Every finding on record at Kingspoint Healthcare Services, Inc.

A recertification survey entrance was conducted on 08/13/2024 at 11:00am with the Administrator.Census:L&C- 1 LHHS: 0PAS: 99 Complaint(s): #443608; #344955; #342078; and #337575 An exit conference was conducted on 08/15/2024 at 3:50 pm with the Administrator and the Supervising Nurse. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. The Agency is compliant with 42 CFR part 484.22 Emergency preparedness requirement for Home Health Agencies.

A recertification survey entrance was conducted on 08/13/2024 at 11:00am with the Administrator.Census:L&C- 1 LHHS: 0PAS: 99 Complaint(s): #443608; #344955; #342078; and #337575 An exit conference was conducted on 08/15/2024 at 3:50 pm with the Administrator and the 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. ADM-Administrator Alt. Adm/A.A. – Alternate Administrator RAA - Retired Alternate Administrator PAS- Personal Assistance Service L&C - Licensed and Certified LHHS - Licensed Home Health Services PRO – Provider POC – Plan of care QAPI - Quality Assessment and Performance Improvement Program CM: Case manager ADM-Administrator ALT/ADM: Alternate Administrator DON – Director of Nursing ADON – Alternate Director of Nursing TULIP: Texas Unified Licensure Information Portal HHA – Home Health Agency EVV: Electronic Visit Verification p.m. – post meridian a.m. – ante meridian

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency's governing body failed to ensure that an ongoing program for quality improvement and patient safety was implemented and maintained in that: the agency governing body did not meet in 2022 and 2023 or document effort taken for not actively admitting patient under L&C license since 2017. These failures could prevent the agency from identifying potential problems and implementing corrective actions to ensure the health and safety of the patients. Review of agency policies revised 011318 titled: “Quality Assessment and Performance Improvement Program" purpose read in part “to develop, implement, evaluate, and maintain and effective, ongoing Agency-wide, data-driven …QAPI program.” Policy read in part, 1. “I. The Governing Body will ensure that the QAPI program: A. Reflects the complexity of the organization and service. B. Involves all agency services, and any branch offices, if applicable… 2. II. The Agency will focus primarily on its processes and/or system performances rather than an individual’s performance… 3. III. The Agency will maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. 4. IV. When planning for performance improvement, Agency leaders will consider the following: A. Identifying the major functions and processes carried out by the Agency: 1. Scope of services 2. Operations 3. Staff and patient/client needs 4. Identified problems. 5. Survey issues.” Review of the agency policy reviewed on 030122 titled, “Quality Assessment Performance Improvement – Addendum” read in part. “A. The Agency maintains a Quality Assessment and Performance Improvement program that is implemented by a QAPI Committee B. The QAPI Committee will consist of, at a minimum, the Administrator, supervising nurse or therapist, and individuals representing the scope of services provided by the Agency. C. The QAPI Committee will meet twice a year or more often if needed and will maintain a written record of the meetings with appropriate signatures. Procedure …B. The QAPI Plan will be reviewed and updated at least once within the calendar year, or more often if needed.” Review of Quality Assessment and Performance Improvement (QAPI) manual provided by the administrator on 08/15/2024 at 10:25a.m, revealed that all QAPI committee meetings dated 12/28/2022, 06/30/2022, 12/27/2023, 06/29/2023, and 06/28/2024 were duplicated each quarter. The QAPI meetings showed no client care this period, no issues of professional conduct, no medication errors, there were zero patient satisfaction survey, no complaints, no infections, no incident, no documented issues with the effectiveness and safety of all services provided, client chart analysis with visits frequency consistent with the POC, and skilled Nurses notes reflected ongoing teaching. The committee meetings signature sheet consists of only the administrator. There was no evidence that the agency discussed capital expenditures for 3 years, operating budget in 2022 and 2023. During entrance conference on 08/13/2024 at 11:00 a.m. with the agency administrator (Adm), the Adm. said the agency has served clients under PAS category and had not serviced any client under L&C and LHHS since 2017. During interview on 08/15/2024 with the Adm and DON at 10:30a.m. Surveyor asked who consist of the agency’s QAPI committee, the administrator stated that the Adm, Alt Adm, 2 outside members, and a doctor are part of the agency governing body but have not had any opportunities to have meetings since 2018 due to Alt. Adm illness. Adm stated he puts the paper together and because the agency is not operating its category of L&C and LHHS, he does not think it should be included. During interview on 08/15/2024 with the DON at 11:45a.m. DON stated he is part of the Governing Body and QAPI committee. DON added that the committee were not having a QAPI meeting because there were no skilled patients, rendering the meeting unnecessary.

A recertification survey entrance was conducted on 8/3/21 at 11:35 am with the Administrator. Census: L&C-0 LHHS:0 PAS: 170 An exit conference was conducted on 8/5/21 at 5:40 pm with the administrator and the alternate administrator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. The Agency is compliant with 42 CFR part 484.22 Emergency preparedness requirement for Home Health Agencies.

A recertification survey entrance was conducted on 8/3/21 at 11:35 am with the Administrator. Census: L&C-0 LHHS:0 PAS: 170 An exit conference was conducted on 8/5/21 at 5:40 pm with the administrator and the alternate 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 Deficiencies. Acronyms used PT-Physical Therapy OT -Occupational Therapist PAS- Personal Assistance Service L & C - Licensed and Certified LHHS - Licensed Home Health Services SN- Skilled Nurse RN - Registered Nurse EHR- Electronic Health Record ADM-Administrator CR(s) - Clinical Record(s)

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure that the clinical Occupational and Physical therapy notes for 1 of 2 discharged patients (#7) were readily accessible / available for review during the survey. This failure resulted in the surveyor not being able to determine the quality of care/treatment provided to the patient by the agency contractors. Findings Onsite Observation On 8/5/21 at 2:54 pm when the surveyor followed up with the ADM regarding the Physical and Occupational Therapy note retrieval, the ADM stated, "Let me check my computer." The surveyor witnessed the ADM attempting to retrieve the therapy notes electronically via Kinnser (software program). When the ADM attempted to open the visit note, the following message was displayed, "An error has occurred, the page you are attempting to view cannot be displayed ...." Record review Record review of the plan of care for certification period 12/20/19 - 2/17/20 digitally signed by RN B, on 12/18/19 revealed in part, " ... Primary Diagnosis: Fluid Overload, unspecified. The orders for discipline and treatments included: Skilled Nurse (SN): 1W1{one visit for one week}, q w x 8{every week for 8 weeks}, 2 prn {2 visits as needed} for exacerbation and or labs." Physical Therapy (PT): Evaluation, Treatment. Occupational Therapy (OT): Evaluation, Treatment ..." Record review of the Patient #7's (closed) paper-based record for Episode: 12/20/19 - 2/17/20 presented to the surveyor in a manilla envelope included Occupational Therapy visits / notes dated as follows: Week 1 (12/22/19 -12/28/19): 2 visits notes. Week 2 (12/29/19 -1/4/20): No visit notes. Week 3 (1/5/20 -1/11/20): No visit notes. Further review revealed that the Physical therapy notes for 12/27/19,12/30/19, 1/3/20, 1/6/20, 1/8/20 and 1/13/20 were not available for review. Further review of the Occupational Therapy notes revealed the following: Occupational Therapy Documentation Record review of a document titled, 'Re-Evaluation OT' digitally signed by OT A with Visit Date:12/13 revealed in part, " ..., OT Diagnosis: Impaired self-care decreased mobility .... Patient #7, Frequency and duration: Effective date:12/22/19 Frequency: 2 time(s) a week for 3 week(s) ..." Record review of a document titled, 'OT' digitally signed by OT A with Visit Date:12/20/19 revealed in part, " ..., Patient #7, Diagnosis: Impaired self-care decreased mobility ..." Record review of a document titled, 'OT' digitally signed by OT A with Visit Date:12/27/19 revealed in part, " ..., Patient #7. Diagnosis: Impaired self-care decreased mobility ..." Record review of a document titled, 'OT' digitally signed by OT A with Visit Date:12/28/19 revealed in part, " ..., Patient #7. Diagnosis: Impaired self-care decreased mobility ..." Record review of the Patient #7's closed/discharged paper-based record for Episode: 12/20/19 - 2/17/20 presented to the surveyor in a manilla envelope revealed the following Physical Therapist visits/notes: Week 1 (12/22/19 -12/28/19): One visit note (not 2 as per POC) Week 2 (12/29/19 -1/4/20): No visit notes. Week 3 (1/5/20 -1/11/20): No visit notes. The Physical Therapy notes for 1/3/20 ,1/8/20 and 1/10/20 were not available for review Record review of the Physical Therapy notes revealed the following: Physical Therapy Documentation Record review revealed of a document titled, 'PT Re-Evaluation' digitally signed by PT A with Visit Date:12/13/19 revealed in part, " ..., PT Diagnosis: Difficulty walking, muscle weakness ... Patient #7, Frequency and duration: Effective date:12/22/19 Frequency: 2 time(s) a week for 3 week(s). Record review of a document titled, 'PT' digitally signed by PT A with Visit Date:12/20/19 revealed in part, " ..., Patient #7, Diagnosis: Difficulty walking, muscle weakness ..." Record review of a document titled, 'PT' digitally signed by PT A with Visit Date:12/23/19 revealed in part, " ...Patient #7. Diagnosis: Difficulty walking, muscle weakness..." Record review of the document titled, 'Patient Print Chart: Patient #7'. revealed the following information in part, " ... Occupational Therapy Task Name Target Date Visit Date Status OT 1/3/20 1/3/20 Complete OT A OT 1/4/20 1/4/20 Missed Visit (Approved) OT A OT 1/8/20 1/8/20 Complete OT A OT Re Eval 1/10/20 1/10/20 Complete OT A Physical Therapy Task Name Target Date Visit Date Status PT 12/2719 12/27/19 Complete PT A PT 12/30/19 12/30/19 Complete PT A PT 1/3/20 1/3/20 Complete PT A PT 1/6/20 1/6/20 Complete PT A PT 1/8/20 1/8/20 Complete PT A PT 1/13/20 1/13/20 Complete PT A.." The agency was not able to make these Physical therapy and Occupational therapy visit notes accessible to the surveyor for record review because, per the Administrator, the agency did not have access to these notes in Kinnser. Interview During interview with the ADM on 8/5/21 at 12:20 pm, he presented the surveyor with a document titled, 'Patient Print Chart: Patient #7'. The ADM stated that the vendor software company told him the therapy agency did something so there is a disconnection. He further informed the surveyor that he could not print or open the PT or OT notes in the vendor software. During interview with the ADM on 8/5/21 at 2:58 pm, the surveyor asked him if he had followed up with the therapy company regarding the therapy notes retrieval. The ADM stated, "They {Therapy} don't want to send it to me. They are reluctant to send it to me because we haven't resolved the dispute on the bill balance." Review of the agency policy titled 'Medical Record Content' revealed in part " ... IV. If the agency is using an EHR {Electronic Health Record} system, the agency must provide surveyor access to all its records as requested and readily provide the equipment and information necessary to assist the surveyor in the review process..."