certified EP-Emergency Preparedness

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to maintain an emergency preparedness communication plan that complied with Federal, State, and local laws, in two of two EP binders reviewed. The communication plan did not include the names and contact information for agency staff, entities providing services under arrangement, patients' physicians, and volunteers. The failure could place the agency’s client’s health and safety at risk if an actual emergency or disaster occurred in their area of service. The failure could also cause the agency to lack the ability to contact staff, clients, client’s physicians, and entities providing services, in the event of an actual emergency or disaster in the agency’s service area. FINDINGS Included: During the entrance conference with the Adm/DON, on 06/07/2022 at 12:55 p.m., the surveyor requested all agency EP records and documents since the last survey dated 06/05/2019. Review of the agency’s EP binders revealed that the agency did not maintain an emergency preparedness communication plan that included the names and contact information for agency staff, entities providing services under arrangement, patients' physicians, and volunteers. The binder revealed that the agency’s Continuity of operations business plan had not been updated since 2012/2011. During an interview on 06/07/2022 at approximately 3:30 p.m. the surveyor asked the Adm/DON if there were any other records or documents to add/provide for the agency’s EP records. The Adm/DOM replied, “No that’s it.” The plan failed to include a communication plan with names and contact information for agency staff, contract staff, physicians and volunteers. On 06/13/2022 during an interview with the Adm/DON at approximately 1:15 p.m., the surveyor discussed the above findings of why the agency had not maintained an emergency preparedness communication plan that included the names and contact information for agency staff, entities providing services under arrangement, patients' physicians, and volunteers. The Adm/DON stated that the information could be retrieved from the agency’s electronic record system. The surveyor discussed that during the entrance conference the surveyor requested client and staff lists with contact information, but the Adm/DON was not able to retrieve the information and therefore, took several hours to hand type the information into the computer to provide the requested lists. The Adm/DON replied, “That day apparently what I was depending on in [the electronic record system] failed me.” The surveyor also discussed how the agency’s clients could be adversely affected by the agency not being able to access the names and contact information for agency staff, entities providing services under arrangement, patients' physicians, and volunteers, in the event of an actual emergency or disaster. The Adm/DON replied, “If we cannot readily access the information, they could suffer a lot of consequences from that.” Review of agency policy titled “Emergency Preparedness and Response Plan EC.8” revised 070120 read in part: “…IV. Continuity of Operations Business Plan A…Administrative staff responsibilities…1. Communication a. The agency will maintain a current listing of staff, contract staff, and volunteers, and all applicable contact numbers for use as a communication/disaster calling tree…

An entrance conference was conducted on 06/07/2022 at 12:55 p.m. with the Adm/DON. The Adm/DON was informed that the purpose of the survey was for a 36-month recertification inspection. L&C Census: 1 An exit conference was conducted on 06/13/2022 at 2:00 p.m. with the Adm/DON. The preliminary findings were discussed. The agency was given an opportunity to provide additional information. Additional information was provided. Written instructions were provided to the agency for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. Abbreviation List: Adm-Administrator Alt Adm-Alternate Administrator DON-Director of Nursing/Supervising Nurse ALT DON-Assistant Director of Nursing/Alternate Supervising Nurse L & C- Licensed and Certified POC-Plan of Care SOC- Start of Care SN-Skilled Nursing HHA-Home Health Agency

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 interview, the agency failed to provide written information in one (Patient #1) of one licensed and certified patient who received a home visit. The home health agency (HHA) failed to provide the patient and caregiver with a copy of written instructions which outlined: Visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. The failure could place the client at risk to be uninformed and/or unable to identify the staff scheduled to provide care and services on the behalf of the agency. FINDINGS INCLUDED: On 06/07/2022, the agency's sample "Medicare" admission packet was reviewed. The packet contained a form for visit schedules. Clinical Record #1: Review of Client # 1’s record included a POC for the certification period of 04/28/2022 to 06/27/2022 with a SOC date of 05/10/2020. The POC was electronically signed by Adm/DON and dated 04/28/22.The POC included a primary diagnosis of “type 2 diabetes…” The POC included an order for SN visits one time every other week, monthly as needed for exacerbation [of health conditions] During a home visit conducted on 06/09/2022 at approximately 9:30 a.m., a review of Patient #1's home folder revealed that the folder included a blank visit schedule. The visit schedule was not completed to show the frequency of visits by HHA personnel. The home folder did include a current medication list for the certification period of 04/28/2022 to 06/27/2022, but the record did not include a current visit schedule for the certification period of 04/28/2022 to 06/27/2022. During an interview on 06/13/2022 at 1:27 p.m.., the surveyor discussed with the Adm/DON, the above findings of why the agency had not provided Client # 1 with a written visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. The Adm/DON replied, “She knows her schedule.”

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure that the attending physician’s signature was legible, clear, and appropriately authenticated by a primary author who had reviewed and approved the entry, in one (Client # 1) of one licensed and certified record reviewed for authentication. The failure could place the client at risk of harm if care and treatment were not reviewed, approved, and authenticated by the attending physician. FINDINGS IINCLUDED: Clinical Record # 1: Review of Client # 1’s record included a POC for the certification period of 04/28/2022 to 06/27/2022 with a SOC date of 05/10/2020. The POC was electronically signed by Adm/DON and dated 04/28/22.The POC included a primary diagnosis of “type 2 diabetes…” The POC included an order for SN visits one time every other week, monthly as needed for exacerbation [of health conditions]. The record also contained POCs electronically signed by Adm/DON and dated: 02/23/2022; 12/29/2021; 10/26/2021 and 08/31/2021. The POCs listed Client # 1’ attending physician as Identifier 100. The signatures for the physician on the POCs were not legible. During an interview on 06/13/2022 1:27 p.m., the surveyor asked for the agency’s attestation/signature log/authentication of the illegible signatures. The attestation/signature log/authentication was not provided. The Adm/DON replied, “I’m thinking it is legible.” The Adm/DON looked at the signature on the POCs, in Client # 1’s record. The surveyor asked if the agency had an attestation for authentication of the illegible signatures. The Adm/DON replied, “No I don’t.” According to Texas Home Health Licensing Requirement Z-465, §558.297(2): Signed physician orders may be submitted via facsimile machine. The agency is not required to have the original signatures on file. However, the agency must be able to obtain original signatures if an issue surfaces that would require verification of an original signature.