Every finding on record at E Medical Group of College Station LLC

A recertification was conducted on 5/12/2026. The census was: L&CHH: 7 LHH: 0 Abbreviations/Acronyms: L&CHH: Licensed and Certified Home Health LHH: Licensed Home Health The agency had no deficiencies cited.

A recertification was conducted on 5/12/2026 The census was: L&CHH: 7 LHH: 0 Abbreviations/Acronyms: L&CHH: Licensed and Certified Home Health LHH: Licensed Home Health ADMIN: Administrator SOC: Start of Care SN: Skilled Nursing DON: Director of Nursing HHA: Home Health Agency QAPI: Quality Assessment Performance Improvement Program RN: Registered Nurse LVN: Licensed Vocational Nurse PT: Physical Therapist OT: Occupational Therapist AE: Account Executive

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation for 1 (Client 8) of 2 patients. This failure placed patients at risk of harm or receiving inadequate care when complaints were not investigated in a timely manner. Findings included: Review of the agency’s complaint log for year 2024 revealed a complaint received 12/11/2024 at 2:51 PM from [Client 8], which read under “Description”, “CLIENT CALLED OFFICE & ASKED TO SPEAK WITH ADMIN/DON. MESSAGE TAKEN VIA WRITER. CLIENT STATES "I JUST DON’T WANT [RN B] IN MY HOUSE." ADMIN/DON NOTIFIED/INFORMED OF LISTED ABOVE.” Further review revealed under “Complaint log updates” update added by [RN A] on 12/24/2024 at 11:48:42 AM which read “COMPLAINT INTERVENTION: ADMINISTRATOR CALLED CLIENT/FAMILY”, “COMPLAINT PREVENTION: STAFF REASSIGNED” and “COMPLAINT INTERVENTION COMMENTS: PATIENT STATED THAT [RN B] LEFT A USED SYRINGE AND HER PACKAGE OF CHEESE CRACKERS ON THE COUCH AND MY DOG GOT AHOLD OF THAT WITH A NEEDLE ON THE SYRINGE. IT COULD HAVE KILLED MY DOG. ALSO SHE HAS SPILLED All MY MEDICINES ON THE FLOOR 2-3 TIMES AND IT PUTTING ME AND MY ANIMALS AT RISK DUE TO BEING CARELESS. I DO NOT WANT HER BACK IN MY HOUSE." PATIENT ASSURED THERE WOULD BE A REASSIGNMENT IN STAFF EFFECTIVE IMMEDIATELY. PROCESSED: 12/24/2024”. Update added by RN A on 12/26/2024 at 1:28:20 PM revealed “PROCESSED: 12/26/2024”. Per record review of Client 8’s chart revealed SOC date of 6/6/2022. Review of the Plan of Care for Certification Period 11/22/2024-1/20/2025, which corresponded with the complaint date of 12/11/2024, revealed patient received skilled nursing services. Coordination notes that were documented during the above certification period were reviewed and no notes were found that addressed or referenced the complaint received on 12/11/2024 or any subsequent investigation after the receipt of the complaint. Further review of a “Client Coordination Note Report” dated 5/23/2025 revealed patient discharged from HHA on 5/19/2025. In an interview with the Administrator on 5/13/2026 at 1:10 PM, Surveyor 2 reviewed the above complaint with Administrator. Surveyor 2 stated there did not appear to be any follow up investigation related to the complaint, aside from the initial return call to the patient during which information was gathered and the outcome resulted in nurse reassignment. Surveyor 2 asked who was responsible for determining whether an investigation was needed for a complaint and the Administrator stated it was the administrator. Surveyor 2 then asked about the agency's policy regarding complaint investigations. The Administrator stated the agency should speak with the patient, investigate the concerns, speak with the nurse, determine what had occurred, conduct follow-up as needed, and complete a self-report if concerns were identified. The administrator further stated she was not serving in the administrator role at the time of the complaint and therefore could not speak directly to what occurred. Surveyor 2 asked why investigating complaints was important for patient care and the Administrator stated it was important to ensure patients were not being abused, neglected or exploited and to ensure any unsafe nurses did not continue providing care. The Administrator also stated investigations helped prevent future incidents and allowed the agency to provide education, probationary periods, strict supervision or skill reassessment for employees as needed. In an interview with the Administrator on 5/14/2026 at 10:18 AM, Surveyor 2 asked the Administrator what role [RN A] had with the agency, and Administrator stated she had previously served as the Administrator/DON and was no longer employed by the agency. Surveyor 2 also asked about [RN B] who was the subject of the complaint, and the Administrator confirmed RN B's full name since only the first name had been documented in the complaint. The Administrator stated RN B was no longer employed by the agency. The Administrator requested clarification regarding the complaint concern, as documentation reflected that RN A had contacted the patient following the initial receipt of the complaint. Surveyor 2 reviewed the complaint with the Administrator and confirmed the concern was due to the complaint involved a report of a “used syringe” being left on the client's couch and RN B reportedly having “spilled all [the] medications on the floor 2-3 times”, which could have potentially caused harm to the patient. Surveyor 2 further noted there was no documented actions demonstrating that a thorough follow-up investigation had been completed regarding the complaint on the complaint found in the complaint log or within the patient’s clinical record. The Administrator confirmed that no additional evidence of investigation could be provided. Review of agency’s Administrative Policy Manual, revised November 2025, section HH2-3A “Assessment and Reporting of Abuse, Neglect and Exploitation”, Section “Care Continuum”, policy number “CC.035”, under “Guidelines and Procedures”, reads in part “3. The reporting of known or suspected abuse, neglect, and exploitation will be conducted as specified by state law. When a state does not specify a reporting mechanism the employee will adhere to the following guidelines:...c. A written report of the abuse, neglect, and/or exploitation or the suspicion of abuse, neglect, and/or exploitation will be completed and investigated” and further reads “4. The agency management will review the situation and investigate to determine if this is an event that should be reported.”

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to staff its QAPI meeting with an individual representing each scope of services the agency was providing for 3 of 3 years (2023, 2024 and 2025) due to the agency not having PT and OT represented in all of their QAPI meetings. This failure could result in the agency’s inability to identify and correct problems and revise policies as necessary for patients to receive consistent, quality care. Findings included: Review of agency’s QAPI binder for years 2023, 2024 and 2025 revealed meeting sign-in sheets for years 2024 and 2025 that documented meeting dates and attendees with the following titles: 1/16/24 - Administrator, Director of Nurses, RN, LVN; 10/14/24 - Administrator, Director of Nurses, RN, LVN, therapy; 1/16/25 - Administrator, Director of Nurses, RN, LVN, AE; 8/20/25 - Administrator, Director of Nurses, PT. Review of QAPI meeting in-service sign in sheet dated 2/20/2023, provided to Surveyor 2 by the Administrator on 5/14/2026 revealed individuals with the following titles listed: RN, LVN, AE. In an interview with Administrator on 5/13/2026 at 10:18 AM, Surveyor 2 reviewed 2024 and 2025 meetings notes, as 2023 meeting notes were unavailable at time of interview and requested verification regarding which disciplines had provided services to clients in 2023, 2024, and 2025. The Administrator stated she would need to verify and follow up. Surveyor 2 asked whether meeting notes for 2023 were available, and the Administrator stated she would attempt to find them and follow up. In an interview with Administrator on 5/14/2026 at 10:44 AM, the Administrator confirmed patients had received SN, PT and OT services in 2023, 2024 and 2025. Surveyor 2 reviewed the QAPI policy with the Administrator regarding the QAPI committee representation, which stated the committee should consist of “the Administrator, Supervising Nurse, and an individual representing the scope of services provided by the Agency”. Surveyor 2 requested clarification regarding the meeting dated 10/14/2024, in which an individual was listed with the title “therapy”, and asked which therapy discipline the individual represented. The Administrator stated she was unsure, as she was not employed with the agency at that time. The Administrator was asked if an individual representing each scope of services provided by the agency was at each QAPI meeting, and the Administrator stated she was unsure. The Administrator stated she had attempted to locate documentation or notes from the previous Administrators for the QAPI meetings regarding attendants but was unable to find any information. Surveyor 2 asked who was responsible for ensuring all individuals representing the agency’s scope of services were included in the QAPI meetings, and the Administrator stated it was the administrator’s responsibility. Surveyor 2 asked why it was important that all scopes of services being provided are represented in the QAPI meetings, and Administrator stated it was important for consistency of care and quality of care. Review of agency’s Quality Assessment Performance Improvement Program policy manual, revision date August 2022, Section “QAPI”, policy number “QA.001”, under Section “Quality Assessment Performance Improvement Committee” reads in part “The Governing Body appoints a Quality Assessment and Performance Improvement Committee that consists of the Administrator, Supervising Nurse, and an individual representing the scope of services provided by the Agency.”