Every finding on record at Hallmark Homecare LP

An entrance conference was conducted for a Relicensure and Recertification Survey with the Administrator on 9/26/ 2023 at 1:15 p.m. Census: 173 Licensed and Certified Home Health:165 Licensed Home Health: 8 Personal Assistant Services: 0 Hospice:0 Exit conference was conducted on 9/29/2023 at 11:15 a.m. with the Administrator and Assistant Administrator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. No deficiencies were cited. The agency was in substantial compliance with 42 CFR Part 484.102 Emergency Preparedness Requirements for Home Health

An entrance conference was conducted for a Relicensure and Recertification Survey with the Administrator on 9/26/2023 at 1:15 p.m. Census: 173 Licensed and Certified Home Health:165 Licensed Home Health: 8 Personal Assistant Services: 0 Hospice:0 Exit conference was conducted on 9/29/2023 at 11:15 a.m. with the Administrator and Assistant Administrator. 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 Violations. RN – Registered Nurse EMR - Electronic Medical Record LVN - Licensed Vocational Nurse POC – Plan of Care

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to accommodate the patient’s request regarding the delivery of care for one of 13 active patients (Patient #5) whose records were reviewed, in that: Patient #5’s privacy request was not accommodated during delivery of care. This deficient practice places the agency's clients at risk for receiving inadequate service delivery due to the non- adherence of patients’ rights who are under the care of the home health agency. The findings included: Review of Patient #5's clinical record (Plan of Care) revealed a Start of Care date of 8/24/2023 for a POC certification period from 8/24/2023 through 10/22/2023 with a diagnosis of removal of a kidney, obesity, and the placement of a foley catheter. Further record review of the plan of care, dated revealed that skilled nursing visits was ordered 1 every 2 weeks for a foley catheter change. During an observation home visit to Patient #5’s home, revealed that Patient #5 lives in an apartment complex. Further observation revealed Patient #5’s hospital bed was in the living room with two large windows located in the living room leading to the main walkway of the apartment complex. During an observation home visit with Patient #5 at 10:00 am on 9/27/2023, Patient #5’ stated she requires a skilled nurse visit for a Foley catheter (a tube insertion to collect urine) change every 2 weeks. Further observation revealed RN A and LVN A performed the foley catheter change procedure proximal to two windows in the living room with the open blinds leading to the main walkway of the apartment complex. During an interview with the RN A on 9/28/2023 at 11:50 a.m., the RN A was informed Foley catheter change procedure completed in the living room with living room blinds open . The RN A acknowledged the above finding stating that Patient #5 did ask her to close the blinds before the procedure, but she forgot. During an interview with the Administrator on 9/28/2023 at 11:45 a.m., the Administrator was informed of the above findings. The Administrator acknowledged that the blinds should have been closed at Patient #5’s home to adhere to patient privacy rights for a Foley catheter change. Review of the agency’s patient admission resource book revealed, “Texas Human Resources Code Chap 102 Section 102.003 Rights of the Elderly,” read in part, “…g. An elderly individual is entitled to privacy while attending to personal needs and a private place for receiving …medical treatment, written communication…” Review of the agency’s policy titled, “Service Delivery: Patient’s rights” dated 9/2023, revealed “3.2 The Agency educates staff about patient rights. 3.2.1 During orientation the Agency inform employees…including confidentiality…how to respect the patient and her property, and how to individualize care to the patient’s unique situation as well as in Home Health…3.2.2 The Agency encourages employees to be proactive in promoting and protecting the patient’s rights during regularly scheduled, on-site supervisory visits…”