Every finding on record at Hallmark Homecare L P

An intake investigation (#532189 and #545178) was conducted on 11/19/24. The census was: Austin - L&CHHS: 410 Bastrop - L&CHHS: 254 San Antonio - L&CHHS: 398 Abbreviations/Acronyms: CTL: Clinical team leader DME: Durable medical equipment HTN: Hypertension L&CHHS: Licensed and certified home health services LVN: Licensed vocational nurse MD: Medical doctor PRN: Pro re nata (as needed) PT: Physical therapy RN: Registered nurse ROC: Resumption of care SN: Skilled nursing SOB: Shortness of breath VPO: Vice President of Operations

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to provide services as ordered by the physician for 1 of 4 clients (Client #1) This failure placed Client #1 at risk of poor health outcomes and a subsequent hospital admission Findings included: Record review of document titled “Home Health Certification and Plan of Care,” signed and dated 09/18/24 for the certification period from 9/8/2024 to 11/6/2024, revealed that Client 1 had orders for skilled nursing “to perform observation/assessment or pleurx (a hollow catheter that drains fluid from the chest to help with breathing), located right chest by draining 500 cc of fluid each side. Drain right tube 3 x week and drain left tube 1 x a week and 1-3 PRN visit related to distress/discomfort.” Record review of document titled “Visit Note Report,” dated 10/23/24, revealed a narrative note which revealed that only dressing kits were delivered, not kits for draining and that the client was upset. LVN A notified CTL A of need for kits. Record review of document titled “Visit Note Report,” dated 10/25/24, revealed a narrative note by LVN B which revealed “Pt (Client 1) very upset as she is drained 3 x weekly and [last] kit was used today. I (LVN B) emailed CTL A to follow up on order status and let him know that pt (Client 1) is now out of drainage kits.” Record review of document titled “Visit Note Report,” dated 11/11/24, revealed that LVN A indicated “no drainage kits found in the home.” LVN A indicated that she explained this to an unnamed CTL who responded they would pass the order. Pleural drainage was not performed at this visit due to lack of drainage supplies. Record review of document titled “Order Number: 2504307,” dated 11/11/24, revealed an order for drainage kits to be delivered to Client 1’s home on 11/12/24 and for a skilled nursing visit to be scheduled for pleural drainage 11/12/24. Order also indicated “pleural drainage to be performed ASAP.” The order was received and entered by LVN A from MD A. Record review of home visits scheduled for Client 1 revealed that a home visit did not occur on 11/12/24. Record review of document titled “Visit Note Report,” dated 11/13/24, revealed that Client 1’s vital signs were outside of normal parameters with a respiratory rate or 26 (elevated above the normal high range of 20) and a blood pressure reading of 180/90 (elevated compared to the normal of 120/80). LVN A noted in the narrative section that Client 1’s oxygen saturation was between 87-90% (low compared to the normal range of 95-100%). Client 1 was sent to the hospital emergency room and her physician was notified. Record review of document titled “Order Number: 2506934,” dated 11/15/24, revealed that Client 1 was admitted to the hospital on 11/13/24 with a reason for admission which included “SOB, HTN, decreased breath sounds, weakness.” Order indicated that SN were to resume services effective 11/17/24. In an interview with the Administrator on 11/26/24 at 12:28 PM, the surveyor asked about the agency’s process for tracking when patients need more supplies. Administrator reported that clinicians should do a count every time they have a visit, but there was not an actual number to alert if there were too few kits. Administrator reported that from ordering to receiving, it could take 2-3 days to get a pleural drain kit. Once a clinician requests the supplies, it must be put in by a CTL If it was over $100 then it must also be approved by upper management. Administrator reported that upper management is usually able to approve the item that same day and the Administrator identified upper management at VPO. Surveyor asked specifically why orders were not delivered in the time needed to provide ordered patient care for Client 1 after it was noted that there was a request on 11/11/24. Administrator reported that it was not approved because the VPO did not get to it that day and they have to approve the request. Surveyor asked about the order for a nurse to go see Client 1 on 11/12/24 and drain the pleural drain. Surveyor noted that a visit did not occur that day and asked the Administrator if anyone every notified MD A that the visit was missed and care was not provided. Administrator reported that she does not believe that communication occurred and that she could not find documentation that it was communicated. Surveyor asked who would have been responsible to communicate that information. The Administrator responded that it should have been communicated by either CTL B or LVN A. Surveyor asked what the agency has done since this incident to prevent it from happening again. Administrator reported that CTL A is the new CTL for Client 1 and that they are utilizing biweekly calendar reminders to ensure that supplies are delivered. Additionally, they have stocked 5 extra pleural drain kits in the office in case they cannot be delivered. Administrator stated that education has been provided to staff who interact with Client 1 most often, and that they have an in-service planned for all staff regarding supply management in December. In an interview with CTL B on 11/26/24 at 1:03 PM, the surveyor asked CTL B who would have been responsible to notify the MD A that the skilled nursing visits and pleural drain procedure did not occur as ordered on 11/12/24. CTL B reported that it should have been reported by LVN A. In an interview with CTL A on 11/26/24 at 1:05 PM, surveyor asked about the nurses’ notes on 10/23/24 and 10/25/24, which described a need for drainage kit supplies. CTL A reported that he was filling in for CTL B who normally coordinates for Client 1. CTL A reported that the 10/23 order did not make sense and only indicated the need for either the kits or the tubes, he could not recall which. CTL A copied a previous order instead but when sent to the Administrator for approval she was concerned that the quantity was too high. CTL A then corrected the order to a lower quantity and it was approved and arrived at Client 1’s home the following day. CTL A reported that CTL B completed the order on 11/11/24 preceding Client 1 being hospitalized. In an interview with CTL B on 11/26/24 at 1:14 PM, the surveyor asked about the process for ordering supplies for Client 1 when LVN A noted she was out of pleural drain kits on 11/11/24. CTL B reported that LVN A asked her to place a order for drain kits and CTL B placed the order on 11/11/24. The following day CTL B noticed that the order was still pending and notified the Administrator. At this time, the Administrator responded that it could not be approved because it was too large of a quantity and that only 2 weeks’ worth of supplies could be ordered at a time. CTL B changed the order to reflect this quantity on 11/12/24. The Administrator reported that she could not approve the order after it was changed because she was driving. CTL B reported that the order was approved on 11/14/24 by the VPO. CTL B was unable to say why the order was not approved later in the day on 11/12/24 or on 11/13/24. In an interview with the VPO on 11/26/24 at 1:36 PM, the surveyor asked why the order for pleural drain kits for Client 1 was not approved on 11/12/24 or 11/13/24. VPO responded stating that there was not excuse. VPO is the individual to give final approval and she reported that she was at a conference with limited email access. Because of this, she required additional notification via text of phone call for time sensitive matters. VPO reported that she had thought the order was approved when it was originally requested on 11/11/24.VPO reported that she has provided education to the Administrator that it is okay to approve a higher quantity. Surveyor asked what else was being done to make sure this does not happen again. VPO responded that everyone now has email reminders to make sure orders are approved the same day that they are entered. Moving forward RN A will also see Client 1 on a weekly basis to ensure that there is enough product. Surveyor asked whose responsibility it was to contact MD A when the 11/12/24 order to see Client 1 and drain her drains did not occur. VPO reported that it should have been completed by LVN A, with LVN A calling the RN in office to MD A. In an interview with LVN A on 11/26/24 at 2:03 PM, the surveyor asked why the visit that was supposed to take place on 11/12/24 was not communicated with the MD A. LVN A reported that she was not scheduled with Client 1 on 11/12/24 and therefore she did not call. Review of policy titled “Scope of services,” dated 10/17/24, revealed that it is part of the agency’s responsibility to “obtain access to equipment and supplies that facilitate appropriate care.” Review of policy titled “Admission process & patient assessment,” dated 10/20/2023, revealed that criteria for admission included that “the agency has adequate, suitable staff and resources to provide the needed services,” and that “the physical facilities and equipment are adequate to meet the safety and care needs of the patient.” Review of policy titled “Coordination of services,” dated 10/18/2023, revealed that it was a responsibility of staff to “promptly alert the physician to any changes which suggest a need to modify the plan of care” and to “document actions which reflect coordination according to established procedures.” Established procedures included that the licensed professional would “notify the physician, patient and family, and other staff of significant events of revisions in the plan.”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: The agency failed to use professional standards of practice when maintaining client records and to keep client records confidential and safeguarded against loss and misuse. Based on record review and interview, the agency failed to adhere to professional standards of practice when maintaining client records by not including accurate pulmonary and integumentary assessment data for 1 of 4 clients (Client #1). This failure placed clients at risk of health decompensating without recognition due to inaccurate assessment notes. Findings included: Record review of document titled “Home Health Certification and Plan of Care,” signed and dated 09/18/24 for the certification period from 9/8/2024 to 11/6/2024, revealed that Client 1 had orders for skilled nursing to “observe and assess [the] respiratory system.” Orders also included “to perform observation/assessment or pleurx (a hollow chest catheter that drains fluid from the chest to help with breathing), located right chest by draining 500 cc of fluid each side. Drain right tube 3 x week and drain left tube 1 x a week and 1-3 PRN visit related to distress/discomfort.” Under the section titled “DME and Supplies,” pleurx supplies were listed. Record review of document titled “Visit Note Report,” dated 10/23/24, revealed “examination reveals no abnormal findings of the pulmonary system,” and “no abnormal integumentary assessment findings” despite the patient having pleural drains. LVN A indicated in narrative section “slight posterior wheezing” and performance of pleural drainage. No additional details of lung sounds, locations, or skin quality at drain sites were noted. Record review of document titled “Visit Note Report,” dated 11/8/24, revealed “examination reveals no abnormal findings of the pulmonary system. Narrative note did include “lungs clear to auscultation.” LVN A indicated “no abnormal integumentary findings” despite Client 1 having a pleural drain. LVN A did not make comments on the integumentary system in the narrative section. Record review of document titled “Visit Note Report,” dated 11/11/24 revealed “examination reveals no abnormal findings of the pulmonary system” and “no abnormal integumentary findings” despite Client 1 having a pleural drain. Lung sounds, skin condition at drain site, or other details related to the pulmonary and integumentary systems were not included in the narrative section of the note. Record review of document titled “Visit Note Report,” dated 11/13/24, revealed that Client 1’s vital signs were outside of normal parameters with a respiratory rate or 26 and a blood pressure reading of 180/90. LVN A noted in the narrative section that Client 1’s oxygen saturation was between 87-90%. “Examination reveals no abnormal findings of the pulmonary system” and “no abnormal integumentary findings” despite the presence of a pleural drain and vital signs indicated a possible decompensated pulmonary status. Narrative portion does not indicate details regarding lung sounds or skin assessment. Record review of document titled “Order Number 2509722,” dated 11/20/24, revealed an order description which included a skilled nursing frequency effective the week of 11/17/24 of twice a week for 1 week followed by 3 times a week for 6 weeks. Orders included “skilled nurse to observe and assess respiratory system (and) skilled nurse to perform observation/assessment of pleurx.” Record review of document titled “Visit Note Report,” dated 11/21/24, revealed “examination reveals no abnormal findings of the pulmonary system” and “no abnormal integumentary findings” despite Client 1 having a pleural drain. In narrative section, RN A indicated “respiratory status within normal limits” despite “severe breathlessness” being noted under the respiratory section and Client 1 being on 2 liters of oxygen. RN A did not describe lung sounds or skin condition at drain site in the narrative section. Record review of document titled “Visit Note Report,” dated 11/22/24, revealed “examination reveals no abnormal findings of the pulmonary system” and “no abnormal integumentary findings” despite Client 1 having a pleural drain. LVN A noted “non productive cough” in narrative section, but did not include any findings related to lung sounds or skin condition at drain site and if the client was receiving oxygen. Record review of document titled “Visit Note Report,” dated 11/25/24, revealed “examination reveals no abnormal findings of the pulmonary system” and “no abnormal integumentary findings” despite Client 1 having a pleural drain. LVN A did not include any details on lung sounds or skin condition at drain site in the narrative section. In an interview with the Administrator on 11/26/24 at 12:28 PM, the surveyor read aloud visit notes for Client 1 by LVN A which indicated “examination reveals no abnormal findings of the pulmonary system [and] no abnormal integumentary findings” despite Client 1 having a pleural drain, compromising both their pulmonary and integumentary systems. The surveyor showed the Administrator that RN A described Client 1’s respiratory status “within normal limits” despite it being noted the Client 1 had “severe breathlessness” and being on 2 liters of oxygen. Surveyor showed Administrator that lung sounds are rarely described among visit notes for Client 1. Surveyor asked Administrator what the agency expectation was for documenting assessment findings. Administrator reported that documentation of assessment findings for Client 1 was not acceptable. Administrator stated that lung sounds should be assessed and documented for all patients, not just those with a pulmonary or respiratory condition. Administrator reported that RN A and LVN A should not have documented “no abnormals” for either pulmonary or integumentary system because the patient has a pleural catheter (drainage of the chest cavity). In an interview with the VPO on 11/26/24 at 1:36 PM, the surveyor asked about agency expectations for documenting assessment findings for different body systems. Surveyor read aloud visit notes for Client 1 by LVN A which indicated “examination reveals no abnormal findings of the pulmonary system [and] no abnormal integumentary findings” despite Client 1 having a pleural drain, compromising both their pulmonary and integumentary systems. RN A described Client 1’s respiratory status “within normal limits” despite it being noted the Client 1 had “severe breathlessness” and being on 2 liters of oxygen. The VPO responded that this was not acceptable and that more training would be provided. The VPO found training modules specifically related to assessment and documentation of the pulmonary system and reported she would provide training to staff via online classes and modules. Surveyor asked the VPO how this affected client care. The VPO responded that if clinicians who are routinely seeing the patient were unable to see them then new incoming staff will be misled about the patient’s current state of health. All staff are supposed to review the prior 1 or 2 notes prior to seeing a patient. This would impact their perception of the patient’s care. In an interview with LVN A on 11/26/24 at 2:03 PM. Surveyor asked LVN A why she indicated that there were no abnormal pulmonary or integumentary findings for Client 1 when they had a pleural catheter. LVN A reported that what she meant was that Client 1 was not having an exacerbation. Surveyor asked LVN A why she did not document assessment findings as standard for nursing, which was to document in comparison to a healthy patient without disease ailments. LVN A reported that this was just how she has been doing it. Surveyor asked LVN A if she thought that was safe for the patient if in the event that she was unable to see them then a new nurse would not have accurate documentation to compare it to. LVN A responded that she understood and that it would be better and safer for her to document findings at each visit as compared to a healthy patient. Review of policy titled “Scope of services,” dated 10/17/24, revealed that it was a responsibility of the registered nurse to “follow the nursing process in identifying nursing-prescribed actions such as assessment and teaching,” and that it is a role of the LVN to “comply with accepted nursing standards and principles.” Review of policy titled “Clinical records,” dated 05/03/2024, indicated that documentation by nurses and LVNs included “clinical or visit notes.” Agency definition of clinical note was included as “a notation of contact with a patient that is written and dated by a nurse, therapist, or social worker which describes signs and symptoms, treatment and drugs administered and the patient’s reaction, and any changes in physical, emotional or social condition which may affect the patient’s outcome or response to care.” The agency definition of assessment noted indicated that it were to include “pertinent assessment findings.”

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: The agency failed to enforce its written policy to make sure client care was coordinated among all service providers to promote optimal client outcomes. Based on record review and interview, the agency failed to enforce its written policy to make sure client care was coordinated for 1 or 4 clients (Client 1), in that LVN A did not inform MD A of a missed visit on 11/12/24 and was unable to perform chest tube drainage on 11/11/24. This failure placed Client #1 at risk of health decompensation by not receiving care that was ordered or communicating that it could not be provided. Findings included: Record review of document titled “Home Health Certification and Plan of Care,” signed and dated 09/18/24 for the certification period from 9/8/2024 to 11/6/2024, revealed that Client 1 had orders for skilled nursing “to perform observation/assessment or pleurx ( a hollow catheter that drains fluid from the chest to help with breathing), located right chest by draining 500 cc of fluid each side. Drain right tube 3 x week and drain left tube 1 x a week and 1-3 PRN visit related to distress/discomfort.” Record review of document titled “Order Number: 2504307,” dated 11/11/24, revealed an order for drainage kits to be delivered to Client 1’s home on 11/12/24 and for a skilled nursing visit to be scheduled for pleural drainage 11/12/24. Order also indicated “pleural drainage to be performed ASAP.” The order was received and entered by LVN A from MD A. Record review of home visits scheduled for Client 1 revealed that a home visit did not occur on 11/12/24, and that no pleural drainage was performed by LVN A on 11/11/24. In an interview with the Administrator on 11/26/24 at 12:28 PM the surveyor asked the Administrator about the order for a nurse to go see Client 1 and drain the pleural drain on 11/12/24. Surveyor asked the Administrator if the ordering provider was notified when this visit did not occur. Administrator responded that she did not see a communication to the ordering provider in the clinical record and therefore she assumed that it was not communicated to them. Surveyor asked Administrator who would have been responsible for relaying this information to the ordering provider. Administrator responded that it should have been communicated by either LVN A or CTL B. In an interview with CTL B on 11/26/24 at 1:03 PM, the surveyor asked CTL B if she reported that the ordered visit on 11/12/24 for Client 1 did not occur to the ordering provider. CTL B responded that she did not report that the visit did not occur or would not be occurring and that it should have been LVN A to report this information. In an interview with the VPO on 11/26/24 at 1:36 PM, the surveyor asked who would have been responsible for communicating to the MD A that the visit ordered on 11/12/24 for Client 1 did not occur. The VPO responded that LVN A should have reported this to MD A or they should have contacted the RN in office for them to report that they could not complete the order. In an interview with LVN A on 11/26/24 at 2:03 PM. The surveyor asked LVN A why it was not communicated to MD A when the visit that was supposed to take place on 11/12/24 with Client 1 did not occur. LVN A responded that she did not know and that she did not report it because she was not scheduled with Client 1 on 11/12/24. LVN A was unable to suggest who should have reported this. Review of policy titled “Coordination of services,” dated 10/18/2023, revealed that it was the responsibility of the licensed profession to “notify the physician, patient and family, and other staff of significant events or revisions in the plan.”

A recertification survey entrance conference was conducted on 04/04/2023 at 09:00 a.m. with the Administrator. Census: License and Certified: San Antonio: 311 Bastrop: 229 Austin: 508 An exit conference was conducted on 04/07/2023 at 04:00 p.m. with the Administrator and Supervising Nurse. 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.

A recertification survey entrance conference was conducted on 04/04/2023 at 09:00 a.m. with the Administrator. Census: License and Certified: San Antonio: 311 Bastrop: 229 Austin: 508 An exit conference was conducted on 04/07/2023 at 04:00 p.m. with the Administrator and Supervising Nurse. 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. Acronyms: ALF - Assisted Living Facility. MAR - Medication Administration Record. ST - Speech Therapist LVN - Licensed Vocational Nurse

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the patient's clinical record identified all medications that the patient is taking for one of 17 patients (Patient #5) whose records were reviewed in that: Patient # 5's current medication profile did not include the order for Humalog KwikPen (U-100) Insulin 100 units/ml Subcutaneous was discontinued from the patient's medication regimen. This failure could affect all clients in the agency and could place the clients at risk for ineffective drug therapy, significant side effects, and adverse drug reactions. The findings were: Review of Patient #5's plan of care (dated 03/10/2023) for certification period from 02/09/2023 to 04/09/2023 revealed diagnoses of Alzheimer's Disease (a progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain. It is the most common cause of premature senility.), Unspecified, and Type II Diabetes. Record review of this plan of care and current medication report included an order for Humalog (a hormone produced in the pancreas which regulates the amount of glucose in the blood.) KwikPen (U-100) Insulin 100 units/ml Subcutaneous as directed according to a sliding scale ( a glucose level scale used to administer the dose of insulin based on blood glucose level) before meals and at bedtime. A home visit was conducted on Patient #5 at his residence at an assisted living facility on 04/05/2023 at 08:20 a.m. Record review of Patient #5's Medication Administration Record at the ALF revealed order for Humalog was not on the ALF's MAR. During an interview on 04/05/2023 at 08:23 a.m., LVN C stated Patient #5 was at hospital and readmitted to ALF on 2/9/2023, Humalog was discontinued at hospital. LVN C stated further stated she called Patient #5's primary care doctor to verify the admission medications orders before the medications were input into the MAR. Record review of Patient #5's clinical record revealed home visits conducted on 03/21/2023, 03/31/2023, and 04/01/2023 by ST E. During an interview with ST E at 4/7/23 at 2:33 p.m., stated normally will ask the nurse at the ALF if there were any new meds or any recent changes, and the nurse will let me know if there were or not. Further interview revealed she talked to LVN C yesterday (04/06/2023) and LVN C informed her the Humalog was discontinued. ST E further revealed she should have gone over the ALF's medications with the agency's medication profile at each visit. During an interview on 04/07/2023 at 03:30 p.m., the Administrator revealed when Patient #5 was discharged from a rehabilitation admitted to the ALF , the order for Humalog was on the medication profile but was discontinued by the nurse practitioner. The Administrator further revealed she does not think the agency staff know how to do a medication reconciliation. Record review of the agency's policy titled "Clinical Records (05/23/2022) read in part, "2.1 Clinical record is a compilation of the patient's total home health care, related documentation of the care delivery process, and contains pertinent past and current findings...the record includes: 2.1.3 Drug...treatment and activity orders." No additional documentation was provided by the time of exit or within two business days.