Every finding on record at The Medical Team Inc

A recertification survey was conducted on 03/17/2025. The census was: L&CHHS: 0 LHHS: 0 PAS: 13 The agency is in substantial compliance with no deficiencies cited. Abbreviations/Acronyms: L&CHHS: Licensed and Certified Home Health Services LHHS: Licensed Home Health Services PAS: Personal Assistance Services

A recertification survey was conducted on 03/17/2025. The census was: L&CHHS: 0 LHHS: 0 PAS: 13 Abbreviations/Acronyms: HHA: Home Health Agency L&CHHS: Licensed and Certified Home Health Services LHHS: Licensed Home Health Services PAS: Personal Assistance Services PRN: Pro re nata SN: Supervising Nurse W: Week Wk: Week

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to include skilled professionals in their QAPI meetings in 6 out of 6 QAPI meetings over the last 3 years. Failure of the agency to have skilled professionals represented in the QAPI program resulted in missed opportunity for the employed Registered Nurses to provide clinical input on best practices and contribute to improving client care. Findings included: Review of document titled “Quarterly Performance Improvement Meeting,” dated 04/18/2022, revealed that attendees included the Administrator and the PAS Coordinator/Supervisor. An attendant did not attend this meeting. Review of document titled “Organization Budget and Activities,” dated 04/25/2022, revealed that attendees included the Chief Financial Officer, Chief Executive officer, Director of Clinical Operations, Vice President, and previous administrator. A nurse did not attend this meeting. Review of document titled “Quarterly Performance Improvement Meeting,” dated 04/20/2023, revealed that attendees included the Administrator and the PAS Coordinator/Supervisor. A nurse did not attend this meeting. Review of document titled “Quarterly Performance Improvement Meeting,” dated 10/13/2023, revealed that attendees included the Administrator, Attendant A, and the PAS Coordinator/Supervisor . A nurse did not attend this meeting. Review of document titled “Quarterly Performance Improvement Meeting,” dated 04/08/2024, revealed that attendees included the Administrator and the PAS Coordinator/Supervisor. A nurse did not attend this meeting. Review of document titled “Quarterly Performance Improvement Meeting,” dated 10/07/2024, revealed that attendees included the Administrator, Attendant A, and the PAS Coordinator/Supervisor . A nurse did not attend this meeting In an interview with the administrator at 2:25 PM on 3/17/25, the administrator asked Surveyor B if the Supervising Nurse had to be in-person at the QAPI meetings. Surveyor B asked the administrator if the Supervising Nurse had called in by phone for the meetings. Administrator did not answer the question but stated he “discussed everything” with the Supervising Nurse. Supervising Nurse/s name was not on the attendance list at this time. In an interview with the administrator and PAS Coordinator on 3/20/25 at 1:52 PM., Surveyor went through all documented QAPI meetings for the last 3 years and had administrator and coordinator confirm the signatures on attendance sheets. Administrator and Coordinator reported that the people who attended the meetings held the positions listed above. Surveyor showed Administrator and PAS Coordinator the agency’s QAPI policy indicating requirements for meetings. Administrator reported that the coordinator also performs the role as supervisor for attendants. Surveyor A asked why the attendant did not attend the QAPI meetings. Administrator stated she is often busy taking care of patients and unable to come to the agency for the meetings. Surveyor A asked why the Supervising Nurse did not attend the meetings. Administrator stated the Supervising Nurse lives in a different city, but that he is updated on the content of the meetings. He stated he did not think the Supervising Nurse needed to be there because they are not currently providing skilled nursing services to any patients. Surveyor B asked how not including all necessary parties at the QAPI meetings could impact client care. Administrator reported that he did not think it impacted client care because they talk to the team every day. In a record review of agency policy titled, “Quality Assessment Performance Improvement Plan”, undated, the document read, “The QAPI Committee will consist of, at a minimum, the Administrator, Supervisor, representation from disciplines providing services.”

An Entrance Conference was conducted on 04/04/2022 with Service Coordinator, PHC Supervisor and by telephone the Administrator at 12:24 p.m. The agency representatives were informed that the purpose of the visit was a recertification survey and a follow up the survey completed 06/14/2019. Written information regarding "What To Expect During Your Agency's Survey" was provided. The agency census was: Austin (Parent): L&CHHS- 0, LHHS-0, PAS-19 An Exit Conference was conducted on 04/06/2022 with Service Coordinator, PHC Supervisor and Administrator at 12:25 p.m. The agency representative was advised the agency was in substantial compliance with all applicable 42 CFR, Chapter IV, Part 484 Home Health Services Conditions of Participation for Emergency Preparedness.

An Entrance Conference was conducted on 4/4/2022 with Service Coordinator, PHC Supervisor and by telephone the Administrator at 12:24 p.m. The agency representatives were informed that the purpose of the visit was a recertification survey and a follow up the survey completed 6/14/2019. Written information regarding "What To Expect During Your Agency's Survey" was provided. The agency census was: Austin (Parent): L&CHHS- 0, LHHS-0, PAS-19 An Exit Conference was conducted on 4/6/2022 with Service Coordinator, PHC Supervisor and Administrator at 12:25 p.m. The preliminary findings of the survey were discussed. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions for submitting a plan of correction within 10 days of receipt of the Statement of Deficiencies and procedures for requesting an Informal Review were provided. Abbreviations: L&CHHS- Licensed and Certified Home Health Services LHHS- Licensed Home Health Services PAS- Personal Assistance Services PHC- Primary Home Care POC- Plan of Care SN- Skilled Nursing PT- Physical Therapy OT- Occupational Therapy QAPI- Quality Assessment Performance Improvement

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 Supervising Nurse failed to ensure that care was provided according to a patient's needs as written in the POC for five of seven discharged patients (Patients #2, #3, #5, #6 and #7) whose clinical records were reviewed, in that: Patient #2 did not receive Skilled Nursing visits as ordered in the POC. Patient #3 did not receive Skilled Nursing visits as ordered in the POC. Patient #5 did not receive Skilled Nursing and Occupational Therapy visits as ordered in the POC. Patient #6 did not receive Physical Therapy visits as ordered in the POC. Patient #7 did not receive Physical Therapy as ordered in the POC. This failure had the potential to place the agency patients at risk of not having their needs met and had the potential to result in negative patient outcomes. Findings Include: 1. Review of the clinical record for Patient #2 revealed a POC dated 01/03/2020 to 03/02/2020. The POC read in part: “Orders and Treatments: SN 2w9 (two times a week for 9 weeks). Further review of the clinical record revealed only one SN visit on 01/03/2020 for the week of 01/03/2020. The clinical record did not contain documentation as to why the second visit was not done for the week of 01/03/2020. 2. Review of the clinical record for Patient #3 revealed a POC dated 01/15/2020 to 03/14/2020. The POC read in part: “Orders and Treatments: SN 3w9 (three times a week for 9 weeks). Further review of the clinical record revealed only two SN visits on 01/15/2020 and 01/17/2020 for the week of 01/15/2020. The clinical record did not contain documentation as to why the third visit was not done for the week of 01/15/2020. 3. Review of the clinical record for Patient #5 revealed a POC dated 12/31/2019 to 02/28/2020. The POC read in part: “Orders and Treatments: SN 1w9 (one time a week for 9 weeks). Further review of the clinical record did not reveal a SN visit for the weeks of 02/02/2020 or 02/09/2020. The clinical record did not contain documentation as to why SN visits were not completed for those weeks. The clinical record contained an order for OT dated 01/22/2020 which read in part: “effective 01/22/2020 frequency 1w1, 3w2 (one time a week for one week, three times a week for 2 weeks). The clinical record did not contain documentation of OT visits for the weeks of 01/26/2020 or 02/02/2020. The clinical record did not contain documentation as to why OT visits were not completed for those weeks. 4. Review of the clinical record for Patient #6 revealed a POC dated 01/18/2020 to 03/17/2020. The POC read in part: “Orders and Treatments: PT 1wk4 (one time a week for 4 weeks). Further review of the clinical record revealed PT was provided 2wk2, 1wk1 (two times a week for two weeks, then one time a week for one week. The clinical record did not contain additional orders for PT. 5. Review of the clinical record for Patient #7 revealed a POC dated 01/23/2020 to 03/22/2020. The POC read in part: “Orders and Treatments: PT eval and treat. Further review of the clinical record did not reveal a Physical Therapy evaluation or documentation as to why the evaluation was not completed. 6. During an interview with the Supervising Nurse on 04/05/2020 at 1:45 p.m. these findings were reviewed. The Supervising Nurse stated he would review the patient records for documentation as to why visits were not completed 7. During an interview with the Supervising Nurse on 04/06/2020 at 10:59 a.m. the Supervising Nurse stated missed visit documentation was not in the clinical records for Patients #2, #3, #5, #6 and #7. Supervising Nurse stated documentation should have been in the communication section of the clinical record, or a missed visit note completed. Supervising Nurse stated it was hard to speculate as to why visits were not done, and stated he was unsure if this failure would affect care due to not knowing why the visits were missed. 8. Review of the agency policy and procedure manual revealed a policy entitled “Orders for Skilled Care, revised 080116.” The policy read in part: “The agency will obtain orders and provide care in accordance with physician’s orders…”

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to maintain documentary evidence of the agency’s quality assessment and performance improvement (QAPI) documents for 2019, 2020 and 2021. This failure placed the agency out of compliance to ensure the QAPI documentations were made available for review by the surveyor, to ascertain the agency's compliance with the established standards of client care and safety. Refer to G 642

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to maintain documentary evidence of the agency’s quality assessment and performance improvement (QAPI) documents for 2019, 2020 and 2021. This failure placed the agency out of compliance to ensure the QAPI documentations were made available for review by the surveyor, to ascertain the agency's compliance with the established standards of client care and safety. Findings Include: 1. During the entrance interview on 04/06/2022 at 12:24 pm, this surveyor requested QAPI documents/ meeting minutes for the years 2019, 2020 and 2021. 2. During an interview with the Administrator on 04/05/2022 at 1:30 p.m., the Administrator stated he had checked with the external storage facility and had been unable to find the requested QAPI documents. The Administrator stated with the move in January 2022 he was unsure where the binders are. Administrator stated they are checking a storage office in San Antonio. 3. During an interview with the Administrator on 04/06/2020 at 10:59 a.m., the Administrator stated he could not locate the QAPI meeting minutes for the years 2019, 2020 and 2021. The Administrator stated the missing documents could potentially pose a risk to clients due to the lack of having data to compare previous years, but stated currently the agency has had no complaints, infections or staffing issues. 4. Review of the agency policy and procedure manual revealed a policy entitled “Quality Assessment Performance Improvement Plan” revised 100116. The policy read in part: “VII. QAPI documents will be kept confidential. The QAPI program will be made available to Texas Health and Human Services staff.”