Every finding on record at Encompass Home Heath of Dfw LLC

An investigation survey (Intake #556329, #556330 and #548863) was conducted on 01/30/2025. The census was 676 (licensed & certified). Abbreviations: HH – Home Health 2X – 2 times POC- Plan of Care SOC- Start of Care RN- Registered Nurse

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients were free from neglect for 1 of 11 patients (patient #4) whose record was reviewed, in that: the nurse (RN S) did not provide wound care for Patient #4. This failure placed Patient #4 at risk for wound deterioration by not receiving wound care as outlined in the patients plan of care which could lead to slower healing wound or, potentially, hospitalization if the wound deteriorated. Record review for Patient #4: Review of the plan of care (POC) for certification period 4/10/2024 to 6/8/2024 revealed in part: A start of care date of 8/14/2023. The plan of care was electronically signed and dated by the physician on 05/01/2024. The frequency of visits for skilled nurse was 1 time per week for 1 week and then 2 times per week for 8 weeks. Review of the section titled, “Orders of Discipline and Treatments:” read in part, “laceration and multiple toes on bilateral feetright [sic] great toeorder [sic]: HH nurse to change dressing 2X per week…” Review of the report titled, “Coordination Notes Report” revealed a note on page 3 of 4 dated 4/29/2024 that was entered by the Administrator read, “Physician notified of missed wound care visit on Saturday.” During an interview with the Administrator, she clarified the Saturday missed visit was for the date 4/27/2024. Review of the report titled, “Witness Affidavit” that was signed by the Administrator and dated 06/10/2024 read in part, “On 04/29/2024 I spoke with (RN S) regarding a patient visit being completed. (RN S) stated she had seen the patient on 04/27/2024… a few mins later (RN S) called back and stated, “I don’t want to lie to you I didn’t see him.” On 02/04/2025 at approximately 2:50 PM The surveyor conducted an interview with the Administrator. The surveyor asked the Administrator if RN S conducted a skilled nurses visit on 04/27/2024 for Patient #4. The Administrator stated, “at first she said she did see Patient #4 and did his wound care but when I told her the silent global positioning satellite (this is a system the agency uses to monitor the agency staff’s location at the time a nursing assessment is started) ping did not show her at the patients address she admitted that she didn’t visit the patient.” The surveyor asked what the outcome could be of missing a wound care visit. The Administrator stated, “the patient’s wound could deteriorate or maybe if there was signs of an infection it could be missed but we did a nurses visit on 04/29/2024 to evaluate the patient and there wasn’t any adverse effects or wound degression noted from the missed visit.” The surveyor asked what the agency investigation findings were. The Administrator stated, “we confirmed the findings of neglect and reported RN S to the Board of Nursing.” On 02/07/2025 at approximately 2:39 PM the surveyor conducted a phone interview with RN S. The surveyor asked if on 04/27/2024 RN S had a skilled nurses visit for patient #4. RN S stated, “yes.” The surveyor asked if the visit scheduled on 04/27/2024 was to provide wound care for patient 4. RN S stated, “yes.” The surveyor asked RN S if she conducted the nursing visit that was scheduled on 04/27/2024 for Patient #4. RN S stated, “no, I had a lot of stuff going on at that time plus the stuff going on at work. I was tired and I felt like I couldn’t get a hold of it and I made a very stupid mistake. I mean I it was a really stupid mistake.” The surveyor asked what the outcome of not completing a nursing visit that is scheduled for a client. RN S stated, “I mean… I mean he didn’t get the care that he needed. It could cause him to not get his dressing change done and the wound could get worse.” The surveyor asked RN S if she felt that by not conducting the nursing visit it could be considered neglect. RN S stated, “I don’t know I have never done anything like this it was a stupid mistake. I knew it was stupid.” Review of the agency’s policy titled, “Patient abuse, neglect & exploitation Texas S17” original issue date: 01-01-2000 reviewed date: 09-25-2024 read in part, “…2.0 Definitions… 2.3 Neglect is the failure of a caregiver to supply… health care when reasonably able to do so…”

A complaint survey was initiated on 12/22/2022. The census was: LHH-0 LCHH- Grapevine-155 Duncanville-103 Denton-143 Burleson-254 Intakes: 300804 358203 395542 Total agency census: 655 Abbreviations FMLA-family and medical leave act OASIS-outcome and assessment information set LHH-Licensed Home Health LCHH-Licensed and Certified Home Health POC-Plan of Care SN-Skilled Nursing Services EMR-electronic medical record RN-registered nurse LVN-licensed vocational nurse VP-vice president PIP-performance improvement plan MSW-medical social worker cc-carbon copy

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to complete the reassessment including the administration of the OASIS in the last 5 days of the 60 day episode in 5 (#2, #4, #5, #6, & #7) of 8 active patient charts reviewed. This failure resulted in omission of care/treatment, missed visits, emergency room visits, hospitalization and the plan of care for the next 60 day episode not being created and sent to the physician to review and revise timely. Findings include: Patient #2 chart review: The electronic medical record included a plan of care for episode 9/30/22 through 11/28/22 with a start of care of 9/30/22. The primary diagnosis was encounter for change or removal of non-surgical wound dressing. The plan of care included orders for skilled nursing 1 time a week for 1 week, 2 times a week for 4 weeks and 1 time a week for 4 weeks. There was no evidence in the record of an update and revision of the comprehensive assessment, including the collection of the OASIS data in the last 5 days of the episode from 11/24/22 through 11/28/22. Patient #2’s initial assessment on 9/30/22 signed and dated by RN 3 indicated a wound assessment that included 4 wounds identified as follows: Wound #7: Anterior mid pre-tibial right skin tear. Onset 2/18/22, reactivated 9/30/22, inactivated 10/28/22 Wound #10: Anterior pre-tibial left skin tear. Onset 5/2/22, reactivated 9/30/22, inactivated 10/28/22. Wound #12: Mid upper right arm skin tear. Onset 9/26/22. Wound #13 Mid upper left arm skin tear. Onset 9/26/22, inactivated 10/22/22. Patient #2’s last skilled nurse visit note on 11/21/22 signed and dated by LVN 1, indicated wound care was provided to the right mid upper arm per physician orders. No evidence of a wound to Patient #2’s lower left leg. No other wounds or wound orders found in patient #2’s chart. Patient #2’s chart contained an order that read in part…”Patient not available for recert the week of 11/20/22…Patient will be recerted the week of 11/27/22…” signed and dated by LVN 3 and co-signed and dated by RN 2 on 11/29/22. The record did not contain a comprehensive assessment due 11/24/22 to 11/28/22. Patient #2 was admitted via emergency department to a hospital on 12/19/22 for a wound infection. Patient #1 had surgery performed for incision and drainage of an infected wound to the lower left leg on 12/20/22. Patient #2 was discharged from the agency on 12/29/2022 by the Administrator/Supervising Nurse. Patient #2 remained in the hospital at the exit survey conference on 12/30/2022. In an interview on 12/22/22 at 11:30 am with the Administrator/Supervising Nurse, the surveyor reviewed the above findings. The Administrator/Supervising Nurse said the patient went with family the week of Thanksgiving and the nurse declined the next scheduled visit. This surveyor asked who was notified if a nurse declined a visit. The administrator said that through the agency software, when a nurse declined a visit, the “workflow” created a task for the scheduler. The scheduler had an electronic “to do” list and the scheduler should handle it by scheduling another clinician. The surveyor asked why the recertification visit was not re-scheduled. The Administrator requested time to research and get back to the surveyor. An interview was conducted on 12/22/22 at 3:36 pm with the Administrator/Supervising Nurse. The surveyor asked the Administrator why the recertification visit for Patient #2 was not re-scheduled. The Administrator explained that because the recertification visit was moved out of the current episode, the software wouldn’t let it be rescheduled with no new episode in the patient chart because the recertification had not been completed. An interview was conducted on 12/22/22 at 3:36 pm with the Administrator/Supervising Nurse. This surveyor asked the Administrator/Supervising Nurse who was the case manager for Patient #2’s care and any follow-up that the patient would need. The Administrator/Supervising Nurse said RN 1, but she was currently on FMLA due to surgery. Surveyor asked if the RN 1’s surgery was before or after the missed recertification visit. The Administrator/Supervising Nurse said, “Before.” The surveyor asked who was responsible for taking care of RN 1’s patients. The Administrator/Supervising Nurse said, “it was a catch as you can, she (RN 1) is my only full-time nurse.” An interview was conducted on 12/23/22 at 1:05 pm with the Administrator/Supervising Nurse. The surveyor asked the Administrator/Supervising Nurse who was assigned to RN 1’s patients and responsibilities when she went on FMLA. The Administator/Supervising Nurse said, “We didn’t make a specific assignment.” Surveyor asked if there were any other patients for which care was not provided as ordered. The Administrator/Supervising Nurse said “Yesterday we identified a few others. My regional VP is working with me to identify any other patients that didn’t have their recertification completed timely.” Surveyor asked about the process for identifying those patients. The Administrator/Supervising Nurse said, “Through software reports and looking through patient charts. Our plan is to identify if any other recertification or care was missed so we can identify the root cause. I can send you my PIP now if you like.” Patient #4 chart review: The electronic medical record included a plan of care for episode 10/11/22 through 12/9/22 with a start of care of 10/11/22. The primary diagnosis was Non-ST Elevation Mycardial Infarction (heart attack, a blockage of blood flowto the heart muscle). The plan of care included orders for skilled nursing 1 time a week for 1 week, 1 time every other week for 2 weeks and 1 time a week for 6 weeks and MSW 1 time a week for 1 week and 1 time every other week for 2 weeks. Patient #4 last skilled nurse visit note was dated and signed on 11/30/22 by LVN 2. An order dated 12/9/22 read in part…”Calendar frequency SN effective 12/4/2022 1 week 1 signed and dated by RN 2…” There was no evidence in the record of an update and revision of the comprehensive assessment, including the collection of the OASIS data in the last 5 days of the episode from 12/5/22 to 12/9/22. Patient #4 was recertified/reassessed with the administration of OASIS on 12/27/22 by RN #2. Patient # 5 chart review: The electronic medical record included a plan of care for episode 10/10/22 through 12/8/22 with a start of care of 10/10/22. The primary diagnosis was hemiplegia following cerebral infarction (paralysis of partial or total body function on one side of the body) affecting left non-dominance side. The plan of care included orders for skilled nursing 1 time a week for 9 weeks, physical therapy 2 times a week for 3 weeks and occupational therapy 1 time a week for 1 week. Patient #5 last skilled nurse visit note was dated and signed on 11/29/22 by RN 2. There was no evidence in the record of an update and revision of the comprehensive assessment, including the collection of the OASIS data in the last 5 days of the episode from 12/4/22 to 12/8/22. Patient #5 was recertified/reassessed with the administration of OASIS on 12/29/22 by RN 2. Patient #6 chart review: The electronic medical record included a plan of care for episode 9/23/22 through 11/21/22 with a start of care of 10/3/20. The primary diagnosis was encounter for attention to cystostomy. The plan of care included orders effective 10/9/22 for skilled nursing 1 time a week for 1 week, 1 time every 4 weeks for 4 weeks and 1 time a week for 1 week. The plan of care included orders for the skilled nurse to change the patient’s suprapubic catheter every month with 18 french with 30 cc bulb. There was no evidence in the record of an update and revision of the comprehensive assessment, including the collection of the OASIS data in the last 5 days of the episode from 11/17/22 to 11/21/22. Patient #6’s most recent suprapubic catheter change was 11/9/22. Patient #6’s last skilled visit note was dated and signed on 11/9/22 by RN 4. Patient #6 received a courtesy visit on 12/23/22 for a suprapubic catheter change. No adverse effects were noted. Patient #6 was recertified/reassessed with the administration of OASIS on 12/27/22 by RN 2. Patient #7 chart review: The electronic medical record included a plan of care for episode 10/2/22 through 11/30/22 with a start of care of 6/14/20. The primary diagnosis was encounter for attention to cystostomy (a surgical creation of an opening into the bladder). The plan of care included orders effective 10/9/22 for skilled nursing 1 time a week for 1 week, 1 time every 4 weeks for 4 weeks and 1 time a week for 1 week. The plan of care included orders for the skilled nurse to change the patient’s suprapubic catheter every 4 weeks with 18 french with 10 cc bulb. There was no evidence in the record of an update and revision of the comprehensive assessment, including the collection of the OASIS data in the last 5 days of the episode from 11/26/22 to 11/30/22. Patient #7’s most recent suprapubic catheter change was 11/29/22 at his physician’s office. Patient #7’s last skilled nurse visit was 10/28/22 signed and dated by RN 1. Patient #7’s caregiver refused visits until week of 12/27/22 when suprapubic catheter change was due. No adverse effects were noted. Patient #7 was recertified/reassessed with the administration of OASIS on 12/29/22 by RN 2. An interview was conducted on 12/28/22 at 3:45 pm with the Administrator/Supervising Nurse. The surveyor reviewed Patient #6’s chart findings: his plan of care was not followed because his frequency was not followed. Patient #6’s catheter was not changed monthly per orders and recertification was not completed in the 5 day window. The Administrator said, “We did a courtesy visit on 12/23/22 and he was recertified yesterday.” The surveyor reviewed Patient #7’s chart findings: his plan of care was not followed in that the frequency was not followed, recertification was not completed in the 5 day window and the catheter was not changed per orders. The Administrator said, “The Family Member refused a skilled nurse visit until the week of 12/27/22 when Patient #7’s catheter is due to be changed.” The surveyor reviewed chart findings for Patient #4 and Patient #5: the plans of care were not followed due to frequency not being followed causing the recertification including the administration of the OASIS to not be completed in the 5 day window. The Administrator/Supervising Nurse said, “it was a scheduling error due to the RN 1 being on FMLA.” The Administrator/Supervising Nurse went on to say, “They were all scheduling errors addressed in the PIP implemented on 12/22/22.”

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 the patients received services as written in the individualized service plan for 5 (#2, #4, #5, #6, & #7) of 8 active patient charts reviewed. The failure placed the Patients at risk of hospitalization and negative outcomes. Findings include: Patient #2 chart review: The electronic medical record included a plan of care for episode 9/30/22 through 11/28/22 with a start of care of 9/30/22. The primary diagnosis was encounter for change or removal of non-surgical wound dressing. The plan of care included orders for skilled nursing 1 time a week for 1 week, 2 times a week for 4 weeks and 1 time a week for 4 weeks. Skilled nursing visits were documented on 9/30/22, 10/5/22, 10/7/22, 10/12/22, 10/14/22, 10/17/22, 10/22/22, 11/1/22, 11/4/22, 11/8/22, 11/11/22, 11/15/22, 11/18/22 and 11/21/22. There was no evidence of the 2nd ordered visit for week 6, week of 10/23/22 or one skilled nurse visit in week 9, for the week of 11/20/22. The agency failed to follow the plan of care orders for skilled nursing visit frequency. Patient #4 chart review: The electronic medical record included a plan of care for episode 10/11/22 through 12/9/22 with a start of care of 10/11/22. The primary diagnosis was Non-ST Elevation Mycardial Infarction (heart attack, a blockage of blood flowto the heart muscle). The plan of care included orders for skilled nursing 1 time a week for 1 week, 1 time every other week for 2 weeks and 1 time a week for 6 weeks and MSW 1 time a week for 1 week and 1 time every other week for 2 weeks. Skilled nursing visits were documented on 10/11/22, 10/27/22, 11/9/22, 11/16/22, 11/23/22, and 11/30/22. There was no evidence of a skilled nurse visit for week 9, week of 12/4/22. The agency failed to follow the plan of care orders for skilled nursing visit frequency. Patient # 5 chart review: The electronic medical record included a plan of care for episode 10/10/22 through 12/8/22 with a start of care of 10/10/22. The primary diagnosis was hemiplegia following cerebral infarction (paralysis of partial or total body function on one side of the body) affecting left non-dominance side. The plan of care included orders for skilled nursing 1 time a week for 9 weeks, physical therapy 2 times a week for 3 weeks and occupational therapy 1 time a week for 1 week. Skilled nursing visits were documented on 10/13/22, 11/4/22, 11/9/22, 11/21/22, and 11/29/22. There was no evidence of a skilled nurse visit not for weeks 2, 3, 6, or 9. The agency failed to follow the plan of care orders for skilled nursing visit frequency. Patient #6 chart review: The electronic medical record included a plan of care for episode 9/23/22 through 11/21/22 with a start of care of 10/3/20. The primary diagnosis was encounter for attention to cystostomy (a surgical creation of an opening into the bladder). The plan of care included orders effective 10/9/22 for skilled nursing 1 time a week for 1 week, 1 time every 4 weeks for 4 weeks and 1 time a week for 1 week. Skilled nursing visits were documented on 10/10/22 and 11/9/22. There was no evidence of a skilled nurse visit for week 9. The agency failed to follow the plan of care orders for skilled nursing visit frequency. Patient #7 chart review: The electronic medical record included a plan of care for episode 10/2/22 through 11/30/22 with a start of care of 6/14/20. The primary diagnosis was encounter for attention to cystostomy (a surgical creation of an opening into the bladder). The plan of care included orders effective 10/9/22 for skilled nursing 1 time a week for 1 week, 1 time every 4 weeks for 4 weeks and 1 time a week for 1 week. The plan of care included orders for the skilled nurse to change the patient’s suprapubic catheter every 4 weeks with 18 french with 10 cc bulb. A skilled nursing visit was documented on 10/28/22 with missed visit notes for 10/12/22, 11/8/22 and 11/17/22. There was no evidence of a skilled nursing visit or a missed visit note for week 8. The agency failed to follow the plan of care orders for skilled nursing visit frequency. An interview was conducted on 12/23/22 at 9:09 am with the Administrator/Supervising Nurse. The surveyor reviewed an order on 11/9/22 for Patient #2 that changed the wound care and increased the skilled nursing visits to 3 times a week until healed. Surveyor explained that the visits were not increased to 3 times a week. The surveyor asked the Administrator/Supervising Nurse why the visits were not increased. The Administrator said, “I do not know, I would have to dig into that.” Surveyor reviewed that the frequency was not followed the week of 10/23/22 as only one visit was made by RN 1 on 10/28/22. The surveyor asked the Administrator/Supervising Nurse if she knew why the frequency was not followed that week. The Administrator/Supervising Nurse said, “Not off the top of my head.” An interview was conducted via phone on 12/28/22 at 3:45 pm with the Administrator/Supervising Nurse. The Surveyor asked why Patient #4, #5, #6 and #7’s plans of care related to frequency were not followed. The Administrator/Supervising Nurse said, “They were all scheduling errors.”