Every finding on record at Proficient Home Health Care Services Inc

A recertification survey was conducted on 12/12/2022. The licensed and certified home health services census was 21. No deficiencies were cited.

A recertification survey was conducted on 12/12/2022. The licensed and certified home health services census was 21. Deficiency was cited. Abbreviations/Acronyms Adm – Administrator Alt Adm - Alternate Administrator DON - Direction of Nurses (Supervising Nurse) CNA-Certified Nurse Aide CFO-Chief Financial Officer Health and Human Services Commission (HHSC)

Administrator CFR(s): 484.115(a) Standard: Administrator, home health agency. (1) For individuals that began employment with the HHA prior to January 13, 2018, a person who: (i) Is a licensed physician; (ii) Is a registered nurse; or (iii) Has training and experience in health service administration and at least 1 year of supervisory administrative experience in home health care or a related health care program. (2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to have an alternate administrator who met the qualifications required for the position, in one of one current Alternate Administrator whose personnel record was reviewed. Alt Adm A did not meet the federal requirements to hold an undergraduate degree; and have experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. The failure could cause harm to the agency’s patients if the alternate administrator did not meet qualifications for the supervision and management of the safe delivery of patient care and services. FINDINGS INCLUDED: During the entrance conference on 12/07/2022 at approximately 1:15 p.m., the Adm/DON self-identified as the administrator and identified Alt Adm A as the alternate administrator. Alt Adm A: During an interview on 12/09/2022 at approximately12:30 p.m. the Alt Adm A provided the designation date to the position of Alternate Administrator for Alt Adm A as 09/01/2022. Review of the Alt Adm A’s personnel record revealed the following: There was no signed job description for the position of alternate administrator. The record included signed job descriptions for the positions of CFO and Disaster Coordinator, dated 05/16/2022. The record also included a signed application for the position of CFO, dated 05/03/2011. The application included work experience as a filing clerk and certified nursing assistant. The application also included educational history of high school graduate and attending an associate degree program, “not yet” graduated. The personnel record did not include any records that indicated Alt Adm A held an undergraduate degree; and have experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. During an interview with Alt Adm A on 12/12/2022 at approximately 1:35 p.m., the surveyor discussed the above findings and asked the Alt Adm A to discuss her educational experience. Alt Adm A stated that she was a CNA and had registered nurse training from another country. The surveyor asked for transcripts or a degree certificate for an undergraduate degree. The Alt Adm A stated she did not have it. The surveyor requested that the information be faxed to the HHSC Arlington office within two days (due by 12/14/2022). The Surveyor also discussed how could not ensuring that the agency’s administrative staff met regulatory and agency policy requirements adversely affect the agency’s clients. The Alt Adm A stated that it could harm the patients. The Adm/DON replied, “We are not equipped to give the maximum to our patient.” On 12/15/2022 at 10:00 a.m., the agency had not faxed any additional documentation to the Arlington office. Review of agency policy titled "Responsibilities of The Administrator LD.5" revised 011318 read in part: "...Policy II. The Administrator will be responsible for… 1. The Agency defines the responsibilities of the Administrator to include, but not limited to: ...B. Ensuring the Agency employs…qualified personnel…D. Ensuring the Agency …is in compliance with all applicable federal, state, and local laws and regulatory agencies related to the health and safety of patients/clients…IV. The License hold will designate, in writing, an Alternate Administrator who meets qualifications and conditions of an administrator to act in the absence of the Administrator…”