Every finding on record at Texas Home Health Skilled Services L P

An investigation was conducted on 6/18/2026 for intake #1082455. The census was: L&CHH: 552 LHH: 0 Abbreviations/Acronyms: L&CHH: Licensed and Certified Home Health LHH: Licensed Home Health ER: Emergency Room MD: Medical Doctor ANE: Abuse, Neglect and Exploitation HHS: Health and Human Services

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to report to Texas HHS within 24 hours knowledge of alleged neglect which alleged clinician did not listen to heart and lung sounds of 1 (Client #1) of 3 patients. The failure placed patients at risk of receiving inadequate care, and/or risk of emotional harm. Findings include: Review of the Consumer Rights and Services Incident Investigation Worksheet for intake #1082455 reported by Agency 1’s Alternate Administrator located in TULIP (a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) revealed a received date and time of 4/10/2026 at 2:34 PM. Further review revealed Agency 1 first learned of the incident 4/8/2026 at 4:01 PM. Review of the Complaint Report for Client #1 revealed Family 1 called Agency 1 on 4/8/2026 at 4:01 PM. Further review revealed under “Description” it read “SPOKE WITH [Family 1] REGARDING WHAT CLINICIANS ARE TO DO WHILE IN THE HOME REGARDING LISTENING TO THE HEART AND LUNGS. HE IS UPSET THAT NOT ONE CLINICIAN HAS SAT HER UP AND LISTENED TO HER HEART AND LUNGS SINCE SHE HAS BEEN ON SERVICES AND NOW SHE IS IN THE ER WITH FLUID OVERLOAD, DIZZINESS, [shortness of breath] AND SLURRED SPEECH. I DID EXPLAIN TO HIM THAT THEY ARE TO DO A COMPLETE HEAD TO TOE ASSISSMENT WITH EACH VISIT, WHICH INCLUDES LISTENING TO THE HEART AND LUNGS AND NOTIFY MD OF ANY ABNORMAL FINDINGS. HE STATED IF THEY WOULD HAVE LISTENED THEN THEY MAY NOT BE IN THE ER RIGHT NOW. HE STATES "I AMANGRY BECUASE I FEEL THIS COULD HAVE BEEN AVOIDED". Further review of the Complaint Report revealed the following course of action by the agency: 4/9/2026 Alternate Administrator investigated accusations and notified Administrator of findings, decision made to initiate compliance call; 4/10/2026 compliance call conducted at 9AM, reviewed investigation which determined there were actions not performed by clinicians per company policy/expectations and based on findings, it was determined self-report to state would be done 4/10. Interview with the Administrator and Alternate Administrator on 6/22/2026 at 3:06 PM. The Administrator was asked about the agency’s process for receiving complaints. The Administrator stated the individual who took the complaint would enter it into the system and it would be forwarded to the Alternate Administrator for follow up. The Administrator was asked to review the above complaint and determine whether it provided sufficient cause to believe the patient may have been the subject of ANE. The Administrator stated that a review of the patient’s record would have been necessary before reaching that determination. The Surveyor asked why a self-report was not submitted to Texas HHS after the findings were identified during the chart review completed by the Alternate Administrator on 4/9/2026. The Alternate Administrator stated that a compliance meeting was held on 4/10/2026 to review the findings and it was determined at that time that a self-report should be submitted to Texas HHS. The Administrator was asked what the Agency’s policy was for self-reporting to Texas HHS and Administrator could not recall the exact time frame but stated the reporting was required within a short period. Surveyor reviewed the agency’s policy with the Administrator and Alternate Administrator which stated “Suppose an agency has cause to believe that a patient served by the Agency has been abused, neglected, or exploited by an agency employee, volunteer, or contractor. This includes any family members employed by the Agency. In that case, the Agency must report the information immediately, meaning within 24 hours.” Surveyor discussed with the Administrator and Alternate Administrator the distinction between having “cause to believe” and completing a full agency investigation. Following further discussion and clarification, both the Administrator and the Alternate Administrator acknowledged that the complaint should have been reported within 24 hours and agreed that the report was submitted late. The Surveyor asked the Administrator why it was important to report ANE to the state within the required 24-hour timeframe. The Administrator stated it was important to ensure that a proper investigation could be done, and it was also a condition of participation. The Administrator further stated, “we have to fend for the defenseless.” Review of the Agency’s policy “Reporting Abuse, Neglect, Fraud, or Exploitation of Clients” reference# C 2.1 last reviewed date 1/16/2026 under “Procedure” read in part “6. The Executive Director or designee will immediately (as soon as possible, but not more than twenty-four (24) hours after being notified of the incident) initiate an investigation of all alleged violations.” Further review revealed under “Texas Reporting Responsibilities”, under “Agency Self-Reporting to HHSC” read in part “Suppose an agency has cause to believe that a patient served by the Agency has been abused, neglected, or exploited by an agency employee, volunteer, or contractor. This includes any family members employed by the Agency. In that case, the Agency must report the information immediately, meaning within 24 hours, to: Effective September 1, 2023, all self-reported cases involving all payors shall be reported online to TULIP Online Licensure Application System | Texas Health and Human Services or by emailing ciicomplaints@hhs.texas.gov or by calling 1-800-458-9858.”

An Entrance Conference was conducted on 1/12/2023 at 10:15 a.m. with the Alternate Administrator and the Regional Director of Operations. The agency representatives were informed that the purpose of the visit was an investigation of complaint # IQ95058. The agency census was: Austin: L&CHHS- 638 An Exit conference was conducted on 1/17/2023 at 1:40 p.m. with the Administrator, Alternate Administrator, Regional Director of Operations, Director of Clinical Operations and by tele conference the Area Quality Specialist, Vice President of Operations, Vice President of Quality Assurance and Regional QAPI Nurse. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Additional information was not received. Written instructions were provided for submitting a plan of correction within 10 days of receiving the Statement of Deficiencies. Abbreviations: L&CHHS- Licensed and Certified Home Health Services QAPI- Quality Assurance and Performance Improvement UTI- Urinary Tract Infection S/S- Signs and Symptoms PRN- As needed UA- Urinalysis, a test of the urine that can be used to detect infections. UA/ CS- Urinalysis with Culture and Sensitivity, a test of the urine that can be used to detect infections and isolate the microorganism present. RNPCM- Registered Nurse Patient Care Manager CM- Case Manager POC- Plan of Care NP- Nurse Practitioner

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to communicate and coordinate care with the physician for 1 of 3 patients (Patient #1) with urinary devices for which records were reviewed, in that: a. The agency failed to communicate with the physician when Patient #1 requested a urinalysis due to a possible UTI. b. The agency failed to notify the physician when visits for urinary monitoring and treatment were missed and when client declined treatment. c. The agency failed to verify client’s report of orders for antibiotics with the physician. This failure resulted in a delay of the physician being notified of treatment changes for Patient #1 and may have contributed to the hospitalization of Patient #1. Findings: 1. Review of the clinical record of Patient #1 revealed a POC dated 10/21/2022 to 12/19/2022. The POC read in part: “Diagnoses: Chronic Kidney Disease, Encounter for Fitting and Adjustment of Urinary Device…Instruct patient/ caregiver on suprapubic catheter care including cleansing of insertion area daily with soap and water, s/s of UTI, fluid requirements, positioning of tubing and bag, s/s of complications and infection control measures. Skilled nurse to change suprapubic catheter monthly and prn…Genitourinary system will be evaluated, and exacerbations identified with interventions implemented to minimize complications.” 2. The clinical record contained a coordination note dated 10/29/2022, Note Type On Call, which read in part: “Message received via telemed. Patient (#1) needs someone to perform a UA. Chart review reflects no current orders for prn UA/ CS collection on current POC. Will need orders. Scheduled nurse on call for follow up regarding the above.” A missed visit was noted on 10/30/2022, reason, no answer. 3. The clinical record contained a document entitled “Visit Note Report” dated 11/1/2022 which read in part: “Patient’s suprapubic catheter not changed today. Patient requested for it not to be changed. He wants to keep it at the beginning of every month starting December. Patient states that he thought over the weekend that he was developing a UTI, spoke to his doctor and she said to take his leftover antibiotic Mobic. Discussed with patient we couldn’t take a urinary sample due to him being on a previous antibiotic and would give us a false answer.” The note was signed by the LVN. During an interview with the LVN on 1/17/2022 at 11:17 am, he stated he did not notify his CM or the physician about patient’s request for UA and did not verify with physician that an antibiotic had been ordered. LVN stated he took the patient’s word that he had spoken with physician and was on antibiotics and did not question the Mobic (Mobic is not an antibiotic but is an anti-inflammatory pain reliver). The LVN stated the protocol was to notify the physician and verify medication and to notify the Case Manager. Review of the POC and medication profile did not reveal an antibiotic or Mobic. During an interview with Patient #1 on 1/17/2022, the patient was asked if he could recall talking to the physician at the end of October or first part of November 2022 or recalled being on or starting any left-over antibiotics. Patient stated he did not recall being on antibiotics from the time of admission to the agency (10/21/2022) to hospital admission on 12/8/2022. 4. The clinical record contained a document entitled “Visit Note Report” dated 11/8/2022 which read in part: “Patient’s suprapubic catheter not changed today. Patient requested that his catheter be changed next week at the next visit.” The note was signed by the LVN. During an interview with the LVN on 1/17/2022 at 11:17 am, he stated he did not notify the physician about patient’s request to postpone the catheter change. The clinical record contained order number “7204237” which read in part: “Patient is requesting to have his catheter changed due to his previous urinary tract infection. He said let’s do it next week instead of at the end of the month. This order has been declined.” During an interview with the Alternate Administrator on 1/18/2023 at 1:22 p.m. the Alternate Administrator stated the order was declined by RNPCM. RNPCM joined the interview and stated order was declined due to it did not contain date of visit, catheter type and required a call to the physician. RNPCM stated she notified LVN by phone that order needed to be corrected. RNPCM and Alternate Administrator verified that order was not corrected, and physician was not notified of patient’s request to have catheter changed the following week. 5. The clinical record contained a coordination note dated 11/14/2022 which read in part: “Missed visit, no answer.” The clinical record does not contain documentation that the physician was notified of the missed visit. 6. The clinical record contained a document entitled “Visit Note Report” dated 11/23/2022. The document read in part: “Pt greeted me at door, requested suprapubic catheter be changed. Said it was supposed to be done last week but he did not get a visit last week. Attempted to change suprapubic catheter, met with resistance, unable to remove it, left in place. Patient agrees to follow up with urologist. Care coordination with NP office and (Urologist office).” The note is signed by the RN. 7. During an interview with Patient #1 on 1/12/2022 at 9:13 a.m., patient stated he was seen in his urologist office on 12/7/2022 for a catheter change and stated the urologist did lab at that time. Patient #1 stated he did not get the results of the lab because he was admitted to the hospital on 12/8/2022 through the Emergency Department due to a UTI. 8. During review of Patient #1’s record with the Alternate Administrator on 1/17/2023 at 10:07 a.m., the Alternate Administrator stated LVN did not coordinate care on 11/1/2022 and stated LVN failed to verify antibiotics with the physician and LVN should have clarified antibiotics with the physician and updated orders. Alternate Administrator stated LVN should have coordinated with physician after both the 11/1/2022 and 11/8/2022 visits. Alternate Administrator stated LVN was counseled on 1/16/2023. This was verified in the employee record. 9. Review of the agency policy and procedure manual revealed the following policies: “Care Planning, Coordination and Assessment Process” revised 11/1/22. The policy read in part: “16. The case manager or primary clinician is responsible for facilitating communication about patient status change of orders among all assigned disciplines and with the patient physician or allowed practitioner.” “Medication Profile, Review and Reporting of Findings: revised 2/15/22. The policy read in part: “6. As part of each visit the skilled nurse or therapist review’s the patient’s medication regimen including medication name, dosage, frequency, and instructions with patient and/ or caregiver, and looks for new, discontinued, or changed medication or non-adherence. 7. The patient’s physician is promptly notified of issues found during the medication review or when a medication order/ clarification is needed.”