Every finding on record at Guardian Angels Athome Care Inc

A complaint survey for Intake # 1074212 was initiated on 07/23/2026. Census: Licensed and Certified: 249 Licensed Home Health: 0 Personal Assistance Services: 0 Acroynyms: CII- Complaint and Incident Intake HHSC- Health and Human Services Commission POC- Plan of Care SN- Skilled nurse PT- Physical Therapy HEP- Home Exercise Program DON- Director of Nurses SOC- Start of Care HH- Home Health RN- Registered Nurse

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 interviews, the agency failed to ensure that a patient received home health services as ordered in the individualized POC for 1 (Patient #1) of 3 discharged patient records reviewed. The RN failed to ensure a Physical Therapy evaluation and treatment plan was completed as ordered by the physician. This failure potentially placed patients at risk of not receiving interventions when needed to prevent complications, and a decline in the patients’ health status. FINDINGS INCLUDE: Review of a Complaint Intake #1074212 dated 03/13/2026 revealed a complainant reported to CII the agency failed to provide patient services. In a phone interview on 07/22/2026 at 8:55 AM with the complainant, the surveyor asked about the care and services for the agency provided for Patient #1 prior to discharge. The complainant stated the (agency) staff came to visit Patient #1 a few times and had promised to send therapy and other staff. The complainant stated no one else came and they were not happy with the way things were going. Patient #1 discharged from the agency to be admitted to another agency for services. Patient #1: Review of the record revealed a POC dated 02/23/2026 to 04/23/2026 with a SOC date 02/23/2026. The POC included the following diagnoses: Fracture (partial or complete break in the bone) of left pubis (the lower and front part of the hip bone); fracture of sacrum (located at the base of the spine at the lower back, wedged between the two hip bones of the pelvis); History of falling; Spinal stenosis (the narrowing of the open spaces in the spine, which can press on the spinal cord and nerves) and Difficulty in walking. The POC listed physician orders for SN visits once a week for nine weeks and PT evaluation and treatment. The POC included, “PT visits are required to establish HEP with focus on exercises to improve balance, gait for safe ambulation, mobility, and transfers. Goal: Patient will have improve in balance/gait/transfer. … Physical therapy eval (evaluation) and treat (treatment) to evaluate week of 02/23/2026. …SN to assess patient’s compliance with home exercise program. …” The POC was digitally signed by RN A and dated 02/23/2026. Review of the record revealed a SOC visit dated 02/23/2026 conducted by RN A. SN missed visits were dated 03/09/2026 and 03/19/2026. A PT referral dated 02/24/2026 included, “Decline Reason: Declining PT service due to no coverage. …” A PT referral dated 02/26/2026 included, “Decline Reason: no coverage. …” No additional PT referrals were requested for a PT evaluation/treatment for Patient #1. A Discharge visit was conducted 03/19/2026 by RN A and included, “… Care Coordination Discharge from home health service … Reason for Discharge: … Per patient / family request, … Another HH … .” In an interview with the DON via teleconference and the Administrator in person, on 07/23/2026 at 3:00 PM, the Surveyor asked if RN A was available. The Administrator stated RN A was not available, but the DON was available via teleconference and would join the conversation. The Surveyor reviewed the findings and asked why RN A did not follow the plan of care and ensure a PT evaluation and treatment plan for Patient #1. The DON stated she (DON) was hired by the agency in April 2026, after the discharge of Patient #1. The Administrator stated the agency had a change in administration during 2025 to 2026 and the agency was re-organizing from changes with therapy companies at the time. He stated the agency only had two contracted PT companies to work with at that time and both had been sent the referral but declined the (patient’s) case. He stated he wasn’t sure if RN A had followed up with the PT referral. The DON stated she has tried to add more therapy companies and signed the agency up with the PT company, Identifier C. Agency policy, revised date 01/01/2026, quoted in part, “Plan of Care, … Purpose: To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems. … Procedure: … II. An RN is responsible for coordinating the Plan of Care when multiple disciplines are involved, or when more than one agency is involved, … V. Each patient/client must receive the home health services that are written in an individualized Plan of Care, …” Agency policy, revised date 01/01/2026, quoted in part, “Implementing Care and Treatment, … Purpose: To ensure patient/client care and treatment are provided as identified in the care planning process. … Procedure: … I. The Agency is responsible for patient/client care and must conduct and provide, either directly or under arrangement, all services rendered to patients/clients.

Purpose of visit: Recertification/Re-Licensure Survey A Recertification/Re-Licensure/Complaint Survey entrance conference was conducted on 07/24/2023 with the Administrator and the Administrative Assistant at 10:40 AM. Agency Census: Licensed and Certified Home Health Services (L&CHHS) 280 Licensed Home Health Services (LHHS) 131 Personal Assistance Services (PAS) 0 Exit Conference was conducted on 07/27/2023 with the Administrator, Alternate Administrator, and the Director of Nursing at 2:51 PM. The preliminary findings were discussed. The agency was in substantial compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

Purpose of visit: Recertification/Re-Licensure Survey A Recertification/Re-Licensure/Complaint Survey entrance conference was conducted on 07/24/2023 with the Administrator and the Administrative Assistant at 10:40 AM. Agency Census: Licensed and Certified Home Health Services (L&CHHS) 280 Licensed Home Health Services (LHHS) 131 Personal Assistance Services (PAS) 0 Exit Conference was conducted on 07/27/2023 with the Administrator, Alternate Administrator, and the Director of Nursing at 2:51 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: Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Licensed and Certified Home Health Services (L&CHHS) Skilled Nursing (SN) W (week) PRN (as needed) Q (every) Disease (ds) Atherosclerosis (Athscl) heart disease of native coronary artery without (w/o) angina pectoris (ang pctrs) Ulcer (skin sore) Paraplegia (inability to move the lower parts of the body) Lymphedema (Lymphedema is swelling in various areas of your body that happens when something affects your lymphatic system. Your lymphatic system collects excess fluid, proteins and toxins from your cells and tissues and returns them to your bloodstream.) Hyperlipidemia (Hyperlipidemia is abnormally elevated levels of any or all lipids (fats, cholesterol, or triglycerides) or lipoproteins in the blood.) Physical Therapy (PT) Home Health Aide (HHA) Primary Home Care Aide (PHCA) Activities of Daily Living (ADL)

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, observation and interviews, the agency failed to provide the patient and/or caregiver with written information outlining a visit schedule including frequency of visits by home health agency staff or staff acting on behalf of the agency. In 3 (Patients #1, 2 and 3) of 3 patients observed, the agency failed to provide a written visit schedule to the patients. The failure of the agency to provide a written schedule of staff visits, including frequency, placed the agency's 3 patients at risk of decreased benefits from services provided when staff attempted to visit the patients at the same time or multiple visits from staff were provided on the same day. The failure placed the patients at risk of missed visits by staff when visits were not scheduled and conflicted with other appointments and the availability of the patients. FINDINGS INCLUDE: Patient 1: Patient #1's clinical record contained a Plan of Care dated 05/13/2023-07/11/2023. The Plan of Care listed Pressure ulcer of right buttock, stage 3; Pressure ulcer of left buttock, stage 2; Paraplegia, complete…... as diagnoses. The Plan of Care contained an order for Skilled Nursing (SN) 2W8 (2 times a week for 8 weeks) + 2 PRN (as needed) Visits for disease (ds) exacerbation. During a home visit conducted on 07/26/2023 approximately 8:00 AM, the surveyor asked Patient #1 if the surveyor could review the home folder. Patient #1 directed the surveyor to the top of the dresser to obtain the home folder. The surveyor asked if there were any papers missing from the home folder or any agency papers kept somewhere else. Patient #1 stated, "nothing is missing from the folder" A written visit schedule was not found in the agency home folder. The surveyor asked how the patient knew when the nurse would be making a visit. Patient #1 stated, "the nurse calls before coming." Patient #1 did not receive a written visit schedule from the agency for SN services. Patient 2: Patient #2's clinical record contained a Plan of Care dated 04/03/2023-06/02/2023. The Plan of Care listed Lymphedema, not elsewhere classified…Non-pressure chronic ulcer of left ankle w fat layer exposed, Venous insufficiency (chronic) (peripheral)... as diagnoses. The Plan of Care contained an order for Skilled Nursing (SN): Q60 days (every 60 days) …Physical Therapy (PT): 2w8 (2 times a week for 8 weeks) … Home Health Aide (HHA): Primary Home Care Aide (PHCA) assist in ADL. During a home visit conducted on 07/25/2023 approximately 11:30 AM, the surveyor asked Patient #2 if the surveyor could review the home folder. Patient #2 directed the surveyor to the top of the dresser to obtain the home folder. The surveyor asked if there were any papers missing from the home folder or any agency papers kept somewhere else. Patient #2 stated, "nothing is missing from the folder" A written visit schedule was not found in the agency home folder. The surveyor asked how the patient knew when the nurse and the PT would be making a visit. Patient #3 stated, "I don’t really know when the nurse is coming, she calls before coming. The physical therapist usually comes on Monday and Wednesday, they call before coming." Patient #1 did not receive a written visit schedule from the agency for SN or PT services. Patient 3: Patient #3's clinical record contained a Plan of Care dated 05/27/2023-07/25/2023. The Plan of Care listed Hyperlipidemia, unspecified; Atherosclerosis (Athscl) heart disease of native coronary artery without (w/o) angina pectoris (ang pctrs) …Chronic diastolic (congestive) heart failure; Chronic kidney disease, stage 3a…as diagnoses. The Plan of Care contained an order for Skilled Nursing (SN) 1WK9 (1 time a week for 9 weeks) …Physical Therapy (PT) discharging. During a home visit conducted on 07/25/2023 approximately10:40 AM, the surveyor asked Patient #3 if the suveyor could review the home folder. Patient #3’s caregiver provided the surveyor with the home folder. The surveyor asked if there were any papers missing from the home folder or any agency papers kept somewhere else. Patient #3 and the caregiver stated, "No.". A written visit schedule was not found in the agency home folder. The surveyor asked how the patient knew when the nurse would be making a visit. The caregiver stated, " She calls before coming” Patient #3 nodded in agreement. The surveyor asked if physical therapy is still coming. The caregiver and Patient #3 stated, "No.” Patient #3 did not receive a written visit schedule from the agency for SN services. During an interview on 07/26/2023 at approximately 12:06 PM, the surveyor reviewed the findings from the home visits with the Director of Nursing. The surveyor asked why the patients had not been provided a visit schedule from the agency. The Director of Nursing stated, “The nurses were instructed to complete the calendars and leave a copy in the home folders. We will make sure to re-educate the nurses.” Record review of agency policy: "Implementing Care and Treatment," dated 080120, read in part, "…II. 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. 2. Patient/Client medication schedule/instructions, including medication name, dosage, time of medication administration, frequency, and which medications will be administered by agency personnel and personnel acting on behalf of the agency. 3. Any treatments to be administered by agency personnel and personnel acting on behalf of the Agency, including therapy services…. The written information must be updated as the plan of care changes…”

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review, observations and interview, the agency failed to provide patients and/or caregiver with written medication schedule/instructions. In 3 (Patient's #1, #2 and #3) of 3 home visits conducted with patients, the agency failed to provide a medication schedule with instructions written in plain language, without medical abbreviations, to the patients. The failure of the agency to provide written medication schedule/instructions placed the agency's 3 patients at risk of adverse effects, drug reactions, ineffective drug therapy, significant side effects, drug interactions, duplicated drug therapy and noncompliance with drug therapy. FINDINGS INCLUDE: Patient 1: Patient #1's clinical record contained a Plan of Care dated 05/13/2023-07/11/2023. The Plan of Care listed Pressure ulcer of right buttock, stage 3; Pressure ulcer of left buttock, stage 2; Paraplegia, complete…... as diagnoses. The Plan of Care contained an order for Skilled Nursing (SN) 2W8 (2 times a week for 8 weeks) + 2 PRN (as needed) Visits for disease (ds) exacerbation. During a home visit conducted on 07/26/2023 approximately 8:00 AM, the surveyor asked Patient #1 if the surveyor could review the home folder. Patient #1 directed the surveyor to the top of the dresser to obtain the home folder. The surveyor asked if there were any papers missing from the home folder or any agency papers kept somewhere else. Patient #1 stated, "nothing is missing from the folder." The surveyor asked Patient #1 who handled the medications. Patient #1 stated "The nurse and my wife." The surveyor found no evidence of a medication list written in plain language in the patient's home folder. Patient 2: Patient #2's clinical record contained a Plan of Care dated 04/03/2023-06/02/2023. The Plan of Care listed Lymphedema, not elsewhere classified…Non-pressure chronic ulcer of left ankle w fat layer exposed, Venous insufficiency (chronic) (peripheral)... as diagnoses. The Plan of Care contained an order for Skilled Nursing (SN): Q60 days (every 60 days) …Physical Therapy (PT): 2w8 (2 times a week for 8 weeks) … Home Health Aide (HHA): Primary Home Care Aide (PHCA) assist in ADL. During a home visit conducted on 07/25/2023 approximately 11:30 AM, the surveyor asked Patient #2 if the surveyor could review the home folder. Patient #2 directed the surveyor to the top of the dresser to obtain the home folder. The surveyor asked if there were any papers missing from the home folder or any agency papers kept somewhere else. Patient #2 stated, "nothing is missing from the folder.” The surveyor asked Patient #2 who handled the medications. Patient #2 stated "My best friend and my Attendant assist." The surveyor found no evidence of a medication list written in plain language in the patient's home folder. Patient 3: Patient #3's clinical record contained a Plan of Care dated 05/27/2023-07/25/2023. The Plan of Care listed Hyperlipidemia, unspecified; Atherosclerosis (Athscl) heart disease of native coronary artery without (w/o) angina pectoris (ang pctrs) …Chronic diastolic (congestive) heart failure; Chronic kidney disease, stage 3a…as diagnoses. The Plan of Care contained an order for Skilled Nursing (SN) 1WK9 (1 time a week for 9 weeks) …Physical Therapy (PT) discharging. During a home visit conducted on 07/25/2023 approximately10:40 AM, the surveyor asked Patient #3 if the surveyor could review the home folder. Patient #3’s caregiver provided the surveyor with the home folder. The surveyor asked if there were any papers missing from the home folder or any agency papers kept somewhere else. Patient #3 and the caregiver stated, "No". The surveyor asked Patient #1 who handled the medications. Patient #1 stated "The nurse and my wife." The surveyor found no evidence of a medication list written in plain language in the patient's home folder. During an interview on 07/26/2023 at approximately 12:10 PM, the surveyor reviewed the findings from the home visits with the Director of Nursing. The surveyor asked why the patients had not been provided a written medication schedule/instructions from the agency. The Director of Nursing stated, “The nurses were instructed to leave a copy of the Plan of Care which have the list of medications in plain language in the home folders. We will make sure to re-educate the nurses.” Record review of agency policy: "Implementing Care and Treatment," dated 080120, read in part, "…II. 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. 2. Patient/Client medication schedule/instructions, including medication name, dosage, time of medication administration, frequency, and which medications will be administered by agency personnel and personnel acting on behalf of the agency. 3. Any treatments to be administered by agency personnel and personnel acting on behalf of the Agency, including therapy services…. The written information must be updated as the plan of care changes…”

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on record review, observation and interviews, the agency failed provide the patient and/or caregiver with written information outlining treatments to be administered by Home Health Agency personnel and personnel acting on behalf of the Home Health Agency, including therapy services. In 2 (Patients #1 and 2) of 2 patients observed with wound care, the agency failed to provide written wound care to be administered to the patients. The failure of the agency to provide a written wound care to be administered by Home Health Agency personnel and personnel acting on behalf of the Home Health Agency, placed the agency's 2 patients at risk of improper wound care, delayed wound healing, wound infection, or deterioration of the wound. FINDINGS INCLUDE: Patient 1: Patient #1's clinical record contained a Plan of Care dated 05/13/2023-07/11/2023, quoted in part, " The Plan of Care listed Pressure ulcer of right buttock, stage 3; Pressure ulcer of left buttock, stage 2; Paraplegia, complete…... as diagnoses. The Plan of Care contained an order for Skilled Nursing (SN) 2W8 (2 times a week for 8 weeks) + 2 PRN (as needed) Visits for disease (ds) exacerbation. The Plan of Care contained wound care orders for 4 wounds. During a home visit conducted on 07/26/2023 approximately 8:00 AM, the surveyor observed the skilled nurse perform wound care on Patient #1. The surveyor asked Patient #1 if the surveyor could review the home folder. Patient #1 directed the surveyor to the top of the dresser to obtain the home folder. The surveyor asked if there were any papers missing from the home folder or any agency papers kept somewhere else. Patient #1 stated, "nothing is missing from the folder." Written instructions on wound care were not found in the agency home folder. The surveyor asked the patient and his caregiver if either of them knew how to perform the wound care. Patient #1 and the caregiver stated, "No." Patient #1 did not receive a written instructions from the agency for wound care. Patient 2: Patient #2's clinical record contained a Plan of Care dated 04/03/2023-06/02/2023. The Plan of Care listed Lymphedema, not elsewhere classified…Non-pressure chronic ulcer of left ankle w fat layer exposed, Venous insufficiency (chronic) (peripheral)... as diagnoses. The Plan of Care contained an order for Skilled Nursing (SN): Q60 days (every 60 days) …Physical Therapy (PT): 2w8 (2 times a week for 8 weeks) … Home Health Aide (HHA): Primary Home Care Aide (PHCA) assist in Activities of Daily Living …wound care orders for 3 wounds performed Monday and Wednesday by therapist. During a home visit conducted on 07/25/2023 approximately 11:30 AM, the surveyor asked Patient #2 if the surveyor could review the home folder. Patient #2 directed the surveyor to the top of the dresser to obtain the home folder. The surveyor asked if there were any papers missing from the home folder or any agency papers kept somewhere else. Patient #2 stated, "nothing is missing from the folder" A written visit schedule was not found in the agency home folder. Written instructions on wound care were not found in the agency home folder. The surveyor asked the patient and his caregiver if either of them knew how to perform the wound care. Patient #1 and the caregiver stated, "No." Patient #1 did not receive a written instructions from the agency for wound care. During an interview on 07/26/2023 at approximately 12:15 PM, the surveyor reviewed the findings from the home visits with the Director of Nursing. The surveyor asked why the patients had not been provided a written information outlining treatments, such as the wound care to be administered by HHA personnel and personnel acting on behalf of the Home Health Agency, including therapy services. The Director of Nursing stated, “The nurses were instructed to leave a copy of the Plan of Care which have the wound care instructions in the home folders. We will make sure to re-educate the nurses.” Record review of agency policy: "Implementing Care and Treatment," dated 080120, read in part, "…II. 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. 2. Patient/Client medication schedule/instructions, including medication name, dosage, time of medication administration, frequency, and which medications will be administered by agency personnel and personnel acting on behalf of the agency. 3. Any treatments to be administered by agency personnel and personnel acting on behalf of the Agency, including therapy services…. The written information must be updated as the plan of care changes…”

An Incident investigation (Intake #359755) was conducted on 06/28/2022. The census was 263. Abbreviation’s list: CRS- Consumer Rights and Services DFPS- Department of Family and Protective Services RN- Registered Nurse PT- Physical Therapist PCP- Primary Care Physician POC- Plan of Care SOC- Start of Care WNL- Within normal limits OT- Occupational Therapist ST- Speech Therapist Hha- Home health aide SN- Skilled Nurse Collagen- wound healing treatment Abd pad- highly absorbent sterile dressing Coban- trade name for a self-adherent compression bandage PRN- as needed DON- Director of Nurses ROC- Resumption of Care HHSC- Health and Human Service Commission QA- Quality Assurance EHR- Electronic Health Record IV- Intravenous Mg/dl- milligram per deciliter FM- Family member Cg- Caregiver

An Incident investigation (Intake #359755) was conducted on 06/28/2022. The census was 263. Abbreviation’s list: CRS- Consumer Rights and Services DFPS- Department of Family and Protective Services RN- Registered Nurse PT- Physical Therapist PCP- Primary Care Physician POC- Plan of Care SOC- Start of Care WNL- Within normal limits OT- Occupational Therapist ST- Speech Therapist Hha- Home health aide SN- Skilled Nurse Collagen- wound healing treatment Abd pad- highly absorbent sterile dressing Coban- trade name for a self-adherent compression bandage PRN- as needed DON- Director of Nurses ROC- Resumption of Care HHSC- Health and Human Service Commission QA- Quality Assurance EHR- Electronic Health Record IV- Intravenous Mg/dl- milligram per deciliter FM- Family member Cg- Caregiver

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to ensure a reassessment was completed within 48 hours of the patient’s return home after a hospital discharge for 1 (Patient #1) of 3 patients whose records were reviewed for wound care to identify changes in care needs. This failure places agency patients at risk of changes in health status which are not addressed by the agency. FINDINGS: Agency policy, revised date 050119, quoted in part, “PATIENT/CLIENT REASSESSMENT/RECERTIFICATION/SIGNIFICANT CHANGE IN CONDITION/POST HOSPITAL ASSESSMENT PE.4, PURPOSE: To establish criteria for reassessment of the patient/client and revision of the plan of care based on this assessment. POLICY: … III. The Resumption of Care Comprehensive Assessment, will be completed within forty-eight (48) hours of return home from a hospital admission lasting twenty-four (24) hours or more … PROCEDURE: … III. Post Hospital, A. The RN or Therapist will complete a Resumption of Care Comprehensive Assessment (post hospital) within forty-eight (48) hours of return home from a hospital admission… “ Agency policy, revised date 011318, quoted in part, “RESPONSIBILITIES OF THE ADMINISTRATOR LD.5, … POLICY: I. The Agency Administrator will assume overall responsibility and authority for the day to day operations of the Agency, … II. The Administrator will be responsible to implementing and supervising the administrative policies and operations of the Agency and for administratively supervising the provision of all services to Agency patients/clients on a day-to-day basis…. PROCEDURE: … N. Administratively supervising the provision of quality care to Agency patients/clients, O. Supervising to ensure implementation of Agency policy and procedures….” Patient #1: Review of the clinical record for Patient #1 revealed a POC with a SOC date 04/13/22 and certification period 04/13/22 - 06/11/22. The POC listed the following diagnoses: Aphasia following cerebral infarction (difficulty with speech); Hypertensive chronic kidney disease; Type 2 Diabetes Mellitus with chronic kidney disease; Chronic obstructive pulmonary disease; Atrial fibrillation and Long term (current) use of Insulin. Physician orders included: SN visits once a week for nine weeks; PT visit once a week to evaluate and treat; OT visit once a week to evaluate and treat; ST once a week to evaluate and treat and hha three times a week for nine weeks. On 05/12/22 at approximately 10:21 AM, the agency received a FAX transmission from Hospital A titled, “HOSPITAL MEDICINE DISCHARGE SUMMARY, discharge date 05/11/2022…” The summary included on page 11, “… Glucose 689…” (According to Johns Hopkins University Medical School, a normal fasting blood glucose level is between 70-100 mg/dl of blood) and on page 13, “… Patient was given some IV insulin and will be admitted for further management of his hyperglycemia….” A ROC reassessment was completed by RN A on 05/18/22, seven days after Patient #1 had been discharged from the hospital. The reassessment included: On page 16: Wound #1- located on the patient’s Left Great toe top and Wound #2- located on the patient’s Left Great toe tip. On page 19: “… skin breakdown noted to L. Great toe in 2 places. Wound care provided….” A review of the entire record found no evidence of a ROC reassessment conducted within 48 hours of the patient’s return home from the hospital. In an interview on 07/12/22 at approximately 11:00 AM, with the Administrator, DON and RN A, the surveyor reviewed the findings and confirmed the agency policy that required a patient be reassessed within 48 hours of return home from a hospital admit. The surveyor asked why a reassessment was not completed within 48 hours of when the patient had been discharged home. RN A stated she was notified on 05/16/22 of the patient’s 05/11/22 discharge and she saw the patient 05/18/22. The Administrator stated the ROC reassessment was scheduled on 05/12/22 and the assessment should have been done then. In an interview with the Administrator on 07/12/22 at approximately 12:30 PM, the surveyor reviewed the findings and asked how these failures impacted the patient’s care. The Administrator stated, “we need to add double staffing on insurance cases, between the scheduling department and staffing, because the patient went back to the hospital.”

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 interviews, the agency failed to ensure the patient received the home health services written in the individualized plan of care for 1 (Patient #1) of 3 patient records reviewed. Patient #1 did not receive SN visits as ordered by the physician. This failure placed the patient at risk when skilled nursing interventions were needed to prevent complications and a decline in the patient’s health status. FINDINGS: Patient record #1: Review of the clinical record for Patient #1 revealed a POC with a SOC date 04/13/22 and certification period 04/13/22 - 06/11/22. The POC listed the following diagnoses: Aphasia following cerebral infarction (difficulty with speech); Hypertensive chronic kidney disease; Type 2 Diabetes Mellitus with chronic kidney disease; Chronic obstructive pulmonary disease; Atrial fibrillation and Long term (current) use of Insulin. Physician orders included: Skilled nurse visits once a week for nine weeks. Skilled nursing visits were not conducted the Weeks #4 and #5 of the certification period: Week #4: 05/01/22 -- 05/07/22 and Week #5: 05/08/22 – 05/14/22. The following visits were completed by ST, OT and PT Weeks #4 and #5: ST: 05/02/22 and 05/09/22 OT: 05/06/22 PT: 05/12/22 The record contained a Transfer Assessment date 05/10/22, completed by the DON, that read in part, “… (patient) Transferred to an inpatient facility – patient not discharged from agency….” The assessment was completed offsite, not during a home visit. A review of the entire record found no evidence of SN visits for Weeks #4 and #5. Patient #1 did not receive any SN visits between 04/26/22 (the date a Resumption of care visit was completed by RN A) and 05/18/22 (the date a Resumption of care visit was completed by RN A). Two SN visits were missed during this period. In an interview with the Administrator, RN A and the Administrative Assistant, on 07/12/22 at approximately 12:00 noon, the surveyor reviewed the findings of the clinical record and asked why the patient did not receive any SN visits between 04/26/22 and 05/18/22? RN A stated she wasn’t sure why they (SN visits) were not done, that if the scheduler didn’t put the visits in the EHR system, she would not have known to do them. The Administrative Assistant stated the insurance authorization for Patient #1 originally did not approve SN visits. The agency received authorization on 05/05/22 for 4 SN visits to be performed between 05/03/22 – 05/23/22, but she was not sure why the visits were not done. In an interview with the Administrator on 07/12/22 at approximately 12:30 PM, the surveyor reviewed the findings and asked how these failures impacted the patient’s care? The Administrator stated, “we need to add double staffing on insurance cases, between the scheduling department and staffing, because the patient went back to the hospital.” Agency policy, revised date 011318, quoted in part, “ORDERS FOR CARE PC.7 PURPOSE: To ensure patient/client is provided in accordance with physician’s orders and federal and state laws and regulations. POLICY: The Agency will obtain orders and provide care in accordance with physician’s orders which are established prior to initiating patient/client care and reviewed/revised by the physician every sixty (60) days and as needed….” Agency policy, revised date 011318, quoted in part, “RESPONSIBILITIES OF THE SUPERVISING NURSE LD.6, … DEFINITION: The Supervising Nurse is the Registered Nurse responsible for supervising skilled services… POLICY: The Supervising Nurse, appointed by the Administrator, is responsible for the daily direction of patient/client care… PROCEDURE: I. The responsibilities of the Supervising Nurse include but are not limited to: H. Ensuring that a patient’s/client’s Plan of Care is executed as written, …”

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 interviews, the agency failed 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 all providers involved in the care of patients, including the PCP and contracted PT, who provided care for 1 (#1) of 3 patients whose records were reviewed for wound care. This failure could place patients at risk of services being duplicated or omitted and could lead to a decline in health status. FINDINGS: Agency policy, revised date 050119, quoted in part, “MONITORING PATIENT CARE COORDINATION OF CARE PC.10, PURPOSE: To ensure coordination of patient/client care and treatment., POLICY: … II. The Agency will collaborate with other providers of health care services involved in the care of a patient/client, …, PROCEDURE: … C. 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…. III. Agency staff are expected to contact the Agency to report patient/client needs and changes…. IV. Skilled professionals who provide services to Agency patient/clients directly or under arrangement must participate in the coordination of care. A. Effective interchange and reporting, as well as collaboration and coordination of care will occur between all Agency personnel providing care, whether the care and services are provided directly or under arrangement….” On 06/24/22 the agency self-reported an allegation of Neglect to CRS Complaint Hotline and DFPS. On 06/28/222, at approximately 1:00 PM, during an interview with the DON, the surveyor asked about care and services provided to Patient #1. The DON stated a complaint was received on 06/23/22 from FM A who reported Patient #1’s wound had deteriorated and RN A failed to notify the physician. The surveyor was provided 7 black/white copies of photographs of Patient #1’s Left Great toe. The DON stated the agency reported an allegation of Neglect as required to HHSC and provided an agency report and investigation conducted by the DON, documented on a Communication dated 06/23/22. The agency report included the statement from RN A, “… I have pictures of the patients toe at admit….” Patient #1: Review of the clinical record for Patient #1 revealed a POC dated 04/13/22-06/11/22 with a SOC date 04/13/22. The POC listed the following diagnoses: Aphasia following cerebral infarction (difficulty with speech); Hypertensive chronic kidney disease; Type 2 Diabetes Mellitus with chronic kidney disease; Chronic obstructive pulmonary disease; Atrial fibrillation and Long term (current) use of Insulin. Physician orders included: SN visits once a week for nine weeks; PT visit once a week to evaluate and treat; OT visit once a week to evaluate and treat; ST once a week to evaluate and treat and hha three times a week for nine weeks. A POC dated 06/12/22-08/10/22 with a verbal SOC was completed 06/08/22 by the RN A. The POC listed the following diagnoses: Type 2 diabetes mellitus with foot ulcer; Non-pressure chronic ulcer of other part of left foot limited to breakdown of skin; Aphasia following cerebral infarction and Hemiplegia following cerebral infarction affecting right side. Physician orders included: SN visits three times a week for eight weeks and twice a week for one week; PT visit once a week to evaluate and treat; OT visit once a week to evaluate and treat; ST once a week to evaluate and treat and hha three times a week for eight weeks and twice a week for one week, effective week 06/12/2022. A SOC assessment dated 04/13/22, completed by RN A included on Page 15, “… Skin color: Pink/WNL, … Skin is intact….” A PT evaluation dated 04/29/22, completed by PT A included a physical assessment, “… Skin: … Dark area on left big toe with blister…” PT visit frequency and duration was once a week for one week and twice a week for four weeks. A ROC assessment dated 05/18/22, completed by RN A Page 16, “Wound 1: L. Great toe top: … cleansed wound with sterile water/wound cleaner, pat dried with clean gauze, applied collagen to wound, applied abd pad, wrap with Coban. Wound 2: L. Great toe tip: … cleansed wound with sterile water/wound cleaner, pat dried with clean gauze, applied collagen to wound, applied abd pad, wrapped with Coban. Wound care to be performed three times weekly and PRN.” A SN visit dated 06/13/22, completed by RN A, Page 1, noted wound care performed to Patient #1’s Left Great toe top (Wound #1) and the Left Great toe tip. On Page 4, RN A documented, “… Conferenced with: (Blank); … Physician Contacted Re: (Blank) … Next Physician Visit: 6/15/22…” A “late entry” communication note dated 06/24/22, completed by RN A read, “… Late Entry: 06/01/2022 SN attempted to call provider regarding wound care for pt. Office staff stated they would leave a message for the provider to call back. Advised pt. and pt cg to call 911 or to go to the hospital if concerned of infection….” Review of the record failed to reveal any evidence of communication with the PT regarding the patient’s bruised Left Great toe (noted 04/29/22) or evidence of communication with the PCP regarding the decline of the patient’s Left Great toe. On 07/06/22, at approximately 3:00 PM, during a phone interview with Patient #1’s FM A, the patient’s health status was discussed. FM A stated RN A clipped the patient’s Left Great toenail during the SN visit on 06/10/22. During a SN visit with RN A on 06/13/22, FM A stated, “the toe looked bad and I wondered if antibiotics were needed, (Patient #1) was complaining of pain, but the nurse said he was fine and no pain medicine was required.” During the physician visit on 06/14/22, FM A and [Patient #1] were instructed to go directly to the hospital and were told he (patient) would “likely lose the toe.” Patient #1 was admitted to the hospital on 06/14/22 and on 06/15/22 the Left Great toe was amputated “due to a severe infection.” FM A stated she sent pictures of the patient’s infected Left Great toe to RN A on 06/15/22 before surgery. FM A stated Patient #1 was discharged home on 06/22/22, but she did not want the previous agency nurse to come back, “the nurse (RN A) never told us to seek medical attention.” On 07/12/22, at approximately 10:00 AM, during an interview with the Administrator, DON and RN A the surveyor confirmed the dates photographs #1-7 were taken. Picture #1 was taken by RN A on 05/18/22 during a ROC assessment and Pictures #2-7 were taken by Patient #1’s FM A on 06/15/22, the day prior to amputation of the patient’s Left Great toe. The surveyor reviewed the agency Communication dated 06/23/22 and the statement from the RN A, “… I have pictures of the patients toe at admit….” The surveyor asked RN A if there were any additional photographs taken by the RN A, including during the SOC on 04/13/22 on the admission day for Patient #1? RN A stated she only took the one photograph on 05/18/22 during the ROC assessment. The surveyor reviewed the PT Evaluation dated 04/26/22, with the notation, “… Skin: … Dark area on left big toe with blister…” and asked if the staff were aware of the PT notation? DON and RN A stated they were not (aware) of the PT’s notation. The DON stated no one had notified them of the PT’s notation (regarding the toe). The surveyor asked who in the agency was responsible for reviewing the PT visit notes for the patients? The DON stated, “the QA department reviews PT notes and any abnormal finding should have been reported to the MD and discussed during case conference and additional coordination done, but it was not discussed.” The surveyor reviewed Picture #1 and Pictures #2-7 and noted significant degression of the wound between 05/18/22 (Pic #1) and 06/15/22 (Pics #2-7). The surveyor asked RN A if she had reported the change in condition of Patient #1’s Left Great toe on 06/13/22, date of the last SN visit before the amputation. RN A stated she had not reported to the physician because, “he (Patient #1) was going to the doctor that day, I told his wife to tell the doctor.” Review of the record failed to reveal any evidence of communication with the PT regarding the patient’s bruised Left Great toe or any evidence of communication with the PCP regarding the decline of the patient’s Left Great toe. In an interview with the Administrator on 07/12/22 at approximately 12:30 PM, the surveyor reviewed the findings of the clinical record review and interviews and the lack of coordination of care with Patient #1’s PT, RN A and PCP. The surveyor asked how these failures impacted the patient’s care? The Administrator stated, “we need to add double staffing on insurance cases, between the scheduling department and staffing, because the patient went back to the hospital.”