Every finding on record at Efe Healthcare Services Inc

Purpose: A recertification/ re-licensure survey was entered on 2/5/2025 with the Administrator and the Office Manager. Census: L&CHHS: 11 The Agency was in compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Services.

Purpose: A recertification/ re-licensure survey was entered on 2/5/2025 with the Administrator and the Office Manager. Census: L&CHHS: 11 Abbreviations: AA- Administrative Assistant ADM- Administrator CMS- Centers for Medicare & Medicaid Standards DON- Director of Nurses OASIS- Outcome and Assessment Information Set OM- Office Manager

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to transmit OASIS data for each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the beneficiary for 91 of 91 OASIS assessments submitted from 01/01/24 to 02/05/25. Failure of the agency to transmit OASIS data within the required time frame prevented the agency’s patient data from being made available to CMS for analysis to evaluate the agency performance levels in the provision of patient care. Findings The surveyor reviewed the OASIS Error Detail Report for the agency in the IQIES portal on 02/05/2025, as part of the preparation for the survey. The report documented 91 late assessments transmitted from 01/01/2024 to 02/05/2025 were submitted more than 30 days after the M0090 (the date of completion of the assessment.) During the entrance conference on 02/05/2025 at 11:30 AM with the Administrator and Office Manager, the surveyor noted the late submissions found during survey preparation and asked for OASIS final validation reports from 01/01/2024 to 01/01/25. The surveyor reviewed the OASIS Agency Final Validation (01/25/24 to 01/25/25) reports provided by the agency which documented the late OASIS submissions with the comment “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” In a phone interview 2/7/2025 at 2:30 pm with the DON/ Alternate Administrator, the surveyor asked about the process for OASIS. The DON stated, “after the initial assessment I review it and lock it. The AA does the transmission. We have 30 days to transmit it.” Surveyor asked if there were any reasons the OASIS might be submitted late. The DON stated, “sometimes if there’s a change in the doctor and we didn’t find out about on time that might delay the transmission. On average it’s g072 hours to see the patient, do the OASIS, and lock the OASIS,” An interview was conducted with the Administrator (ADM), Office Manager (OM), and the Administrative Assistant (AA) on 2/7/2025 at 3:30 pm. The surveyor reviewed the late transmissions of OASIS assessments with the ADM, OM, and AA. The surveyor asked who was responsible for transmitting the assessments. The Administrator stated the Administrative Assistant did the transmissions, and transmitted as soon as an OASIS was completed. The Surveyor asked what reasons might cause late transmissions. The Administrator stated, “human error.” The agency had a policy titled: “8.10 Timelines” revised dated 012910. The policy read in part: POLICY -Agency will ensure timely provision of service and services to meet the client's needs in compliance with all federal and state laws and regulations. Agency will also establish timely parameters for all client record information. All Agency staff, and physician/physician office staff as appropriate, will be oriented to the following parameters: … Encoding and locking OASIS data for the state within seven (7) days of the completion of the Comprehensive Assessment. Completed, encoded and locked OASIS data will be transmitted with thirty (30) days of the M0090 date…”

Purpose of visit: Recertification survey Entrance Date: 2/15/2022 at 12:00 noon with the Administrator. Agency Census: 82 Licensed and Certified Home Health - 9 Licensed Home Health - 0 Personal Assistance Services - 73 Exit Date: 2/22/2022 at 5:15 PM with the Administrator, DON, and the Office Manager. 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.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview the agency's written emergency preparedness and response plan failed to include a continuity of operations business plan that addresses emergency financial needs, essential functions for client services, critical personnel, and how to return to normal operations as quickly as possible for 4 of 4 years reviewed (2019, 2020, 2021 and currently for 2022). This failure meant the agency may not be able to provide safe and appropriate care to clients and directions to staff during emergencies, and the agency may not be able to return to normal operations as quickly as possible. The surveyor requested Emergency Preparedness plan and documents for the last three (2019, 2020, and 2021) during the entrance conference on 02/15/2022 at noon. The surveyor reviewed the binder titled: Emergency Preparedness provided by the agency on 02/22/2022. The binder contained an 8 page form titled: “Continuity of Operations Business Plan” that was blank. A review of the entire binder and documents provided by the agency failed to find a completed continuity of operations plan. An interview was conducted with the Administrator on 02/22/2022 at approximately 4:00 PM. The surveyor asked who the Disaster Coordinator was for the agency. The Administrator stated: “I am.” The surveyor reviewed the findings of the review of the Emergency Preparedness documents provided by the agency. The Administrator reviewed the Emergency Preparedness binder and stated: he “Usually has (the) consultant do this. I can’t find it (a completed continuity of operations business plan).” The surveyor asked about the outcome of the failure to maintain a completed continuity of operations plan. The Administrator stated: “I have given you what I have." No additional information was provided to answer the question about the outcome of the failure to develop the required emergency preparedness documents by the end of the survey. Agency policy review revealed a policy titled: “Emergency Preparedness and Response Plan EC.8” dated 08/01/2011 which read in part: To ensure Agency develops, maintains, and implements a written Emergency Preparedness Plan (Plan), based on the Agency’s risk assessment. To establish a plan of action for providing continuous patient care and continuous business operations in the event of a disaster. To ensure compliance with “Emergency Preparedness Planning and Implementations,” Licensing Standards for Home and Community Support Services Agencies, Subsection 97.256…Agency’s written Emergency Preparedness and Response Plan will include:…A Continuity of Operations Business Plan to address emergency financial needs, essential functions for patient services, critical personnel, and how to return to normal operations as quickly as possible…”

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on record review and interview the agency's written emergency preparedness plan failed to include facility based and community-based risk assessments and failed to address the COVID-19 pandemic for 4 of 4 years reviewed (2019, 2020, 2021 and currently for 2022). The outcome was the agency patients and staff were at risk during an emergency because the agency had not documented a risk assessment and actions for the specific risks that were likely to occur in the agency’s service area. The surveyor requested Emergency Preparedness plan and documents for the last four years (2019, 2020, 2021, and currently for 2022) during the entrance conference on 02/15/2022 at noon. The surveyor reviewed the binder titled: Emergency Preparedness provided by the agency on 02/22/2022. The binder contained a one- page blank form titled: “Analysis of Risk Assessment for Potential Disasters.” A review of the entire binder and documents provided by the agency failed to find a completed risk assessment. An interview was conducted with the Administrator on 02/22/2022 at approximately 4:00 PM. The surveyor reviewed the findings of the review of the Emergency Preparedness documents provided by the agency. The surveyor asked who the Disaster Coordinator was for the agency. The Administrator stated: “I am.” The surveyor asked about the blank Risk Assessment document. The Administrator reviewed the Emergency Preparedness binder provided to the surveyor. The Administrator stated: he “Usually has (the) consultant do this. I can’t find it (a completed risk assessment). The surveyor asked about the outcome of the failure to develop and maintain a risk assessment including COVID-19 information. The Administrator stated: “I have given you what I have.” No additional information was provided to answer the question about the outcome of the failure to develop the required emergency preparedness documents by the end of the survey. Agency policy review revealed a policy titled: “Emergency Preparedness and Response Plan EC.8” dated 08/01/2011 which read in part: To ensure Agency develops, maintains, and implements a written Emergency Preparedness Plan (Plan), based on the Agency’s risk assessment. To establish a plan of action for providing continuous patient care and continuous business operations in the event of a disaster… The written plan will be based on a risk assessment that identifies the disasters from natural and man-made causes that are likely to occur in Agency’s service area…”

Purpose of visit: Recertification survey Entrance Date: 2/15/2022 at 12:00 noon with the Administrator. Agency Census: 82 Licensed and Certified Home Health - 9 Licensed Home Health - 0 Personal Assistance Services - 73 Exit Date: 2/22/2022 at 5:15 PM with the Administrator, DON, and the Office Manager. 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: DON- Director of Nurses PAS - Personal Assistance Services EPP – Emergency Preparedness Plan BPH- Benign Prostatic Hyperplasia

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to provide 3 (Patients 1, 2, and 3) of 3 patients, whose home folders were reviewed during home visits, with the names, addresses, and telephone numbers of the following Federally - funded and state-funded entities that served the area the 3 patients resided in: Agency on Aging Center for Independent Living Protection and Advocacy Agency, and Aging and Disability Resource Center. This failure prevented the agency patients from accessing and obtaining community services that were not provided by the agency. Patient 3, who was being evicted from her home with very short notice, needed resources for housing. On 02/15/2022 during the entrance conference at noon, the surveyor requested a sample admission packet the agency would use for new patient admissions. The surveyor reviewed the sample admission folder provided by the Administrator on 02/15/2022 at 4 PM. The home folder portion of the admission folder contained a form titled: “Other Sources of Information” which documented the following resource information: the FEMA number and website, Red Cross website and no telephone number, Department of Aging and Disability (the previous name for Health and Human Services Commission) website and no telephone number, Texas Evacuation Routes website and no telephone number, Assistance with evacuation - 211 and website, and blank areas for Local Department of Social Services with no websites or phone numbers. Review of all the documents in the sample admission packet revealed no names, addresses and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. Record review for Patient 1 revealed a POC dated 11/03/2021 to 01/01/2022 and a POC dated 01/02/2022 to 03/02/2022. The POC listed orders for a skilled nursing visits one time per week for nine weeks and two visits as needed for disease exacerbation. Record review for Patient 2 revealed a POC dated 12/18/2021 to 02/15/2022. The POC listed orders for a skilled nursing visits one time per week for nine weeks and two visits as needed for disease exacerbation. During a home visit to the residence of Patient 1 and Patient 2 on 2/18/2022 at approximately 11 AM, the surveyor reviewed the home folders provided by the agency to Patient 1 and Patient 2. The home folders contained a form titled: “Other Sources of Information” which documented the FEMA number and website, Red Cross website and no telephone number, Department of Aging and Disability (the previous name for Health and Human Services Commission) website and no telephone number, Texas Evacuation Routes website and no telephone number, Assistance with evacuation -211 and website, and blank areas for Local Department of Social Services with no websites or phone numbers. Review of all the documents in the home folders revealed no names, addresses and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. An interview was conducted with Patient 1 during the home visit on 2/18/2022. The surveyor asked if any documents had been removed from the home folder. Patient 1 stated “no.” Patient 1 stated the agency had brought new folders for Patient 1 and Patient 2 the day before the home visit by the surveyor. The surveyor asked if Patient 1 was aware of how to contact the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. Patient 1 stated she was not aware of how to contact those resources. A telephone interview was conducted with Patient 2 on 02/18/2022 at 1:47 PM. The surveyor asked if any documents had been removed from the home folder. Patient 2 stated “no.” The surveyor asked if Patient 2 was aware of how to contact the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. Patient 2 stated he was not aware of how to contact those resources. Record review for Patient 3 revealed a POC dated 12/17/2021 to 02/14/2022. The POC listed orders for skilled nursing visits one time per week for nine weeks. During a home visit with Patient 3 on 2/18/2022 at approximately 12:00 PM, the surveyor reviewed the home folder provided by the agency to Patient 3. The surveyor asked if any documents had been removed from the home folder. Patient 1 stated “no.” The home folders contained a form titled: “Other Sources of Information” which documented the FEMA number and website, Red Cross website and no telephone number, Department of Aging and Disability (the previous name for Health and Human Services Commission) website and no telephone number, Texas Evacuation Routes website and no telephone number, Assistance with evacuation -211 and website, and blank areas for Local Department of Social Services with no websites or phone numbers. Review of all the documents in the home folder revealed no names, addresses and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. The surveyor asked if Patient 3 was aware of how to contact the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. Patient 3 stated she was not aware of how to contact those resources. Patient 3 stated she was being evicted from her home with very short notice, that she could not go out to look for a new place to live due to her heart condition, and she needed resources for housing. An interview was conducted with the DON on 2/18/22 at 3:45 PM. The surveyor shared the findings of the sample home folder review, patient home visit folder reviews and interviews. The surveyor noted the sample and home folders did not contain the names, addresses, and telephone numbers of the Federally funded and state-funded entities that served the areas the patients resided in. The DON stated: “We will look at that.” The surveyor asked what the outcome of the failure was for the agency patients. The DON stated: “That is not going to be nice.” No additional documents or statements were provided to explain or correct the findings were provided by the end of the survey. An interview was conducted with the Administrator on 02/22/2022 at 3:54 PM. The surveyor shared the findings of the sample home folder review, patient home visit folder reviews and interviews. The Administrator reviewed the sample home folder that contained a form titled: “Other Sources of Information” document and stated: “This one is not enough?” The surveyor noted the sample and home folders did not contain the names, addresses, and telephone numbers of the Federally funded and state-funded entities that served the areas the patients resided in. The Administrator stated: “We thought this was it.” The surveyor asked what the outcome was for the agency patients of the failure to provide the resource information. The Administrator stated: “We can get it before we go. Usually, they call us for information, and we are going to get it.” No additional information to correct or clarify the findings was provided by the end of the survey including how this non-compliance might affect the patient’s care. A review of the Agency policy and procedures on 02/22/2022 at approximately 3:00 PM revealed no policy and procedures directing agency staff to provide the required the names, addresses, and telephone numbers of the following Federally - funded and state-funded entities that served the areas the agency patients resided in: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center.

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 record review and interview, the agency failed to ensure that patients received home health services as ordered in the individualized POC for three of seven patient records reviewed (Patient 3, 4 and 5). Weights were not conducted as ordered for Patients #3 and #4. Patient #5’s out-of-range blood pressure was not reported to the physician as ordered. These failures placed the patients at risk of not receiving life sustaining interventions when needed to prevent complications, and a decline in the patients’ health status. Record review for Patient 3 revealed a POC dated 12/17/2021 to 02/14/2022 with a start of care date of 04/21/2021. The POC listed diagnoses of Bilateral Osteoarthritis of Knee, Hypertensive Heart Disease with Heart Failure, Asthma, Hyperlipidemia, Chronic Pain, Presence of Heart Assist device, Abnormalities of Gait and Mobility, Mild Cognitive Impairment, Gastro-Esophageal Reflux Disease, and Long-Term Use of Anticoagulants. The POC listed orders for skilled nursing visits one time per week for nine weeks. The POC included an order for the “SN to weigh patient every visit and report weight gain or loss of 5 lbs. in one week.” Record review revealed nurses notes dates 12/29/2021, 01/05/2022, 01/12/2022, 01/18/2022, 01/26/2022, and 02/02/2022 signed by the LVN which contained no weights for the patient. An interview was conducted with the DON on 02/18/2022 at 4:26 PM. The surveyor reviewed the findings of the clinical record review and home visit and asked about the LVN not recording weights on weekly visits. The DON stated: “I will have to speak with the nurse. Every patient with CHF has to be weighed.” The surveyor asked the DON what the outcome of the failure was for the patient. The DON stated: “I know we have to report weight gain. If the patient is not weighed, we can’t report it (to the doctor ).” Record review for Patient 4 revealed a POC dated 12/01/2021 to 1/29/2022 with a start of care date of 02/10/2020. The POC listed diagnoses of Bilateral Osteoarthritis of Knee, Heart Failure, Overactive Bladder, Chronic Obstructive Pulmonary Disease, Vitamin D Deficiency, Nicotine Dependence, Hypertension, Insomnia, Abnormalities of Gait and Mobility, Gastro-Esophageal Reflux Disease, History of Falling, Amnesia, Disorders of Teeth and Supporting Structures, Long-Term Drug Therapy, Hypercalcemia, and Hypersomnia. The POC listed orders for skilled nursing visits one time per week for nine weeks. The POC included an order for “SN to notify Physician of weight gain or loss or 5 lbs. in one week.” Record review revealed nurses notes dates 12/07/2021, 12/14/2022, 12/28/2022, 01/04/2022, 01/11/2022, and 01/18/2022 signed by the LVN which contained no weights for the patient. The surveyor attempted to interview the LVN on 02/18/2022 and was unable to reach the nurse. An interview was conducted with the DON on 02/18/2022 at 4:00 PM. The surveyor reviewed the findings of the clinical record review and asked about the LVN was not recording weights on weekly visits. The DON stated: “I returned the notes to her (the LVN) to document weights.” The surveyor asked the DON what the outcome of the failure was for the patient. The DON stated: “If the patient complies with the medications, diet, walking three times per week, and curtailing her smoking the outcome will be better.” Record review for Patient 5 revealed a POC dated 06/14/2021 to 08/12/2021 with a start of care date of 06/14/2021. The POC listed diagnoses of Hypertensive Heart Disease with Heart Failure, Chronic Obstructive Pulmonary Disease, Hyperlipidemia, Dyspnea, Benign Prostatic Hyperplasia, Chronic Kidney Disease, and Dependence on Supplemental Oxygen. The POC listed orders for skilled nursing twice a week for two weeks, one time per week for seven weeks. The POC contained orders for the nurse to “notify physician of …Systolic BP greater than 140 or less than 80.” Record review revealed nurses’ notes dated: 06/28/2021 with a BP of 146/80, 07/05/2021 with a BP of 148/88, no visit for the week of 07/04/2021, 07/15/2021 with a BP of 144/80, 07/20/2021 with a BP of 148/89, 07/28/2021 with a BP of 144/70, and 08/02/2021 with a BP of 150/82 which were signed by the Supervising Nurse. Each note was marked with an X beside “No MD contact”. A review of the entire record found no evidence of notification of the out of parameter blood pressures to the physician as ordered on the POC. An interview was conducted with the DON on 02/18/2022 at 4:10 PM. The surveyor reviewed the findings of the clinical record review and asked why the high blood pressures were not reported to the physician. The DON stated: “We usually have 160/100 for the blood pressure.” The surveyor asked what patient 5’s risks were for rehospitalization. The DON stated: “increased blood pressure, and exacerbation of his COPD.” The surveyor asked about the outcome for the patient. The DON stated that Patient 5 had increased shortness of breath, went to the ER, was admitted to the hospital on 08/21/2021 and passed away shorty after being admitted to the ER. Review of the agency policy titled: “Orders for Care TX.5” with a revision date of 100113 read in part: “To ensure patient care is provided in accordance with physician’s orders and federal and state laws and regulations. Policy-Agency will obtain orders and provide care in accordance with physician’s orders which are established prior to initiating patient care and reviewed/revised by the physician every 60 days as needed…”

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: THIS IS A CONTINUING DEFICIENCY CITED DURING THE SURVEY DATED 03/06/2019. Based on record review and interview, the agency failed to ensure the patients' plans of care were as complete and included all the required elements including 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 for 6 patients (1,2,3,4,5, and 6) of 7 records reviewed. This failure may have contributed to the hospitalization of Patients 1, 2 and 5. This has the potential to impact all agency patients. Record review for Patient 1 revealed a POC dated 11/03/2021 to 01/01/2022 and a POC dated 01/02/2022 to 03/02/2022. The POC dated 11/03/2021 listed diagnoses of Anemia, Hypertension, Hyperlipidemia, Type 2 Diabetes Mellitus, Major Depressive Disorder, and Atherosclerotic Heart Disease. The POC listed orders for a skilled nursing visits one time per week for nine weeks and two visits as needed for disease exacerbation. The POC did not contain a description of the patient's specific risks for emergency department visits and hospital re-admissions and all necessary interventions to address the underlying risk factors. Record review for Patient 2 revealed a POC dated 12/18/2021 to 02/15/2022. The POC listed diagnoses of Hypertension, Seizures, Osteoarthritis, Type 2 Diabetes Mellitus. The POC listed orders for a skilled nursing visits one time per week for nine weeks and two visits as needed for disease exacerbation. The record review included an OASIS transfer dated 11/12/21 and resumption of care OASIS dated 11/19/2021. The POC did not contain a description of the patient's specific risks for emergency department visits and hospital re-admissions and all necessary interventions to address the underlying risk factors. During a home visit to the residence of Patient 1 and Patient 2 on 2/18/2022 at approximately 11 AM, the surveyor reviewed the patient’s health issues and previous recent hospitalization with Patient 1. Patient 1 stated she was hospitalized for “fluid in my lungs in November” from an exacerbation of congestive heart failure. A telephone interview was conducted with Patient 2 on 02/18/2022 at 1:47 PM. The surveyor asked about any recent hospitalizations. Patient 2 stated he had “7 seizures in the past year” that required ER visits or hospitalization. Patient 2 stated he could not remember the specific dates. An interview was conducted with the DON on 02/18/2022 at 4:45 PM. The surveyor shared the findings from the clinical record reviews and home visits. The surveyor asked if the DON was also the RN who completed the patient assessments and provided the case management and supervision of the patients reviewed. The DON stated “Yes.” The surveyor asked what Patient 1’s risks were for rehospitalization. The DON stated that Patient 1 was recently hospitalized for Congestive heart failure, was at risk because blood sugar issues, and kidney stones. The surveyor asked what Patient 2’s risks were for rehospitalization. The DON stated that Patient 2 had seizures that caused him to fall and hypertension. Record review for Patient 3 revealed a POC dated 12/17/2021 to 02/14/2022. The POC listed diagnoses of Bilateral Osteoarthritis of Knee, Hypertensive Heart Disease with Heart Failure, Hyperlipidemia, Presence of Heart Assist device, The POC listed orders for skilled nursing visits one time per week for nine weeks. The POC did not contain a description of the patient's specific risks for emergency department visits and hospital re-admissions and all necessary interventions to address the underlying risk factors. During a home visit with Patient 3 on 2/18/2022 at approximately 12:00 PM, the surveyor reviewed the patient health issues and care provided by the agency. Patient 3 stated she had “heart troubles and congestive heart failure. An interview was conducted with the DON on 02/18/2022 at 4:26 PM. The surveyor reviewed the findings of the clinical record review and home visit and asked what Patient 3’s risks were for rehospitalization. The DON stated: “Pain, blood pressure, and bleeding.” The surveyor asked if the patient’s heart failure and heart assist device, could also be risks. The DON stated: “Yes.” Record review for Patient 4 revealed a POC dated 12/01/2021 to 1/29/2022. The POC listed diagnoses of Bilateral Osteoarthritis of Knee, Heart Failure, Overactive Bladder, Chronic Obstructive Pulmonary Disease, Vitamin D Deficiency, Nicotine Dependence, Hypertension, Insomnia, Abnormalities of Gait and Mobility, Gastro-Esophageal Reflux Disease, History of Falling, Amnesia, Disorders of Teeth and Supporting Structures, Long-Term Drug Therapy, Hypercalcemia, and Hypersomnia. The POC listed orders for skilled nursing visits one time per week for nine weeks. The POC did not contain a description of the patient's specific risks for emergency department visits and hospital re-admissions and all necessary interventions to address the underlying risk factors. An interview was conducted with the DON on 02/18/2022 at 4:00 PM. The surveyor reviewed the findings of the clinical record review and asked what Patient 4’s risks were for rehospitalization. The DON stated: “Blood Pressure is unstable, she does not take her medications regularly, and Pain.” The surveyor asked if fluid status changes and shortness of breath could also be risks for Patient 4. The DON stated: “Yes.” Record review for Patient 5 revealed a POC dated 08/13/2021 to 10/11/2021. The POC listed diagnoses of Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease with Heart Failure, Hyperlipidemia, Abnormalities of Gait and Mobility, Benign Prostatic Hyperplasia, Chronic Kidney Disease, and Dependence on Supplemental Oxygen. The POC listed orders for skilled nursing visits one time per week for nine weeks. The POC did not contain a description of the patient's specific risks for emergency department visits and hospital re-admissions and all necessary interventions to address the underlying risk factors. An interview was conducted with the DON on 02/18/2022 at 4:10 PM. The surveyor reviewed the findings of the clinical record review and asked what Patient 5’s risks were for rehospitalization. The DON stated: “increased blood pressure, and exacerbation of his COPD.” The surveyor asked about this patient’s admission to the hospital and subsequent death in August of 2021. The DON stated that Patient 5 had increased shortness of breath, went to the ER, was admitted to the hospital on 08/21/2021 and passed away shorty after being admitted to the ER. Record review for Patient 6 revealed a POC dated 12/27/2021 to 02/24/2022. The POC listed diagnoses of Hypertension, Hyperlipidemia, Abnormalities of Gait and Mobility, Bilateral Osteoarthritis of the Knee, Chronic Pain, and Benign Prostatic Hyperplasia. The POC listed orders for skilled nursing visits one time per week for nine weeks plus 2 as needed for disease exacerbation. The POC did not contain a description of the patient's specific risks for emergency department visits and hospital re-admissions and all necessary interventions to address the underlying risk factors. An interview was conducted with the DON on 02/18/2022 at 4:15 PM. The surveyor reviewed the findings of the clinical record review and asked what Patient 6’s risks were for rehospitalization. The DON stated: “blood pressure fluctuations and trouble urinating because of BPH .” The surveyor asked the DON about the outcome for the agency’s patients regarding the failure to identify the patients’ specific risks for Emergency Room and Hospital readmissions on the Plans of Care. The DON replied: “If we had specific reasons that would help us a lot to manage their care.” The DON stated the outcome for patients with specific risks not being on the POC is that it (The POC) does not show some things that are supposed to be there.” The DON did not dispute the findings of the clinical record reviews and did not provide additional documents or evidence to dispute the findings by the end of the survey. A review of the agency policy titled: “Plan of Care TX.6” with a revision date of 031604 read in part: “to ensure that care provided is appropriately planned in a timely manner to meet the patient’s specific needs and problems. 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 agency policy manual failed to contain a specific policy and procedures which require the Plan of care must contain a description of the patient's risk for emergency department visits and hospital re-admission, and hospital re-admission, and all necessary interventions to address the underlying risk factors.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to integrate services with all providers and to enforce their written policy regarding coordination of services to ensure the effective exchange of information, reporting, and coordination of services between the agency and the primary home care providers who were also providing care for the patients for 2 (2 and 3) of 3 patient records reviewed who also received home visits. The failure meant the agency failed to share information regarding the ongoing care, and changes in service needs of the patients with other providers who were also providing care. Record review for Patient 2 revealed a POC dated 12/18/2021 to 02/15/2022 with a start of care date of 12/23/2020. The POC listed diagnoses of Hypertension, Seizures, Osteoarthritis, Type 2 Diabetes Mellitus, Abnormality of Gait and Mobility, Visual Disturbances, Chronic Pain syndrome, Pain in right and left shoulder, Dorsalgia, Gastroesophageal Reflux Disease, Nausea, and Anxiety Disorder. The POC listed orders for a skilled nursing visits one time per week for nine weeks and two visits as needed for disease exacerbation. The record review failed to find any evidence of communication with the Primary Home Care provider, Identifier A. A telephone interview was conducted with Patient 2 on 02/18/2022 at 1:47 PM. The surveyor asked about PHC services. Patient 2 stated he had attendant services through PHC Identifier A for several years. Patient 2 stated he was with his attendant getting prescriptions from the pharmacy when the surveyor came to the patient’s residence for the home visit. An interview was conducted with the DON on 02/18/2022 at 4:45 PM. The surveyor shared the findings from the clinical record reviews and home visits. The surveyor asked if the DON was also the RN who completed the patient assessments and provided the case management and supervision of the patients reviewed. The DON stated “Yes.” The surveyor asked about the lack of coordination of care with Patient 2’s PHC provider. The DON stated it should be documented in a communication note. Record review for Patient 3 revealed a POC dated 12/17/2021 to 02/14/2022 with a start of care date of 04/21/2021. The POC listed diagnoses of Bilateral Osteoarthritis of Knee, Hypertensive Heart Disease with Heart Failure, Asthma, Hyperlipidemia, Chronic Pain, Presence of Heart Assist device, Abnormalities of Gait and Mobility, Mild Cognitive Impairment, Gastro-Esophageal Reflux Disease, and Long-Term Use of Anticoagulants. The POC listed orders for skilled nursing visits one time per week for nine weeks. The record review failed to find any evidence of communication with the Primary Home Care provider, Identifier B. During a home visit with Patient 3 on 2/18/2022 at approximately 12:00 PM, the surveyor asked about PHC services. Patient 3 stated she had used this agency for PHC services when she was first admitted but had some issues with the attendant and had changed to her current provider PHC provider, Identifier B. An interview was conducted with the DON on 02/18/2022 at 4:26 PM. The surveyor reviewed the findings of the clinical record review and home visit and asked about the lack of coordination of care with Patient 3’s PHC provider. The DON stated, “it should be in the nurses notes or communication note.” No additional information or documentation was provided by the end of the survey to clarify or correct the findings. A review of the agency policy titled: A review of Agency policy with a revision date of 060106 read in part, "Monitoring Patient Care/ Coordination of Care, ... Purpose: To ensure coordination of patient care/treatment…. Agency will collaborate with other organizations providing services (i.e., medical equipment, other home health agencies…) to ensure appropriate coordination of care for the patient…. When other organizations are involved in the patient’s care, Agency staff members notify them of significant changes in the patient’s overall care. This communication is documented in the medical record…”

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases to include COVID-19 for 3 of 3 years reviewed (2020, 2021 and currently in 2022). The agency failed to develop a plan for the appropriate actions that were expected to result in improvement and disease prevention specific to care and services provided in the home setting. This failure resulted is COVID-19 screenings not being conducted and documented, COVID-19 educational materials not being provided to agency clients, and attendants not being trained in personal protective equipment. According to the Texas Administrative Code Z1215: Emergency Rule for HCSSA Response to COVID-19 (f) The agency must determine if a scheduled home visit requires essential or non-essential services. (3) If the visit requires essential services, staff must conduct the visit in person and screen the client and household members using the same criteria for staff. According to the Texas Administrative Code Z1211 (e): Emergency Rule for HCSSA Response to COVID-19, The agency must: (1) document the results of all required screenings. The surveyor requested all agency policy and procedures, infection control records, and COVID-19 information during the entrance conference on 02/15/2022 at noon. The surveyor reviewed the agency provided binder labeled COVID-19 which contained a copy of a document titled: Updated COVID-19 Frequently Asked Questions for HCSSA Providers – February 15, 2022 which was emailed by HHS to agencies on February 15, 2022, the start date for the agency's survey. No other documents were in the COVID-19 binder provided by the agency. On 02/22/2022 the surveyor review of the agency policy and procedure manual provided, COVID-19 binder, and all other binders and logs provided by the agency to revealed no policies and procedures in place the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases for COVID-19. Review of the infection control program in the policy manual provided had a revision date of 04/01/2014, and contained no COVID-19 policies for the agency. During the review of the agency policies and procedures, infection control records, quality assurance documents, staff training records on 02/22/2022, the surveyor found no evidence of policies and procedures for training of attendant staff on personal protective equipment, no evidence attendants were trained on personal protective equipment, no policies, procedures or hand outs for patient information regarding COVID-19 and how to prevent the spread of this infections disease, and no policies on screening and documenting signs and symptoms of COVID-19 for staff, clients and household members. Review of the sample agency admission folders for PAS and Licensed and Certified services provided by the agency on 02/15/2022 revealed no information about COVID-19 and how to prevent COVID -19 infection. During a home visit to the residence of Client 1 and Client 2 on 2/18/2022 at approximately 11 AM, the surveyor reviewed the home folders provided by the agency to the clients. The home folders contained no information regarding COVID-19. During a home visit on 02/18/2022 at 11 AM., the surveyor observed household members in the home during the home visit. The surveyor conducted an interview with Attendant A on 02/18/2022 at 11 AM. The surveyor asked the attendant how they screened for COVID 19 prior to visits. Attendant A stated they screened the patients by taking their temperature before the visits. The surveyor asked if they did any other screening activities. Attendant A stated they did not do any other screening activities. The surveyor asked the attendant if they screened household members, and how they documented COVID-19 screening prior to providing care. Attendant A stated that they did not screen the household members and did not document COVID-19 screening prior to providing attendant services. An interview was conducted with Client 1 during the home visit on 2/18/2022. The surveyor asked if any documents had been removed from the home folder. Client 1 stated “No.” A telephone interview was conducted with Client 2 on 02/18/2022 at 1:47 PM. The surveyor asked if any documents had been removed from the home folder. Client 2 stated “No.” During a home visit with Client 3 on 2/18/2022 at approximately 12:00 PM, the surveyor reviewed the home folder provided by the agency to Client 3. The surveyor asked if any documents had been removed from the home folder. Client 1 stated “No.” The home folders contained no information regarding COVID-19. Review of clinical records for Personal Assistance Services patient 8 and 9 found no evidence of screening for signs and symptoms of COVID-19 infection for the staff, patients and household members. Record reviews for Licensed and certified patients 1,2,3,4,5,6, and 7 revealed no documentation of screening of household members prior to the skilled nurses providing care in the homes. An interview was conducted with the Supervising Nurse on 02/18/2022 at 3:40 PM. The surveyor reviewed the findings of the review of the agency admission folders and the home folders found during the home visits. The surveyor asked about the lack of COVID-19 information in the client packet. The Supervising Nurse stated: “We will look into that.” The surveyor asked about policies for documentation of COVID-19 screening for family members prior to visits. The Supervising Nurse stated: “We don’t document the family member screening.” The surveyor asked policies for COVID-19 training regarding putting on and taking off personal protective equipment for nursing and attendant staff. The Supervising Nurse said: “The attendants were trained on handwashing, but not on personal protective equipment.” The surveyor asked about the outcome for the clients and staff of the agencies lack of policies for COVID-19 and for providing COVID-19 information. The Supervising Nurse stated: “It’s not going to be nice.” No additional information was provided to explain the outcomes or correct the findings by the end of the survey. An interview was conducted on 02/22/2022 at 3:56 PM with the Administrator. The surveyor reviewed the findings from the record reviews, policy reviews and home visits, COVID 19 manual, infection control, Emergency Preparedness, and Quality Assurance documents. The surveyor asked about the agency's lack of Infection Control policies and updates for COVID-19. The Administrator stated: “They (the agency consultant) didn’t tell us we have to do updates to the policy and procedures.” The surveyor asked about a policy to screen the PAS clients and family members prior to providing attendant services. The Administrator stated: " We don’t have a procedure for them to send it (the screening documentation) to us.” The surveyor asked about how the failures to update the infection control policies and procedures was affecting the clients and the staff. The Administrator stated: “We don’t have the policy and proof that we did it.” No additional information was provided by the end of the survey about the outcomes or correct the findings. Agency policy titled: “Infection Control Program IC.1” with a revision date of 04/01/2014 read in part: To outline the policies and procedures for an infection control program which applies to patients, staff and care provided. The program improves patient health outcomes through the identification and reduction of risks of infections in patients and staff. Agency’s infection control program will be based on the following criteria:…Current scientific methods of surveillance and prevention or control of adverse outcomes related to infections, CDC guidelines, Communicable Disease Prevention and Control Act, Health and Safety Code, Chapter 81 and State List of Notifiable Conditions, updated annually…Current federal/state/local laws and regulations…Management will be responsible for coordinating all activities related to the Infection Control Program…Agency will keep abreast of current information about the emergence of epidemics or new infections through local, state and/or federal public health systems…”