Every finding on record at Menas Home Healthcare Solutions Inc

A recertification survey was conducted on 03/17/2026. The census was: Licensed and Certified Home Health Services: 4; Licensed Home Health Services: 0; Personal Assistance Services: 10. The agency was in compliance with no deficiencies cited.

A recertification survey was conducted on 03/17/2026. The census was: Licensed and Certified Home Health Services: 4; Licensed Home Health Services: 0; Personal Assistance Services: 10. Abbreviations: Adm/DON/PAS Sup – Administrator/Director of Nurses/Personal Assistance Supervisor QAPI – quality assessment performance improvement TX - Texas

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain a QAPI Program to include an annual evaluation of the total agency operation to measure, analyze, and track quality indicators, adverse patient events, and other aspects of performance to enable the agency to assess processes of care, services, and operations for three of three years reviewed (2023, 2024, and 2025). This failure caused the agency to have no effective mechanism to monitor, evaluate or improve plan of care, continuity of care and services to agency patients. Findings included: Record review of the QAPI documents on 03/17/2026 that were provided by the Adm/DON/PAS Sup on 03/10/2026 revealed no evidence of annual evaluations of the total operation for 2023, 2024, and 2025 to include an annual evaluation to measure, analyze, and track quality indicators, adverse patient events, and other aspects of performance to enable the agency to assess processes of care, services, and operations . During an interview with the Adm/DON/PAS Sup on 03/17/2026 at 11:45 AM, the surveyor reviewed the surveyor findings of no evidence of annual evaluations of the total operation for 2023, 2024, and 2025 and asked why they had not been completed and why agency policies had not been followed. The Adm/DON/PAS Sup stated her eyes had been very sick, she had not been seeing well and had been unable to complete the documents on her own. The Adm/DON/PAS Sup stated she looked for someone to help organize things while she was sick and decided to hire a consultant to help with QAPI. When the Adm/DON/PAS Sup received documents from the consultant, she realized everything was not completed, including the annual evaluations, but she was not feeling well and did not complete them on her own. The Adm/DON/PAS Sup stated she used to do annual evaluations, but the agency’s consultant told the Adm/DON/PAS Sup annual evaluations were not needed anymore. The Adm/DON/PAS Sup stated she hired the consultant to do the annual evaluations, but the consultant never did them. Agency policy titled, “Quality Assessment Performance Improvement Program – Addendum QAPI.5-TX” last reviewed 04/14/2023 read in part, “… Procedure I. In addition to the requirements defined in the Quality Assessment Performance Improvement program policy in the Quality Assessment Performance Improvement section of the Administrative Policy Manual, the following requirements will also be met… E. The QAPI Plan will be reviewed and updated at least once within the calendar year, or more often if needed…” Agency policy titled, “Agency Evaluation QAPI.45-TX” last reviewed 02/01/2025 read in part, “… Purpose To outline the process for performing an annual agency evaluation and assess the Agency's program for appropriateness, adequacy, effectiveness, and efficiency Policy The Agency leaders (including the Governing Body, managers, and QAPI committee) will participate in an annual evaluation of the organization's performance in relation to its written organizational plan, mission, vision and philosophy…”

A recertification survey was initiated on 2/23/2023. The census was: LCHH-10 LHH-0 PAS-12 Total agency census: 22 The agency was in compliance with 42 CFR part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A recertification survey was initiated on 2/23/2023. The census was: LCHH-10 LHH-0 PAS-12 Total agency census: 22 Abbreviations LHH-Licensed Home Health LCHH-Licensed and Certified Home Health PAS-Personal Assistant Servies POC-Plan of Care SN-Skilled Nursing Services LVN-licensed vocational nurse QAPI-Quality Assurance/Performance Improvement

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to staff the QAPI Committee with a physical therapist and an occupational therapist representing services provided by the agency for 1 (2022) of 3 years reviewed. This failure resulted in the agency's inability to identify and correct problems and to revise policies as necessary for patients to receive consistent, quality care. Findings include: Record review of QAPI binder: Upon request of the agency's QAPI activities, the surveyor was provided with a binder labeled, "Quality Assurance Performance Improvement (QAPI)” An agency form titled, “Quality Assessment/Performance Improvement/Utilization Review Quarterly Report” for 1st, 2nd, 3rd, and 4th quarters indicated active chart audits conducted of services provided by the agency as skilled nursing, physical therapy and occupational therapy. Review of the reports for 1st, 2nd, 3rd, and 4th quarters of 2022 failed to include a physical therapist and an occupational therapist in the QAPI Committee. In an interview on 3/3/23 with the Administrator at 11:55 a.m., the surveyor asked why the QAPI committee did not include a physical therapist and an occupational. The Administrator said, “They will not come to the meeting when I ask them.” Surveyor explained the agency was required to have a therapist at the quarterly meetings when therapy was provided by the agency. The Administrator said, “I cannot get them to come to the meetings, they say they do not do that anymore.” Record review of agency policy: "Quality Assessment Performance Improvement Plan - Addendum QAPI.5-TX," Last Reviewed 030122, read in part, …"Policy I….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”…

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record review and interview the nursing services failed to be provided under the supervision of a registered nurse, according to agency policy in 4 (#4, #7, #8 and #9) of 5 active records reviewed where the agency’s licensed vocational nurses were conducting skilled nursing visits. This failure placed patients’ #4, #7, #8 and #9 at risk for inadequate care and potential harm. Findings include: Patient #4: The record contained a plan of care for episode 11/17/2022 to 1/15/2023 with a start of care date of 11/17/2022. The plan of care included orders for skilled nursing visits 1 time a week for 1 week, 3 times a week for 8 weeks and 1 time a week for 1 week. Patient #4’s record contained 15 skilled nurse visits conducted and signed by LVN 1 and 8 skilled nurse visits conducted and signed by LVN 2 during the episode of 11/17/2022 to 1/15/2023. There was no evidence of a LVN supervisory visit from 11/17/2022 to 1/15/2023. Patient #7: The record contained a plan of care for episode 12/28/2022 to 2/25/2023 with a start of care date of 8/20/2022. The plan of care included orders for skilled nursing visits 2 times a week for 1 week, 3 times a week for 8 weeks. Patient #7’s record contained 21 skilled nurse visit conducted and signed by LVN 3 during the episode of 12/28/2022 to 2/25/2023. There was no evidence of a LVN supervisory visit from 12/28/2022 to 2/25/2023. Patient #8: The record contained a plan of care for episode 11/11/2022 to 1/9/2023 with a start of care date of 9/12/2022. The plan of care included orders for skilled nursing visits 1 time a week for 1 week, 3 times a week for 8 weeks and 1 time a week for 1 week. Patient #8’s record contained 11 skilled nurse visits conducted and signed by LVN 3 during the episode of 11/11/2022 to 1/9/2023. There was no evidence of a LVN supervisory visit from 11/11/2022 to 1/9/2023. Patient #9: The record contained a plan of care for episode 11/22/2022 to 1/20/2023 with a start of care date of 9/23/2022. The plan of care included orders for skilled nursing visits 1 time a week for 8 weeks. Patient #9’s record contained 5 skilled nurse visits conducted and signed by LVN 4 during the episode of 11/22/2022 to 1/20/2023. There was no evidence of a LVN supervisory visit from 11/22/2022 to 1/20/2023. On 3/3/2023 at 12:20 p.m. the surveyor reviewed the findings of no evidence of LVN supervisory visits with the Administrator/Supervising Nurse. The Administrator/Supervising Nurse said, “We still have to do those.” The agency did not dispute the findings. Agency policy: Employee Supervision HR.60 Last Reviewed: 101221 read in part…”Procedure To establish employee supervision practices in accordance with applicable federal and state laws and regulations. Policy l. The agency will provide timely supervision of the following employees by qualified individuals…D. Nursing Services 1. Nursing services are provided under the supervision of a RN. 2. A qualified RN will supervise the licensed professional/vocational nurse (LVN/LPN) at least every 60 days or more frequently if indicated by state practice act or based upon patient/client acuity. Procedure … ll. Supervision will be performed within the time frame defined by policy…”