Every finding on record at Promise Homehealth Inc

• Purpose of visit: Recertification/Relicensure Survey • Entrance date: 5/24/2024 • Census: L&CHHS- 13 PAS-3 The facility was in compliance with no deficiencies cited. Abbreviations: Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Licensed and Certified Home Health Services (L&CHHS) Quality Assurance and Performance Improvement (QAPI) PHC (Primary Home Care) Plan of Care (POC) Start of Care (SOC) Director of Nursing (DON) Skilled Nurse (SN) Administrator (ADM) Employee Misconduct Registry/ Nurse Aide Registry (EMR/NAR) Personal Care Attendant (PCA) Texas Health and Human Services Commission (HHSC) PHC (Primary Home Care) ISP (Individual Service Plan) HHSC (Health and Human Services Commission) q6m (every 6 months)

• Purpose of visit: Recertification/Relicensure Survey • Entrance date: 5/24/2024 • Census: L&CHHS- 13 PAS-3 Abbreviations: Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Licensed and Certified Home Health Services (L&CHHS) Quality Assurance and Performance Improvement (QAPI) PHC (Primary Home Care) Plan of Care (POC) Start of Care (SOC) Director of Nursing (DON) Skilled Nurse (SN) Administrator (ADM) Employee Misconduct Registry/ Nurse Aide Registry (EMR/NAR) Personal Care Attendant (PCA) Texas Health and Human Services Commission (HHSC) PHC (Primary Home Care) ISP (Individual Service Plan) HHSC (Health and Human Services Commission) q6m (every 6 months)

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop, implement, and evaluate performance improvement projects for 3 of 3 (2021, 2022, and 2023) years reviewed. This failure could have resulted in the agency failing to identify and address areas of the agency’s program for which performance could be improved. The findings included: Review of the QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN (QAPI) documentation regarding the agency’s Quality Assessment Performance Improvement Plan (QAPI) Program included no documentation to indicate the agency had developed, implemented, or evaluated a performance improvement project for the years 2021, 2022, and 2023. During an interview with the Administrator on 05/30/24 at approximately 10:35 AM the surveyor presented the above findings. The surveyor asked who was responsible for the agency QAPI program and committee meetings. The Administrator stated, "I am responsible. We aren’t doing the projects because I didn’t know about the projects.” Review of agency policy, dated 1/29/2020, quoted in part, "9.1 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN, read in part” .... Program Activities…Performance Improvement Projects: (Beginning January 13,2018 the Agency will conduct performance improvement projects.) …3. The program will be evaluated, reviewed, and updated or revised at least twice within the calendar, or more often, if needed, by the governing board. QAPI documents will be kept confidential and made available to CMS (Centers for Medicare and Medicaid Services) representatives and/or Texas Department of Aging and Disability Services upon request..."

Purpose of Visit: Re-certification Survey. Entrance Date: 05/26/2021 An entrance conference was conducted with the administrator/supervising nurse, RN A at 11:56 a.m. RN A was informed that the purpose of the survey was for a 36-month recertification inspection. L&C Census: 19 Exit Date: 06/01/2021 An exit conference was conducted at 1:39 p.m. with the administrator/supervising nurse, RN A and the alternate administrator, Employee B. The preliminary findings were discussed. The agency was given an opportunity to ask question and provide additional information. Additional information was not provided. Written instructions were provided to the agency for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. The agency was in substantial compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies. Abbreviation List: L & C- Licensed and Certified EP- Emergency Preparedness

Purpose of Visit: Re-certification Survey. Entrance Date: 05/26/2021 An entrance conference was conducted with the administrator/supervising nurse, RN A at 11:56 a.m. RN A was informed that the purpose of the survey was for a 36-month recertification inspection. L&C Census: 19 Exit Date: 06/01/2021 An exit conference was conducted at 1:39 p.m. with the administrator/supervising nurse, RN A and the alternate administrator, Employee B. The preliminary findings were discussed. The agency was given an opportunity to ask question and provide additional information. Additional information was not provided. Written instructions were provided to the agency for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. Met conditions of participation. Abbreviation List: L & C- Licensed and Certified NOMNC- Notice of Medicare Non-Coverage ABN- Advance Beneficiary Notice POC- Plan of Care SOC- Start of Care HHA- Home Health Agency EHR- Electronic Health Record SN- Skilled Nursing Registered Nurse (RN) Physical Therapist (PT)

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure proper written notice was provided, in advance of terminating on-going care in two (Patients # 6 and 7 of two inactive patient records reviewed. The agency failed to provide patients # 6 and 7 with the Centers for Medicare and Medicaid form titled Notice of Medicare Non-Coverage. The failure could place the patients at risk of harm due to inadequate or inappropriate continuity of care in the patients' post-discharge needs and could prevent the patients from exercising the right to appeal the discharge decision, if desired. FINDINGS INCLUDED: Clinical Record # 6: Record review 05/27/2021. Record review of the electronic clinical record for Patient # 6 contained a POC for the certification period of 12/23/2020 to 02/20/2021 with a SOC date of 06/26/2020 and signed by Supervising nurse, RN A. The POC was not dated by RN A. Patient # 6 was listed on the agency's discharged patient list. The electronic clinical record of patient # 6 did not include a discharge summary nor a written discharge notice. On 05/28/2021 the surveyor asked for the hard copy of Patient # 6's clinical record. RN A provided copies of a discharge summary dated 02/19/2021. The discharge summary indicated that Patient # 6 was discharged on 02/19/2021 with "goals achieved" as the reason for discharge. Patient # 6's records did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 02/19/2021. The records did not include a written NOMNC. Clinical Record # 7: Record review 05/27/2021. Record review of the electronic clinical record for Patient # 7 contained a POC for the certification period of 12/28/2020 to 02/25/2021 with a SOC date of 07/21/2020 and signed by Supervising nurse, RN A. The POC was not dated by RN A. Patient # 7 was listed on the agency's discharged patient list. The electronic clinical record of patient # 7 did not include a discharge summary nor a written discharge notice. On 05/28/2021 the surveyor asked for the hard copy of Patient # 7's clinical record. RN A provided copies of a discharge summary dated 02/24/2021. The summary was not signed or dated by an agency representative. The discharge summary indicated that Patient # 7 was discharged on 02/24/2021 with "goals achieved" as the reason for discharge. Patient # 7's records did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 02/24/2021. The records did not include a written NOMNC. In an interview on 05/28/2021 at approximately 4:15 p.m. with the administrator/supervising nurse, RN A, the surveyor discussed the above findings and asked why the agency had not provided written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for Patients # 6 and 7. RN A stated that RN A thought the ABN form (given at admission to inform patients that some services might not be covered by Medicare and the patient might be responsible for the payment of the services) "covers it" Review of agency policy titled "4.6 PATIENT DISCHARGE" revised 01/29/2020 read in part: "...Agency will deliver the ...[NOMNC] ... the patient (or authorized representative), at least 2 calendar days before Medicare covered services end or the second to the last day of service if care is not provided daily ..."

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on record review, observations at home visits and interviews the agency failed to provide written information in three (Patients #1, 3 and 4) of three patients who received a home visit. The HHA failed to provide the patient and caregiver with a copy of written instructions which outlined: 1. Visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. 2. Name and contact information of the HHA Clinical Manager. The failure could place the patients at risk to be uninformed and/or unable to identify the staff scheduled to provide care and services on behalf of the agency. The failure could violate the patients' right to be informed of whom to contact for health and safety concerns with skilled services. FINDINGS INCLUDED: Review of the agency's sample patient admission packet on 05/26/2021 showed that it did not contain a sample visit schedule or the name and contact information for the agency's clinical manager, the administrator/supervising nurse, RN A. Clinical Record # 1: Record review of the EHR for Patient # 1 revealed that the record contained a POC with a SOC date of 05/07/2021, with the principal diagnosis of bilateral primary osteoarthritis of knee. The POC for certification period 05/07/2021 to 07/05/2021 was signed by the supervising nurse, RN A. The POC was not dated by RN A. The POC included an order for SN visits for one time per week for nine weeks. During a home visit conducted on 05/28/2021 at approximately 10:30 a.m., the surveyor observed and reviewed Patient # 1's home admission folder. Patient # 1's home folder did not include a current visit schedule that included SN visits or the name and contact information for the clinical manager, RN A. Clinical Record # 3: Record review of the EHR for Patient # 3 revealed that the record contained a POC with a SOC date of 05/01/2021, with the principal diagnosis of lumbago with sciatica, left side. The POC for certification period 05/01/2021 to 06/29/2021 was signed by the supervising nurse, RN A. The POC was not dated by RN A. The POC included an order for SN visits for one time per week for nine weeks and PT visits for one time per week for eight weeks. During a home visit conducted on 05/28/2021 at approximately 11:15 a.m., the surveyor observed and reviewed Patient # 3's home admission folder. Patient # 3's home folder did not include a current visit schedule that included SN visits, PT visits or the name and contact information for the clinical manager, RN A. Clinical Record # 4: Record review of the EHR for Patient # 4 revealed that the record contained a POC with a SOC date of 05/14/2021, with the principal diagnosis of lumbago with sciatica, left side. The POC for certification period 05/14/2021 to 07/12/2021 was signed by the supervising nurse, RN A. The POC was not dated by RN A. The POC included an order for SN visits for one time per week for nine weeks. During a home visit conducted on 05/28/2021 at approximately 11:40 a.m., the surveyor observed and reviewed Patient # 4's home admission folder. Patient # 4's home folder did not include a current visit schedule that included SN visits or the name and contact information for the clinical manager, RN A. On 05/28/2021 at approximately 1:00 p.m., the surveyor discussed the above findings with the supervising nurse, RN A and asked why the agency had not provided a current visit schedule and the name and contact information for the clinical manager, RN A. RN A replied, "I wasn't aware of that. We use a consultant."