Every finding on record at Regency Provider Services Inc

Purpose of visit: Recertification survey Entrance conference date: 01/07/2025 The census was:62 Licensed and Certified patients: 09 No deficiencies were cited.

Purpose of visit: Recertification survey Entrance conference date: 01/07/2025 The census was: 62 Licensed and Certified patients: 09 Abbreviations: Adm –Administrator DON - Director of Nurses Alt Adm - Alternate Administrator CMS - Centers for Medicare & Medicaid Services HHA – Home Health Agency IQIES - IQIES - Internet Quality Improvement and Evaluation System OASIS - Outcome Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to electronically transmit completed OASIS (a standardized data set that measures the quality and outcomes of home health patients) assessments to the CMS system for all Medicare patients within 30 days of completing the OASIS assessment of the beneficiary (patients) for 31.15% (19 of 61) of assessments transmitted during 01/06/2024 – 01/06/2025. Failure of the agency to transmit OASIS data within the required time frame prevented the agency's patient data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. Findings included: During pre-survey review on 01/06/2025: The surveyor reviewed the agency OASIS report titled, “HHA Error Summary by Agency” from IQIES (an internet-based system that includes survey and certification functions) during the one-year of 01/06/2024 – 01/06/2025. The HHA Error Summary by Agency report included 19 of 61 OASIS assessments (31.15%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment. An interview was conducted with the Alt Adm on 01/07/2025 at 1:30 PM during the entrance conference. The Alt Adm said the Adm/DON was responsible for OASIS assessment submission to the CMS system. An interview was conducted with the Adm/DON on 01/14/24 at 11:45 AM. The Adm/DON said she was responsible for OASIS assessment submission to the CMS system. The surveyor asked what the agency policy for OASIS assessment submission was. The Adm/DON said it’s 30 days. The surveyor reviewed the error summary report which included 19 of 61 OASIS assessments submitted late and asked what tracking system agency had to ensure timely submission of OASIS assessments. The Adm said there was no valid reason, she was frustrated with Medicare claim denials. The Adm did not dispute the findings said there was no tracking system, which resulted in the agency not following its policy. Agency Policy titled, "IM. 7 TIMELINES” with a revised on 01/13/18, read in part “Policy: The Agency will ensure timely …...and regulations. Procedure: II. All completed and encoded OASIS …. Within thirty (30) days of the M0090 date.”

Purpose of visit: Recertification survey Entrance Date: 12/06/2021 at 10:15 AM with the Administrator / DON. Agency Census: 115 Licensed and Certified Home Health -40 Licensed Home Health - 0 Personal Assistance Services - 75 Exit Date: 12/14/2021 at 2:00 PM with the Administrator/ DON. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. The agency was in substantial compliance with the Conditions of Participation for Emergency Preparedness.

Purpose of visit: Recertification survey Entrance Date: 12/06/2021 at 10:15 AM with the Administrator / DON. Agency Census: 115 Licensed and Certified Home Health -40 Licensed Home Health - 0 Personal Assistance Services - 75 Exit Date: 12/14/2021 at 2:00 PM with the Administrator/ DON. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations: DON- Director of Nurses PAS - Personal Assistance Services QAPI – Quality Assurance Performance Improvement TDFPS – Texas Department of Family and Protective Services DADS- Department of Aging and Disability Services ADL’s – Activities of Daily Living APS – Adult Protective Services

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 record review and interview the agency failed to provide 4 (Patients 2,3,4, and 5) of 4 patients, whose home folders were reviewed during home visits, with the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that served the area the 4 patients resided in: Agency on Aging Center for Independent Living Protection and Advocacy Agency, and Aging and Disability Resource Center. This failure prevented the agency patients from accessing and obtaining community services that were not provided by the agency. On 12/06/2021 the surveyor requested a sample admission packet the agency used for new patient admissions. The surveyor reviewed the sample admission folder provided by the Administrator on 12/13/2021 at 8:30 AM. Review of all the documents in the sample admission packet revealed no names, addresses and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. Record review for Patient 2 revealed a POC dated 12/03/2021 to 01/31/2022 with a start of care date of 10/04/21. The POC listed diagnoses of Primary Cellulitis of other sites, Pressure Ulcer of Left Buttock, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hypertension, and Lymphedema. The POC listed orders for a skilled nursing visits three times per week for nine weeks. During a home visit with Patient 2 on 12/13/2021 at approximately 11 AM, the surveyor reviewed the home folder provided by the agency to Patient 2. Review of all the documents in the home folder revealed no names, addresses and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. The home folder contained a form titled: “Contact Information for Agency Name and Federal and State Public Agencies which had areas to complete the Protection and Advocacy Agency Name, address and phone number, and Aging and disability Resource Center name, address and phone number. The form was blank with no agency names, no addresses, and no phone numbers. An interview was conducted with Patient 2 and his Family member during the home visit on 12/13/2021. The surveyor asked if any documents had been removed from the home folder. Patient 2 stated “no.” The surveyor asked if Patient 2 was aware of how to contact the community resources whose information was blank in the home folder. Patient 2 stated he was not aware of how to contact the resources. Record review for Patient 3 revealed a POC dated 12/012021 to 01/29/2022 with a start of care date of 06/04/2021. The POC listed diagnoses of Atherosclerotic Heart Disease of Native Coronary Artery, Obstructive Sleep Apnea, Anemia in Chronic Kidney Disease, Radiculopathy, Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease or End Stage Renal Disease, Gastro-Esophageal Reflux Disease, Idiopathic Gout, Dependence on Renal Dialysis, and Trigeminal Neuralgia. The POC listed orders for skilled nursing visits one time per week for nine weeks. During a home visit with Patient 3 on 12/13/2021 at approximately 12:42 PM, the surveyor reviewed the home folder provided by the agency to Patient 3. Review of all the documents in the home folder revealed no names, addresses and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. The home folder contained a form titled: “Contact Information for Agency Name and Federal and State Public Agencies which had areas to complete the Protection and Advocacy Agency Name, address and phone number, and Aging and disability Resource Center name, address and phone number. The form was blank with no agency names, no addresses, and no phone numbers. An interview was conducted with Patient 3 and his Family member during the home visit on 12/13/2021. The surveyor asked if any documents had been removed from the home folder. Patient 3 and the Family member stated “no.” The surveyor asked if Patient 3 was aware of how to contact the community resources whose information was blank in the home folder. Patient 3 stated he was not aware of how to contact the resources. Record review for Patient 4 revealed a POC dated 11/03/2021 to 01/01/2022 with a start of care date of 05/12/2020. The POC listed diagnoses of Essential Hypertension, Atheroschlerotic Heart Disease of Native Coronary Artery, Vascular Dementia, Polyosteoarthritis, Vitamin Deficiency, Abnormalities of Gait and Balance, Hearing Loss, Presence of Cardiac Pacemaker, and Cerebral Infarction. The POC listed orders for a skilled nursing visits one time per week for nine weeks. During a home visit with Patient 4 on 12/13/2021 at approximately 1:17 PM, the surveyor reviewed the home folder provided by the agency to Patient 4. Review of all the documents in the sample admission packet revealed no names, addresses and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. The packet contained a form titled: “Contact Information for Agency Name and Federal and State Public Agencies which had areas to complete the Protection and Advocacy Agency Name, address and phone number, and Aging and disability Resource Center name, address and phone number. The form was blank with no agency names, no addresses, and no phone numbers An interview was conducted with Patient 4 and his family member during the home visit on 12/13/2021 at approximately 1:17 PM. The surveyor asked if any documents had been removed from the home folder. Patient 4 stated “no.” The surveyor asked if Patient 4 was aware of how to contact the community resources whose information was blank in the home folder. Patient 4 stated there were not aware of how to contact the resources. Record review for Patient 5 revealed a POC dated 12/01/21 to 01/29/22 with a start of care date of 02/04/2021. The POC listed diagnoses of Atherosclerotic Heart Disease of Native Coronary Artery, Essential Hypertension, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Mixed Hyperlipidemia, and Monoplegia of Upper Limb following Subarachnoid Hemorrhage Affecting Dominant Side. The POC listed orders for a skilled nursing visits one time per week for nine weeks. During a home visit with Patient 5 on 12/13/2021 at approximately 1:40 PM, the surveyor reviewed the home folder provided by the agency to Patient 5. Review of all the documents in the sample admission packet revealed no names, addresses and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. The packet contained a form titled: “Contact Information for Agency Name and Federal and State Public Agencies which had areas to complete the Protection and Advocacy Agency Name, address and phone number, and Aging and disability Resource Center name, address and phone number. The form was blank with no agency names, no addresses, and no phone numbers. An interview was conducted with Patient 5 and his Family member present during the home visit on 12/13/2021. The surveyor asked if any documents had been removed from the home folder. Patient 5 and the Family member stated “no.” The surveyor asked if Patient 5 was aware of how to contact the community resources whose information was blank in the home folder. Patient 5 stated he was not aware of how to contact the resources. An interview was conducted with the Administrator / DON on 12/14/21 at 11:55 PM. The surveyor shared the findings of the sample home folder review, patient home visit folder reviews and interviews. The surveyor noted the sample and home folders did not contain the names, addresses, and telephone numbers of the Federally funded and state-funded entities that served the areas the patients resided in. The Administrator stated: “We have to fill it out.” The Administrator stated: “It was an oversight.” No additional information to correct or clarify the findings was provided by the end of the survey including how this non-compliance might affect the patient’s care. Agency policy review of the policy titled: “Patient/Client Rights and Responsibilities…RI.2” dated 011318 read in part: “Agency staff will be responsible for knowing, observing, and implementing the patient’s/client’s rights, patient/client conduct and patient/client responsibilities on an ongoing basis… VI. The patient/client has the right to:…K. 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/client resides: 1. Agency on Aging, 2. Center for Independent Living, 3. Protection and Advocacy Agency, 4. Aging and Disability Resource Center; and 5. Quality Improvement Organization…”

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 record review and interview, the agency failed to conduct any Performance Improvement Projects for 3 (2018, 2019, and 2020) of three years of the survey review period. This failure placed the agency's patients at risk of receiving inadequate care and services that could lead to negative health outcomes. The surveyor requested all agency QAPI documents/reports/manuals on 12/06/2021. A white three ring binder containing QAPI documents was provided by the Administrator. The surveyor reviewed the records contained in the QAPI binder provided on 12/14/2021. A review of the entire binder revealed no documentation of Performance Improvement Projects for 2018, 2019, 2020, and to December 14, 2021 (the exit date of the survey). An interview was conducted on 12/14/2021 at 12:46 PM with the Administrator / DON. The surveyor shared the findings of the review of the QAPI policies, plan, and documents provided by the agency. The surveyor stated there was no evidence of Performance Improvement Projects found for 2018, 2019, and 2020. The Administrator stated: “We didn’t write it down. We are improving wound care, so they don’t get hospitalized.” The surveyor noted there was no documentation of any performance improvement projects including for wound care. The Administrator stated: “We didn’t make a plan like we were supposed to. I didn’t make a plan. We will get that taken care of.” The agency did not dispute the survey findings and did not provide any additional documentation to explain or correct the findings. The agency did not provide any information on how this lack of compliance affected the agency clients. Review of the agency policy and procedures manual revealed a policy titled: “Performance Improvement Process QAPI.5” with a revision date of 01/13/2018 which read in part: “II. The Governing Body will determine the number and scope of distinct Performance Improvement Projects (PIP) conducted annually. III. When developing and prioritizing the improvement activities or projects, the Governing Body will consider the following: A. The scope, complexity, and past performance of the Agency’s services and operations; B. The expected impact of the improvement on performance, patient/client outcomes and safety; C. High-risk, high-volume, or problem-prone areas of service to include the incidence, prevalence, and severity of problems in those areas; D. Data obtained from OASIS generated reports (i.e., OBQM, PBQM and OBQI); E. Previous problematic issues where there is clear evidence of poor patient/client outcomes; and F. Agency resources. IV. All performance improvement activities/projects undertaken will be documented and include the reasons for conducting and the measurable progress achieved.”