Every finding on record at Sure Home Health Services LLC

A recertification survey was conducted on 04/21/2025. The census was 11 (Licensed and Certified) and 0 (Licensed Home Health). The agency is in compliance with no violation cited.

A recertification survey was conducted on 04/21/2025. The census was 11 (licensed & certified). Abbreviations: OASIS -outcome and assessment information set CMS- Center for Medicare and Medicaid Services IQIES – Internet Quality Improvement & Evaluation System M0090 – The date the OASIS assessment was completed.

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 transmit completed OASIS (a tool used by CMS to collect certain patient information) assessment to CMS within 30 days of completing the OASIS assessment, in that: from 08/01/2024 to 04/21/2025 there were 26 assessments transmitted greater than 30 days from the assessment completion date. This Failure 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. Pre-survey review of the report titled, “OASIS Error Detail Report” taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed 26 (patients 1, 5 and 6) assessments contained error number -3330 with the error message of, “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” On 04/21/2025 at approximately 12:54 PM the surveyor conducted an interview with the Administrator. The surveyor discussed the OASIS report titled, “OASIS Error Detail Report.” The surveyor explained that from 08/01/2024 to 04/21/2025 the agency transmitted 26 OASIS greater than 30 days from the completion date (M0090) to CMS. The surveyor asked who was responsible for transmitting the OASIS assessment to CMS. The Administrator stated, “The Alternate Administrator but it’s not his fault. The nurses don’t get their stuff in on time” The surveyor asked why the agency had 26 OASIS assessment that were transmitted past 30 days to CMS. The Administrator stated, “It’s these nurses. They don’t get the information in on time and then we have to wait to get the OASIS transferred when it gets signed.” Record review for Patient 1: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 64570836 submission date 02/19/2025 with 1 total record processed. Record 1 (Patient 1) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 1 (Patient 1) of the OASIS Agency Final Validation report that was submitted on 02/19/2025 had a M0090 completion date of 01/15/2025. Record review for Patient 5: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 64283225 submission date 12/23/2024 with 1 total records processed. Record 1 (Patient 5) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 1 (Patient 5) of the OASIS Agency Final Validation report that was submitted on 12/23/2024 had a M0090 completion date of 10/17/2024. Record review for Patient 6: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 64192890 submission date 12/04/2024 with 5 total records processed. Record 5 (Patient 6) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 5 (Patient 6) of the OASIS Agency Final Validation report that was submitted on 12/04/2024 had a M0090 completion date of 09/27/2024. On 04/25/2025 at approximately 10:20 AM the surveyor conducted an interview with the Alternate Administrator. The surveyor discussed the OASIS report titled, “OASIS Error Detail Report.” The surveyor explained that from 08/01/2024 to 04/21/2025 the agency transmitted 26 OASIS greater than 30 days from the completion date (M0090) to CMS. The surveyor asked who was responsible for transmitting the OASIS assessment to CMS. The Alternate Administrator stated, “I am since I am the technical guy for the office I do.” The surveyor asked why the agency had 26 OASIS assessment that were transmitted past 30 days to CMS. The Administrator stated, “I don’t really know I think that it’s the nurses. We have a lot of nurses that don’t work full time for us and they don’t get the assessments in on time. We have been trying to hire full time nurses that work for us and we think they may help with the late OASIS submissions.” The surveyor discussed the findings from the patient record reviews. The surveyor explained that during record review he found Patients 1, 5 and 6 had OASIS that were transmitted to CMS more than 30 days after the M0090 dates. The surveyor asked why the OASIS were transmitted past 30 days. The Alternate Administrator stated, “It’s really the nurses not locking their assessments and then we can’t submit the OASIS.” The surveyor asked how the failure to submit the OASIS to CMS within 30 days could affect the clients services. The Alternate Administrator stated, “I don’t know the answer to that question.” Review of Agency policy titled, “Timelines” with a revision date of 050111 read in part: “…1.11 Completed and encoded OASIS data will be transmitted to the state within 30 days of the M0090 date.”

An entrance conference was conducted with the Admin. DON on 5/12/2022 at 10:30 AM. They were informed the purpose of the visit was to conduct a recertification survey and an investigation of complaints (295088, 313859, and 236498). The "Home and Community Support Services Agencies (HCSSA's), What to Expect During Your Agency's Survey" was provided and explained. Written information was provided with instructions on how to complete the on-line "Comment Card Survey" was provided. Licensed and Certified Home Health: 8 An exit conference was conducted with the Admin. and the DON on 5/24/2022 at 3:00 PM. The preliminary findings of the survey were discussed, and a written copy provided. The agency representatives were afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Violations. The agency representatives were informed complaints 313859 and 295088 were unsubstantiated, complaint 236498 was substantiated and not cited. The agency was in substantial compliance with 42 CFR Part 484.22. Emergency Preparedness Requirements for Home Health agencies.

An entrance conference was conducted with the Admin. DON on 5/12/2022 at 10:30 AM. They were informed the purpose of the visit was to conduct a recertification survey and an investigation of complaints (295088, 313859, and 236498). The "Home and Community Support Services Agencies (HCSSA's), What to Expect During Your Agency's Survey" was provided and explained. Written information was provided with instructions on how to complete the on-line "Comment Card Survey" was provided. Licensed and Certified Home Health: 8 An exit conference was conducted with the Admin. and the DON on 5/24/2022 at 3:00 PM. The preliminary findings of the survey were discussed, and a written copy provided. The agency representatives were afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Violations. The agency representatives were informed complaints 313859 and 295088 were unsubstantiated, complaint 236498 was substantiated and not cited. Definitions: Admin (Administrator) POC (Plan of Care) SOC (Start of Care) DC (discharge) DON (Director of Nursing) RN (Registered Nurse) Texas Board of Nursing (BON)

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the Administrator failed to ensure that 1 (RN A) of 2 agency RNs, who’s personnel records were reviewed, met nursing licensure qualifications to provide nursing services in a home health setting. RN A’s nursing license verification had current disciplinary action that included RN A was not to be employed by a home health agency. The Administrator’s failure to employ qualified personnel, by employing RN A, who was not qualified to provide nursing services in an unsupervised, home health setting, placed 3 (Clients 4, 8, and 9) of 4 discharged clients’ records reviewed, at risk of harm from receiving unsafe, substandard care. Findings: Review of RN A’s personnel record included a report from the Texas Board of Nursing. The report included RN A’s name and registered nurse license number. The report included “notification - current discipline - suspend/probate – 1/21/2021.” The report also included “Board Orders.” RN A’s “Board Orders” included, “… RESPONDENT SHALL NOT be employed by a nurse registry, temporary nurse employment agency, hospice, or home health agency. RESPONDENT SHALL NOT be self-employed or contract for services. Multiple employers are prohibited….” RN A’s personnel record included a job description for the title of “RN” signed and dated 12/22/21 and signed by the agency DON on 12/22/21. RN A’s personnel record included a “Pre-employment" interview signed and dated by the agency DON on 12/21/22. Review of an agency document, provided to the surveyor, listed a schedule of RN A’s visits. The list included client names and visit dates from RN A’s date of hire, 12/27/2021 to current. The list indicated RN A provided 27 skilled nursing visits, in an unsupervised, home based setting. Patient 4: Review of discharged Patient 4’s POC included a SOC date of 1/26/22. Patient 4’s diagnoses included, Essential Hypertension, Prediabetes, and Schizophrenia. Physician orders included, skilled nursing visits, 1 time a week for 9 weeks for vitals check and medication education. The POC included, “patient has a condition such that leaving his or her home is medically contraindicated.” Patient 4’s discharge record included skilled nurse visit notes, signed by RN A dated, 2/12/22, 2/19/22, 2/26/22, 3/1/22, 3/8/22, 3/16/22, 3/28/22, 4/11/22, 4/25/22, and 5/9/22. Patient 4: During a phone interview on 5/16/22 at 2:45 PM, with discharged Patient 4 and Patient 4’s attendant, Attendant A, the surveyor asked if the patient was happy with the agency’s nursing services. Patient 4 and Attendant A reported RN A only visited 1 time on 1/26/22 to do “an intake” and then came 1 other time to cut Patient 4’s fingernails and toenails. Patient 4: During a home visit on 5/20/22 at 4:45 PM, to Patient 4’s residence, the surveyor reviewed the home folder and observed the agency’s “vital signs log” in the home folder. RN A signed the agency’s “vital signs log” 1 time on 1/26/22. There was no further documentation on the client’s “vital signs log” that indicated RN A visited the patient's home after 1/26/22. Patient 8: Review of discharged Patient 8’s POC included a SOC date of 1/10/22. Patient 8’s diagnoses included, Pneumonia, Asthma, and Schizoaffective disorder, and bi-polar. Physician orders included, skilled nursing visits, 1 time a week for 9 weeks for vitals check and medication education. The POC included, “patient has a condition such that leaving his or her home is medically contraindicated.” Patient 8’s discharge record included skilled nurse visit notes, signed by RN A dated, 2/17/22, 2/24/22, 3/4/22, 3/28/22, 4/7/22, 4/11/22, 4/22/22 and 4/26/22. Client 8: During a phone interview on 5/18 at 10:25 AM, with discharged Patient 8, the surveyor asked Patient 8 if she was happy with the nursing services. Patient 8 reported RN A only came a couple of times and another nurse RN B came 1 time. Patient 8 reported she was not sure but she would get the home folder and look at the sign in sheet that was in the home folder. Patient 8 reported RN A signed the “vital signs log” one time on 1/10/22, and RN B signed the log 1 time on 3/6/22. Patient 8 asked if the surveyor would like a copy of the “vital signs log” and would send a copy. Patient 8 said those are the only times she can remember a nurse coming to visit. Patient 9: Review of discharge Patient 9’s POC included a SOC date of 1/4/22. Client 9’s diagnoses included, Transient Cerebral ischemic attack, pain in right and left knee, chronic kidney disease, and diabetes II. Physician orders included, skilled nursing visits, 1 time a week for 9 weeks for vitals check and medication education. The POC included, “patient has a condition such that leaving his or her home is medically contraindicated.” Patient 9’s discharge record included skilled nurse visit notes, signed by RN A dated, 1/12/22, 1/18/22, 1/25/22, 2/8/22, 2/22/22, 3/15/22, 3/29/22, 4/12/22 and 4/26/22. The surveyor attempted to reach Patient 9 and left phone messages for Patient 9 and Patient 9’s family member. The surveyor did not receive a return call. Review of RN A’s personnel record included a form titled "Job Description/Performance Evaluation” signed and dated on 3/26/22 by RN A and the DON. The form included a “date onsite supervisory visit completed,” that was blank. The rest of the form was blank. There was no documentation of supervision in RN A’s personnel record. The surveyor requested documentation that RN A was supervised for each home visit that RN A documented skilled nurse visit notes. The surveyor was provided with 16 forms titled “Sure Home Health Timesheet.” Each form was individualized with a patient’s name and each form had 1 visit listed for each patient. Each form was signed and dated by RN A and the Director of Nursing. There was no evidence of documentation that RN A was supervised for all of the patients visits she documented skilled nursing notes. Interview: During an interview with the Administrator and the Director of Nursing on 5/24/22 at 3:00 PM, the surveyor asked if all of RN A’s visit were supervised by a RN. The DON stated RN A was only supposed to be assigned to do SOC visit assessments, in the home, and only if the DON could go with RN A. The DON said she accepted that the agency scheduled RN A to do weekly visits, unsupervised, without the DON’s permission. The DON said she told the schedulers not to schedule RN A for weekly visits without supervision, but they did anyway. Documentation of supervision provided to the surveyor for Patient’s 4, 8 and 9: Review of the timesheets provided to the surveyor, revealed a timesheet for discharged Patient #4. There was one line filled out that included a date of 1/26/22, time of 11:20, visit type-SOC, and patient initials. The top of the form was signed by RN A and the DON. The rest of the timesheet was blank, there were no other dates included on the timesheet that indicated the 10 visits RN A provided to Patient 4 were completed and were supervised. Review of the timesheets provided to the surveyor, revealed a timesheet for discharged Patient #8. There was one line filled out that included a date of 1/10/22, time of 1 PM to 2 PM, visit type-SOC, and initials by the patient. The top of the form was signed by RN A and the DON. The rest of the timesheet was blank, there were no other dates included on the timesheet that indicated the 8 visits RN A provided to Patient 8 were completed or supervised. Review of the timesheets provided to the surveyor, revealed a timesheet for discharged Patient #9. There was one line filled out that included a date of 1/4/22, time of 12:30 PM - 3:30 PM, visit type-SOC, and initials by the patient. The top of the form was signed by RN A and the DON. The rest of the timesheet was blank, there were no other dates included on the timesheet that indicated the 9 visits RN A provided to Patient 9 were completed or supervised. The surveyor conducted a telephone interview with RN A on 5/18/22 at 8:15 AM. RN A said she was hired by the agency to do Quality Assurance in the office and to drive the DON to client visits. The surveyor asked RN A about the stipulations on RN A's nursing license, and asked if she was cleared to work in home health. RN A responded “No, it says I have to be supervised by a supervising nurse at all times." RN A said she spoke with her licensing case manager and RN A was told she was not to see patients without supervision. The surveyor asked RN A if she had visited patients without supervision. RN A replied, “maybe 1 or 2 times that may have happened.” The surveyor asked RN A if she wrote skilled nursing notes for all the visits she was assigned to do. RN A replied "yes." The surveyor asked RN A if she signed the “vital signs log” in the patients' homes, when she visited Patients 4 and 8. RN A replied “yes." After review of Patient 4 and Patient 8's home folders and the patients' "vital signs log," there was no evidence RN A signed the “vital signs log” in Patient 4 and Patient 8’s home folders for the visits RN A documented skilled nursing notes. The surveyor called the Texas Board of Nursing on 5/24/22 at 12:58 PM. The surveyor spoke with the Supervisor of Case Management, Identifier A. Identifier A reviewed RN A’s license stipulations and looked up the employer information that was reported by the agency. Identifier A reported the form that was sent to the Texas Board of Nursing regarding RN A’s employment did not indicate the employer was a home health agency and did not indicate RN A would be employed by a home health agency. Identifier A reported RN A was not to work for a home health agency. Identifier A stated the home health agency should not have employed RN A and must terminate RN A’s employment immediately. Identifier A stated she would notify the enforcement department that RN A was no longer employed by the home health agency. During the exit interview on 5/24/22 at 3:00 PM, with the Administrator and the DON, the surveyor reviewed the findings and asked how the failure to employ a qualified nurse could affect agency patients. The Administrator said it would not be a problem now they have already terminated RN A’s employment. The DON said the agency schedulers should not have assigned RN A to do visits unsupervised. There was no further documentation provided. Agency Policies: “Responsibilities of the Administrator LD.6” with a revised date of 102507. “Administrator of a Licensed and Certified Agency….1.7 Employs or contracts with qualified personnel….” “Selection of Agency Staff HR.5” with a revised date of 010406. “Agency will establish a process for the recruitment and selection of staff that ensures equal consideration of applicants whose qualifications are commensurate with anticipated job responsibilities….Agency leaders will review Federal and State employment laws and regulations…verification of qualifications/experience/job history. Verification of education/training/licensure/certification including contract staff….” The agency hired RN A with stipulations on RN A’s license that the RN would not work for a home health agency. The agency hired RN A with knowledge of the stipulations, despite what the terms of their own policy read.