Every finding on record at Simply T & T Incorporated

Purpose of visit: Recertification survey Entrance Date: 05/19/2021 at 9:17 AM with the Administrator/LVN, Employee A and the Alternate Administrator, Employee B. Agency Census: 101 Licensed and Certified Home Health - 0 Licensed Home Health - 0 Personal Assistance Services - 101 Exit Date: 05/24/2021 at 2:30 PM with the Administrator/LVN, Employee A and the Alternate Administrator, Employee B. 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. The agency was in substantial compliance with 2 CFR Part 484.22 Emergency Preparedness Conditions of Participation for Home Health Agencies with no deficiencies written.

Purpose of visit: Recertification survey Entrance Date: 05/19/2021 at 9:17 AM with the Administrator/LVN, Employee A and the Alternate Administrator, Employee B. Agency Census: 101 Licensed and Certified Home Health - 0 Licensed Home Health - 0 Personal Assistance Services - 101 Exit Date: 05/24/2021 at 2:30 PM with the Administrator/LVN, Employee A and the Alternate Administrator, Employee B. 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. The agency was in compliance with the Conditions of Participation for Home Health Agencies with standard level deficiencies written. Abbreviations: # - number ADR - Additional Development Request ANE - Abuse Neglect and Exploitation CMS - Center for Medicare and Medicaid HCSSA - Home and Community Support Services Agency LVN- Licensed Vocational Nurse NAR/EMR - Nurse Aide Registry / Employee Misconduct Registry OASIS - Outcome and Assessment Information Set POC / POCs - Plan of Care / Plans of Care QAPI - Quality Assessment / Performance Improvement RN- Registered Nurse

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients' plans of care were complete and included the following: A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors for 7 (patients 1, 2, 3, 4, 5, 6, and 7) of 7 discharged patient records reviewed. This failure placed the patients at a greater risk of a decline in their health status and subsequent emergency room visits and hospital re-admissions, when the agency's staff failed to provide interventions to address the patients underlying risk factors. Findings: Record review for the patient 1 revealed a POC dated 11/23/2019 to 01/21/2020 with a start of care date of 10/04/2017. The POC listed diagnoses of Heart Failure, Type 2 Diabetes Mellitus, Hyperglycemia, Polyarteritis nodosa, Stage 5 End Stage Renal Failure, Acquired Absence of Left Leg Below Knee, Dependence on Renal Dialysis, and Tobacco Use. The POC listed orders for skilled nursing visits twice a week for three weeks and then one time per week for 6 weeks. A review of the entire POC revealed no description of the patient's specific risks for emergency department visits and hospital re-admission, and interventions to address the underlying risk factors. The record review revealed a Transfer OASIS dated 01/02/202 which documented the patient was admitted to the hospital on 01/01/2020. The record also contained a communication note dated 12/11/2019 which documented the patient was discharged from the hospital on 11/06/2019. Record review for the patient 2 revealed a POC dated 11/23/2019 to 01/21/2020 with a start of care date of 10/04/17. The POC listed diagnoses of Type 2 Diabetes Mellitus, Hypertensive Heart Disease, Obstructive Sleep Apnea, Blindness Both Eyes, Gastro-Esophageal Reflux Disease, Hemiplegia Following Cerebral Infarction, and Schizoaffective Disorder, Bipolar Type. The POC listed orders for skilled nursing one time per week for 9 weeks. A review of the entire POC revealed no description of the patient's specific risks for emergency department visits and hospital re-admission, and interventions to address the underlying risk factors. Record review for the patient 3 revealed a POC dated 03/30/2019-05/28/2019 with a start of care date of 08/02/2018. The POC listed diagnoses of Hypertension, Hyperlipidemia, Polyosteoarthritis, Muscle Spasm of the Back, Paraplegia, Carpel Tunnel Syndrome, Vitamin D Deficiency. The POC listed orders for skilled nursing one time per week for 9 weeks. A review of the entire POC revealed no description of the patient's risk for emergency department visits and hospital re-admission, and interventions to address the underlying risk factors. Record review for the patient 4 revealed a POC dated 06/03/19 to 08/01/19 with a start of care date of 06/03/19. The POC listed diagnoses of Hemiplegia Following Subarachnoid Hemorrhage, Unsteadiness on Feet, Other Seizures, Essential Hypertension, Type 2 Diabetes Mellitus, Gastro-Esophageal Reflux Disease, Bipolar Disorder, and Dependence on Wheelchair. The POC listed orders for skilled nursing one time per week for 9 weeks. A review of the entire POC revealed no description of the patient's specific risks for emergency department visits and hospital re-admission, and interventions to address the underlying risk factors. Record review for the patient 5 revealed a POC dated 11/12/2019 to 01/10/2020 with a start of care date of 11/12/2019. The POC listed diagnoses of Type 2 Diabetes Mellitus, Full Incontinence of Feces, Encounter for Attention to Cystostomy, and Cerebral Vascular Infarction Right Dominant Side. The POC listed orders for skilled nursing one time per week for 9 weeks. A review of the entire POC revealed no description of the patient's specific risks for emergency department visits and hospital re-admission, and interventions to address the underlying risk factors. Record review for the patient 6 revealed a POC dated 11/18/2019 to 01/16/2020 with a start of care date of 01/22/2019. The POC listed diagnoses of Type 2 Diabetes Mellitus, Hypertension with Heart Failure, Hemiplegia Following Cerebral Infarction, Atherosclerotic Heart Disease of Native Coronary Artery, Hypercholesterolemia, Osteoarthritis, Low Back Pain, Urinary Incontinence, and Dependence on Wheelchair. The POC listed orders for skilled nursing visits one time per week for 9 weeks. A review of the entire POC revealed no description of the patient's specific risks for emergency department visits and hospital re-admission, and interventions to address the underlying risk factors. Record review for the patient 7 revealed a POC dated 11/21/2018 to 01/19/2019 with a start of care date of 12/01/2016. The POC listed diagnoses of Type 2 Polyosteoarthritis, Hypertension, Gastro-Esophageal Reflux Disease, Cirrhosis of the Liver, and Major Depressive Disorder. The POC listed orders for skilled nursing visits one time per week for 9 weeks. A review of the entire POC revealed no description of the patient's specific risks for emergency department visits and hospital re-admission, and interventions to address the underlying risk factors. An interview was conducted with the Administrator / LVN on 05/19/21 at 9:17 AM. The surveyor requested a list of active and discharged patients. The Administrator / LVN stated the agency had "no Medicare since 01/2020." The surveyor requested a list of the discharged patients. The surveyor provided a list of the patient records needed for record review from the discharged list provided. An interview was conducted with the Administrator / LVN on 05/24/2021 at . The surveyor reviewed the findings from the clinical record reviews and asked why none of the Plans of Care for patients 1-7 included a description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. The Administrator, Employee A, stated: "When they did the ADR those were their findings and that is why we gave it up. All these things you caught were on the ADR and that is when I said I'm done. They didn't pay me after 2019 because of the ADR results." No additional information was provided to explain or clarify the findings by the end of the survey.

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 after 2019, one of three years of the review period of the survey. The agency failed to conduct any Performance Improvement Projects for the entire year in 2020. This failure placed the agency's patients at risk of receiving inadequate care and services that could lead to negative health outcomes. Findings: The surveyor requested all agency QAPI documents/reports/manuals on 05/19/2021. A binder labeled "Agency Profile Manual" was provided by the Administrator, Employee A and a binder labeled "QAPI", was also provided by the Administrator, Employee A. Record review of the binders revealed no documentation of Performance Improvement Projects after the 2019 report. There were no projects documented for 2020. An interview was conducted on 05/24/2021 at 1:50 PM with the Administrator, Employee A. The surveyor shared the findings of the review of the QAPI policies, plan, and documents provided by the agency. The surveyor asked why there was no evidence of any Performance Improvement Projects for 2020. Employee A replied: That is "correct. No QAPI in 2020. We stopped doing it." The surveyor asked if the Administrator had anything else to add regarding the findings. The Administrator stated: "I can't add anything." The agency did not dispute the survey findings and did not provide any additional documentation to explain or correct the findings.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on record review and interview the Administrator failed to ensure a clinical manager was available during all operating hours from 03/05/2020 to the end of the survey. The agency failed to directly employ or contract with an individual who met the qualifications as a clinical manager from 03/05/2020 to the end of the survey. This failure placed any clients admitted by the agency at risk of poor care and negative health outcomes when no qualified clinical manager was available to supervise and direct the care. The agency's other nursing staff were also at risk of being unable to reach a qualified clinical supervisor in the event of a concern or question about a patient's change in status and care needs. Findings: The surveyor reviewed the agency records in the Texas Uniform Licensure Portal on 05/18/2021 at approximately 2 PM. The agency licensure records revealed a current license to provide HCSSA services including the categories of Licensed and Certified Services. The agency records also indicated the agency had a current active CMS Certification number. Review of the untitled document provided by the Administrator / LVN, Employee A on 05/24/2021 at 12:50 PM revealed the Clinical Manager's, Employee C's last day of employment was 03/05/2020 and the Alternate Clinical Manager, Employee D's last day of employment was 03/29/2019. An interview was conducted with the Administrator / LVN on 05/19/21 at 9:17 AM. The surveyor asked for the name of the Clinical Manager and Alternate Clinical Manager. The Administrator stated the agency had "no Medicare since 01/2020." The Administrator stated the agency did not have a Clinical Manager since January of 2020. The surveyor requested the Clinical Manager's , Employee C and Alternate Clinical Manager's , Employee D who were listed as the Clinical Manager and Alternate Clinical Manager in the agency licensure records, be available for questions when the clinical record review findings were discussed. An interview was conducted with the Administrator / LVN 05/24/21 at 11: 55 AM. The surveyor asked if the Clinical Manager and Alternate Clinical Manager were available to answer questions about the agency clinical record reviews. The Administrator stated she tried to reach them to be available by phone. The Administrator stated the Clinical Manager was not available and the Alternate Clinical Manager didn't respond to the Administrator / LVN's contact attempts. The surveyor asked if the agency had notified CMS that the agency was giving up the CMS Certification number and was no longer able to provide licensed and certified services. The Administrator stated: "No" they had not notified CMS that the agency was giving up the certification number and was no longer able to provide licensed and certified services. The Administrator stated: "I called the (CMS) Dallas office in March 2021 and they sent me what to do" to surrender the certification number in an email. The surveyor asked why the agency had not followed the instructions sent to the agency in the March 2021 email. The Administrator stated: "I am debating with in my mind and today I'm making a decision." The surveyor asked if the agency had a current Clinical Manger or Alternate Clinical Manager. The Administrator stated: "No." No additional information was provided to explain or correct the findings.

Retention of records CFR(s): 484.110(c)(1)(2) Standard: Retention of records. (1) Clinical records must be retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time. (2) The HHA's policies must provide for retention of clinical records even if it discontinues operation. When an HHA discontinues operation, it must inform the state agency where clinical records will be maintained. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure the clinical records for 3 of 7 discharged client records reviewed were retained for at least 5 years after the discharge of the patient. The failure by the agency meant the surveyor was unable to review the entire clinical record during the survey and unable to determine compliance with the regulations for the agency. Findings: During an interview on 05/19/2021 at 9:17 AM, the surveyor requested and reviewed the patients lists provided by the Administrator / LVN. On 05/19/2021 at 10:15 AM, the surveyor requested the entire discharged clinical records for Patient's #1-7. The Administrator/LVN stated the unsigned Plans of Care, physician orders, assessments and nurses' notes were available on the EMR. The Administrator / LVN stated that the rest of the clinical records were stored off-site in paper form in storage. The surveyor requested the agency retrieve the 7 clinical records requested from storage and bring to the agency for review by the surveyor. Record review of the clinical records available on the EMR revealed signed Plans of Care, physician orders, discharge notices, consent forms, written communication notes, and coordination of care notes received by fax or email were not available in the EMR for Patient's #1-7. During an interview on 05/20/2021 at 11:30 AM with the Administrator / LVN, the surveyor explained the missing items needed to complete the clinical record reviews and requested the complete clinical records for Patients #1-7. Review of the patient records provided by the Administrator / LVN revealed no additional records were provided for Patients 1,2 and 7. The partial records reviewed for Patient 1 included an unsigned POC for care provided 11/23/2019 to 01/21/2020. The partial records reviewed for Patient 2 included an unsigned POC for care provided 11/23/2019 to 01/21/2020. The partial records reviewed for Patient 7 included an unsigned POC for care provided 11/21/2018 to 01/19/2019. Each of these 3 patient's EMR records indicated the agency had provided care within the last 3 years. During an interview on 05/24/2021 with the Administrator / LVN at 10:15 AM, the Administrator stated "No charts were found (for Patients 1, 2 and 7). I cannot find these clinical records." The surveyor asked the Administrator / LVN why the clinical records were not available for the survey. The Administrator / LVN stated: "Between moving the office I can't find them. I can get the notes [from the EMR] but the orders are the problem. These [Patients 3,4,5 and 6] are the most current Patients. I decided to keep these in the file cabinet in the office." The Administrator / LVN stated Patients 1.2 and 7's clinical records were in a storage building and the Administrator / LVN went to the storage, but could not find the clinical records. Review of Agency policy and procedures revealed a policy titled: "Medical Record Information Retention and Destruction IM.13" with a revision date of 02/01/2017 which read in part: "Agency will maintain all adult medical records for a minimum of seven (7) years after discharge of the patient/client and for any additional time as deemed necessary in the event of an audit. litigation or other disputes." Review of Agency policy and procedures revealed a policy titled: "Medical Record Content IM.8" with a revision date of 10/01/11 which read in part: "To ensure each medical record., whether paper, electronic or combination, contains complete information which identifies the patient, describes care provided, results, significant events and continuity among disciplines. Policy - Agency will initiate and maintain an individual and accurate medical record for each patient receiving care in compliance with all federal and state laws and regulations. The record may be in a paper, electronic or combination format..."