Every finding on record at Texas Home Health Group of College Station LLC

An investigation was conducted on 6/23/26 for intake #1077953 & #1097643. The census was: L&CHH: 385 Abbreviations/Acronyms: L&CHH: Licensed and Certified Home Health

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review on 5 clients receiving care through agency and staff interviews, the agency failed to ensure skilled professionals-maintained responsibility to prepare clinical notes in that the agency did not enforce a written policy for implementation of care for required documentation on significant events or notification of EMS assistance for Client #2. PTA 1 failed to document significant events at home visit of Client #2, which resulted in Client need to EMS assistance and hospitalization. Record review of Client #2 visit notes with PT staff, including the visit of PTA 1 on 3/20/26 when Client was sent to hospital. After review of documentation surveyor was unable to locate any record noted of Client #2 status upon home visit or no notification of EMS mentioned within the Client record. Further record review of other home visit documentation with other PT staff from agency with Client #2 revealed narrative documentation to include Client status, his mobility, participation in PT activities, etc. Review of documentation within records did not reveal home visit on 3/20/26 for PTA 1 with Client #2, which reflects no visit occurred on this date with this Client by PTA 1. Interview with Administrator on 6.24.26 at 10:00 AM in reference to policy that addressed when an emergency occurs with the Client that warrants 911 or emergency assistance, what was the policy for this. Administrator stated she does not know offhand and will reach out to agency staff who can assist in locating the policy needed. Interview with Administrator on 6.24.26 at 10:00 AM on clarification of how care is documented with agency staff, for instance PT vs. PTA on home visits. Asked Administrator what is required for the visit in reference to the documentation. Asked Administrator if there is specific documentation that is required by agency for each specialty for home visits. Administrator stated she does not know exactly what they are trained in for PT, so she will contact the Senior Clinical Instructor, who is responsible for training physical therapy staff. Administrator stated she will set up an interview via Teams with questions/answers. Interview with Senior Clinical Instructor via Teams on 6.24.26 at 10:55 AM in reference to visit notes pertaining to PT, surveyor asked about clarification on difference in PT vs. PTA documentation. Sr Clinical Instructor stated the PT staff are trained to use SOAP documentation which is built into the visit note. She stated she S (subjective) O (observation) A (assessment) P (plan) addresses the status of the client during the home visit to include how they participated, etc. She stated that the narrative note is included when additional documentation is required, for instance a change in Client status, need for notification of physician, call to the agency due to some concerns or even if emergency services are necessary. She also included that if this is required documentation in coordination notes it is necessary to include the additional information which occurred during the home visit. Asked Sr Clinical Instructor if this is required for all PT staff, which she stated that all staff are trained to document this and must be included in the Client record with all the necessary information. Sr. Clinical Instructor also shared the computer screen of Client #2 and provided details on where the notes should be located as well as provided an explanation how the documentation is expected to be viewed. Interview with Administrator on 6.24.26 at 11:30 AM, surveyor asked Administrator if she was aware of the agency policy on documentation on emergency care, which she stated she couldn’t recall offhand, however she stated all agency staff are required to contact emergency services at any time a client needs assistance. The Administrator also included the agency should be made aware of any change in status, especially if EMS is necessary for a Client. Review of agency policy, “Emergency Care Protocols” dated 11/10//25 revealed, procedure: professional personnel finding a patient needing immediate medical care shall contact the emergency response system and stay with the patient, giving necessary care following Section 15 (Emergencies) of the VNAA Manual unit emergency services arrive. The physician or allowed practitioner and Agency’s Clinical Manager are contacted as soon as possible. Clinical documentation should be included in Client records.

An investigation of complaint 94622 was conducted on 12/07/2022. The census was: College Station (Parent): L&CHHS- 182, LHHS- 77, PAS- 0 Brenham (Branch): L&CHHS- 223, LHHS- 113, PAS- 0 Huntsville (Branch): L&CHHS- 236, LHHS- 104, PAS- 0 Abbreviations: L&CHHS- Licensed and Certified Home Health Services LHHS- Licensed Home Health Services PAS- Personal Assistance Services RN- Registered Nurse LVN- Licensed Vocational Nurse PRN- as needed SNV- skilled nurse visit ER- emergency room MD- medical doctor Admin- Administrator Alt Admin- Alternate Administrator SN- Supervising Nurse Comp- Complainant Pt- patient

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to comply with applicable federal requirements for home health agencies for 1 of 5 patients (Patient #1) in that the patient’s plan of care was not followed as ordered. This failure resulted in skilled nursing care not being provided in accordance with the patient’s plan of care. Review of the clinical record for Patient #1 revealed a start of care date of 03/02/2022 with a diagnosis of Encounter for Attention to Cystostomy, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Retention of Urine. Review of the plan of care for the time period 10/28/2022 – 12/26/2022 revealed orders: SN (skilled nursing) 1 visit a week for 1 week, 1 visit every other week for 8 weeks (3SNV). May initiate telehealth or remote monitoring visits as needed. Instruct patient/caregiver on suprapubic catheter care including cleansing of insertion area 2X daily with soap and water, S/S (signs and symptoms) of UTI; fluid requirements; positioning of tubing and bag, s/sx of complications and infection control measures. Skilled nurse to change 22Fr catheter with 10 ml balloon monthly and prn. Allow 3 prn snv to assess for clogged/dislodged/leaking catheter and may change catheter prn. Further review of the clinical record for Patient #1 for the time period 10/28/2022 – 12/08/2022 revealed SN visits were conducted: 10/28/2022- RN (in person), 11/02/2022- LVN (telehealth), 11/09/2022- LVN (telehealth), 11/16/2022- LVN (telehealth), 11/16/2022- LVN (in person), 11/28/2022- LVN+RN (in person). Review of the agency’s complaint report revealed documentation of a complaint dated 11/28/2022, which read in part “Description: Per 11/28/22- RN documented -phone call made to [patient’s] provider/[Family Member A]. [Family Member A] stated [Family Member B] does not want her to touch catheter and she is going to take him to the ER. States urologist told them to take him to ER since home health will not do their job. [Family Member B] then came on phone and stated his bladder is about to bust and it’s not their job to do anything with his catheter. [Family Member A] then got on the phone and stated she has been told not to flush or touch catheter even though she does and will not be told by SN what she is expected to do then hung up on SN. Attempted to call CG back with no response. Intervention/Resolution Comments: After speaking with [RN A] she says one of the daughters [Family Member A] is the provider and has been taught how to do the cath flushes and irrigation. She lives next door. Our staff are needed to change out the catheter as RX’D by the doctor. We sent LVN with RN to observe the cath change last week so that she can change it out with RN watching her on the next due date to keep the [Family Members] happy as they were scared to let an LVN do anything with it.” Review of agency documentation titled “CLIENT COORDINATION NOTE REPORT” dated 11/28/22, read in part “At 1:30PM C (cell?) phone call received from patient’s daughter [Family Member B] that patient has not had any drainage in bedside drainage bag since catheter was changed. Patient is not showing any signs of discomfort and catheter not leaking around insertion site. Skilled nurse instructed patient caregiver to encourage increased fluids due to patient’s history of not drinking enough water and to monitor drainage bag. Caregiver asked if skilled nurse would be making visit to check catheter. Caregiver refused to adjust or flush catheter at this time stating she does not touch his catheter. Patient’s provider and other daughter [Family Member A] is able to flush catheter and not home at the moment. Skilled nurse stated she will call later to check on patient status and instruct [Family Member A] to adjust and possible flush catheter if not effective. 3:09PM Skilled Nurse called patient’s daughter [Family Member B] who had initially called, and she stated she is not currently with patient and can’t sit around at patient’s house all day watching for urine to drain. She stated if patient has problems tonight, she will just take him to the emergency room. Skilled Nurse voiced ER visit is not required and that Caregiver [Family Member A] is capable of flushing catheter, however nurse attempted to call [Family Member A] to provide instruction and was unable to leave voicemail. Will reattempt phone call later this afternoon.” Review of additional coordination documentation dated 11/28/2022 read in part, “Phone call made to patient’s provider/daughter [Family Member A]. [Family Member A] stated her sister does not want her to touch catheter and she is going to take him to the ER. States urologist told them to take him to ER since home health will not do their job. [Family Member B] then came on the phone and stated his bladder is about to bust and its not their job to do anything with his catheter. [Family Member A] then got on the phone and stated she has been told not to flush or touch catheter even though she does and will not be told by SN what she is expected to do, then hung up on SN. Attempted to call CG back with no response. Clinical Supervisor (RN- B) and nurse for (MD- B) notified. 4:58PM- Faxed to MD.” The note was input by RN- B. A telephone interview was conducted on 12/07/2022 @11:30AM with Comp- A. Surveyor asked complainant to discuss what occurred on 11/28/2022 regarding Patient #1. Comp- A stated on 11/28/2022 at 9:30AM an RN changed the suprapubic catheter for Patient #1. At 12:50PM Comp- A stated she called the agency and reported there was no urine in the drainage bag and requested a nurse visit at that time because she felt the catheter had not been inserted correctly. Comp- A stated the nurse refused to make a visit and advised her to have the patient drink more water. Comp- A stated the RN told her a caregiver had been trained to flush the catheter and she should do it. Comp- A stated she advised the nurse that the caregiver was not there and no one in the home was willing to do anything to the catheter. Comp- A stated midafternoon she called the nurse again to request she go to see the patient and check his catheter. Comp-A stated she advised RN that when she left there still wasn’t any urine in the drainage bag. Comp- A stated RN again refused to make a nurse visit because she was in Summerville. Comp- A stated another family member called the agency at 5:00PM and requested a nurse come to see the patient because there still wasn’t any urine in the drainage bag. Comp- A stated the nurse again refused so the family member informed the agency the family would have to take him to the ER. Comp- A stated on 11/29/2022 Patient #1 was taken to the urologist’s office due to a distended bladder and no urine in the drainage bag. A nurse at the urologist’s office replaced the suprapubic catheter. After the catheter was replaced, urine flowed without difficulty. A telephone interview was conducted on 12/08/2022 @ 1:26PM with RN- A. Surveyor asked RN to discuss what occurred on 11/28/2022 regarding Patient #1. RN- A stated one of the patient’s daughters was his caregiver and had been trained how to flush and reposition the patient’s catheter when necessary. RN- A stated the caregiver had done it prior to this incident. RN- A confirmed she told Comp- A she could not make a skilled nurse visit. RN- A stated she instructed Comp- A to give the patient more water and to wiggle and flush the catheter. RN- A stated Comp- A refused, and stated the caregiver was not there. Surveyor asked RN- A why she did not make a prn skilled nurse visit to assess the suprapubic catheter. RN- A stated she did not make a prn visit because she had other patients to see that day and there was a caregiver there that knew how to flush the catheter. RN- A confirmed she was advised by family members no one at the residence was willing to flush or reposition the catheter. An interview was conducted on 12/08/2022 @2:55PM with the Alt Admin/ASN. The plan of care for Patient #1 for the time period 10/28/2022- 12/26/2022 was reviewed. Alt Admin/ASN confirmed SN orders included 3 prn skilled nurse visits to assess for a clogged/dislodged/leaking catheter. Surveyor asked Alt Admin/ASN if a prn skilled nurse visit should have been conducted on 11/28/2022 since no willing caregiver was available to assess/flush the catheter. Alt Admin/ASN stated “yes.” A telephone interview was conducted on 12/08/2022 with RN- B at 2:08PM. RN- B stated she was the Branch Director for the Brenham office. RN- B confirmed the information provided in the Client Coordination Note Report dated 11/28/2022 was relayed to her by RN- A. RN- B stated she was advised of the issue with Patient #1’s catheter at approximately 4:00PM. RN- B stated at that time she instructed RN- A to call the patient/caregiver and offer to make a skilled nurse visit. RN- B stated no one answered the phone. Review of the agency’s policies and procedures revealed a policy titled, “PHYSICIAN PLAN OF CARE, HH2.1.5”, which read in part “The appropriate health care personnel must perform services as specified in the plan of care.”