Every finding on record at Lubbock Essential Home Health Care Inc

Purpose of visit: Recertification survey Entrance date: 08/07/23 at 9:26 a.m. with the Administrator/Supervising Nurse, Alternate Administrator/ Alternate Supervising Nurse, and Director of Medicaid Programs. Census: L&C – 0 LHH – 0 PAS – 171 During the entrance conference the administrator said the agency transferred and/or discharged all L&C patients by 12/31/22 and the agency contacted the state regarding procedure for placing L&C on hold and are not admitting L&C patients at this time and she and the Alternate Administrator/Alternate Supervising Nurse are the only nurses employed at the agency at this time. This surveyor was presented with a document on 08/10/23 at 3:00 p.m., titled, “Agenda of the Annual Meeting of the Board of Directors of Lubbock Essential Home Health” dated December 15th 2022” that read in part, “…The Governing Board of Lubbock Essential Home Health Care Inc, has opted to close the Medicare home health segment of the business because expenses continue to exceed the revenues the program generated the board recognizes that the ongoing operational expenses cannot be sustained without impacting other programs. The Agency is not accepting any new patients before the closure expected to take place by the end of this month…” An exit conference was conducted on 08/11/23 at 1:06 PM with the Administrator/Supervising Nurse, Alternate Administrator/Alternate Supervising Nurse, and Director of Medicaid Programs. Preliminary findings were discussed, the staff was informed of the investigation finding, and the agency staff was given the opportunity to ask questions and to provide additional information. All questions were answered. No additional information was provided. Written and verbal instructions were provided for submitting a plan of correction within 10 days of receipt of the statement of deficiencies. Acronyms: L&C – Licensed and Certified LHH – Licensed Home Health PAS – Personal Assistance Services MSW – Master of Social Work EVV – Electronic Visit Verification - A document that lists the client name, date of service, hours of service and attendants name that provided the services. RN – Registered Nurse TULIP - Texas Unified Licensure Information Portal – A database utilized by the state to maintain licensing demographic information, complaint and self-reported incidents on Home Health and Hospice agencies for the State of Texas.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to enforce its emergency preparedness policy regarding the assignment of a triage category for 1 of 7 (#6) discharged patient that received services whose record was reviewed. This failure placed the patient at risk of harm due to the agency’s inability to determine the patients immediate service and evacuation needs during an emergency. Findings include: Patient #6 - Review of the clinical record indicated a start of care date of 09/23/22. The record did not include an emergency preparedness triage code for this patient. During an interview conducted on 8/10/23 at 2:11 p.m., when asked for the patient’s emergency preparedness triage category the alternate administrator said there was not an emergency preparedness triage form in the record. Review of the agency policy titled, “Emergency Preparedness and Response Plan” dated 07/01/20 revealed, “… 2. Patient/Client Triage – a. Coordination of patient care and communication regarding the patient’s status will transpire through informal verbal and written communication… B. The Emergency Preparedness and Response Plan will include procedures to triage patients/clients that allow the Agency to: (1) Readily access recorded information about an active patient’s/client’s triage category in the event of an emergency to implement the Agency’s response and recovery phases; (2) Categorize patients/clients into groups based on: (a) Services provided (b) Patient’s/client’s need for continuity of the services (c) Availability of someone to assume responsibility for the patient’s/client’s emergency response plan if needed by the patient/client. … 2. Patient /Client Triage -a. The Disaster Coordinator, Alternate and clinical staff will ensure that the current list of patients/clients is maintained, prioritized by care needs and based on specific services provided… B. 2. A. Upon admission to the Agency and on an ongoing basis, the patient’s/client’s condition and needs will be assessed for triage prioritization based on specific services provided. Criteria for prioritizing may include but are not limited to: I – Life threatening (or potential- requires ongoing care… II – Not life threatening – patient/client might suffer severe adverse effects from interruption of services… III – Visits could be postponed 24-48 hours without adverse effects… IV – Visits could be postponed 72-96 hours without adverse effects…”

Purpose of visit: Recertification survey Entrance date: 08/07/23 at 9:26 a.m. with the Administrator/Supervising Nurse, Alternate Administrator/ Alternate Supervising Nurse, and Director of Medicaid Programs. Census: L&C – 0 LHH – 0 PAS – 171 During the entrance conference the administrator said the agency transferred and/or discharged all L&C patients by 12/31/22 and the agency contacted the state regarding procedure for placing L&C on hold and are not admitting L&C patients at this time and she and the Alternate Administrator/Alternate Supervising Nurse are the only nurses employed at the agency at this time. This surveyor was presented with a document on 08/10/23 at 3:00 p.m., titled, “Agenda of the Annual Meeting of the Board of Directors of Lubbock Essential Home Health” dated December 15th 2022” that read in part, “…The Governing Board of Lubbock Essential Home Health Care Inc, has opted to close the Medicare home health segment of the business because expenses continue to exceed the revenues the program generated the board recognizes that the ongoing operational expenses cannot be sustained without impacting other programs. The Agency is not accepting any new patients before the closure expected to take place by the end of this month…” An exit conference was conducted on 08/11/23 at 1:06 PM with the Administrator/Supervising Nurse, Alternate Administrator/Alternate Supervising Nurse, and Director of Medicaid Programs. Preliminary findings were discussed, the staff was informed of the investigation finding, and the agency staff was given the opportunity to ask questions and to provide additional information. All questions were answered. No additional information was provided. Written and verbal instructions were provided for submitting a plan of correction within 10 days of receipt of the statement of deficiencies. Acronyms: L&C – Licensed and Certified LHH – Licensed Home Health PAS – Personal Assistance Services MSW – Master of Social Work EVV – Electronic Visit Verification - A document that lists the client name, date of service, hours of service and attendants name that provided the services. RN – Registered Nurse TULIP - Texas Unified Licensure Information Portal – A database utilized by the state to maintain licensing demographic information, complaint and self-reported incidents on Home Health and Hospice agencies for the State of Texas.

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 interview and record review, the agency failed to ensure that the plan of care was followed as ordered by the physician for 2 of 3 (#3 and #4) discharged patients that had orders to receive or had received social worker services. This failure could cause deterioration of the patient's health status, and the potential for patient dissatisfaction regarding services. Findings include: Patient #3 - Review of the plan of care dated 10/23/22 to 12/21/22 included a physician’s order for MSW visit 1week 1. Review of the clinical record did not indicate an MSW visit was performed. During an interview conducted on 8/10/23 at 2:06 p.m., when asked if the social worker conducted a visit the alternate administrator/alternate supervising nurse said she did not find a social worker visit and she did not know why it was not done. Patient #4 - Review of the plan of care dated 10/21/22 to 12/19/22 included a physician’s order for MSW visit 1week 1. Review of the MSW visit notes indicated social worker services were provided on 10/26/22 and 11/03/22. The record did not include a physician’s order for social worker services on provided on 11/03/22. During an interview conducted on 8/10/23 at 2:08 p.m., when asked if there was a physician order for the MSW visit performed 11/03/22 the alternate administrator/alternate supervising nurse said she did not find a physician order for that visit. The social worker is no longer an employee at the agency. Review of the agency policy titled, “Orders for Care” with a revision date of 11/01/20 included, “Purpose: to ensure patient/client care is provided in accordance with a physician and or non-physician practitioner order and federal and state laws and regulations. Policy: the agency will obtain orders and provide care in accordance with physicians and or non-physician practitioners orders…” Review of the agency policy titled, “Implementing Care and Treatment” included, “…VII. When the provision of care and treatment cannot be implemented as established on the care planning documents the patient’s/client’s physician and or non-physician practitioner will be notified. If the agency misses visits or services as required by the plan of care, it must notify the responsible physician and or non-physician practitioner of the missed visit…”

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interviews and record review, the agency failed to ensure that care was provided as ordered by the physician: The agency failed to ensure the skilled nurse performed wound care as ordered by the physician for 1 of 3 (#6) discharged patient receiving skilled nursing services to provide wound care. The agency failed to ensure the skilled nurse obtained a physician’s order to discharge 2 of 7 (#3 and #4) discharged patients prior to discharge from agency services This failure has the potential to result in ineffective and inappropriate medical interventions and could cause a deterioration of the patients’ wound status, This failure placed discharged patients at risk of not having needs met after discharge by failing to obtain a physician’s order and informing the physician of the patient’s ongoing service needs. Findings include: Patient #6 - Review of the clinical record indicated a start of care date of 09/23/22. Review of the plan of care dated 11/22/22 to 01/20/23 included a physician’s order for wound care to Non pressure chronic ulcer left foot 2nd toe. There was no documented evidence of a physician’s order for wound care to Left buttock. Review of the skilled nursing visit note dated 12/12 22 indicated a wound was noted on Left buttock and indicated the skilled nurse cleansed the wound with wound cleaner, pat dry, covered with foam and secured with tape. The visit note indicated the physician was notified and would address the wound at the next physician appointment scheduled 12/14/22. Review of the skilled nursing visit note dated 12/14/22 indicated a wound was noted on Left buttock and indicated the skilled nurse cleansed the wound with wound cleaner, pat dry, covered with foam and secured with tape. The visit note indicated the physician was notified and would address the wound at the next physician appointment scheduled 12/16/22. This skilled nurse is no longer an employee at the agency. During an interview conducted on 8/10/23 at 2:11 p.m., when asked where the physicians orders were located for the wound care to the left buttock the alternate administrator said she did not find a physician order for wound care to the left buttock. Patient #3 - Review of the plan of care dated 10/23/22 to 12/21/22 indicated a start of care date of 10/23/22. The clinical record indicated the patient was discharged 12/20/22 there was no physicians order to discharge the patient. During an interview conducted on 8/10/23 at 2:06 p.m., when asked if there was a physician's order to discharge or transfer this patient the alternate administrator said she did not find a physician’s order to discharge or transfer this patient. Patient #4 - Review of the plan of care dated 10/21/22 to 12/19/22 indicated a start of care date of 10/21/22. The clinical record indicated the patient was discharged 12/15/22. The record did not include a physician’s order to discharge the patient. During an interview conducted on 8/10/23 at 2:08 p.m., when asked if there was a physician's order to discharge or transfer this patient the alternate administrator said she did not find a physician’s order to discharge or transfer this patient. Review of the agency policy titled, “Orders for Care” with a revision date of 11/01/20 included, “Purpose: to ensure patient/client care is provided in accordance with a physician and or non-physician practitioner order and federal and state laws and regulations. Policy: the agency will obtain orders and provide care in accordance with physicians and or non-physician practitioners orders…”

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to complete and send discharge summaries to the primary care physician for 7 of 7 (Patient #1, #2, #3, #4, #5, #6, and #7) discharged patients whose records were reviewed. This failure placed discharged patients at risk of not having needs met after discharge by failing to identify the patients ongoing needs after discharge from the agency. Findings include: Patient #1 - Review of the clinical record for the certification period from 11/12/22 to 01/10/23 indicated the patient was discharged from services on 12/21/22. The record did not indicate a discharge summary was completed and sent to the physician. During an interview conducted on 08/10/23 at 2:03 p.m., when asked if there is a discharge summary available for this patient the alternate administrator said no discharge summary was found for this patient. Patient #2 - Review of the clinical record for the certification period from 10/25/22 to 12/23/22 indicated the patient was discharged from services on 12/21/22. The record did not indicate a discharge summary was completed and sent to the physician. During an interview conducted on 08/10/23 at 2:04 p.m., when asked if there is a discharge summary available for this patient the alternate administrator said no discharge summary was found for this patient. Patient #3 - Review of the clinical record for the certification. From 10/23/22 to 12/21/22 indicated the patient was discharged from services on 12/20/22. The record did not indicate a discharge summary was completed and sent to the physician. During an interview conducted on 08/10/23 at 2:06 p.m., when asked if there is a discharge summary available for this patient the alternate administrator said no discharge summary was found for this patient. Patient #4 – Review of the clinical record for the certification period from 10/21/22 to 12/19/22 indicated the patient was discharged from services on 12/15/22. The record did not indicate a discharge summary was completed and sent to the physician. During an interview conducted on 08/10/23 at 2:08 p.m., when asked if there is a discharge summary available for this patient the alternate administrator said no discharge summary was found for this patient. Patient #5 - Review of the clinical record for the certification period of 11/12/22 to 01/10/23 indicated the patient was discharged on 12/15/22. The record did not indicate a discharge summary was completed and sent to the physician. During an interview conducted on 08/10/23 at 2:09 p.m., when asked if there is a discharge summary available for this patient the alternate administrator said no discharge summary was found for this patient. Patient #6 - Review of the clinical record for the certification period from 11/22/22 to 01/20/23 indicated the patient was discharged from services on 12/15/22. The record did not indicate a discharge summary was completed and sent to the physician. During an interview conducted on 08/10/23 at 2:11 p.m., when asked if there is a discharge summary available for this patient the alternate administrator said no discharge summary was found for this patient. Patient #7 - Review of the clinical record for the certification period of 10/26/22 to 12/24/22 indicated the patient was discharged on 12/15/22. The record did not indicate a discharge summary was completed and sent to the physician. During an interview conducted on 8/9/23 at 1:35 PM when asked if discharge summaries had been completed for the discharged patients the administrator/supervising nurse said the previous alternate administrator/supervising nurse RN O and the previous alternate supervising nurse RN N assured her the discharges were done correctly but she can see now that the discharges were not all done correctly. During an interview conducted on 08/10/23 at 2:13 p.m., when asked if there is a discharge summary available for this patient the alternate administrator said no discharge summary was found for this patient. Review of the policy titled, “Patient/Client Transfer, Discharge and Agency Dissolution” with the revision date of 08/01/20 included, “…K. a complete discharge summary will be sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient/client after discharge from the agency (if any) within five (5) business days of the patient’s/client’s discharge…”