Every finding on record at Healthcare of West Texas, LLC

A Complaint Survey entrance conference was conducted on 11/06/23 with the Administrator & Supervising Nurse C, at 9:22 A.M. Census: L&C – 164 LHH – 120 An exit conference was conducted on 11/13/23, with the Administrator, Supervising Nurse C, CEO, Compliance Reviewers L & M, at 2:28 P.M. 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/Violations. Intakes #101320, 97626, 101677, and 96318 Abbreviations: 1.) CII - Complaint and Incident Intake 2.) L&C - Licensed and Certified 3.) LHH - Licensed Home Health

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to immediately report knowledge of alleged acts of abuse, neglect and exploitation of 2 of 4 agency patients (Patient #1 & Patient #4) by an agency employee to Health and Human Services Commission. Failure of the agency to report alleged acts of abuse, neglect and exploitation has the potential to place patients at risk of further abuse, neglect and exploitation and allegations may not be addressed in a timely manner. Based on record review and interview, the agency failed to immediately report within 24 hours, knowledge of alleged acts of abuse, neglect and exploitation of 2 of 4 agency patients (Patient #1 & Patient #4) by an agency employee to Health and Human Services Commission. Failure of the agency to report alleged acts of abuse, neglect and exploitation has the potential to place patients at risk of further abuse, neglect and exploitation and allegations may not be addressed in a timely manner. Findings: Review of Intake #454028, dated 9/26/2023, indicated the allegations of neglect and patient rights was reported to CII, by Supervising Nurse C on 9/26/2023, notifying CII of the allegations of neglect and patient rights involving Patient #1. Review of Intake #454028, under the “General Intake Notes” section “The reporter first learned of the incident on 9/18/2023.” The agency did not report the incident to CII until 8 days after being notified of the incident. Review of the Provider Investigation Report, dated 9/26/2023, the allegations of neglect and patient rights was reported to Health and Human Services Commission on 9/26/2023. In the “Description of Injury/Assessment” section of the form “9/18/2023, Patient #1 was ordered to take Novolog 2 units subcutaneous twice a day & Levemir 10 units subcutaneous every day. Both medications are kept in the same location in the patient’s refrigerator. Skilled nurse administered Novolog 10 units subcutaneous times 1 dose. When returning the insulin to the refrigerator Licensed Vocational Nurse G became aware she administered the incorrect dose of the medication. During an interview on 11/12/23 at 3:18 p.m., with Administrator, when asked why the intake was not reported to the state within 24 hours of her knowledge, she said, “When the incident occurred we were focusing on the patient care with new orders and skilled nurse to watch the patient every hour after the incident for 4 hours. Upon further review our compliance team and a discussion with Region 1 – Regional Director with Home and Community Support Services Agencies we concluded a self-report was necessary. Then it was called in on 9/26/23.” Review of Intake #358156, dated 6/17/2022, indicated the allegations of patient rights was reported to CII, by Administrator on 6/17/2022, notifying CII of the allegations of patient rights. Review of Intake #358156, under the “General Intake Notes” section “The reporter first learned of the incident on 6/17/2022.” The agency did not report to CII until 3 days after being notified of the incident. Review of the Provider Investigation Report, dated 6/17/2022, the allegations of patient rights was reported to Health and Human Services Commission on 6/17/2022. In the “Description of Injury/Assessment” section of the form “Licensed Vocational Nurse H, reported that she [was] given a new patient at an assisted living facility on 6/10/22. She reports that the Director/Owner was there when she arrived and appeared to be the only employee available. She asked him about our patient, [Patient #4] and he pointed her to the patient’s room. She completed her visit and drew blood on the patient. She stated that she addressed the patient as [Patient #4] and that she responded to the name and discussed information regarding her diagnosis and medications. On 6/14/2022 Licensed Vocational Nurse H returned to the same facility and the current staff that was available took her to the patient’s room that was not the same patient she saw on 6/10/2022. The staff made it clear that this was the correct patient and the patient said yes. During an interview on 11/12/23 at 3:30 p.m., with Administrator, when asked why the intake was not reported to the state within 24 hours of her knowledge, she said, “I am not sure why. I am usually right on these kind of things.” Review of a policy titled “Abuse, Neglect, Exploitation and Complaints,” date unknown, indicated, “Who have cause to believe a client served by the agency has been abused, neglected or exploited by an agency employee shall report the information immediately, meaning with 24 hours to; A. Department of Family and Protective Services at 1-800252-5400 and B. CII at ciicomplaints@hhs.texas.gov or call 1-800-458-9858.