Every finding on record at Excellent Healthcare Services, Inc.

A recertification inspection survey was conducted on 02/24/2026. Licensed and certified home health services census was 16. No deficiencies cited.

A recertification inspection survey was conducted on 02/24/2026. Licensed and certified home health services census was 16. Abbreviations and Acronyms: Admin-Administrator Alt. Admin-Alternate Administrator DON-Director of Nurses Admin Assist-Administrative Assistant POC- Plan of Care SN- Skilled Nursing QIO-Quality Improvement Organization HHA-Home Health Agency CMS-Centers for Medicare and Medicaid Services CNSI-Classified national Security Information

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 interviews, the agency failed to ensure patients’ right to be advised of the name, address, and telephone number of a federally funded entity that serviced the area where the patient resided, in two (Patients # 2 and 3) of three patients who received home visits. The agency failed to advise the patients of the Quality Improvement Organization (QIO’s) name, address, and telephone number that serviced the area where the patient resided. The failure placed the patients’ physical health and safety at risk if they were unable to access the QIO to appeal a premature discharge. The failure could place the patients at risk of not having time to access needed resources (medical equipment or outpatient services) that were available for them in their service area. Findings included: Review of agency’s record titled, “Contact Information…Federal and State Public Agencies” dated 01/13/18 revealed an area titled, “Quality Improvement Organization.” The record provided an area to print the name, address, and phone number for QIO that serviced the area where the patients resided. Further review revealed that the area listed the name, address, and telephone number of the agency’s consultant provider (Consultant #100). Continued review revealed that the name, address, and telephone number of the Quality Improvement Organization that serviced the area where the patients’ resided was not listed. Patient # 2 Review of the clinical record for Patient # 2 revealed a POC for the certification period of 01/06/2026 to 03/06/2026. Review of the POC revealed a start of care date of 09/19/2023 and a primary diagnosis of osteoarthritis (chronic joint disease where cartilage between bones break down and the bones then rub together) of both knees. The DON signed and dated the POC on 01/05/2026. The POC contained orders for SN visits one time per week for nine weeks. During a home visit, record review, and interview on 02/26/2026 at 10:00 a.m., the surveyor reviewed the agency folder, which included patient rights records, that the agency provided to the patient at admission. Review of the records revealed that it included the following: the agency’s record titled, “Contact Information…Federal and State Public Agencies” dated 01/13/18 revealed an area titled, “Quality Improvement Organization.” The record provided an area to print the name, address, and phone number for QIO that serviced the area where the patient resided. Further review revealed that the area listed the name, address, and telephone number of the agency’s consultant provider (Consultant #100). Continued review revealed that the agency did not list the name, address, and telephone number of the Quality Improvement Organization that serviced the area where the patient resided. The surveyor asked Patient # 2’s family member if the agency staff had advised [Patient # 2] of the name and contact information for how to appeal a discharge if Patient # 2 did not agree with the discharge decision. Patient # 2’s family member stated that the agency did not advise [Patient # 2] the name and contact information for the current QIO. Patient # 3 Review of the clinical record for Patient # 3 revealed a POC for the certification period of 01/07/2026 to 03/07/2026. Review of the POC revealed a start of care date of 03/13/2025 and a primary diagnosis of generalized osteoarthritis (chronic joint disease where cartilage between bones break down and the bones then rub together) of multiple joints of the body. The DON signed and dated the POC on 01/06/2026. The POC contained orders for SN visits one time per week for nine weeks. During a home visit, record review, and interview on 02/26/2026 at 12:00 p.m., the surveyor reviewed the agency folder, which included patient rights records, that the agency provided to the patient at admission. Review of the records revealed that it included the following: the agency’s record titled, “Contact Information…Federal and State Public Agencies” dated 01/13/18 revealed an area titled, “Quality Improvement Organization.” The record provided an area to print the name, address, and phone number for QIO that serviced the area where the patient resided. Further review revealed that the area listed the name, address, and telephone number of the agency’s consultant provider (Consultant #100). Continued review revealed that the agency did not list the name, address, and telephone number of the Quality Improvement Organization that serviced the area where the patient resided. The surveyor asked Patient # 3’s family member if the agency staff had advised [Patient # 3] of the name and contact information for how to appeal a discharge if Patient # 3 did not agree with the discharge decision. Patient # 3’s family member could not answer because of a language barrier. During an interview on 02/27/2026 at 2:42 p.m. with Admin, DON, and Surveyor B, Surveyor A asked who was responsible for ensuring that the patient rights information for federally funded entities (Quality Improvement Organization name and contact information) was correct. Admin replied, “It’s the job of a clinical person. It’s everybody.” DON replied, “It was [Former Admin].” Admin replied, “Now it’s me.” Surveyor A asked what the agency’s processes were for ensuring the information provided to patients was correct and updated. Admin replied, “We are trying to update them. I tell the Admin Assist that the policy is updated. I think most of the time she talks to the nurses. Not all of the forms have been corrected.” Surveyor A reviewed the findings and asked why the patients were not advised of the correct name, address, and telephone number of the correct QIO that served the area where the patients resided. Admin replied, “Because some of the policies were not changed, some time we were thinking they were okay.” Review of agency policy titled “Patient/Client Rights and Responsibilities” last reviewed 05/01/24 read in part: “Purpose [:] To ensure all patients/clients their representatives (if any) and agency staff acknowledge, observe, and implement the patient's/client’s rights and responsibilities…Procedure [:] I. Agency staff will be responsible for knowing, observing, and implementing the patient's/client’s rights, patient/client conduct, and patient/client responsibilities on an ongoing basis…VI. The patient/client has the right to…K. Be advised of the names, addresses, and telephone numbers of the following Federally funded and state-funded entities that service the area where the patient/client resides: 1. Agency on Aging 2. Center for Independent Living 3. Protection and Advocacy Agency, 4. Aging and Disability Resource Center; and 5. Quality Improvement Organization...” Review of Center for Medicare Advocacy website on 03/10/2026 at, https://medicareadvocacy.org/medicare-quality-improvement-organization-changes-name/, revealed the following: Beneficiary and Family-Centered Care Quality Improvement Organizations (BFCC-QIOs) help Medicare beneficiaries with their concerns about quality of care, and in filing an appeal if coverage is ending too soon. As of July 1, 2024, the BFCC-QIO formerly known as [Former QIO] is officially [Current QIO]. In December of 2022, CNSI, “a leading provider of innovative healthcare technology solutions,” and [Former QIO], “a leading provider of technology-enabled care management, quality oversight and clinical assessment services” merged. The [Current QIO] brand was born in 2023, and notices with the new brand’s logo have been received by Medicare beneficiaries. [Current QIO] assures beneficiaries there have been no changes to the services it provides. [Current QIO]’s service areas include the following CMS Regions…Region 6…[Texas]…”

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interviews the agency failed to provide the patient with a written visit schedule with frequency that was consistent with the patient’s most current plan of care for two (Patients # 2 and 3) of three patients who received a home visit and whose home admission folders were reviewed. The failure placed the patient’s physical health and safety at risk if the patient and caregiver did not understand what services to expect from the HHA, the purpose of each service, and when to expect the services. Findings include: Patient # 2 Review of the clinical record for Patient # 2 revealed a POC for the certification period of 01/06/2026 to 03/06/2026. Review of the POC revealed a start of care date of 09/19/2023 and a primary diagnosis of osteoarthritis (chronic joint disease where cartilage between bones break down and the bones then rub together) of both knees. The DON signed and dated the POC on 01/05/2026. The POC contained orders for SN visits one time per week for nine weeks. During a home visit and record review, on 02/26/2026 at 10:00 a.m., the surveyor reviewed the agency folder, which included patient rights records, that the agency provided to the patient at admission. Review of the folder revealed that it did not include a visit schedule that included frequency of visits by HHA SN that was consistent with the most current plan of care. Patient # 3 Review of the clinical record for Patient # 3 revealed a POC for the certification period of 01/07/2026 to 03/07/2026. Review of the POC revealed a start of care date of 03/13/2025 and a primary diagnosis of generalized osteoarthritis (chronic joint disease where cartilage between bones break down and the bones then rub together) of multiple joints of the body. The DON signed and dated the POC on 01/06/2026. The POC contained orders for SN visits one time per week for nine weeks. During a home visit and record review 02/26/2026 at 12:00 p.m., the surveyor reviewed the agency folder, which included patient rights records, that the agency provided to the patient at admission. Review of the folder revealed that it did not include a visit schedule that included the frequency of visits by HHA SN that was consistent with the most current plan of care. During an interview on 02/27/2026 at 3:24 p.m. with Admin, DON, and Surveyor B, Surveyor A asked who was responsible for ensuring that the agency’s patient rights information, a written visit schedule with frequency was provided to the patients. DON stated that the (admission) nurse was responsible. DON admitted Patients # 2 and # 3. Surveyor A asked what the agency’s process was for ensuring the written visit schedule with frequency was provided. DON stated that the agency mailed it to the patients or sent it with the nurse. Surveyor A asked why Patients # 2 and # 3 did not have visit schedules in the home that was consistent with the current plan of care. DON, replied, “I don’t know why that is. What is a visit schedule? I didn’t know anything about that one (written visit schedule). I’m only familiar with (providing) the frequency.” Review of agency policy titled, “Implementing Care and Treatment” last reviewed on 01/01/2026 revealed the following, “…VI. Written information to the patient/client. A. The Agency must provide the patient/client, and caregiver, with a copy of written instructions outlining: 1. The visit schedule, including frequency of visits by Agency personnel and personnel acting on behalf of the Agency… The written information should be updated as the Plan of Care changes…”