Every finding on record at Hygia Healthcare LLC

Purpose of visit: Recertification Entrance conference date 3/18/2025 The census was - 301 Licensed and Certified patients – 301 Licensed Home Health patients – 0 Personal Assistance Service patients -0 Abbreviations: RN- Registered Nurse OASIS- Outcome and Assessment Information Set CMS – Centers for Medicare and Medicaid Services IQIES - Internet Quality Improvement and Evaluation System Adm – Administrator DON – Director of Nurses Alt DON – Alternate Director of Nurses QA – Quality Assurance QAPI – Quality Assurance Performance Improvement QIO - Quality Improvement Organization KEPRO - Keystone Peer Review Organization PIP(s) – Performance Improvement Project (s) PRN – As needed POC – Plan of Care mg – milligrams

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to develop and maintain an emergency preparedness plan that included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach (preparing for a wide range of potential threats and disasters to minimize the impact of any event) for 3 (2022, 2023, and 2024) of three years reviewed. This failure meant patients and staff were potentially at risk in the event of an emergency. During the entrance conference on 03/18/2025 at 12:40 PM the surveyor requested all Emergency Preparedness plans and documents for the last three years. The surveyor reviewed the Emergency preparedness plan and documents provided on 03/25/25. The surveyor found blank risk assessment documents in the binders provided labeled 2022, 2023 and 2024. A review of all the documents provided found no evidence of completed risk assessments for 2022, 2023, or 2024 for the agency. The surveyor requested to interview the DON / Alternate Disaster Coordinator regarding the Emergency preparedness program on 03/25/2025 at 10:30 AM. The Administrator stated the DON/ Alternate Disaster Coordinator was still out due to complications from a medical procedure. An interview was conducted with the Administrator / Disaster Coordinator on 03/25/25 at 4:00 PM. The surveyor asked how long the Administrator had been the agency’s Disaster Coordinator. The Administrator stated “since I was designated Administrator in 2022.” The surveyor asked if the Administrator was responsible for ensuring the agency had a completed risk assessment for emergency preparedness. The Administrator stated he was responsible. The surveyor showed the blank assessments that were in the emergency preparedness documents provided by the agency. The Administrator stated there was “no excuse and it’s not stored anywhere else.” The Administrator stated the agency had implemented their disaster plan during the recent winter storms. The surveyor asked about the policy for the emergency preparedness program. The Administrator stated he would provide a copy of the policy. Review of agency policy on 03/25/2025 titled: Emergency Preparedness and Response Plan EC.40 dated 05/01/2024 read in part: The Agency will establish and maintain an emergency plan … The Plan will: Be based on and include a documented all hazards risk assessment (facility-based and community based) that identifies the disasters from natural and man-made causes that are likely to occur in the Agency’s service area and/or facility…The Agency will conduct a facility and community-based risk assessment that uses and all hazards approach prior to establishing an emergency plan to identify potential disaster including by not limited to …tornadoes, fire, epidemics, pandemics, terrorism, etc., likely to occur in the Agency’s service area…

Purpose of visit: Recertification and Relicensure survey Entrance conference date 3/18/2025 The census was - 301 Licensed and Certified clients – 301 Licensed Home Health clients – 0 Personal Assistance Service clients-0 Abbreviations RN- Registered Nurse OASIS- Outcome and Assessment Information Set CMS – Centers for Medicare and Medicaid Services IQIES - Internet Quality Improvement and Evaluation System Adm – Administrator DON – Director of Nurses Alt DON – Alternate Director of Nurses QA – Quality Assurance QIO - Quality Improvement Organization KEPRO - Keystone Peer Review Organization Prn – As needed POC – Plan of Care mg – milligrams

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to encode and electronically transmit each completed OASIS assessment (a tool used by CMS to collect and report patient information for quality improvement and monitoring) to the CMS system within 30 days of completing the patient’s assessment for 122 OASIS assessments submitted from 3/04/2024 to 3/03/2025. This failure prevented CMS from analyzing patient’s data and the agency’s performance in comparison to other agencies, which potentially placed patients at risk for substandard care due to inaccurate OASIS information. The surveyor reviewed the OASIS error report in IQIES for period 3/04/2024 to 3/03/2025. The error report revealed late submissions greater than 30 days for 122 comprehensive patient assessments. An interview was conducted with the Administrator on 3/18/2025 at 12:45pm. The surveyor shared the OASIS late submissions and asked about the agency’s process on submitting OASIS data. The Adm stated per company policy the RN’s had 24 to 48 hours to complete the admissions. The Adm said the completed admissions were sent to a contracted QA for review and coding and then back to the RN for corrections. The surveyor asked who was responsible for the OASIS submissions. The Adm said the OASIS was sent electronically by the RN upon signing the comprehensive assessment after final review. The surveyor asked why the agency’s timeline policy was not followed. The Adm stated “It’s nearly impossible to get the admissions completed in 24 to 48 hours with the prn nurses.” The Adm said the Agency did not have any full time RNs except for the DON and Alt DON. The Adm stated the contracted QA at times is slow to complete the reviews and coding and contribute to the late submissions. Review of Agency’s policy “Timelines, IM.35, revision 10/25/2024” reads in part “All completed and encoded OASIS data will be transmitted…from the Agency or the Agency Contractor to the CMS collection site within 30 days of the M0090 date (last date that information is used to complete the comprehensive assessment and determine OASIS coding).”

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record reviews and interviews the agency failed to provide the name, address, and phone number for the Agency on Aging location in Tarrant County and failed to provide the correct name and phone numbers for the Quality Improvement Organization (QIO) for 7 (Patients 1,2,3,4,5,6, and 7) of 7 patients’ records reviewed. This failure potentially placed patients at risk for not receiving information, referrals, and community services through federally funded and state funded agencies. Review of the Agency’s home health folder, on 3/18/2025 revealed an undated reference list with no listing for Tarrant County under counties served by the Agency on Aging. The list contained the outdated QIO Texas contact information for KEPRO (Keystone Peer Review Organization) and did not show the July 1,2024 updated CMS contractor information and phone number for Acentra Health (contracted by CMS to receive appeals from patients regarding home health discharge decisions). Review of the undated Agency’s service area list provided by the Administrator on 3/18/2025 at 2:55pm revealed Tarrant County as an area the agency provided services. Record review of Patient 1’s home health folder during a home visit in Tarrant County on 3/20/2025 revealed an undated reference list with no listing for Tarrant County under counties served by the Agency on Aging. The list contained the outdated QIO Texas contact information for KEPRO and did not include the updated CMS contractor information and phone number for Acentra Health. Review of Patient’s Plan of care for period 12/03/2024-01/31/2025 showed a start of care date of 10/04/2024. An interview was conducted with Patient 1 on 3/20/2025 at 12:50pm. The surveyor asked if any pages had been removed from the folder. Patient 1 stated no pages were removed from the folder. Record review of Patient 2’s home health folder during a home visit in Tarrant County on 3/20/2025 revealed an undated reference list with no listing for Tarrant County under counties served by the Agency on Aging. The list contained the outdated QIO Texas contact information for KEPRO and did not include the updated CMS contractor information and phone number for Acentra Health. Review of Patient’s Plan of care for period 12/29/2024-02/26/2025 showed a start of care date of 10/30/2024. An interview was conducted with Patient 2 on 3/20/2025 at 1:35pm. The surveyor asked if any pages had been removed from the folder. Patient 2 stated no pages were removed from the folder. Record review of Patient 3’s home health folder during a home visit in Tarrant County on 3/20/2025 revealed an undated reference list with no listing for Tarrant County under counties served by the Agency on Aging. The list contained the outdated QIO Texas contact information for KEPRO and did not include the updated CMS contractor information and phone number for Acentra Health. Review of Patient’s Plan of care for period 01/08/2025-03/08/2025 showed a start of care date of 01/08/2025. An interview was conducted with Patient 3 on 3/20/2025 at 2:10pm. The surveyor asked if any pages had been removed from the folder. Patient 3 stated no pages were removed from the folder. Record review of Patient 4’s home health folder during a home visit in Tarrant County on 3/20/2025 revealed an undated reference list with no listing for Tarrant County under counties served by the Agency on Aging. The list contained the outdated QIO Texas contact information for KEPRO and did not include the updated CMS contractor information and phone number for Acentra Health. Review of Patient’s Plan of care for period 01/24/2025-03/24/2025 showed a start of care date of 11/25/2024. An interview was conducted with Patient 4 on 3/20/2025 at 11:45am. The surveyor asked if any pages had been removed from the folder. Patient 4 stated no pages were removed from the folder. Record review of Patient 5’s home health folder during a home visit in Tarrant County on 3/20/2025 revealed an undated reference list with no listing for Tarrant County under counties served by the Agency on Aging. The list contained the outdated QIO Texas contact information for KEPRO and did not include the updated CMS contractor information and phone number for Acentra Health. Review of Patient’s Plan of care for period 02/26/2025-04/26/2025 showed a start of care date of 08/30/2024. An interview was conducted with Patient 5 and a Spanish language translator on 03/20/2025 at 3:30 PM during the home visit. The surveyor asked if any information or resource lists were removed from the home folder provided by the agency. The patient stated no pages were removed from the folder. The patient stated he would prefer the information to be provided in Spanish and that his family member who assisted him spoke and read in Spanish and English. Record review of Patient 6’s home health folder during a home visit in Tarrant County on 3/20/2025 revealed an undated reference list with no listing for Tarrant County under counties served by the Agency on Aging. The folder did not include an updated list with the QIO contractor information and phone number for Acentra Health. Review of Patient’s Plan of care for period 2/10/2025-04/10/2025 showed a start of care date of 06/15/2024. An interview was conducted with Patient 6 on 03/20/2025 at 2:15 PM during the home visit. The surveyor asked if any information or resource lists were removed from the home folder provided by the agency. The patient stated no pages were removed from the folder. Record review of Patient 7’s home health folder during a home visit in Tarrant County on 3/20/2025 revealed an undated reference list with no listing for Tarrant County under counties served by the Agency on Aging. The list contained the outdated QIO Texas contact information for KEPRO and did not include the updated CMS contractor information and phone number for Acentra Health. Review of Patient’s Plan of care for period 02/24/2025-04/24/2025 showed a start of care date of 02/24/2025. An interview was conducted with Patient 7 on 03/20/2025 at 1:00 PM during the home visit. The surveyor asked if any information or resource lists were removed from the home folder provided by the agency. The patient stated no pages were removed from the folder. An interview was conducted with the Administrator on 3/25/2025 at 3:45pm. The surveyor shared the findings of the missing and incorrect information on the agency’s resource list. The Adm stated he was not aware that the QIO Texas contact information was incorrect. The surveyor asked the Adm about the agency’s policy on providing an updated resource list for Federal and State funded agencies. The Adm said the resource lists were provided to the patients during the admission visits and the “Order’s Team” was responsible for updating the packets. The surveyor asked the Adm what the possible impact could have been with the patients not having the updated contact information for the Federal and State funded agencies. The Adm stated “It can impact the patient greatly. They usually rely on us to assist them with basically everything. They'll reach out to us fast when they have questions or concerns.” Review of Agency’s policy “Patient/Client Rights and Responsibilities, Rights of The Elderly, RI.2, revision 01/13/2018” reads in part “The patient/client has the right to: Be advised of the names, addresses, and telephone numbers of the following Federally- funded and state-funded entities that serve the area where the patient/client resides: Agency on Aging… Quality Improvement Organization.”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interviews and record reviews the agency failed to include in the plan of care an individualized description of the patient's risks for emergency department visits and hospital readmissions to address the underlying risk factors for 3 (Patients 5, 8 and 9) of 17 patient records reviewed. The failure to provide all required detailed information in an individualized plan of care subjected the patients to the risk for poor quality and unsafe care. Record review of Patient 5 revealed a POC for period 02/26/2025 to 04/26/2025 signed by RN A. The POC revealed Eliquis (a blood thinning medication to treat and prevent blood clots) 5 mg twice a day under the medication section. The risk for bleeding was not present in the POC under safety precautions and the patient’s risks for emergent care and acute care hospitalization. Record review of Patient 8 revealed a POC for period 01/21/2025 to 03/21/2025 signed by RN B. The POC revealed Xarelto (a blood thinning medication to treat and prevent blood clots) 20 mg daily under the medication section. The risk for bleeding was not present in the POC under safety precautions and the patient’s risks for emergent care and acute care hospitalization. Record review of Patient 9 revealed a POC for period 12/11/2024 to 02/08/2025 signed by RN A. The POC revealed Eliquis (a blood thinning medication to treat and prevent blood clots) 5 mg twice a day under the medication section. The risk for bleeding was not present in the POC under safety precautions and the patient’s risks for emergent care and acute care hospitalization. An interview was conducted with RN A on 3/25/2025 at 1:41pm. The surveyor shared the POC findings of Patients 5 and 9. The surveyor asked about the agency’s policy on adding hospitalization risks on the POC. RN A stated the registered nurses “add the risks in OASIS and it generates on the plan of care.” The surveyor asked about the process of adding the risks on the POC. RN A stated the agency’s OASIS assessment software had a “drop down key, you select Yes or No, I think it has a section that says Other that you can select and free type.” The surveyor asked why the agency’s policy was not followed. RN A said, “I missed it.” An interview was conducted with RN B on 3/25/2025 at 12:34pm. The surveyor shared the POC findings of Patient 8. The surveyor asked about the process of individualizing patient’s risks for hospitalization on the POC. RN B stated, “I go by the diagnosis…and put together the plan of care, I include any medical needs, so they are complete.” The surveyor asked about the agency’s policy on adding risks for hospitalizations on the POC. RN B stated the register nurses “need to add the risk factors that go with the disease process.” The surveyor asked why the agency’s policy was not followed. RN B stated the agency’s software did not have the feature to customize the risks under risks for hospitalization. RN B said, “if I missed some of the risks that's probably why.” An interview was conducted with the Alt DON / agency owner on 3/25/2025 at 1:00pm via telephone. The surveyor shared the POC findings of Patients 5, 8 and 9 and asked about the agency’s process of adding individualized hospitalization risks to the POC. The Alt DON stated, “I know in OASIS they can enter things.” The surveyor informed the Alt DON that RN A stated the software did not give her the option to add individual risks including the risk for bleeding under hospitalization risks. The Alt DON said, “I’m going to double check because it’s supposed to…I think there’s a section where you can select other, and you can type it in there.” The Alt DON called the surveyor at 3:05pm and stated the risks for hospitalization are entered in OASIS and generates in the safety measures and in the teaching section. The Alt DON said the software did not allow the user to add the individualized risks for infection or bleeding under hospitalization risks, but it could be entered under safety measures. The surveyor asked why the bleeding precautions were not under the safety measures. The Alt Adm stated, “the nurses just forgot it or overlooked it.” An interview was conducted with the Adm on 3/25/2025 at 3:45pm. The surveyor shared the discussion with the Alt DON / agency owner regarding the POC findings for Patients 5, 8, and 9. The surveyor asked the Adm if he could provide any additional information. The Adm stated he was not a nurse and agreed with the Alt DON /agency owner’s response. Review of Agency’s policy “Plan of Care, PC.35, revision 09/19/2024” reads in part “The individualized Plan of Care must include the following: A description of the patient’s/client’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors.”

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: This failure was previously cited during the survey dated 04/25/2022. Based on record review and interview the agency failed to conduct performance improvement projects for 3 (2022, 2023, and 2024) of 3 years. This failure meant the agency lacked quality improvement projects undertaken to improve care and services and the patients were at risk of poor-quality care. During the entrance conference on 03/18/2025 at 12:40 PM the surveyor requested all QAPI documents for the last three years. The surveyor requested to interview the DON regarding the QAPI program on 03/25/2025 at 10:30 AM. The Administrator stated the DON was still out due to complications from a medical procedure. The surveyor reviewed the QAPI documents provided on 03/25/25. The surveyor found quarterly reports which documented “PIPS Not identified per agency” in each quarterly report for 2024, 2023, and 2022 provided to the surveyor. Review of the agency QA binders provided labeled 2022, 2023 and 2024 documented no evidence the agency had identified and conducted Performance Improvement Projects. An interviewed was conducted with the Alternate DON / agency owner on 03/25/2025 at 1:00 PM via telephone. The surveyor reviewed the findings of the review of the QAPI program for the agency and asked about the QAPI program. The Alternate DON / agency owner stated they had a consultant that assisted the agency with preparing quarterly reports and a sample of record reviews. The surveyor asked about the agency’s Performance Improvement projects. The Alternate DON stated the agency focused on good hand washing technique and making sure signs of infection were addressed. The surveyor asked if the agency had documentation of the Performance Improvement Projects for the last three years. The Alternate DON stated the Administrator might have those. An interview was conducted with the Administrator on 03/25/25 at 4:00 PM. The surveyor reviewed the findings of the QAPI program documents reviewed. The surveyor asked about the agency Performance Improvement Projects. The Administrator stated the agency used a consultant to prepare the quarterly reports. The surveyor asked who was responsible for ensuring Performance Improvement Projects were conducted. The Administrator stated he was responsible, had overlooked it. The surveyor asked about the policy for the Performance Improvement Projects. The Administrator stated he would provide a copy of the policy. Review of agency policy titled “Quality Assessment Performance Improvement Program” numbered QAPI.5 dated 03012024 read in part: “Policy I. The Governing Body will ensure that the QAPI program: A. Reflects the complexity of the organization and services; B. Involves all Agency services … The Agency will maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS… QAPI documents will be kept confidential and will be made available to State Home Health licensing Agency staff on request… Review of Agency policy titled: “Performance Improvement Process: Improvement Activities” numbered QAPI.25 and dated 05/01/2024 read in part: Policy – The Governing Body will be responsible for setting the priorities for improvement activities or projects based on Agency functions, the defined data collection, the resources required to facilitate the improvement, and the organization’s mission. The Governing Body will determine the number and scope of distinct Performance Improvement Projects (PIP) conducted annually.