Every finding on record at Lhcg Cxxxvii, LLC

An agency self-report investigation (Intake #546866) was conducted on 04/04/2025. The census was: LCHHS: 279; LHHS: 0. Abbreviations: Adm – Administrator AM - Ante meridiem DON - Director of Nurses Dr – doctor ED – emergency department ED – Executive Director EMT - Emergency Medical Technician Eval - evaluation HHSC – Health and Human Services IV - intravenous LCHHS - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services LVN – licensed vocational nurse MD – medical doctor NA – not applicable PM - Post meridiem prn – as needed Pt – Patient RN - registered nurse SN – skilled nurse TPO – paid time off Wed - Wednesday

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient's right to be free from neglect by an agency employee (RN A) for one of one patient (Patient 1) with diabetes (high blood sugar) who developed a foot wound in that the agency nurse failed to notify the physician of the wound and obtain wound care orders. This failure resulted in Patient 1 being harmed and hospitalized with a diabetic foot ulcer and skin infection that required surgical debridement (removal of dead skin and foreign material from a wound) and IV antibiotics (medicine used to fight infections). The failure placed all clients at potential risk of poor care and a deteriorating health status. Findings included: The active employee roster provided to the surveyor by the Adm/DON on 04/03/2025 at 12:45 PM included RN A’s hire date was 08/27/2023. Record review of the Texas Unified Licensing Information Portal (a database utilized by the state to maintain licensing, demographic information, complaints and self-reported incidents on Home Health and Hospice agencies for the State of Texas) included a self-reported incident (Intake #546866) in which the Adm/DON reported to the HHSC Complaint and Incident Intake on 11/22/2024. The report included an allegation of Neglect of Patient 1 by RN A. The report read in part, “… Patient [Patient 1] called… 11/15/24… stated [RN A] wrapped his right foot with Coban (bandage wrap) during visit on Wednesday 11/13/24 and his foot is now purple and there is another wound on right foot… advised patients [Family Member] who ws (sic) present and concerned to remove wrap. He did and… is going to take him to the hospital. Patient was admitted. [RN A] had documentation of new wound in his narrative but did not add the wound to the wound record report nor did he document the care he provided and no order for care provided… Met with [RN A] Monday 11/18/24… to discuss mistakes. He did confirm he wrapped with Coban and did not have an order to do so. Discussed the severity of these mistakes…” Record review of Patient 1’s electronic health record included a plan of care dated 10/24/2024 - 12/22/2024 with a start of care date of 10/24/2024 that was electronically signed by RN B on 10/24/2024. The plan of care included a diagnosis of diabetes with nerve damage and peripheral vascular disease (slow and progressive disorder of the blood vessels that can cause narrowing, blockage, or spasms)and orders for the nurse to visit the patient once a week for nine weeks. The plan of care included orders for the nurse to assess the lower extremities for the presence of lesions every visit. The plan of care included goals for the patient/caregiver to verbalize/demonstrate knowledge in preserving skin integrity and to verbalize an understanding of diabetic foot care. The plan of care did not include evidence of any wounds or wound care orders. The record included a start of care nurse visit note (nurse visit #1) conducted by RN B on 10/24/2024. The visit note did not include evidence of any wounds or wound care orders. The record included a nurse visit note (nurse visit #2) conducted by RN A on 11/01/2024. The visit note read in part, “… integumentary (skin) findings… wound(s)… care coordination document communication with other disciplines/individuals (… patient, caregivers… supervisor) involved with this case. Include attended/scheduled physician/authorized practitioner appointments along with any changes made to the plan of care since the last visit… NA… pt has a wound to second toe on right foot. wound assessed and bandaid replaced…” The visit note did not include evidence the physician was notified and wound care orders obtained. The record included a nurse visit note (nurse visit #3) conducted by RN A on 11/03/2024. The visit note read in part, “… integumentary… Indicate integumentary findings… No problems identified…” The visit note did not include evidence of any wounds or wound care orders. The record included a nurse visit note (nurse visit #4) conducted by RN A on 11/13/2024. The visit note read in part, “… integumentary (skin) findings… wound(s)… document communication with other disciplines/individuals (… patient, caregivers… supervisor) involved with this case. Include attended/scheduled physician/authorized practitioner appointments along with any changes made to the plan of care since the last visit… NA… assessment complete. pt has a wound to top of right foot…” The visit note did not include evidence the physician was notified and wound care orders obtained. The visit note did not include any wound care provided. The record included a client coordination note report completed by RN C on 11/15/2024 that read in part, “… [Family Member] called and reported foot is hurting/discolored and has new wounds on it stated he called the nurse and was instructed to take the wrap off…” The record included a physician order #35869315 completed by RN C on 11/15/2024 that read in part, “… patient called reporting new wounds to foot after wrapping the foot. SN to perform prn for eval and contact MD for further orders…” The record included a nurse visit note completed by the Adm/DON on 11/15/2024 that read in part, “… date collection only – no visit made… this assessment is currently being completed for the following reason… transferred to an inpatient facility… which inpatient facility has the patient been admitted… hospital… for what reason(s) did the patient require hospitalization… wound infection or deterioration… date… 11/15/2024…” The record included an agency complaint report processed by the Adm/DON and dated 11/15/2024 that read in part, “… [Family Member] states that nurse wrapped the leg on Wed and it began to hurt. He called the nurse who put the wrap on Wed and was instructed to take it off. [Family Member] stated that the foot was discolored and there was a "awful" wound on the extremety (sic) that needs to be looked at. Advised that wills (sic) end (sic) nurse out to evaluate and contact the Dr… ED notified. Clinician involved on PTO and not able to reach today. Filed incident report, had managers discussion with [RN A] upon return. Patient unfortunately was hospitalized…” The record included a client coordination note report completed by LVN on 11/18/2024 that read in part, “… hospital hold… date of admission: 11/15 Admitting diagnosis: Diabetic foot infection Hospital Name: [Hospital]…” The record included hospital records from [Hospital] that included an admission date of 11/15/2024 with a diagnosis of diabetic right foot infection and cellulitis (bacterial infection of the skin and tissues beneath the skin). The record read in part, “… Patient…presented to [Hospital] ED with complaining of worsening of diabetic foot .. infection… 2 days ago, patient noticed, he had 2 small open wounds on… the right foot… Patient's wounds were addressed by the home health nurse today and noticed significant progress with swelling/erythema (redness) to majority of his right foot and recommended the patient to come to the ED for further evaluation… Patient was treated with IV vancomycin (antibiotic used to treat serious infections that is administered through a vein) in the ED… debridement today…” The record included medical records from [Skilled Nursing Facility] that included Patient 1 was admitted to the facility on 12/02/2024 and included a diagnosis of diabetes with a foot ulcer and skin infection. The record contained a clinical notes report dated 12/02/2024 that included Patient 1 arrived at [Skilled Nursing Facility] in a wheelchair with EMT assistance. The patient had a right foot wound and an IV in the left arm for the administration of IV antibiotics every 8 hours for 7 days. Record review of RN A’s personnel record included that on 10/08/2024, RN A completed a skills lab check-off /competency assessment where RN A demonstrated competency in wound cleansing and dressing application utilizing proper hand hygiene; compression wraps (a wrap dressing used to alleviate swelling); and verbalized how to assess for diabetic ulcers and indications, contraindications and basic treatment options. The record included RN A was oriented to the agency's policies and procedures, including abuse, neglect, exploitation, and client rights. The surveyor called Patient 1 on 04/04/2025 at 12:06 PM; the call was not returned. During an interview with Patient 1’s Family Member, the Family Member reported: Patient 1 had a history of toe amputations, skin grafts (a surgical procedure that involves removing healthy skin from one area of the body to another), and foot complications due to diabetes and sensitive feet. Patient 1 was hospitalized in November 2024 due to a foot infection. What started as one small wound turned into three wounds, and the doctors were afraid the foot infection would reach the bone. The wound wrap used by [RN A] may have worsened the wound. The foot with the wound developed a blockage that prevented the wound from healing. While hospitalized, Patient 1 developed a bowel obstruction that required additional testing. Patient 1 was hospitalized for approximately two weeks, discharged and re-hospitalized several days later for an additional week due to confusion and weakness. Following the second hospital discharge, Patient 1 was placed in a skilled nursing facility and stayed for three weeks before returning home. The foot wound eventually healed. During an interview with the Adm/DON on 04/04/2025 at 1:44 PM, the surveyor asked what agency processes failed with Patient 1. The Adm/DON stated she did not know why RN A did wound care without notifying the physician and obtain an order. The failure was poor judgment and caused harm to Patient 1 who required hospitalization. RN A was placed on a 2-day work leave after the incident and wound care competency was re-verified before RN A returned to work. During an interview with RN A on 04/04/2025 at 11:15 AM, RN A reported: Patient 1 had one scabbed foot wound on the 11/13/2024 nurse visit. There were no wound care supplies in the home. RN A did not want to leave the scabbed wound open so he covered the wound with supplies RN A had on hand and applied a 4 X 4 (medical gauze) and wrapped the wound with Coban. Patient 1 ended up having circulatory problems that worsened the wound. RN A did not notify the doctor and did not obtain doctor orders for the wound care provided. RN A could not recall why he did not document the wound care provided and a wound assessment on the 11/13/2024 visit note. The surveyor asked what the outcome was for Patient 1. RN A stated Patient 1 was hospitalized for reasons unrelated to the wound but RN A could not remember the reasons for the hospitalization. The surveyor stated the hospital records included Patient 1 was hospitalized due to a wound infection on his foot. RN A stated he vaguely remembered Patient 1 had a wound infection. Patient 1 had no harm and was not neglected by RN A because RN A would not put Patient 1 in harm's way. RN A thought he was doing the right thing by addressing the wound but the [home health agency] disagreed with him. RN A was placed on a 2-day leave of absence because of the incident and received additional agency training. During an interview with RN B on 04/04/2025 at 12:55 PM, RN B reported: RN B was not aware Patient 1 had a wound before 11/15/2024. On her 10/24/2024 admission visit (Visit #1), Patient 1 did not have a wound. On 11/15/2024, RN B was notified by RN A that Patient 1 had a wound that had worsened. RN B notified Patient 1’s mobile nurse practitioner to obtain orders but the patient went to the hospital before RN B had time to make a home visit to assess the wound. The surveyor called RN C on 04/04/2025 at 12:54 PM; the call was not returned. RN C was no longer employed by the agency. Agency policy titled, “Patient Rights, Responsibilities And Conduct Requirements (Texas Only) 1.001T” with a revised date of 12/01/21 read in part, “… Patient Rights… 10. The patient has the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect, misappropriation of property, and exploitation by an agency employee, volunteer, or contractor…” Agency policy titled, “Patient Abuse, Exploitation, and Neglect: Assessment, Identification and Reporting (Texas only) 2.1.005 T” with a revised date of 11/1/24 read in part, “… PURPOSE: To identify, assess and report victims of actual or suspected abuse, exploitation and/or neglect… Definitions as defined in Texas Human Resource Code Chapter 48, section 48.002… B. Neglect Failure to provide one’s self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services… Definitions of Employee Reportable Conduct as defined in the Texas Human Resource Code Chapter 48 section 48.401… Reportable Conduct: Includes: abuse or neglect that causes or may cause death or harm to an individual receiving agency Services…”

A Recertification survey entrance was conducted on 1/11/2024 at 1:00 PM. Patient census: Licensed and Certified Home Health – 225 No deficiencies cited.

A Recertification survey entrance was conducted on 1/11/2024 at 1:00 PM. Patient census: Licensed and Certified Home Health – 225 Definitions: SOC - Start of Care POC - Plan of Care DON - Director of Nursing RN - Registered Nurse SN – Skilled Nurse PT – Physical Therapy ESRD - End Stage Renal Disease OASIS- Outcome and Assessment Information Set (group of standard data elements home health agencies integrate into their comprehensive assessments to collect and report to CMS). CMS – Centers for Medicare and Medicaid Services. Agency met Medicare Conditions of Participation with Standard deficiencies.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review, observation, and interview, RN A failed to ensure accurate comprehensive assessments were provided to 1 (Patient #5) of 5 patient records reviewed with home visits. RN A conducted 4 comprehensive assessments on 5/23/2023, 7/20/2023, 9/19/2023 and 11/16/2023, and failed to provide and document an accurate assessment that included pertinent diagnoses consistent with the patient’s current health status, at the time of the assessment. RN A’s failure to conduct an accurate comprehensive assessment could cause a decline in the patient’s health status due to the patient not being provided a thorough and complete physical assessment by the clinician to determine the care and needs of the patient. Findings include: Review of Patient #5’s clinical record included a POC with a SOC date of 3/31/22 and a certification period of 11/21/2023 – 1/19/2024. The POC listed a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease (a disease that affects the way the body processes blood sugar and can affect blood vessels in kidneys that can cause kidney damage). Other diagnoses included, ESRD (a condition in which a person’s kidneys cease functioning on a permanent basis that’s leads to dialysis) and Dependence on renal dialysis (a condition in which a person must have frequent treatments that help the body remove extra fluid and waste products from the blood when the kidneys are not able to). The POC included orders for a skilled nurse visit one time a week for 8 weeks. Review of Patient #5’s clinical record included skilled nursing notes ordered by the patient’s physician for one time a week for 8 weeks that included the following dates, 11/21, 11/28, 12/6, 12/12, 12/21, 12/26/2023, 1/3/2024, 1/10, 1/17/2024. Review of the skilled nursing notes, included in Patient #5’s clinical record, did not include any documentation regarding the patient’s diagnoses of ESRD and/or dialysis. A home visit was conducted on 1/18/24 at 11:30 AM with Patient #5. Patient #5 reported he never had a kidney problem or dialysis. In an interview with the Administrator/DON on 1/19/24 at approximately 3:15 PM, the surveyor went over the findings regarding Patient #5’ diagnoses of ESRD and Dependence on Renal dialysis. The Administrator/DON asked if she could check on the finding. At approximately 3:30 PM the Administrator/DON returned and stated Patient #5 did not have ESRD and was not dependent on dialysis. The Administrator/DON stated she was not sure why the diagnoses were included on the patient’s comprehensive assessments and the patient’s POCs. She stated she looked back at previous POCs and found the diagnoses were included on the POCs beginning May 25, 2023, through January 17, 2024. The surveyor continued to review Patient #5’s clinical record that included the following. Patient #5’s clinical record included a POC with a SOC date of 3/31/22 and a certification period of 5/25/2023 – 7/23/2023 signed and dated by RN A on 5/23/2023. The POC listed a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Other diagnoses included, ESRD and Dependence on renal dialysis. Physician orders included SN effective 5/28/23, 1 time a week for 8 weeks and PT effective 6/4/23 for 1 time a week for 1 week. Patient #5’s clinical record included a POC with a SOC date of 3/31/22 and a certification period of 7/24/2023 – 9/21/2023 signed and dated by RN A on 7/20/2023. The POC listed a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Other diagnoses included, ESRD and Dependence on renal dialysis. The POC included orders for a skilled nurse visit one time a week for 8 weeks. Patient #5’s clinical record included a POC with a SOC date of 3/31/22 and a certification period of 9/22/23 to 11/20/23 signed and dated by RN A on 9/19/2023. The POC listed a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Other diagnoses included, ESRD and Dependence on renal dialysis. The POC included orders for a skilled nurse 3 times a week for 1 week and 1 time a week for 8 weeks. The surveyor conducted a phone interview on 2/1/2024 at 10:30 AM with RN A and reviewed the findings regarding the comprehensive OASIS assessments that RN A provided to Patient #5. RN A stated she knew Patient #5 very well and had done the past several comprehensive OASIS assessments. RN A stated Patient #5 has a diagnosis of DMII and has an order from the physician for a urinary catheter change once every month by agency nurses. RN A stated she knew Patient #5 did not have ESRD and was not dependent on dialysis. She stated she may have inadvertently added the diagnoses, but that Patient #5 did not have either of the diagnoses. The agency’s policy read as follows, “Patient Assessment, Initial and Reassessment, policy # 2.1.002” with the last review date of 01/01/2024. The policy included, “The comprehensive assessment is the responsibility of one clinician…. All patients receive ongoing and periodic reassessments. Comprehensive OASIS assessments are made prior to patient recertification for all adult patients receiving skilled care…. Procedure: 1. Upon admission and reassessments, the qualified clinician performs the following assessment activities and collects the following data: A. Current health status, psychological, functional, and cognitive status… H. pertinent physical findings L. pertinent medical history….”

A complaint investigation (Intake 379157) entrance conference was conducted on 03/30/2023. The census was: LCHHS: 230 LHH: 0 The agency was found in compliance with 42 CFR Part 484.22 Emergency Preparedness Requirements for HHA and no deficiencies were cited. Abbreviations: CFR: Code of Federal Regulations LCHHS: Licensed and Certified Home Health Services LHH: Licensed Home Health Services

A complaint investigation (Intake 379157) entrance conference was conducted on 03/30/2023. The census was: LCHHS: 230 LHH: 0 Abbreviations: Ix – one time Adm – Administrator Admin - Administrator AM - Ante meridiem ASAP – as soon as possible BW - bloodwork cc- cubic centimeter cath – catheter dc – discharge d/t – due to DON - Director of Nurses Dr - doctor Etc – etcetera EOT -End of treatment ER – emergency room F - french Fr – French FFR - french HHA – home health agency IV - intravenous LCHHS - Licensed and Certified Home Health LHHS - Licensed Home Health Services MD – medical doctor OON – out of network PCM -Patient care manager PICC – peripherally inserted central catheter PM - Post meridiem prn - as needed Pt – Patient PT – Physical Therapist POC - plan of care Reg – requests RN – registered nurse SN - skilled nurse TCF - Telephone call from TCT – telephone call to W - with WCC – wound care clinic

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to document both the existence of complaints and the resolution of complaints for 19 of 19 complaints reviewed (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17). This failure placed patients at risk of grievances/complaints not being addressed allowing the patient care issues to continue. Findings include: Record review of the agency complaint log dated 01/06/2022-03/28/2023 included zero complaints for Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17. Record review of the agency on call (a designated agency telephone number for patient’s, family members, etc. to access care from the agency during and after regular business hours) log dated 07/01/2022-03/30/2023 did not include any complaints received for Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17. Complaint 1: Record review of the on call log included a call received from Patient 1 on 09/17/2022 at 10:06 AM that read in part, “…req to speak to Admin/upset, complaint…nurse not scheduling a timeframe for visits…” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…I spoke with her and she told me she had an MD appointment. She had a nursing visit the day prior 9/16 and was wanting a specific time for all her visits, we are unable to promise a specific timeframe for all visits…” Complaint 2: Record review of the on call log included a call received regarding Patient 2 on 10/04/2022 at 5:26 PM that read in part, “…never got return phone call back after first vist (sic) only had 1 nurse vist(sic)/wants a nurse vist(sic).” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…Had the admitting nurse call as she had not completed the documentation and we were unable to see what the patient's schedule was without that documentation being completed…” Complaint 3: Record review of the on call log included a call received from a family member of Patient 3 on 11/19/2022 at 12:28 PM that read in part, “…had admit visit but no nurses have been to home since…” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…Patient had requested us not come as her insurance is OON and was referred to another agency per patient request…” Complaint 4: Record review of the on call log included four calls received regarding Patient 4: Call 1: 08/30/2022 at 11:55 PM received from Patient 4 read in part, “…leakage from cath…” Call 2: 08/31/2022 at 1:53 AM received from Patient 4 read in part, “…super pubic (sic) cath (a hollow flexible tube that is used to drain urine from the bladder that is inserted into the bladder through a cut in the tummy a few inches below the navel) not draining and bladder full…” Call 3: 08/31/2022 at 3:33 AM received from a family member of Patient 4 read in part, “…complications with catheter leaking, needs assistance…” Call 4: 08/31/2022 at 4:11 AM received from a family member of Patient 4 read in part, “…this is the 4th call been trying to get RN since 11:45 PM…has a super pubic (sic) and there is an issue with it…” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/04/2023 at 2:40 PM, the surveyor asked why the on call nurse did not return the calls and why a nursing visit was not conducted on 08/30/2023 or 08/31/2023 after receiving the calls. An email received by the surveyor from Adm/DON on 04/04/2023 at 4:02 PM read in part, “…I was the RN on call this night, my phone did an update in the middle of the night and I'm unsure if the ringer got turned down or off but I woke around 5 AM and called the patient back and spoke with her husband, the catheter was leaking. I apologized profusely and told them I would be there within 20 minutes, threw on my scrubs and went to see her. We had orders for PRN but never scheduled myself the visit to document on it….” In an email sent to Adm/DON on 04/04/2023 at 4:37 PM, the surveyor clarified if Adm/DON conducted a nursing visit on 08/31/2023 but did not document the visit. Adm/DON replied, “Yes, ma'am…” In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…This is the one with the phone malfunction that I went to see the patient…” Complaint 5: Record review of the on call log included a call received from a family member of Patient 5 on 02/06/2023 at 2:17 PM that read in part, “…[family member]…requesting BW, and urine results as soon as possible it has been 2 weeks now…” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…we don't send lab results to patients, they are dropped off at the lab and results are sent to the following MD. [family member] wanted us to give her the results and we are unable to do that…” Complaint 6: Record review of the on call log included a call received from a family member of Patient 6 on 02/22/2023 at 7:46 PM that read in part, “…upset/enroute (sic) to ER/req supervisor…” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…Patient and [family member] wanted PICC line to be removed during SN visit the previous day however no order was received to remove the line from…MD.…” Complaint 7: Record review of the on call log included a call received from Patient 6 on 02/26/2023 at 7:11 PM that read in part, “…PICC line (an acronym for a Peripherally Inserted Central Catheter: a long IV line usually inserted in a smaller vein in the upper arm and terminates in a larger vein in the chest near the heart) site is burning/no nurse visit since last Tuesday/needs a visit.” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…Patient scheduled as ordered 1x weekly per MD order…” Complaint 8: Record review of the on call log included a call received regarding Patient 7 on 02/22/2023 at 4:51 PM that read in part, “…nurse has not shown up for infusion.” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…nurse arrived on return call to family at 5:01 PM..” Complaint 9: Record review of the on call log included a call received from a family member of Patient 7 on 03/03/2023 at 4:48 PM that read in part, “…nurse has not shown up.” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…education was provided to caregiver during visit day prior, family was educated on administration and reported understanding. During previous conversations they were to take over IV administration as we could not continue to see patient daily…” Complaint 10: Record review of the on call log included a call received from Patient 15 on 02/02/2023 at 10:59 AM that read in part, “…patient is still waiting on a nurse to come out. Patient states that it is urgent.” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…During business hours call, on return call at 11:04AM to patient she reported she had gone to the ER early in the morning d/t abdominal pain and reports that they drew her labs and dressing changed and no need for nurse to come as she didn't want to waste one of her visits. Complaint 11: Record review of the on call log included a call received from Patient 8 on 02/01/2023 at 9:02 AM that read in part, “…needs…PIC (sic) line out. Was told a week ago it would be done, needs assistance ASAP.” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…He was out of town when the order came in from the MD, patient went out of town again the following week. Whie (sic)PCM was looking for a nurse to see patient, patient removed his own line on second return call to patient…” Complaint 12: Record review of the on call log included a call received a call from Patient 9 on 03/02/2023 at 5:13 PM that read in part, “…did not have good experience with physical therapist today…” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…They had [PT] from the Denton office previously and had a good rapport with her. Subsequent visits were scheduled to [PT]…” Complaint 13: Record review of the on call log included a call received a call from Patient 10 on 07/16/2022 at 12:00 PM that read in part, “…wanting to know what happened with nurse visit/no one showed up yesterday.” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…Not return call to nurse, [family member] wants to be the one communicated with for all visits and for staff to text and call her instead of calling patient. Visit was completed on Saturday 7/16…” Complaint 14: Record review of the on call log included three calls received regarding Patient 11: Call 1: 01/07/2023 at 8:18 AM received from Patient 11 read in part, “…wants to know when PICC line is coming/Pt is in discomfort.” Call 2: 01/07/2023 at 11:18 AM received from Patient 11 read in part, “…PICline (sic).” Call 3: 01/07/2023 at 3:03 PM received from Patient 11 read in part, “…update on PICC line-upset.” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…TCF patient stating that she is finished w her antibiotics but her PICC line is still in and should would like it removed today. PCM reviewed file and noted that prior SN had contacted [family member] and was awaiting EOT clarification...TCT [MD]…She gave order to dc [PICC] line…confirmed that order was received for EOT for 1.4.23 but no order to DC PICC. Order taken verbally to remvve (sic) the [PICC] line. PCM wrote order and scheduled patient for DC of PICC line today with…nurse. Line was removed same day as calls…” Complaint 15: Record review of the on call log included a call received a call from Patient 16 on 01/03/2023 at 5:34 PM that read in part, “Pt call to notify nurse has not shown up.” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…-- No nursing visit scheduled. 1/3/23 TCF patient who states that she fell on Saturday but she denies any pain swelling or injury. Informed her that PCM would call her MD and SN would visit her tomorrow 1/4…” Complaint 16: Record review of the on call log included a call received from a family member of Patient 17 on 01/03/2023 at 5:16 PM that read in part, “…nurse was supposed to come out today and has not shown yet.” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…Patient scheduled for 1x weekly nursing visits, visit was scheduled for 1/4…” Complaint 17: Record review of the on call log included a call received a call from Patient 12 on 09/10/2022 at 9:47 AM that read in part, “Questions…care schedule. Reg better communication…” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…Patient had just been admitted on 09/07, was questioning her schedule. PCM called her back and discussed schedule, call was resolved…” Complaint 18: Record review of the on call log included three calls received regarding Patient 13: Call 1: 11/22/2022 at 7:04 PM received from Patient 13 read in part, “…need catphter (sic) fixed.” Call 2: 11/22/2022 at 7:12 PM received from Patient 13 read in part, “…Pt had a catheter change and when she urinate (sic) it went on the pad and nothing went in the catheter.” Call 3: 01/23/2023 at 7:40 AM received from a family member of Patient 13 read in part, “…fault (sic) equipment for catheters/would like to speak with [Adm/DON].” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…Patient felt that catheter supplies coming from [medical supply supplier] was faulty…” Complaint 19: Record review of the on call log included two calls received regarding Patient 14: Call 1: 11/09/2022 at 4:43 PM received from a family member of Patient 14 read in part, “…Bandage was suppose (sic) to be changed today/wasn’t changed.” Call 2: 11/09/2022 at 4:49 PM received from Patient 14 read in part, “ETA of RN today.” The complaint was not included in the complaint log. The agency failed to initiate a complaint investigation within 10 days after the agency's receipt of the complaint and document all components of the investigation. In an email sent to Adm/DON on 04/05/2023 at 6:06 PM, the surveyor asked why the complaint was not documented and investigated as a complaint. An email received by the surveyor from Adm/DON on 04/10/2023 at 2:28 PM read in part, “…Patient was scheduled to go to WCC on 11/9, when he called to report it wasn't changed he reported he didn't go to the WCC, next nursing visit was supposed to be 11/11 moved visit to Thursday to address wound since patient didn't go to the WCC as planned…” During an interview with Adm/DON on 04/11/2023 at 5:20 PM, the surveyor asked why the 19 complaints were not documented as complaints in the agency complaint log, complaint investigations initiated within 10 days after the agency's receipt of the complaint and all components of the investigation documented. Adm/DON stated she wasn’t thinking all of the things were complaints and didn’t consider them complaints, but following the emails from the surveyor, she had talked to other employees and now understands what a complaint is. Agency policy number 1.007T titled, “GRIEVANCE PROCEDURE, PATIENT COMPLAINTS (TEXAS ONLY)” with a revision date of 12/01/2021 read in part, “…PURPOSE: To establish a process for patients, caregivers, and referral sources to communicate areas of concern in regards to patient care and services as well as an internal process to investigate, address findings and follow-up with the individual(s) who initiated the concern. POLICY: The agency will investigate complaints made by the patient, legal representative, caregiver, and/or family. Complaints investigated will include, but not limited to the following: Treatment or care furnished inappropriately or inconsistently Mistreatment or neglect Abuse (verbal, mental, sexual, or physical) Injuries of unknown source Misappropriation of patient’s property by anyone furnishing services on behalf of the agency… PROCEDURE: 1. Staff receiving complaints either in person, by phone, or through the mail shall document the patient complaint. Agencies will document the complaint within the information system. The Executive Director or Clinical Director will receive automated workflow regarding the complaint. An investigation will be initiated no later than 10 days from date complaint received. 2. The Executive Director or Clinical Director interviews the patient, family, and involved staff or other individuals and takes appropriate actions to resolve the issue. 3. If the Executive Director or Clinical Director is unable to resolve the complaint, the Executive Director and/or Area Executive Director/Vice President are notified for further investigation and analysis. 4. If the Area Executive Director/Vice President is unable to resolve the complaint, the Division President is notified for final resolution of the issue. 5. After the investigation and analysis is completed but no later than 30 days after the complaint/grievance filing, the Executive Director or Clinical Director will follow-up with the patient and/or complainant and document within the information system. 6. Agencies can access the complaint report within the information system. Any supportive documentation regarding the complaint should be kept in a confidential file…” Agency policy number 5.008 titled, “ON-CALL PROCESS (TO INCLUDE DURING AFTER HOURS AND CARE)” with a revision date of 03/01/2019 read in part, “POLICY: The agency ensures that patients, caregivers, and/or their physicians, as well as referral sources and other health care providers, have access to a staff clinician 24 hours-a-day by means of providing an on-call nurse during and after office hours. A RN will be available at least by telephone while any services are provided… PROCEDURE…The agency will provide each client, upon admission to services, a designated on-call telephone number and will instruct each client to call this number to access care from the agency after regular business hours… To ensure that a clinician can be contacted by telecommunications, during and after office hours, each agency will establish a call schedule for their offices…The respective answering service will contact the on-call clinician immediately after the patient related call is received. The total response time from patient/caregiver call to patient/caregiver contact by clinician will be no longer than 30 minutes…Clinicians will document responses and outcomes of appropriate calls on the On-Call Event Coordination note…Clinicians will submit the On-Call Event Coordination Note and any supporting patient documentation by next business day and verbally communicate all on-call issues to appropriate Executive Director/Clinical Director and/or Patient Care Manager…The Executive Director/Clinical Director will assure that appropriate follow-up- visits are scheduled if needed…”

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient received home health services as ordered in the individualized POC for one of two patient records reviewed (Patient 13) in that: Suprapubic (a hollow flexible tube that is used to drain urine from the bladder that is inserted through a cut in the tummy) urinary catheter orders were not followed as ordered in the POC. This failure placed the patient at risk of not receiving interventions as ordered and could potentially cause complications and a decline in health status. Findings include: Patient 13: Record review of the electronic health record included a POC dated 09/12/2022-11/10/2022 that included a diagnosis of bladder dysfunction, encounter for fitting and adjustment of urinary device and urinary tract infection. The POC read in part, “…skilled nurse for insertion of an 18 FFR 30 cc balloon indwelling catheter…instill 30 cc of sterile water into balloon. Change every 4 weeks and prn…” The record included a skilled nursing visit conducted on 09/17/2022 by RN B that read in part, “…Genitourinary…indwelling…catheter…catheter size 18…insertion date: 09/17/2022…Interventions provided…insert/change…catheter…utilizing aseptic technique…18 F 30 cc balloon catheter inserted. Balloon inflated with 25 cc sterile water…” RN B inflated the catheter balloon with 25 cc sterile water instead of the ordered 30cc sterile water. The surveyor emailed RN B on 04/17/2023 at 4:35PM and asked why 25 cc was used to inflate the urinary balloon instead of the ordered 30 cc. The surveyor received an email from RN B on 04/17/2023 at 8:28 PM that stated when she pushed the fluid filled syringe to inflate the balloon, the syringe popped off of the catheter and 5 cc was wasted, so only 25 cc remained. RN B stated no additional syringes were available so she only inserted the 25 cc’s that was left in the syringe. In an email sent to Adm/DON on 04/20/2023 at 12:40 PM, the surveyor stated, “You previously stated you needed to check with the nurses on the following... “[Patient 13]…visit 09/17/22…Why was 25 cc used to inflate the balloon instead of the ordered 30cc? The Adm/DON replied in an email on 04/20/2023 at 4:28 PM that RN B stated, “During the visit on 9/17, she documented correctly 25 cc were instilled d/t the syringe popping off and that was the last of the supplies in the home at that time, so she instilled 25 instead of the ordered 30. Agency policy number 2.1.007 titled, “PLAN OF CARE (POC)” with a revision date of 12/01/2021 read in part, “…PURPOSE…To ensure that physician/authorized practitioner’s orders are followed…PROCEDURE… 8. Alterations to the POC are made only with the physician/authorized practitioner’s approval…” Agency policy number 1.001T titled, “PATIENT RIGHTS, RESPONSIBILITIES CONDUCT AND REQUIREMENTS (TEXAS ONLY)” with a revision date of 12/01/2021 read in part, “…Patient Rights… 13. The patient has the right to receive all services outlined in the plan of care…” Agency policy number 5.004T titled, “OPERATIONS PATIENT CARE FOR DELIVERY (TEXAS ONLY)” with a revision date of 01/01/2018 read in part, “…PURPOSE: The leaders provide the framework for planning, directing, coordinating, providing, and improving health care and services that respond to patient and community needs to improve patient health outcomes… POLICY: Leadership, which may include Senior Management…provides organization direction and staffing for patient care services according to the scope of care or services offered…PROCEDURE… 5. Patient care and services are appropriately integrated throughout the organization, and facilitated by communication and coordination among Executive/Clinical Directors. This enables individuals to work together on a variety of activities, such as: g. assuring development, implementation and updates of individualized plan of care…”