Every finding on record at Med-Source Healthcare Services Inc

A recertification survey entrance conference was conducted on 06/22/2021 at 10:30 a.m., with the Administrator/Supervising Nurse. Agency's census: Personal Assistance Services (PAS) - 297 Licensed Home Health Services (LHHS) - 0 Licensed and Certified Home Health Services (L&CHHS) - 0 An exit conference was conducted on 06/24/2021 at 3:12 p.m., with the Administrator/Supervising Nurse. The preliminary findings were discussed. The agency was in complaince with no deficiencies cited.

A recertification survey entrance conference was conducted on 06/22/2021 at 10:30 a.m., with the Administrator/Supervising Nurse. Agency's census: Personal Assistance Services (PAS) - 297 Licensed Home Health Services (LHHS) - 0 Licensed and Certified Home Health Services (L&CHHS) - 0 An exit conference was conducted on 06/24/2021 at 3:12 p.m., with the Administrator / Supervising Nurse. The preliminary findings were discussed. The agency was given 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 DADS - Department of Aging and Disability Services HHSC - Texas Health and Human Services Commission TULIP - Texas Unified Licensure Information Portal CMS - Centers for Medicare and Medicaid Services QAPI - Assessment and Performance Improvement

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on observation, interview and record review the administrator failed to be responsible for all day-to-day operations of the home health agency, in that: 1. The Administrator did not address the agency not admitting patients under Licensed and Certified Home Health Services (L&CHHS) for the past seven years, in the Quality Assessment and Performance Improvement (QAPI) committee meetings. 3. The Administrator submitted inaccurate documentation, for the agency's licensure renewal, that the agency provided services to one patient under the Licensed and Certified Home Health Services (L&CHHS) category during licensure period of 12/31/2018 to 12/31/2020 This failure provided the state database with inaccurate information and did not allow for surveyor to review the agency's compliance in providing skilled services or its compliance with the Code of Federal Regulations, Part 484. Findings Include: Record review of the HHSC data site, Texas Unified Licensure Information Portal (TULIP), showed the following: 1. The agency maintained a current license to provide Licensed and Certified Home Health Services (L&CHHS); Licensed Home Health Services (LHHS) and Personal Assistance Services (PAS) for licensure period of 12/31/2018 to 12/31/2020. 2. The license holder submitted a renewal application for licensure (Form 2021) for the category of Licensed and Certified Home Health Services (L&CHHS), Licensed Home Health Services (LHHS) and Personal Assistance Services (PAS). 3. The agency census as of 12/31/2020 was one (1) patient under the Licensed and Certified Home Health Services (L&CHHS); 0 under the Licensed Home Health Services (LHHS) and 300 under Personal Assistance Services categories. Review of the agency's Quality Assessment and Performance Improvement (QAPI) program did not contain any documentation of the agency's efforts or plan to admitting patients in its Licensed and Certified Home Health Services (L&CHHS) category. During the entrance conference on 06/22/2021 at 10:30 a.m., Surveyor requested from the Administrator/Supervising Nurse to furnish the agency's current active patient census under each category of the agency license. The agency Administrator / Supervising Nurse stated, "The agency is only providing PAS services, we have no skilled services, the last time we provided skilled services was in 2014." Surveyor asked why the agency stopped providing skilled services and what was the agency plan for its Licensed and Certified Home Health Services (L&CHHS) category. Administrator/Supervising Nurse stated, "We have not been providing skilled and we have no plan to start providing skilled services. During our last survey, Personal Assistance Services (PAS) category was only one reviewed. Not providing skilled services was not a problem." Surveyor asked what the agency plan was, regarding the Medicare provider number since the agency was not providing services under the L&CHHS category. The Administrator / Supervising Nurse stated, "I just update CMS website every 6 months, I'm looking into how to separate the category from Personal Assistance Services (PAS)." In another interview with the Administrator / Supervising Nurse on 06/24/2021 at 10:15 a.m., surveyor presented above findings regarding the one patient serviced under Licensed and Certified Home Health Services (L&CHHS) category reported in the TULIP system during licensure period of 12/31/2018 to 12/31/2020. The agency Administrator / Supervising Nurse stated, "It has been 7 years since my last skilled services. I cannot remember who the patient was. I no longer have (the software) to check for the patient, Do you have a name for the patient?" Interview during the exit conference with the Administrator / Supervising Nurse on 06/24/2021 at 3:12 p.m., Surveyor asked if the agency was planning to admit patients on L&CHHS category. The Administrator / Supervising Nurse stated, "Yes. If we have referral. It has been hard to get patients."