Every finding on record at High Plains Senior Care, LLC

An investigation (Intakes #1079449 & #1030529) was conducted on 04/02/2026. The agency census was 545 (HHA). The Census was: 545 L&CHHS: 545 LHHS: 0 Pas: 0 Abbreviations L&CHHS- Licensed & Certified Home Health Services LHHS- Licensed Home Health Services PAS- Personal Assistance Services QAPI- Quality Assessment & Performance Improvement PIP- Performance Improvement Plan POC- Plan of Care HHA- Home Health Aide PT- Physical Therapy SNV- Skilled Nurse Visit SN- Skilled Nurse MV- Missed Visit BM- Branch Manager SOC- Start of Care ROC- Resumption of Care MWF- Monday, Wednesday, Friday PRN- As needed visit FC- Foley catheter Q- Every COORD- Coordination RN- Registered Nurse FM- Family Member d/t- Due to MD- Medical Doctor EFF- effective VM- Voicemail

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure 4 (Patient #2, #3, #4, and #5) out of 6 patients reviewed, received all services outlined in the plan of care. This failure had the potential to place patients at risk of not having their needs met and had the potential to result in negative patient outcomes. 1. Review of the clinical record for Patient #2 revealed a POC dated 01/03/2026-03/03/2026. With the following diagnosis enlargement of the prostate, unable to empty the bladder, and history of small stones in the urinary system that can cause pain and block urine. SN services including PROVIDE INSTRUCTION/REINFORCEMENT FOR BENIGN PROSTATIC HYPERPLASIA WITH LOWER URINARY TRACT SYMPTOMS, INSTRUCTION TO INCLUDE BUT IS NOT LIMITED TO THE DEFINITION, CAUSES, RISK FACTORS, POSSIBLE COMPLICATIONS, AND SIGNS AND SYMPTOMS OF DISEASE EXACERBATION TO REPORT, SKILLED NURSE TO INSTRUCT PATIENT/CG ON OBTAINING/MONITORING/LOGGING DAILY WEIGHTS AND NOTIFY AGENCY AND/OR MD OF WEIGHT GAIN OF 3LBS IN 24 HOURS OR 5LBS IN ONE WEEK. SKILLED NURSE TO REVIEW MEDICATION PROFILE AND RECONCILE MEDICATIONS AS NEEDED. SKILLED NURSE MAY INSTRUCT AND REINFORCE MEDICATION TEACHING RELATED TO USE OF MEDICATIONS TO TREAT DISEASE PROCESSES. SKILLED NURSE MAY FILL MEDIPLANNER PER CURRENT MEDICATION ORDERS/PROFILE AS NEEDED, SKILLED NURSE TO PROVIDE AND INSTRUCT REGARDING FALL PREVENTION INTERVENTIONS. SKILLED NURSE TO PROVIDE/INSTRUCT REGARDING INTERVENTION(S) TO MONITOR AND MITIGATE PAIN AND SKILLED NURSE TO PROVIDE INSTRUCTIONS REGARDING INTERVENTION(S) TO PREVENT PRESSURE ULCERS. The POC read in part: “Orders and Treatments: SN 1wk8 (one time a week for 8 weeks) and PT 2wk8 effective 1/4/26: 2wk7, 1wk1 effective 3/8/26. Further review of the clinical record revealed SN visit on 01/09/2026, 1/19/2026, and 2/13/2026. With the following Missed visits for SN 1/16/2026, 1/30/2026, 2/6/2026, 2/20/26, 2/27/2026 due to staffing shortages as per Missed Visit Report. Coordination notes were completed for MV but no documentation on MD being notified. Record review of a complaint report, dated 02/10/26, regarding Client #2, signed by RN F, indicated, “CARE GIVER CALLED ASKING WHY PATIENT HAS NOT BEEN SEEN BY A NURSE IN ALMOST 30 DAYS. CAREGIVER STATED HE WAS SEEN ON A MONDAY BUT OTHER THAN THAT HE HAS NOT BEEN SEEN AND HE NEEDS TO BE SEEN … BM SPOKE WITH SCHEDULER AND [Administrative Assistant E] … SPOKE WITH SCHEDULER AND [Administrative Assistant E] REGARDING MISSED VISITS VIA TEAMS … MV WILL BE LOOKED AT/POSSIBLE NEW PROCESS TO AVOID THIS INCIDENT …” 2. Review of the clinical record for Patient #3 revealed a POC dated 01/06/2026 to 03/06/2026. With the following diagnosis a pocket of pus that formed in the bottom opening, heart failure, and blood with high levels of fat. SN services including SKILLED NURSE TO INSTRUCT PATIENT/CG ON OBTAINING/MONITORING/LOGGING DAILY WEIGHTS AND NOTIFY AGENCY AND/OR MD OF WEIGHT GAIN OF 3 LBS IN 24 HOURS OR 5 LBS IN ONE WEEK. SKILLED NURSE TO PROVIDE INSTRUCTION/REINFORCEMENT FOR RECTAL ABSCESS. INSTRUCTION TO INCLUDE BUT IS NOT LIMITED TO THE DEFINITION, CAUSES, RISK FACTORS, POSSIBLE COMPLICATIONS, AND SIGNS AND SYMPTOMS OF DISEASE EXACERBATION TO REPORT. REINFORCE MEDICATION TEACHING RELATED TO USE OF MEDICATIONS TO TREAT DISEASE PROCESSES. SKILLED NURSE MAY FILL MEDIPLANNER PER CURRENT MEDICATION ORDERS/PROFILE Q PRN. SKILLED NURSE TO PROVIDE AND INSTRUCT REGARDING FALL PREVENTION INTERVENTIONS. SKILLED NURSE TO PROVIDE/INSTRUCT REGARDING INTERVENTION(S) TO MONITOR AND MITIGATE PAIN. SKILLED NURSE TO PROVIDE INSTRUCT REGARDING INTERVENTION(S) TO PREVENT PRESSURE ULCERS. The POC read in part: “Orders and Treatments: SN 1wk9 (one time a week for 9 weeks). Further review of the clinical record revealed SN visit on 1/6/2026 for SOC. With the following Missed visits for SN 1/14/2026, 1/20/2026, 1/30/2026 for staffing shortages and 2/03/2026 MV for No authorization from insurance. No visit or documentation for week of 2/08/2026-2/14/2026. Coordination note for MV on 2/03/26, No other coordination notes made for MVs, Coordination note dated 1/27/2026 received a call from patient to request discharge due to not being seen at all, AS per branch manager nurse will be sent out next day for discharge, discharge was not made until 2/17/2026 disregarding request made by patient to branch manager at Lubbock office. No discharge summary and or documentation MD was notified of Discharge and or MVs. Record review of a complaint report, dated 01/27/26, regarding Patient #3, signed by RN F, indicated, “PATIENT COMPLAINED THAT HE HAS NOT BEEN SEEN. ADMISSION ON 01.06.2026 BY A NURSE … THIS NURSE SPOKE WITH SCHEDULER. PATIENT'S [sic] VISITS WERE MISSED DUE TO STAFFING. THIS NURSE ATTEMPTED TO HAVE ANOTHER NURSE COME OUT TO SEE HIM TODAY BUT HE REFUSED DUE TO APPOINTMENTS ALREADY MADE … PATIENT REQUESTED TO BE DISCHARGED. THIS NURSE ASKED THAT A NURSE COME OUT TOMORROW AND PATIENT AGREED.” 3. Review of the clinical record for Patient #4 revealed a POC dated 09/27/2025-11/25/2025. With the following diagnosis aftercare following joint replacement surgery, presence of left artificial hip joint, high sugars in the blood and high blood pressure. SN services including SKILLED NURSE TO ASSESS/EVALUATE AND EDUCATE CO-MORBID CONDITIONS INCLUDING AFTERCARE FOLLOWING JOINT REPLACEMENT SURGERY AND OTHER CONDITIONS THAT PRESENT THEMSELVES DURING THE COURSE OF THIS EPISODE TO IDENTIFY CHANGES AND INTERVENE TO MINIMIZE COMPLICATIONS. SKILLED NURSE TO PROVIDE INSTRUCTION/REINFORCEMENT FOR AFTERCARE FOLLOWING JOINT REPLACEMENT SURGERY. INSTRUCTION TO INCLUDE BUT IS NOT LIMITED TO THE DEFINITION, CAUSES, RISK FACTORS, POSSIBLE COMPLICATIONS, AND SIGNS AND SYMPTOMS OF DISEASE EXACERBATION TO REPORT. ASSESS AND MONITOR SURGICAL INCISION TO LEFT HIP SKILLED NURSE TO REVIEW MEDICATION PROFILE AND RECONCILE MEDICATIONS AS NEEDED. SKILLED NURSE MAY INSTRUCT AND REINFORCE MEDICATION TEACHING RELATED TO USE OF MEDICATIONS TO TREAT DISEASE PROCESSES. SKILLED NURSE MAY FILL MEDIPLANNER PER CURRENT MEDICATION ORDERS/PROFILE QPRN. SKILLED NURSE TO PROVIDE MONITORING FOR THE PRESENCE OF SKIN LESIONS ON THE LOWER EXTREMITIES AND TEACHING/REINFORCEMENT REGARDING PROPER DIABETIC FOOT CARE. SKILLED NURSE TO PROVIDE AND INSTRUCT REGARDING FALL PREVENTION INTERVENTIONS. SKILLED NURSE TO PROVIDE/INSTRUCT REGARDING INTERVENTION(S) TO MONITOR AND MITIGATE PAIN. SKILLED NURSE TO PROVIDE INSTRUCT REGARDING INTERVENTION(S) TO PREVENT PRESSURE ULCERS. The POC read in part: “Orders and Treatments: SN 1wk1, 2wk3, 1wk5 (one time a week for 1 week, 2 times per week for 3 weeks, and 1 time per week for 5 weeks). Further review of the clinical record revealed SN visit on 9/27/2025 for SOC. No documentation Skilled nurse visits were made on 09/28/2025- 10/02/2025. PT evaluation was made on 10/01/2025, Physical therapist notified RN on 10/01/2025 of increased drainage to surgical incision, no follow up visit and or documentation from Nurse. Order for Hospital hold effective 10/02/2025 all services on hold due to admission to hospital, Diagnosis left hip drainage. Plan to resume services upon discharge from hospital. Order dated 10/16/2025, Schedule ROC effective 10/19/2025 SN 1wk1. No visit completed until 10/23/2025, ROC was done no wound care was ordered for MWF, patients caregiver complained wound machine that helps a wound heal by gently sucking out fluid and keeping it clean was not working during visit, no documentation regarding this complain on nurses note. Record review of a complaint report, dated 10/23/25, signed by RN F, regarding Patient #4, indicated, “PATIENT WAS RELEASED FROM [Rehabilitation Hospital #1] ON 10.21.25. SHE WAS INFORMED THAT A NURSE WOULD BE OUT ON 10.22.2025 TO PERFORM A ROC. PATIENT CALLED [Rehabilitation Hospital #1] ON 10.23.2025 STATING THAT NO ONE HAS COME OUT TO SEE HER AND HER WOUND MACHINE IS NOT WORKING. [Rehabilitation Hospital #1] CALLED MARKETER UPSET THAT NO ONE HAS GONE OUT TO SEE THIS PATIENT. PATIENT WAS UPSET AS WELL AND STATED THAT HER WOUND MACHINE IS JUST BEEPING, IT IS NOT SUCTIONING AND SHE WAS EXPECTING SOMEONE TO COME OUT ON 10.22.2025 … BM CALLED AND SPOKE WITH PATIENT, MARKETER CALLED AND SPOKE WITH REFERRAL SCOURCE [sic] … THIS NURSE SPOKE WITH PATIENT ON 10.23.2025, PATIENT STATED THAT HER WOUND MACHINE IS NOT WORKING AND SHE NEEDED A NURSE TO COME SEE HER. SHE STATED THAT SHE WAS EXPECTING SOMEONE ON 10.22.2025. UPON READING COORD NOTES IN THE PATIENT CHART RN STATED THAT SHE CALLED THE PATIENT AND IT WENT TO VM. RN STATED THAT SHE LEFT DOORTAG WITH CALL BACK NUMBER AND TIME OF ARRIVAL. WHEN SPEAKING WITH THE PATIENT THIS NURSE ASKED IF SOMEONE HAD TRIED TO SEE HER ON 10.21.2025, CALLED HER OR LEFT A DOORTAG. PATIENT DENIES GETTING ANY CALLS, DOORTAG NOR ANYONE CAME TO HER HOME. SHE STATED THAT HER AND FM X WERE HOME ALL DAY AND FM X GOES IN AND OUT OF THE FRONTDOOR ALL DAY AND NO NOTE WAS ON THE DOOR. I APOLOGIZED AND STATED A NURSE WOULD BE OUT TODAY TO SEE HER. ALL QUESTIONS AND CONCERNS WERE ADDRESSED IN PHONE CALL. EMAIL WAS SENT TO THE NURSE ASSIGNED TO THE PATIENT STATING NOT MISS TODAY'S VISIT AND MAKE SURE THAT THE WOUND MACHINE IS TAKEN CARE OF. BM WILL FOLLOW UP WITH PATIENT AFTER THE SNV IS PERFORMED, BM ATTEMPTED TO CALL FM FF ALTHOUGH VM WAS FULL AND THIS NURSE WAS UNABLE TO SPEAK WITH THEM AGAIN. PATIENT/FM FF REQUESTED DISCHARGE. SN ATTEMPTED TO SEE PATIENT ALTHOUGH FAMILY REFUSED SNV FOR DISCHARGE. 4. Review of the clinical record for Patient #5 revealed a POC dated 01/23/2026-03/23/2026. With the following diagnosis loss of movement and feeling in the lower half of the body, long-term pain, depends on wheelchair, and fitting and adjustment of urinary equipment to help collect, drain, or control urine. SN services including SKILLED NURSE TO ASSESS/EVALUATE AND EDUCATE CO-MORBID CONDITIONS, INCLUDING PARAPLEGIA AND OTHER CONDITIONS THAT PRESENT THEMSELVES DURING THE COURSE OF THIS EPISODE TO IDENTIFY CHANGES AND INTERVENE TO MINIMIZE COMPLICATIONS. SKILLED NURSE TO INSTRUCT PATIENT / CAREGIVER IN INDWELLING URINARY CATHETER (SOFT TUBE PLACED INTO BLADDER TO DRAIN URINE INTO BAG) MANAGEMENT INCLUDING CARE OF FOLEY CATHETER (SOFT TUBE PLACED INTO BLADDER TO DRAIN URINE INTO BAG), SIGN AND SYMPTOMS OF COMPLICATIONS, PERINEAL CARE, TUBE AND BAG PLACEMENT. SKILLED NURSE FOR INSERTION OF INDWELLING CATHETER (SOFT TUBE PLACED INTO BLADDER TO DRAIN URINE INTO BAG), CHANGE Q MONTH AND PRN DISLODGMENT OR STOPPAGE. SKILLED NURSE TO REVIEW MEDICATION PROFILE AND RECONCILE MEDICATIONS AS NEEDED. SKILLED NURSE MAY INSTRUCT AND REINFORCE MEDICATION TEACHING RELATED TO USE OF MEDICATIONS TO TREAT DISEASE PROCESSES. SKILLED NURSE MAY FILL MEDIPLANNER PER CURRENT MEDICATION ORDERS/PROFILE QPRN. SKILLED NURSE TO PROVIDE AND INSTRUCT REGARDING FALL PREVENTION INTERVENTIONS. SKILLED NURSE TO PROVIDE/INSTRUCT REGARDING INTERVENTION(S) TO MONITOR AND MITIGATE PAIN. SKILLED NURSE TO PROVIDE INSTRUCT REGARDING INTERVENTION(S) TO PREVENT PRESSURE ULCERS. The POC read in part: “Orders and Treatments: SN 1wk1, 2every2wk2, 2wk2, 1wk4 (one time a week for 1 week, 2 visits every 2 weeks for 2 weeks, 2 times per week for 2 weeks, and 1 time per week for 4 weeks) and PT EFFECTIVE 01/25/2026 1WK1,2WK7 (one time a week for 1 week and 2 times per week for 7 weeks). POC dated 03/24/2026-05/22/2026. The POC read in part: “Orders and Treatments: SN 2WK2,1WK7; (2 visits per week for 2 weeks, one visit per week for 7 weeks) PT EFFECTIVE 03/29/2026 2WK7,1WK1 (2 times per week for 7 weeks, 1 time per week for 1 week). Further review of the clinical record revealed SN visit on 1/23/2026 for SOC and MVs on 02/09/2026, 02/13/2026, 2/14/2026, 2/16/2026, 2/20/2026, 4/03/2026, 4/04/2026 for staffing shortages. 3/28 PRN SNV foley (SOFT TUBE PLACED INTO BLADDER TO DRAIN URINE INTO BAG) dislodged – update frequency d/t new FC placed – effective 4/5 SN 1w7(1 time per week for 7 weeks), 4/4 PRN SNV FC (SOFT TUBE PLACED INTO BLADDER TO DRAIN URINE INTO BAG) leaking, 4/7 PRN SNV due to FC (SOFT TUBE PLACED INTO BLADDER TO DRAIN URINE INTO BAG) leaking change to frequency order effective 4/5 1w1, 1q6w6. 5. Record review of the agency’s missed visit reports for the parent and branch offices for the time-period of January 2026 – April 2026, indicated the following: For the parent office in Amarillo, Texas, for the time-period of January 2026 – April 2026, the agency had 621 missed client visits due to “STAFFING SHORTAGE.” For the branch office in Dumas, Texas, for the time-period of January 2026 – April 2026, the agency had 65 missed client visits due to “STAFFING SHORTAGE.” For the branch office in Lubbock, Texas, for the time-period of January 2026 – April 2026, the agency had 722 missed client visits due to “STAFFING SHORTAGE.” For a total of 1408 missed client visits due to staffing shortage for the time-period of January – April 2026. Percentage of missed visits for staffing shortages for the time-period of January-April 2026 was 7.86% Percentage of total missed visits for the time-period of January-April 2026, was 28.08% 6. During an interview conducted on 04/08/26 at 12:18 p.m., with Administrative Assistant/Scheduling Manager E, when asked who at the agency was responsible for scheduling client visits, Administrative Assistant/Scheduling Manager E said Scheduler K was responsible for scheduling client visits for the Lubbock office and Scheduler L was responsible for scheduling client visits for the Amarillo and Dumas offices. Administrative Assistant/Scheduling Manager E said if the agency did not have sufficient staff to complete all the necessary client visits the schedulers would notify the Administrator/Supervising Nurse who would make the final determination as to which clients would be seen and which would not. Administrative Assistant/Scheduling Manager E said clients who required “direct skills” would be priority for receiving visits and clients who were to receive “non-direct skills” would be moved to allow the visits on the clients who required direct skills to receive the scheduled visits. Administrative Assistant/Scheduling Manager E said the Administrator/Supervising Nurse was first designated to the position of Administrator in June of 2025. Administrative Assistant/Scheduling Manager E said during the time-period of August 2024 to February 2026, RN/Former Branch Manager F was responsible for determining which clients would be seen and which would not if the agency did not have sufficient staff to provide all scheduled client visits for the Lubbock branch office. Administrative Assistant/Scheduling Manager E said staffing had always been an issue for the agency and said at the time the clients were accepted for services the agency had sufficient staff to provide the clients’ care. Administrative Assistant/Scheduling Manager E said as a scheduler they were responsible for notifying the Administrator when additional staff was needed. Administrative Assistant/Scheduling Manager E said some of the missed visits on the missed visit report which were documented as missed due to staffing shortages might have been missed for other reasons and the staff member may have inadvertently put staff shortage as the reason. Administrative Assistant/Scheduling Manager E said at one time the agency had an issue with a high staff turnover rate in the Lubbock office. Administrative Assistant/Scheduling Manager E said the issue had improved at the time of the interview as the agency had hired staff for that location. Administrative Assistant/Scheduling Manager E said the schedulers would notify the Administrator or Branch Manager of the visits that the agency did not have sufficient staffing to provide and the Administrator or Branch Manager would attempt to find someone to cover those visits. Administrative Assistant/Scheduling Manager E said the Administrator/Supervising Nurse was currently out of the office, but the Alternate Administrator was present. 7. During an interview conducted on 04/08/26 at 12:35 p.m., with the Alternate Administrator and Administrative Assistant/Scheduling Manager E, the Alternate Administrator said when visits were missed due to staffing shortages this typically occurred due to staff turnover and was typically unexpected. The Alternate Administrator said if one employee left, they might take two or three of their friends with them, which could result in unexpected staff shortages. The Alternate Administrator said the agency’s process if visits had to be missed due to staffing shortages was to contact the client and the client’s physician and attempt to reschedule the visit or schedule another employee to complete the visit. The Alternate Administrator said if the client had a “skilled” need the agency would have to discharge the client and transfer them to another agency if they were unable to provide the care. When asked about the Medicare requirement for each client to have a skilled need to be admitted for services, the Alternate Administrator said when he said skilled, he meant a direct care need, such as if the client required wound care. The Alternate Administrator said if a client required a service such as wound care and the agency did not have a nurse to complete the visit the agency would have to call the physician and transfer the client to another provider. The Alternate Administrator said usually the agency would be able to see clients with a “direct” care need and the only reason it would be missed if the agency had no nurses at all who could complete the visit. The Alternate Administrator said if the physician was notified of a missed visit the documentation should be included in a coordination note in the client’s record. Administrative Assistant/Scheduling Manager E said the missed visit report was sent to the physicians daily and said the client’s physician should be notified of all missed visits. The Alternate Administrator said sometimes the visit was moved to another day within the same week and so the ordered frequency was provided and the visit was not truly missed. Surveyor Y discussed the findings regarding Client #3 with the Alternate Administrator and the Alternate Administrator said he was not sure what had occurred and said RN/Branch Manager F would have been responsible for ensuring the client’s visits were completed at that time. 8. Review of the agency policy and procedure manual revealed a policy entitled “Admission process: Admission, Coordination of Care and Eligibility, revised 01/01/2022.” The policy read in part: “Coordination of care with physician: At admission throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician, when changes occur in patients’ condition and when a missed visit occurs altering the Plan of Care.” 9. Review of the agency policy and procedure manual revealed a policy entitled “Plan of Care, revised 01/01/2022.” The policy read in part: “To ensure that physician’s orders are followed.” 10. Review of the agency policy and procedure manual revealed a policy entitled “Operations for Patient care Delivery Policy, revised 01/01/2022.” The policy read in part: “Patient care processes are standardized throughout the organization, with patients having the same level of care receiving the same level of quality of care and services throughout the agency.”

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: This CONDITION is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure 3 (Patient #2, #3, and #5) out of 6 patients received the home health services that are written in an individualized plan of care. The agency failed to provide scheduled skilled nursing visits for 3 out of 6 patients reviewed, resulting in missed visits due to staffing shortages. This failure placed the patients at risk of not having their needs met and had the potential to result in negative patient outcomes, including decline in health status and delayed interventions. Refer to G0572

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure timely communication with physicians regarding significant changes in service delivery, specifically multiple missed visits due to staffing shortages, for 3 (Patient #2, #3, and #5) out of 6 patients. This failure placed patients at risk for unmet healthcare needs and had the potential to result in negative patient outcomes, including delayed interventions, deterioration of clinical status, and lack of appropriate skilled monitoring. 1. Review of the clinical record for Patient #2 revealed a POC dated 01/03/2026-03/03/2026. With the following diagnosis enlargement of the prostate, unable to empty the bladder, and history of small stones in the urinary system that can cause pain and block urine. SN services including PROVIDE INSTRUCTION/REINFORCEMENT FOR BENIGN PROSTATIC HYPERPLASIA WITH LOWER URINARY TRACT SYMPTOMS, INSTRUCTION TO INCLUDE BUT IS NOT LIMITED TO THE DEFINITION, CAUSES, RISK FACTORS, POSSIBLE COMPLICATIONS, AND SIGNS AND SYMPTOMS OF DISEASE EXACERBATION TO REPORT, SKILLED NURSE TO INSTRUCT PATIENT/CG ON OBTAINING/MONITORING/LOGGING DAILY WEIGHTS AND NOTIFY AGENCY AND/OR MD OF WEIGHT GAIN OF 3LBS IN 24 HOURS OR 5LBS IN ONE WEEK. SKILLED NURSE TO REVIEW MEDICATION PROFILE AND RECONCILE MEDICATIONS AS NEEDED. SKILLED NURSE MAY INSTRUCT AND REINFORCE MEDICATION TEACHING RELATED TO USE OF MEDICATIONS TO TREAT DISEASE PROCESSES. SKILLED NURSE MAY FILL MEDIPLANNER PER CURRENT MEDICATION ORDERS/PROFILE AS NEEDED, SKILLED NURSE TO PROVIDE AND INSTRUCT REGARDING FALL PREVENTION INTERVENTIONS. SKILLED NURSE TO PROVIDE/INSTRUCT REGARDING INTERVENTION(S) TO MONITOR AND MITIGATE PAIN AND SKILLED NURSE TO PROVIDE INSTRUCTIONS REGARDING INTERVENTION(S) TO PREVENT PRESSURE ULCERS. The POC read in part: “Orders and Treatments: SN 1wk8 (one time a week for 8 weeks) and PT 2wk8neffective 1/4/26: 2wk7, 1wk1 effective 3/8/26. Further review of the clinical record revealed SN visit on 01/09/2026, 1/19/2026, and 2/13/2026. With the following Missed visits for SN 1/16/2026, 1/30/2026, 2/6/2026, 2/20/26, 2/27/2026 due to staffing shortages as per Missed Visit Report. Coordination notes were completed for MV but no documentation on MD being notified. Record review of the client record for Client #2, for the time-period of 03/18/26 – 04/07/26, indicated the agency provided a skilled nurse visit on 03/20/26. There was no documentation to indicate the agency had received approval from the client’s insurance company to provide skilled nurse visits during this time-period. Record review of the client record for Patient #2, for the time-period of 03/18/26 – 04/07/26, indicated no physical therapy visits were provided between 03/18/26 and 03/31/26. Record review of the agency’s missed visit report, for the time-period of 01/01/26 – 04/06/26, indicated the client had missed physical therapy visits on 03/18/26, 03/20/26, 03/25/26, and 03/27/26 due to insurance denial. Record review of the client record for Patient #2, for the time-period of 03/18/26 – 04/07/26, indicated physical therapy visits were provided on 04/01/26 and 04/03/26. There was no documentation to indicate the agency had received approval from the client’s insurance company to provide physical therapy visits during this time-period. Record review of the agency’s missed visit report, for the time-period of 01/01/26 – 04/06/26, indicated the client had missed skilled nurse visits on 03/13/26 and 03/27/26 due to a staffing shortage. Record review of the client record, for the time-period of 03/04/26 – 04/07/26 did not include skilled nurse or physical therapy missed visit notes, did not include physician orders to discontinue or change the frequency of skilled nurse and physical therapy visits to be provided, and did not include documentation to indicate the physician was notified of the missed visits/failure to provide skilled nurse and physical therapy visits as ordered by the physician in the written plan of care during this time-period. Record review of the client record for Patient #2, for the week of 03/29/26 – 04/05/26, did not include documentation to indicate a skilled nurse visit was provided during this week. There was no documentation of a missed visit note and no physician’s order to discontinue or change the frequency of skilled nurse visits to be provided during this week. Record review of the agency’s missed visit report, for the time-period of 01/01/26 – 04/06/26, did not include documentation of a missed skilled nurse visit for the week of 03/29/26 – 04/05/26. 2. Review of the clinical record for Patient #3 revealed a POC dated 01/06/2026 to 03/06/2026. With the following diagnosis rectal abscess (a pocket of pus that formed in the bottom opening), heart failure, and blood with high levels of fat. SN services including SKILLED NURSE TO INSTRUCT PATIENT/CG ON OBTAINING/MONITORING/LOGGING DAILY WEIGHTS AND NOTIFY AGENCY AND/OR MD OF WEIGHT GAIN OF 3 LBS IN 24 HOURS OR 5 LBS IN ONE WEEK. SKILLED NURSE TO PROVIDE INSTRUCTION/REINFORCEMENT FOR RECTAL ABSCESS. INSTRUCTION TO INCLUDE BUT IS NOT LIMITED TO THE DEFINITION, CAUSES, RISK FACTORS, POSSIBLE COMPLICATIONS, AND SIGNS AND SYMPTOMS OF DISEASE EXACERBATION TO REPORT. REINFORCE MEDICATION TEACHING RELATED TO USE OF MEDICATIONS TO TREAT DISEASE PROCESSES. SKILLED NURSE MAY FILL MEDIPLANNER PER CURRENT MEDICATION ORDERS/PROFILE Q PRN. SKILLED NURSE TO PROVIDE AND INSTRUCT REGARDING FALL PREVENTION INTERVENTIONS. SKILLED NURSE TO PROVIDE/INSTRUCT REGARDING INTERVENTION(S) TO MONITOR AND MITIGATE PAIN. SKILLED NURSE TO PROVIDE INSTRUCT REGARDING INTERVENTION(S) TO PREVENT PRESSURE ULCERS. The POC read in part: “Orders and Treatments: SN 1wk9 (one time a week for 9 weeks). Further review of the clinical record revealed SN visit on 1/6/2026 for SOC. With the following Missed visits for SN 1/14/2026, 1/20/2026, 1/30/2026 for staffing shortages and 2/03/2026 MV for No authorization from insurance. No visit or documentation for week of 2/08/2026-2/14/2026. Coordination note for MV on 2/03/26, No other coordination notes made for MVs, Coordination note dated 1/27/2026 received a call from patient to request discharge due to not being seen at all, AS per branch manager nurse will be sent out next day for discharge, discharge was not made until 2/17/2026 disregarding request made by patient to branch manager at Lubbock office. No discharge summary and or documentation MD was notified of Discharge and or MVs. There were no missed skilled nurse visit notes included for the weeks of 01/11/26 – 01/17/26, 01/18/26 – 01/24/26, 01/25/26 – 01/31/26, and 02/08/26 – 02/14/26. Record review of the client record for Patient #3, for the time-period of 01/06/26 – 02/17/26, did not include a physician’s order to change or discontinue the frequency of skilled nurse visits to be provided. Record review of the client record for Patient #3, for the time-period of 01/06/26 – 02/17/26, did not include documentation to indicate the physician was notified of the missed skilled nurse visits during this time-period. Record review of the client record for Patient #3 included a history and physical form, dated 12/26/25, from Hospital #1, which indicated the client was seen for a rectal abscess (a pocket of pus that forms in the bottom opening), which had been periodically healing and draining. Record review of the client record for Patient #3 did not include documentation to indicate the skilled nurse assessed the client’s rectal abscess (a pocket of pus that forms in the bottom opening) during the time-period of 01/06/26 and 02/17/26. 3. Review of the clinical record for Patient #5 revealed a POC dated 01/23/2026-03/23/2026. With the following diagnosis loss of movement and feeling in the lower half of the body, long-term pain, depends on wheelchair, and fitting and adjustment of urinary equipment to help collect, drain, or control urine. SN services including SKILLED NURSE TO ASSESS/EVALUATE AND EDUCATE CO-MORBID CONDITIONS, INCLUDING PARAPLEGIA AND OTHER CONDITIONS THAT PRESENT THEMSELVES DURING THE COURSE OF THIS EPISODE TO IDENTIFY CHANGES AND INTERVENE TO MINIMIZE COMPLICATIONS. SKILLED NURSE TO INSTRUCT PATIENT / CAREGIVER IN INDWELLING URINARY CATHETER (SOFT TUBE PLACED INTO BLADDER TO DRAIN URINE INTO BAG) MANAGEMENT INCLUDING CARE OF FOLEY CATHETER (SOFT TUBE PLACED INTO BLADDER TO DRAIN URINE INTO BAG), SIGN AND SYMPTOMS OF COMPLICATIONS, PERINEAL CARE, TUBE AND BAG PLACEMENT. SKILLED NURSE FOR INSERTION OF INDWELLING CATHETER (SOFT TUBE PLACED INTO BLADDER TO DRAIN URINE INTO BAG), CHANGE Q MONTH AND PRN DISLODGMENT OR STOPPAGE. SKILLED NURSE TO REVIEW MEDICATION PROFILE AND RECONCILE MEDICATIONS AS NEEDED. SKILLED NURSE MAY INSTRUCT AND REINFORCE MEDICATION TEACHING RELATED TO USE OF MEDICATIONS TO TREAT DISEASE PROCESSES. SKILLED NURSE MAY FILL MEDIPLANNER PER CURRENT MEDICATION ORDERS/PROFILE QPRN. SKILLED NURSE TO PROVIDE AND INSTRUCT REGARDING FALL PREVENTION INTERVENTIONS. SKILLED NURSE TO PROVIDE/INSTRUCT REGARDING INTERVENTION(S) TO MONITOR AND MITIGATE PAIN. SKILLED NURSE TO PROVIDE INSTRUCT REGARDING INTERVENTION(S) TO PREVENT PRESSURE ULCERS. The POC read in part: “Orders and Treatments: SN 1wk1, 2every2wk2, 2wk2, 1wk4 (one time a week for 1 week, 2 visits every 2 weeks for 2 weeks, 2 times per week for 2 weeks, and 1 time per week for 4 weeks) and PT EFFECTIVE 01/25/2026 1WK1,2WK7 (one time a week for 1 week and 2 times per week for 7 weeks). POC dated 03/24/2026-05/22/2026. The POC read in part: “Orders and Treatments: SN 2WK2,1WK7; (2 visits per week for 2 weeks, one visit per week for 7 weeks) PT EFFECTIVE 03/29/2026 2WK7,1WK1 (2 times per week for 7 weeks, 1 time per week for 1 week). Further review of the clinical record revealed SN visit on 1/23/2026 for SOC and MVs on 02/09/2026, 02/13/2026, 2/14/2026, 2/16/2026, 2/20/2026, 4/03/2026, 4/04/2026 for staffing shortages. 3/28 PRN SNV foley (SOFT TUBE PLACED INTO BLADDER TO DRAIN URINE INTO BAG) dislodged – update frequency d/t new FC (SOFT TUBE PLACED INTO BLADDER TO DRAIN URINE INTO BAG) placed – effective 4/5 SN 1w7(1 time per week for 7 weeks), 4/4 PRN SNV FC (SOFT TUBE PLACED INTO BLADDER TO DRAIN URINE INTO BAG) leaking, 4/7 PRN SNV due to FC (SOFT TUBE PLACED INTO BLADDER TO DRAIN URINE INTO BAG) leaking change to frequency order effective 4/5 1w1, 1q6w6. Record review of the client record for Patient #5 did not include documentation to indicate the physician was notified of the missed visits/failure to provide visits as ordered by the physician in the written plan of care. 4. Record review of the agency’s missed visit reports for the parent and branch offices for the time-period of January 2026 – April 2026, indicated the following: For the parent office in Amarillo, Texas, for the time-period of January 2026 – April 2026, the agency had 621 missed client visits due to “STAFFING SHORTAGE.” For the branch office in Dumas, Texas, for the time-period of January 2026 – April 2026, the agency had 65 missed client visits due to “STAFFING SHORTAGE.” For the branch office in Lubbock, Texas, for the time-period of January 2026 – April 2026, the agency had 722 missed client visits due to “STAFFING SHORTAGE.” For a total of 1408 missed client visits due to staffing shortage for the time-period of January – April 2026. Percentage of missed visits for staffing shortages for the time-period of January-April 2026 was 7.86% Percentage of total missed visits for the time-period of January-April 2026, was 28.08% 5. During an interview conducted on 04/08/26 at 12:18 p.m., with Administrative Assistant/Scheduling Manager E, when asked who at the agency was responsible for scheduling client visits, Administrative Assistant/Scheduling Manager E said Scheduler K was responsible for scheduling client visits for the Lubbock office and Scheduler L was responsible for scheduling client visits for the Amarillo and Dumas offices. Administrative Assistant/Scheduling Manager E said if the agency did not have sufficient staff to complete all the necessary client visits the schedulers would notify the Administrator/Supervising Nurse who would make the final determination as to which clients would be seen and which would not. Administrative Assistant/Scheduling Manager E said clients who required “direct skills” would be priority for receiving visits and clients who were to receive “non-direct skills” would be moved to allow the visits on the clients who required direct skills to receive the scheduled visits. Administrative Assistant/Scheduling Manager E said the Administrator/Supervising Nurse was first designated to the position of Administrator in June of 2025. Administrative Assistant/Scheduling Manager E said during the time-period of August 2024 to February 2026, RN/Former Branch Manager F was responsible for determining which clients would be seen and which would not if the agency did not have sufficient staff to provide all scheduled client visits for the Lubbock branch office. Administrative Assistant/Scheduling Manager E said staffing had always been an issue for the agency and said at the time the clients were accepted for services the agency had sufficient staff to provide the clients’ care. Administrative Assistant/Scheduling Manager E said as a scheduler they were responsible for notifying the Administrator when additional staff was needed. Administrative Assistant/Scheduling Manager E said some of the missed visits on the missed visit report which were documented as missed due to staffing shortages might have been missed for other reasons and the staff member may have inadvertently put staff shortage as the reason. Administrative Assistant/Scheduling Manager E said at one time the agency had an issue with a high staff turnover rate in the Lubbock office. Administrative Assistant/Scheduling Manager E said the issue had improved at the time of the interview as the agency had hired staff for that location. Administrative Assistant/Scheduling Manager E said the schedulers would notify the Administrator or Branch Manager of the visits that the agency did not have sufficient staffing to provide and the Administrator or Branch Manager would attempt to find someone to cover those visits. Administrative Assistant/Scheduling Manager E said the Administrator/Supervising Nurse was currently out of the office, but the Alternate Administrator was present. 6. During an interview conducted on 04/08/26 at 12:35 p.m., with the Alternate Administrator and Administrative Assistant/Scheduling Manager E, the Alternate Administrator said when visits were missed due to staffing shortages this typically occurred due to staff turnover and was typically unexpected. The Alternate Administrator said if one employee left, they might take two or three of their friends with them, which could result in unexpected staff shortages. The Alternate Administrator said the agency’s process if visits had to be missed due to staffing shortages was to contact the client and the client’s physician and attempt to reschedule the visit or schedule another employee to complete the visit. The Alternate Administrator said if the client had a “skilled” need the agency would have to discharge the client and transfer them to another agency if they were unable to provide the care. When asked about the Medicare requirement for each client to have a skilled need to be admitted for services, the Alternate Administrator said when he said skilled, he meant a direct care need, such as if the client required wound care. The Alternate Administrator said if a client required a service such as wound care and the agency did not have a nurse to complete the visit the agency would have to call the physician and transfer the client to another provider. The Alternate Administrator said usually the agency would be able to see clients with a “direct” care need and the only reason it would be missed if the agency had no nurses at all who could complete the visit. The Alternate Administrator said if the physician was notified of a missed visit the documentation should be included in a coordination note in the client’s record. Administrative Assistant/Scheduling Manager E said the missed visit report was sent to the physicians daily and said the client’s physician should be notified of all missed visits. The Alternate Administrator said sometimes the visit was moved to another day within the same week and so the ordered frequency was provided and the visit was not truly missed. Surveyor Y discussed the findings regarding Client #3 with the Alternate Administrator and the Alternate Administrator said he was not sure what had occurred and said RN/Branch Manager F would have been responsible for ensuring the client’s visits were completed at that time. 7. During an interview conducted on 04/15/26 at 4:36 p.m., with Nurse Practitioner DD, stated she was not aware of the MVs that were made for patient #5 due to staff shortages. Nurse Practitioner DD looked at the patient’s clinical record during phone call and only was able to locate a note from the agency dated 3/11/2026 but did not mention anything regarding MVs. Stated “I have nothing in my chart indicating MVs, based on my chart No I have no records at this time. I don’t want to implicate someone let me check again, I went to that home today and know that practically home is hard to visit, I was asked to leave. Just so you know. 8. During an interview conducted on 04/07/26 at 4:42 p.m., Patient #2’s Emergency Contact said she was Patient #2’s emergency contact and all communication with the client went through her per the client’s choice. When asked if she and the client had been satisfied with the services provided by the agency, the client’s Emergency Contact said she was not sure if the issue was the agency or the client’s insurance company but the client had to be assessed every so often and when the assessment was completed the client would end up without a nurse or without physical therapy. Patient #2’s Emergency Contact said she would call the agency and ask about the services and was given various explanations for the missed visits. Patient #2’s Emergency Contact said the client was assessed last Friday and she asked PT N if the client was going to receive a nurse visit that week and PT N said there was a nurse visit on the client’s schedule for the week. Patient #2’s Emergency Contact said no one from the agency called and no nurse visit was completed during the week of 03/31/26 and 04/05/26. Patient #2’s Emergency Contact said the agency seemed to have a scheduling problem and said she was willing to work with the agency and be available for visits but there seemed to be an issue with the agency itself. When asked if the agency had provided them with a reason for the missed visits, Patient #2’s Emergency Contact said one time they said they were short-staffed, and then said they had one person doing all the scheduling for both the Amarillo and Lubbock offices and had gotten “rid of” a bunch of employees. Patient #2’s Emergency Contact said then the agency later said that someone should have made the visit but no one had and they didn’t know what had occurred, and then once they said that the client’s services had been denied by the insurance company, and the agency appealed and then the services were approved. Patient #2’s Emergency Contact said she had to call the agency to find out if services would be provided or not. Patient #2’s Emergency Contact said the more physical therapy the client missed the more he was “set back.” Patient #2’s Emergency Contact said the client had not had any recent falls or hospitalizations related to the missed visits and said she had the client perform exercises at home that they had been educated on and knew how to do but there was no physical therapist overseeing his care when the visits were missed. Patient #2’s Emergency Contact said the client had not had any issues related to the missed nurse visits and said basically when the nurse completed visits, they were just checking his signs and symptoms, and vital signs and the client’s blood pressure had been normal. Patient #2’s Emergency Contact said she took the client to the physician for labs and tests and ensured that he had his medications filled and available. Patient #2’s Emergency Contact said even the client’s physical therapist did not understand the reason for the missed visits at times and would tell them that she didn’t know the reason and the client had been on her schedule and was then removed. Patient #2’s Emergency Contact said she had no other concerns with the agency and said her only concern was the scheduling or lack of scheduling of visits. Patient #2’s Emergency Contact said it seemed like the left hand of the agency was not talking to the right hand. 9. During an interview conducted on 04/09/26 at 10:23 a.m., with Patient #3, when asked regarding the agency’s services, Patient #3 said, “They didn’t show up.” Patient #3 said the agency said they would be coming weekly but they did not. Patient #3 said the nurse admitted him and he had one MSW visit and then no visits until his discharge. Patient #3 said the nurse was supposed to make visits weekly, but they never showed up. Patient #3 said the agency did not give him any reason why they had not made the visits. after saying they were going to or explain what had occurred. Patient #3 said he had surgery on the rectal abscess prior to his admission to the agency, but he did not have any wound care ordered for the area. Patient #3 said the agency nurse never looked at or assessed the area during either visit. Patient #3 said he did not refuse assessment of the area and said the nurse “just didn’t look at it.” Patient #3 said he had not experienced any harm related to the agency’s failure to provide the skilled nursing visits as ordered and said FM V was assisting with his care and he had no issues related to the failure of the agency. Patient #3 confirmed he had received the required start of care documentation during the admission visit. 10. Review of the agency policy and procedure manual revealed a policy entitled “Admission process: Admission, Coordination of Care and Eligibility, revised 01/01/2022.” The policy read in part: “Coordination of care with physician: At admission throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician, when changes occur in patients’ condition and when a missed visit occurs altering the Plan of Care.” 11. Review of the agency policy and procedure manual revealed a policy entitled “Plan of Care, revised 01/01/2022.” The policy read in part: “To ensure that physician’s orders are followed.” 12. Review of the agency policy and procedure manual revealed a policy entitled “Operations for Patient care Delivery Policy, revised 01/01/2022.” The policy read in part: “Patient care processes are standardized throughout the organization, with patients having the same level of care receiving the same level of quality of care and services throughout the agency.”

Purpose of visit: Complaint investigation for Intake #321166. Entrance date: 12/21/21 Census: Parent L&C – 414 LHH – 16 PAS - 73 Branch – Lubbock LHH – 0 PAS - 0 Intake #321166 - Substantiated and cited

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patient received all services as ordered by the physician in the plan of care for 1 of 2 (Patient #1) patients whose records were reviewed. This failure could place the agency’s patients at risk of receiving inadequate care and services to meet personal care needs and patient/family dissatisfaction with care. The findings included: Patient #1 - Review of the plan of care dated 11/26/21 to 01/24/22 included a physician’s order for skilled nurse once a week for 9 weeks, physical therapy 2 times a week for 3 weeks, once a week for 1 week, then 2 times a week for 3 weeks, occupational therapy 2 times a week for 5 weeks, social worker once a week for 1 week, and home health aide visits twice a week for 4 weeks beginning the week of 11/28/21. Review of the HHA (home health aide) visit notes indicated only one HHA visit was provided during the week of 11/28/21 to 12/04/21. There were no missed visit notes documented for the week of 11/28/21 to 12/04/21. During an interview conducted on 12/27/21 at 11:13 a.m., with the Administrator/Supervising Nurse, when discussed the reason Patient #1 received only one HHA visit during the week of 11/28/21 to 12/04/21 the Administrator/Supervising Nurse said maybe they were waiting on insurance approval and looked it up on the computer and noted on 11/26/21 insurance approved 4 home health aide visits. The Administrator/Supervising Nurse said RN case manager C is new and the visit wasn’t scheduled according to the computerized calendar. During an interview conducted on 12/27/21 at 11:22 a.m., with RN case manager C, when presented with the findings of who contacts the patient or family member if the HHA is unable to make a scheduled visit, RN case manager C said the HHA contacts and contacts the case manager and/or scheduler. When presented with the findings of if patients are offered a replacement, RN case manager C said if a nurse is scheduled for a visit then they can provide the personal care but that the agency has only 1HHA employed at the present time. When discussed the reason for only one HHA visit during the week of 11/28/21 to 12/04/21 and presented with the plan of care to show the physician’s order for the HHA to provide services 2 times week for 4 weeks, RN case manager C said she was not sure why there was only one visit. During an interview conducted on 12/27/21 at 11:28 a.m., with OTA (Occupational Therapy Assistant) E, when asked if he assisted Client #1 with personal care during his visits, OTA E said he informed Client #1 that he could assist with personal care during his first visit with the client and the client said he had a HHA coming and didn’t need him to help, and since HHA services were ordered he did not ask Client #1 again, that mainly they worked on strengthening and transfers. During an interview conducted on 12/27/21 at 1:51 p.m., with HHA F, when presented of if there was a reason Client #1 was only provided HHA services 1 time during the week of 11/28/21 to 12/04/21, HHA F said Client #1 was only on her schedule for 1 time during that week, and she was out sick the week of 12/12/21 to 12/18/21 and was “pretty sure” she contacted Client #1’s caregiver to let her know she was sick, and the client was not on her schedule to see the week of 12/19/21 to 12/25/21. Review of the agency policy titled, “Patient Rights, Responsibilities, and Conduct Requirements”, included, “… 6. The patient has the right to be notified in advance about the care that is to be furnished, the types (disciplines) of the agency staff who will furnish the care, and the frequency of the visits that are proposed to be furnished. 7. The patient has the right to be advised of any change in the plan of care before the change is made…”