Every finding on record at Life Unlimited Home Health LLC

An entrance conference was conducted on 09/26/2023 at 11:45 a.m. with the Director of Clinical Services, Human Resources Office Manager and by phone with the Administrator. The agency representatives were advised the purpose of the visit was a Recertification survey. The census was: Austin: L&CHHS- 98 LHHS- 0 PAS- 0 An exit conference was conducted on 09/29/2023 at 1:20 p.m. with the Administrator, Director of Clinical Services, Clinical Manager and Human Resources Office Manager. No deficiencies cited.

An entrance conference was conducted on 09/26/2023 at 11:45 a.m. with the Director of Clinical Services, Human Resources Office Manager and by phone with the Administrator. The agency representatives were advised the purpose of the visit was a Recertification survey. The census was: Austin: L&CHHS- 98 LHHS- 0 PAS- 0 An exit conference was conducted on 09/29/2023 at 1:20 p.m. with the Administrator, Director of Clinical Services, Clinical Manager and Human Resources Office Manager. 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.” Abbreviations: L&CHHS- Licensed and Certified Home Health Services LHHS- Licensed Home Health Services PAS- Personal Assistance Services RN- Registered Nurse LVN- Licensed Vocational Nurse Admin- Administrator Alt Admin- Alternate Administrator SN- Supervising Nurse Pt- patient HHA- Home Health Aide DCS- Director of Clinical Services HR- Human Resources CEO- Chief Executive Officer ROC- Resumption of Care HHSC- Health and Human Services Commission

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to enforce a written policy to ensure the patient's individualized plan of care was reviewed by the patient's physician no less than once every 60 days, beginning with the start of care date for 3 of 14 patients (Patient #2, #4 and #5) for which records were reviewed. Failure to ensure the patient's plan of care is reviewed by the physician no less than once every 60 days has the potential to cause harm to agency patients in that the physician may not be aware of changes in the patient's condition or the need for additional care and services. Review of the agency's Policy and Procedure Manual revealed a policy titled "Orders for Care, Reviewed:110120”, which read in part “The agency will obtain orders and provide care in accordance with physician’s and/or non-physician practitioners orders which are established prior to initiating patient/client care and reviewed/revised by the physician and or non-physician practitioner every sixty (60) days and as needed.” Review of the clinical record for Patient #2 revealed a start of care date of 06/02/2023. Review of the plan of care for the certification period 06/02/2023 – 07/31/2023 revealed no documentation that the plan of care was reviewed and signed by the physician. Review of the clinical record for Patient #4 revealed a start of care date of 06/22/2023. Review of the record revealed Patient #4 was hospitalized on 07/24/2023 – 07/29/2023. A skilled nurse visit was conducted on 07/29/2023 for ROC (resumption of care). There was no documentation that the ROC was reviewed and signed by the physician. Review of the clinical record for Patient #5 revealed a start of care date of 03/1/2023. Review of the record revealed a physical therapy evaluation dated 07/20/2023 revealed no documentation that the physician reviewed or signed the physical therapy plan of care. An Interview was conducted on 09/27/2023 at 11:20 a.m. with DCS. The clinical records for Patients #2, #4 and #5. DCS acknowledged orders were not reviewed and signed by the patient’s physician. Surveyor asked what caused this failure. DCS stated it was the responsibility of the HH Operations Representative and Administrative Assistant to obtain signed physician orders.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to designate an Alternate Administrator who meets the qualifications and conditions to act in the absence of the Administrator. Failure to designate an Alternate Administrator to act in the absence of the Administrator has the potential to place the agency's 98 active clients at risk for harm in the event the Administrator is unable to oversee the operations of the agency. Review of the Texas Unified Licensing Information Portal (TULIP) Portal on 09/22/2023 identified (Identifier A) as the Alternate Administrator. TULIP is a database used by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the state of Texas. During the Entrance Conference on 09/26/2023 at 11:45 a.m. the Administrator stated the Director of Clinical Services is the new Alternate Administrator. Surveyor asked when the DCS became the Alternate Administrator and requested to review documentation that HHSC was notified to the change. The Administrator stated DCS was appointed approximately one month ago, and documentation was not submitted to HHSC. Review of the personnel record for DCS revealed no documentation of 8 hours of initial education for Administrators, a job description for the Alternate Administrator or completion of administrator pre-survey modules. An Interview was conducted on 09/29/2023 at 9:45 a.m. with the DCS. DCS stated there was some discussion during the interview process, but she was not hired to be the Alternate Administrator. Documentation of initial administrative clock hours signed job description and documentation of notification to the state for a change in administrator was requested for review. DCS stated she had not completed the presurvey modules or initial administrative clock hours required prior to designation as an administrator. An interview was conducted on 09/29/2023 at 10:05 a.m. with CEO. Surveyor asked when the agency last had an Alternate Administrator. CEO stated Identifier A resigned on 03/31/2023. No additional information was provided. Review of the agency’s online policy and procedure manual revealed a policy titled, “Administrative Structure, Reviewed:080118,” which read, “When the Administrator is not available, a qualified, pre-designated person, who is authorized in writing by the Administrator and the Governing Body, assumes the same responsibilities and obligations as the Administrator.”