Every finding on record at Eclate Health Care Solutions Inc

A relicensure/recertification survey entrance conference was conducted with Administrator A on 03/26/2024 at 3:00 PM. The census was: LHHS: 0 LCHHS: 0 PAS: 1 An exit conference was conducted on 04/04/2024 with Administrator A at 1:30 PM. The preliminary findings were discussed. The agency was found in compliance with 42 CFR Part 484.102 Emergency Preparedness Requirements for Home Health Agencies and no deficiencies were cited.

A relicensure/recertification survey entrance conference was conducted with Administrator A on 03/26/2024 at 3:00 PM. The census was: LHHS: 0 LCHHS: 0 PAS: 1 An exit conference was conducted on 04/04/2024 with Administrator A at 1:30 PM. 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 Deficiencies. Abbreviations: ADON – Alternate Director of Nurses/Alternate Supervising Nurse CFR – code of Federal regulations CMS – Center for Medicare and Medicaid Services DON – Director of Nurses LHHS – licensed home health services LCHHS – licensed and certified home health services PAS – Personal assistance services PM – post meridiem RN – Registered nurse

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included all required elements in three of three records reviewed (Patient 1, 2 and 3) in that: In two of three records reviewed (Patient 1 and 2) the plan of cares did not include the frequency and duration of nursing visits to be made, a description of the patient's risk for emergency department visits and hospital re-admission and all necessary interventions to address the underlying risk factors; patient and caregiver education and training to facilitate timely discharge; patient-specific interventions and education and measurable outcomes and goals identified by the agency and the patient. In three of three records reviewed (Patient 1, 2 and 3) the plan of cares did not include the rehabilitation potential. These failures placed patients at risk of harm from agency staff who could not address the patients' risk factors and type of services needed for appropriate care, placing patients at risk of declining health status and the need for hospitalizations and long term care facility placement. Findings include: Patient 1: Record review of the medical record included a plan of care dated 03/20/2021 to 04/15/2021 signed by RN A on 03/15/2021. The plan of care did not include the nursing frequency and duration of visits to be made; a description of the patient's risk for emergency department visits and hospital re-admission and all necessary interventions to address the underlying risk factors; patient and caregiver education and training to facilitate timely discharge; patient-specific interventions and education and measurable outcomes and goals identified by the agency and the patient and the rehabilitation potential. Patient 2: Record review of the medical record included a plan of care dated 04/10/2021 to 06/08/2021 signed by RN A on 04/05/2021. The plan of care did not include the nursing frequency and duration of visits to be made; a description of the patient's risk for emergency department visits and hospital re-admission and all necessary interventions to address the underlying risk factors; patient and caregiver education and training to facilitate timely discharge; patient-specific interventions and education and measurable outcomes and goals identified by the agency and the patient and the rehabilitation potential. Patient 3: Record review of the medical record included a plan of care dated 02/04/2021 to 04/04/2021 signed by RN B on 03/15/2021. The plan of care did not include the rehabilitation potential. Administrator A stated during an interview on 04/03/2024 at 1:45 PM: The DON was not available for an interview but the ADON was available. The ADON stated during an interview on 04/04/2024 at 12:42 PM: She was appointed the ADON in 2020. It had been a while since the agency provided services for Patient 1, 2 and 3 and she did not remember why the missing information was not included on the plan of cares. The nurse that completed the visit was responsible for completing the plan of care for the patients. The DON or ADON was responsible for ensuring the plan of cares included all the required elements. The DON was responsible for following the agency’s policy regarding the plan of cares; if the DON was not available, the ADON was responsible. RN A and RN B were former agency employees and were not interviewed. Agency policy titled, “Plan of Care TX.6” with a revision date of 04/17/2006 read in part, “… POLICY Agency will utilize data/information gathered during patient assessments in the care planning process which involves the identification of patient goals, actions or interventions that will resolve or alleviate the patient’s problems and/or needs… The patient/caregiver, as well as the patient’s physician, will be encouraged to participate in the patient’s care planning process to determine mutually agreed upon goals… Procedure 1. The appropriate licensed professional staff member, with physician participation, is responsible for developing the plan of care... 3. The 485 [plan of care], which includes the following plan of care elements, is developed in consultation with staff, client, physician and other providers involved in the client’s care and will serve as the initial plan of care: goals/outcomes… frequency and duration of visits… discharge plan… rehabilitation potential…” Agency policy titled, “Responsibilities of the Director of Home Health Services LD.7” with a revision date of 09/21/2004 read in part, “…PURPOSE To define the responsibilities of the Director of Home Health Services to ensure safe, appropriate delivery of patient care… DEFINITION Supervising Nurse is the responsible registered nurse for supervising skilled services provided by the agency… This person may also be known as the Director of Nurses, Director of Home Health Services or a similar title… POLICY Director of Home Health Services… is responsible for the daily direction of patient care and participates in activities relevant to professional services furnished… PROCEDURE 1. Agency defines the responsibilities of the Director of Home Health Services to include but not be limited to… 1.3 Collaborating on development and implementation of policies and procedures which guide and support the provision of care…”

Purpose of Visit: Recertification Survey Conducted entrance conference on 3/19/21 at 3:50 PM with agency administrator. Explained that the purpose of the visit was to complete a recertification survey. Provided What to Expect letter and list of requested documents. Provided opportunity to ask questions. Entrance: 3/19/21 Exit: 3/24/21 Census: L&C: 4 LHH: 0 PAS: 3 Conducted exit conference on 3/24/21 at 4:30 PM with administrator and alternate administrator. Presented and discussed preliminary findings. Provided HHSC letter, "How to Write an Acceptable Plan of Correction." The agency was in compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies.

Purpose of Visit: Recertification Survey Conducted entrance conference on 3/19/21 at 3:50 PM with agency administrator. Explained that the purpose of the visit was to complete a recertification survey. Provided What to Expect letter and list of requested documents. Provided opportunity to ask questions. Entrance: 3/19/21 Exit: 3/24/21 Census: L&C: 4 LHH: 0 PAS: 3 Conducted exit conference on 3/24/21 at 4:30 PM with administrator and alternate administrator. Presented and discussed preliminary findings. Provided HHSC letter, "How to Write an Acceptable Plan of Correction." Definitions: PT: physical therapy SN: skilled nursing OT: occupational therapy L&C: Licensed and Certified Home Health LHH: Licensed Home Health PAS: Personal Attendant Services

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure that each patient received the home health services as written in an individualized plan of care, for 4 of 7 patients receiving Licensed and Certified Home Health Services (Patients #3, #4, #8, and #10). This failure could have placed agency clients at risk for a decline in health status. The findings included: Patient #3 Review of records for Patient #3 found the patient was admitted on 1/19/21. Review of the plan of care (dated 1/19/21-3/19/21) read in part, "Physical therapy to assess functional status, home environment to eliminate structural barriers and improve safety and functional independence ... PT to establish a home exercise program and plan of care as approved by physician." Review of patient chart found no physical therapy notes. In an interview with administrator (Employee A) on 3/22/21 at 1:15 PM, when asked when physical therapy assessed Patient #3, administrator (Employee A) replied, "I'm sure it's documented somewhere. I can print it out for you." As of exit on 3/24/21, the agency had not provided documentation that physical therapy had visited Patient #3. Patient #4 Review of records for Patient #4, found that the patient was admitted on 1/30/21. Review of the plan of care (dated 1/30/21-3/30/21) read in part, "Physical therapy to assess functional status, home environment to eliminate structural barriers and improve safety and functional independence ... PT to establish a home exercise program and plan of care as approved by physician." Review of patient chart found no physical therapy notes. In an interview with administrator (Employee A) on 3/22/21 at 1:15 PM, when asked when physical therapy assessed Patient #4, administrator (Employee A) replied, "I'm sure it's documented somewhere. I can print it out for you." As of exit on 3/24/21, the agency had not provided documentation that physical therapy had visited Patient #4. Patient #8 Review of records for Patient #8, found that the patient was admitted on 1/6/21. Review of the plan of care (dated 1/6/21-3/6/21) read in part, "SN Frequency: 1wk9 once a week [e.g. Skilled Nursing once a week for 9 weeks] ... PT Frequency: 1wk1 [e.g. once per week for one week]" Review of Physical Therapy Start of Care Note (signed by patient's physician) dated 1/07/21 read in part "PT Frequency: PT 2 wk 4" [e.g physical therapy twice a week for four weeks]. Review of Physical Therapy (PT) notes: Week 1 (1/06/21-1/09/21) Physical Therapy Start of Care Note dated 1/07/21 Week 2 (1/10/21-1/16/21) Physical Therapy Note dated 1/12/21 Weeks 3-9 (1/17/21-3/6/21) No PT visit notes, and no documented discharge from PT services. Review of nursing notes found: Week 1 (1/6/21-1/9/21) Start of Care Nurse Note dated 1/6/21. Week 2 (1/10/21-1/16/21) No Nurse Notes, no missed visit notes. Week 3 (1/17/21-1/23/21) A missed nursing visit dated 1/22/21. Patient had requested that the nurse not come. Weeks 4-8 (1/24/21-2/27/21) No Nurse Notes, no missed visit notes. Week 9 (2/28/21-3/06/21) Nurse Discharge Note dated 3/03/21. In an interview with Administrator (Employee A) on 3/23/21 at 1:00 PM, when asked about missing nursing and physical therapy documentation, administrator (Employee A) said, "Those were missed visits. The client was unavailable to meet with nurses." Requested missed visit notes. As of exit on 3/24/21, agency was unable to provide missed visit notes for PT and nursing missed visits. Patient #10 Review of records for Patient #10 found the patient was admitted on 8/12/20. Review of the plan of care (dated 12/11/20-2/1/21) read in part, "SN Frequency: 1w9" [e.g. once per week for 9 weeks]. PT and OT visit notes were found in the patient's chart, but no orders for visits nor updated plans of care were found in the patient's chart. Review of nursing notes found: Week 1 (12/11/20-12/12/20) No Nurse Notes found, no missed visit notes found. Week 2 (12/13/20-12/19/20) Nurse Note dated 12/15/20. Week 3 (12/20/20-12/26/20) Nurse Note dated 12/22/20. Weeks 4-8 (12/27/20-1/30/21) No Nurse Notes, no missed visit notes found. Week 9 (1/31/21-2/01/21) Nurse Discharge Note dated 2/1/21. Review of physical therapy notes found: Week 1 (12/11/20-12/12/20) No physical therapy notes found, no missed visit notes found. Week 2 (12/13/20-12/19/20) Physical therapy assistant note dated 12/15/20 Week 3 (12/20/20-12/26/20) Physical therapy assistant note dated 12/22/20. Week 4 (12/27/20-1/2/21) Physical therapy assistant note dated 12/29/20. Week 5 (1/3/21-1/9/21) Physical therapy assistant note dated 1/05/21. Weeks 6-9 (12/27/20-2/01/21) No physical therapy notes, no missed visit notes, no physical therapy discharge notes found. Review of occupational therapy notes found: Week 1 (12/11/20-12/12/20) No occupational therapy notes found, no missed visit notes found. Week 2 (12/13/20-12/19/20) Occupational therapy evaluation dated 1/16/21. Weeks 3-4 (12/20/20-1/2/21) No occupational therapy notes found, no missed visit notes found. Week 5 (1/3/21-1/9/21) Occupational therapy discharge note dated 1/8/21 Weeks 6-9 (12/27/20-2/01/21) No occupational therapy notes found. In an interview with Administrator (Employee A) on 3/23/21 at 1:00 PM, when asked about missing nursing and physical therapy documentation, Administrator (Employee A) said, "Those were missed visits. The client was unavailable to meet with nurses." Requested missed visit notes. As of exit on 3/24/21, agency was unable to provide missed visit notes for PT and nursing missed visits. Review of agency policy (dated 5/01/19) titled, "Monitoring Patient Care/Coordination of Care) read in part, "The Agency will ... Integrate services, whether services are provided directly or under arrangement, to ensure the identification of patient/client needs and factors that could affect patient/client safety and treatment effectiveness and the coordination of care provided by all disciplines."

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on interview, observation, and record review, the administrator failed to be responsible for all day-to-day operations of the home health agency, in that: A. The agency failed to ensure that each patient received the home health services as written in an individualized plan of care, for 4 of 7 patients receiving Licensed and Certified Home Health Services (Patients #3, #4, #8, and #10). AND B. The Administrator failed to ensure the agency had a written agreement with another agency to furnish nursing and therapy services under arrangement to the agency's patients. This failure resulted in agency patients missing needed services and placed them at risk of health status decline. The findings included: A. Patient #3 Review of records for Patient #3 found the patient was admitted on 1/19/21. Review of the plan of care (dated 1/19/21-3/19/21) read in part, "Physical therapy to assess functional status, home environment to eliminate structural barriers and improve safety and functional independence ... PT to establish a home exercise program and plan of care as approved by physician." Review of patient chart found no physical therapy notes. In an interview with administrator (Employee A) on 3/22/21 at 1:15 PM, when asked when physical therapy assessed Patient #3, administrator (Employee A) replied, "I'm sure it's documented somewhere. I can print it out for you." As of exit on 3/24/21, the agency had not provided documentation that physical therapy had visited Patient #3. Patient #4 Review of records for Patient #4, found that the patient was admitted on 1/30/21. Review of the plan of care (dated 1/30/21-3/30/21) read in part, "Physical therapy to assess functional status, home environment to eliminate structural barriers and improve safety and functional independence ... PT to establish a home exercise program and plan of care as approved by physician." Review of patient chart found no physical therapy notes. In an interview with administrator (Employee A) on 3/22/21 at 1:15 PM, when asked when physical therapy assessed Patient #4, administrator (Employee A) replied, "I'm sure it's documented somewhere. I can print it out for you." As of exit on 3/24/21, the agency had not provided documentation that physical therapy had visited Patient #4. Patient #8 Review of records for Patient #8, found that the patient was admitted on 1/6/21. Review of the plan of care (dated 1/6/21-3/6/21) read in part, "SN Frequency: 1wk9 once a week [e.g. Skilled Nursing once a week for 9 weeks] ... PT Frequency: 1wk1 [e.g. once per week for one week]" Review of Physical Therapy Start of Care Note (signed by patient's physician) dated 1/07/21 read in part "PT Frequency: PT 2 wk 4" [e.g physical therapy twice a week for four weeks]. Review of Physical Therapy (PT) notes: Week 1 (1/06/21-1/09/21) Physical Therapy Start of Care Note dated 1/07/21 Week 2 (1/10/21-1/16/21) Physical Therapy Note dated 1/12/21 Weeks 3-9 (1/17/21-3/6/21) No PT visit notes, and no documented discharge from PT services. Review of nursing notes found: Week 1 (1/6/21-1/9/21) Start of Care Nurse Note dated 1/6/21. Week 2 (1/10/21-1/16/21) No Nurse Notes, no missed visit notes. Week 3 (1/17/21-1/23/21) A missed nursing visit dated 1/22/21. Patient had requested that the nurse not come. Weeks 4-8 (1/24/21-2/27/21) No Nurse Notes, no missed visit notes. Week 9 (2/28/21-3/06/21) Nurse Discharge Note dated 3/03/21. In an interview with Administrator (Employee A) on 3/23/21 at 1:00 PM, when asked about missing nursing and physical therapy documentation, administrator (Employee A) said, "Those were missed visits. The client was unavailable to meet with nurses." Requested missed visit notes. As of exit on 3/24/21, agency was unable to provide missed visit notes for PT and nursing missed visits. Patient #10 Review of records for Patient #10 found the patient was admitted on 8/12/20. Review of the plan of care (dated 12/11/20-2/1/21) read in part, "SN Frequency: 1w9" [e.g. once per week for 9 weeks]. PT and OT visit notes were found in the patient's chart, but no orders for visits nor updated plans of care were found in the patient's chart. Review of nursing notes found: Week 1 (12/11/20-12/12/20) No Nurse Notes found, no missed visit notes found. Week 2 (12/13/20-12/19/20) Nurse Note dated 12/15/20. Week 3 (12/20/20-12/26/20) Nurse Note dated 12/22/20. Weeks 4-8 (12/27/20-1/30/21) No Nurse Notes, no missed visit notes found. Week 9 (1/31/21-2/01/21) Nurse Discharge Note dated 2/1/21. Review of physical therapy notes found: Week 1 (12/11/20-12/12/20) No physical therapy notes found, no missed visit notes found. Week 2 (12/13/20-12/19/20) Physical therapy assistant note dated 12/15/20 Week 3 (12/20/20-12/26/20) Physical therapy assistant note dated 12/22/20. Week 4 (12/27/20-1/2/21) Physical therapy assistant note dated 12/29/20. Week 5 (1/3/21-1/9/21) Physical therapy assistant note dated 1/05/21. Weeks 6-9 (12/27/20-2/01/21) No physical therapy notes, no missed visit notes, no physical therapy discharge notes found. Review of occupational therapy notes found: Week 1 (12/11/20-12/12/20) No occupational therapy notes found, no missed visit notes found. Week 2 (12/13/20-12/19/20) Occupational therapy evaluation dated 1/16/21. Weeks 3-4 (12/20/20-1/2/21) No occupational therapy notes found, no missed visit notes found. Week 5 (1/3/21-1/9/21) Occupational therapy discharge note dated 1/8/21 Weeks 6-9 (12/27/20-2/01/21) No occupational therapy notes found. In an interview with Administrator (Employee A) on 3/23/21 at 1:00 PM, when asked about missing nursing and physical therapy documentation, Administrator (Employee A) said, "Those were missed visits. The client was unavailable to meet with nurses." Requested missed visit notes. As of exit on 3/24/21, agency was unable to provide missed visit notes for PT and nursing missed visits. Review of agency policy (dated 5/01/19) titled, "Monitoring Patient Care/Coordination of Care) read in part, "The Agency will ... Integrate services, whether services are provided directly or under arrangement, to ensure the identification of patient/client needs and factors that could affect patient/client safety and treatment effectiveness and the coordination of care provided by all disciplines." B. In an interview with administrator (Employee A) on 3/19/21 at 3:50 PM, when asked if agency provided physical therapy and occupational therapy services, administrator (Employee A) said, "They're provided by contract." Requested to review the contract between therapy company and agency. In an interview with administrator on 3/22/21 at 4:30 PM, reminded administrator that surveyor had still not seen the contract between the agency and the company providing physical therapy and occupational therapy services. Administrator (Employee A) said, "I will get that for you." In an interview with alternate administrator (Employee B) on 3/24/21 at 1:10 PM, when asked about personnel files, alternate administrator (Employee B) stated, "Some of our nursing staff are provided through a staffing company." Requested to review the contract between the agency and the nursing staffing company. At exit on 3/24/21 at 4:30 PM, informed the agency that they had not provided the contracts for the therapy company and the nursing staffing agency. Agency administrators (Employees A and B agreed to provide these contracts by email before 3/26/21 at 5:00 PM. As of 3/26/21 at 5:00 PM, the agency had not provided any documentation that the agency had a current contract to provide nursing services or physical/occupational therapy services by arrangement. Review of agency policy (dated 1/13/18) titled, "Responsibilities of the Administrator" read in part, "The Agency Administrator will assume overall responsibility and authority for the day to day operations of the Agency, including administrative and leadership functions, supervision of the established organizational plan and responsibility for the entire Agency staff." Review of agency policy (dated 5/01/19) titled, "Monitoring Patient Care/Coordination of Care) read in part, "The Agency will ... Integrate services, whether services are provided directly or under arrangement, to ensure the identification of patient/client needs and factors that could affect patient/client safety and treatment effectiveness and the coordination of care provided by all disciplines."

Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA's patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to have a written agreement with another agency to furnish nursing and therapy services under arrangement to the agency's patients. This failure placed agency patients at risk of receiving services without the supervision and oversight from the agency. The findings included: In an interview with administrator (Employee A) on 3/19/21 at 3:50 PM, when asked if agency provided physical therapy and occupational therapy services, administrator (Employee A) said, "They're provided by contract." Requested to review the contract between therapy company and agency. In an interview with administrator on 3/22/21 at 4:30 PM, reminded administrator that surveyor had still not seen the contract between the agency and the company providing physical therapy and occupational therapy services. Administrator (Employee A) said, "I will get that for you." In an interview with alternate administrator (Employee B) on 3/24/21 at 1:10 PM, when asked about personnel files, alternate administrator (Employee B) stated, "Some of our nursing staff are provided through a staffing company." Requested to review the contract between the agency and the nursing staffing company. At exit on 3/24/21 at 4:30 PM, informed the agency that they had not provided the contracts for the therapy company and the nursing staffing agency. Stated that the agency could provide these by email before 3/26/21 at 5:00 PM. Agency administrators (Employees A and B) agreed to this. As of 3/26/21 at 5:00 PM, the agency had not provided any documentation that the agency had a current contract to provide nursing services or physical/occupational therapy services by arrangement.