Every finding on record at Pbhs Home Health Dfw I, Inc.

Purpose of visit: Recertification survey and Complaint Investigation for Intakes #387247,404014, 555727 was attempted on 11/20/2025. The census was -Unknown Licensed and Certified patients – Unknown Abbreviations: TULIP- Texas Unified Licensure Information Portal CMS – Centers for Medicare and Medicaid Services IQIES – Internet Quality Improvement and Evaluation System OASIS- Outcome and Assessment Information Set HHA- Home Health Agency

Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This ELEMENT is not met as evidenced by: Based on observations and record reviews the agency failed to ensure an administrator, or a pre-designated person was available during all operating hours. This failure resulted in the inability of the surveyor to conduct a recertification and complaint investigation to verify the agency’s compliance with the Federal Regulations for Home Health Agencies, which could lead to poor quality care and patient dissatisfaction with services provided by the agency. Findings: Record review of TULIP (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) on 11/20/2025 revealed the agency’s location, email address, phone number, and names of the Administrator and Alternate Administrator. The agency’s phone number had a notation of “no longer in service.” There was no evidence of an alternate contact number for the agency, Administrator, or Alternate Administrator. TULIP also contained an active state license effective 9/30/2024 with an expiration date of 9/30/2027 and operating hours 9am to 5pm Monday through Friday. The last application in TULIP was dated 9/5/2024 for a “Name of Owner” change. Record review of IQIES (an online program by CMS for managing survey and certification data for healthcare providers) on 11/20/2025 revealed a first attempt by a surveyor on 5/6/2025 for a recertification, relicensure survey and investigation of complaint intakes 555727, 404014 and 387247. Record review of the HHA Activity Report in IQIES on 11/20/2025 revealed the last OASIS (a tool used by CMS to collect and report patient information for quality improvement and monitoring) submissions were dated 1/29/2025. 11/20/2025 at 10:07am the surveyor arrived at the agency address noted in TULIP, located in a residential home and observed a sign posted on the front door from a Realtor. The sign read, “This is a bank-owned property. No trespassing or entry permitted. Violators will be prosecuted. This home is listed for sale…” On the doorstep the surveyor observed a box of unopened mail from the postal service. The entryway did not contain a sign with the name of the home health agency or contact information for the agency. The lights were off at the agency, and no one answered the door when the surveyor rang the doorbell. 11/20/2025 at 10:29am the surveyor called the phone number listed for the agency in TULIP and received a voice recording stating “The number you are dialing is not in service at this time.” 11/20/2025 at 11:08am the surveyor sent an email to the Administrator’s/agency’s email address listed in TULIP. The surveyor wrote in the e-mail that she was at the agency and requested entry. The surveyor informed the home health agency via email of the 2-hour window to allow the surveyor entrance into the agency to avoid enforcement actions against the agency. The surveyor included in an attachment “Memo 2023-01 Inability to Access Records or Perform a Survey by Texas Health and Human Services” with the date and time of the attempted contact with the agency. 11/20/2025 at 11:08am the surveyor received a message via the state’s email provider which read “Your message couldn’t be delivered. The Domain Name System reported that the recipient’s domain does not exist.” 11/20/2025 at 11:35am The surveyor did not locate any active websites, alternate addresses or contact numbers, for the agency on the internet. 11/20/2025 at 11:50am The surveyor searched the Realtor’s website and located the residential home address listed in TULIP for the agency. The home was “pending” sale, and the listing was last updated on 11/15/2025. 11/20/2025 at 12:07pm the surveyor left the address of the agency.