Every finding on record at Reality Health Care, Inc

A Recertification/Re-licensure survey entrance conference was conducted on 03/22/2021 with the Administrator/ Director of Nurses at approximately 11:15 AM. A pre-survey COVID-19 screening was conducted with the Alternate Administrator, per the Texas Health and Human Services protocol. Census: 13 Patients An exit conference was conducted on 03/29/2021 at approximately 3:30 PM with the Administrator/Director of Nurses. The preliminary findings were discussed. Agency is in compliance with Medicare Conditions of Participation.

A Recertification/Re-licensure survey entrance conference was conducted on 03/22/2021 with the Administrator/ Director of Nurses at approximately 11:15 AM. A pre-survey COVID-19 screening was conducted with the Alternate Administrator, per the Texas Health and Human Services protocol. Census: 13 Patients An exit conference was conducted on 03/29/2021 at approximately 3:30 PM with the Administrator/Director of Nurses. The preliminary findings were discussed. Agency is in compliance with Medicare Conditions of Participation. Abbreviations: QAPI-Quality Assurance Performance Improvement NAR/EMR-Nurse Aide Registry/Employee Misconduct Registry

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on records review, home visits and interview, the agency failed to advise 3 (Patients 1, 2 and 3) of 3 patients visited by the surveyor of the names, addresses, and telephone numbers of Federally-funded and state-funded entities that service the area where the patient resides. The agency failed to provide the names, addresses and telephone numbers of the following: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and Quality Improvement Organization. This failure did not conform to the patient's right to be provided information regarding the entities in in accordance with the January, 2018 Federal Conditions of Participation. Findings included: Review of the agency's sample admission packet on 04/25/2021 revealed the packet did not include the Federally-funded and state-funded entities as required by the January, 2018 Federal Conditions of Participation. No information was included in the packet for the name, addresses and telephone numbers of the the entities. Patient 1: Review of an agency form titled "ACTIVE AND INACTIVE PATIENT LISTING" included Patient 1's start of care date 05/31/2021. During a home visit for Patient 1 on 03/29/2021 at approximately 11:00 am, the surveyor reviewed Patient 1's home folder from the agency. The home folder did not include any information on the Federally-funded and state-funded entities that service the area where the patient resided. Review of the folder did not include any evidence the agency had provided Patient 1 the names, addresses or telephone numbers. Patient 2: The agency's ACTIVE AND INACTIVE PATIENT LISTING included Patient 2's start of care date 01/13/2019. During a home visit for Patient 2 on 03/29/2021 at approximately 11:45 am, the surveyor reviewed Patient 2's home folder from the agency. The home folder did not include any information for the Federally-funded and state-funded entities that service the area where the patient resided. Review of the folder did not include any evidence the agency had provided Patient 2 the names, addresses or telephone numbers. Patient 3: The agency's ACTIVE AND INACTIVE PATIENT LISTING included Patient 3's start of care of date 05/30/2020. During a home visit for Patient 3 on 03/29/2021 at approximately 12:45 PM, the surveyor reviewed Patient 3's home folder from the agency. The home folder did not include any information for the Federally-funded and state-funded entities that service the area where the patient resided. Review of the folder did not include any evidence the agency had provided Patient 3 the names, addresses or telephone numbers. An interview was conducted with the Administrator/Supervising Nurse, Employee A, on 03/29/2021 at approximately 2:45 PM where the findings were presented. The surveyor reviewed the admission packet with the Administrator/Supervising Nurse, Employee A. The surveyor asked if the agency gave the patients any documents that included the names, addresses and telephone numbers of the Federally-funded and State-funded entities. Employee A stated the information about the entities had not been added to the admission packets and no other forms or paperwork was given to the patients with the information.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interviews, the agency's governing body failed to ensure that an ongoing program for quality improvement and patient safety was implemented and maintained. The agency failed to address: priorities for improved quality of care and patient safety and ensure that: all improvement actions were evaluated for effectiveness; clear expectations for patient safety were established, implemented, and maintained. The agency failed to maintain a QAPI Program implemented by the QAPI committee. The QAPI program was not ongoing and focused on Patient outcomes that were measurable. The QAPI committee did not review and update or revise the plan of implementation at least once within a calendar year for the years 2018, 2019 and 2020. The failure could place the agency's patients at risk of negative patient care outcomes if substandard care was not identified and corrected by the agency during ongoing QAPI evaluations. FINDINGS INCLUDED: During an interview with the Administrator, Employee A, on 03/22/2021 at approximately 11:45 am, the surveyor requested the agency's QAPI documents. The Administrator stated the agency did not have any QAPI documents or manual for the last 3 years. The Administrator stated the agency had done QAPI in the past. The Administrator asked if the agency had to do a QAPI Program. The surveyor told the Administrator the QAPI was required. The agency's policy and procedure manual included a policy titled "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN" revised on 1/01/2010. The policy read in part: "...PURPOSE To develop a Quality Assessment Performance Improvement Plan (QAPI)/Performance Improvement Plan, implemented by the QAPI/PI committee, that captures significant outcomes that are essential to optimal care and are used in the care planning and coordination of services and events. POLICY Agency will develop a plan that is reviewed and updated or revised at least once with the calendar year, or more often if needed, by the QAPI/PI Committee. Agency will strive to improve operational and patient health outcomes by implementing a performance improvement plan that incorporates the following essential processes: *Designing processes, *Monitoring performance through data collection, *Analyzing current performance, and *Improving and sustaining improved performance over time..." The policy also included: "...Agency leaders will be responsible for setting expectations, developing plans and managing processes to improve the Agency's performance..." The Administrator did not provide any QAPI documents to the surveyor during the survey.