Every finding on record at Three of A Kind Inc

A complaint survey was initiated on 5/12/2023. The census was: LCHH-150 LHH-0 PAS-107 Total agency census: 257 Intakes: 310235, 383375, 383779 Abbreviations LCHH-Licensed and Certified Home Health LHH-Licensed Home Health PAS-Personal Assistant Services RN-Registered Nurse HHA-home health aide EMR-employee misconduct registry NAR-nurse aide registry HHSC-Texas Health and Human Services Commission

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to furnish home health aide services in conformance with physician orders in 1 (Patient #1) of 3 charts reviewed. This failure placed the patient at risk of not receiving the ordered care and services to achieve the patient goals and addressing the patient’s healthcare needs. Findings include: Patient #1: The chart included a plan of care for the episode 8/12/22 through 10/10/22 with a start of care date of 8/17/21 signed and dated by RN A on 8/12/22. The plan of care included diagnosis of Other specified myoneural disorders (lower motor neuron disease), primary lateral sclerosis (a rare neuromuscular disease), chronic fatigue (extreme tiredness lasting more than 6 months), and muscle wasting and atrophy (weakening, shrinking, and loss of muscle tissue). The plan of care included orders for physical therapy effective 8/21/22 for 1 time a week for 1 week followed with 2 times a week for 6 weeks, occupational therapy 1 time a week for 1 week, 2 times a week for 5 weeks and 1 time a week for 3 weeks, home health aide effective 4 times a week for 1 week, 3 times a week for 6 weeks and 1 time a week for 1 week. The chart included evidence of a visit on 8/22/23 with no further documented notes by HHA B for the week of 8/21/22. The HHA failed to follow the frequency of 4 times in the first week. An interview was conducted on 5/15/23 at 12:11 pm with HHA B. The surveyor reviewed the above findings and asked HHA B why she failed to follow the frequency ordered for 4 times in the first week. HHA B said, “I was never told to see the Patient #1 4 times in a week.” An interview was conducted on 5/15/23 at 12:45 pm with the Administrator/Supervising Nurse. The surveyor reviewed the above findings and asked the Administrator/Supervising Nurse why HHA B failed to follow the plan of care frequency for the home health aide visits. The Administrator/Supervising Nurse said, “The visits were not scheduled” The Administrator explained that the agency was in the process of changing from one software system to another and RN A (ex-employee/ Administrator/Supervising Nurse) failed to complete her recertification in the new system, therefore the visits were never scheduled. Agency policy PC.30 Orders for Care last reviewed 11/2/2020 read in part…” Purpose To ensure patient/client care is provided in accordance with a physician and/or non-physician practitioner order and federal and state laws and regulations. Policy The Agency will obtain orders and provide care in accordance with physician’s and/or non-physician practitioner’s orders”…

04/03/2023 Amended Statement of Deficiencies. A federal on-site investigation was conducted for Intake 410174/Incident 96700 on 03/09/2023. Licensed & Certified census was 231. Acronyms/Abbreviations: Adm-Administrator Alt Adm-Alternate Administrator DON-Director of Nursing Alt DON-Alternate Director of Nursing (Alternate Supervising Nurse) EHR- Electronic Health Record Registered Nurse (RN) POC- Plan of Care SN/SNV- Skilled Nursing/Visit PT-Physical Therapy MD-Medical Doctor PRN-Pro Re Nata/As Needed Wound Vac-Wound Vacuum Approx.-Approximately

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on record review and interview, the Clinical Manager failed to coordinate patient care and services to ensure the effective exchange of information, reporting, and coordination of patient services among all agency personnel providing care and services for two (Patients # 2 and # 4) of three patients records reviewed with an allegation of neglect and lack of coordination of services. The failure could place the patients at risk to not have health care needs met and at risk of lack of physician oversight in their ordered treatment and services. FINDINGS INCLUDED: During on on-site investigation for allegations of neglect the surveyor reviewed the agency’s complaint/ incident records. Review of the complaint/incident records a revealed complaint/incident form/report for Clients # 2 and # 4. The surveyor reviewed a random selection of agency complaints from January 2022 through March 2023. Review of the complaint/incident records revealed the following for Patient # 2: A “Patient Complaint Form” for Patient # 2, signed by PT/Former Interim Adm and dated 01/28/2022. The complaint form listed the “date complaint received” as 01/28/2022. The complaint form read in part: “…Patient reports calling our office number to report an issue [with the patient’s] wound vac. The answering service forwarded the message to the on call service, but the on call admin did not return the call that evening. [Patient] reports paying for a private SN to fix the wound vac. [Patient] called the office to [complain of] poor communication/response from our company…Admin called the next morning to apologize and reassure [patient] that we will work to improve communication…” Patient Record # 2: Review of Patient# 2's EHR did not reveal a POC. Continued review of the record revealed a “SN Assessment” dated 01/14/2022 and signed by RN F. The assessment had a start of care date of 01/14/2022 for treatment period of 01/14/2022 to 03/14/2022. The assessment contained “Orders for Discipline and Treatments” that included orders for SN visits for two times per week for one week, three times per week for eight weeks and one time per week for eight weeks (for wound care with wound vac changes). Further review of Patient # 2’s record revealed two missed visit notes dated 01/21/2022 and 01/26/2022 and signed by RN B. The missed visit notes listed the reason for the missed visits as “scheduling error.” The last wound care SN visit note with wound vac change was dated 01/19/2022 and signed by LVN A. Review of the complaint/incident records revealed the following for Patient # 4: A “Patient/Employee Occurrence/Incident Report” for Patient # 4, signed by the Adm/DON and dated 03/07/2023. The report listed a “Date of Occurrence/Event” as 02/14/2023 and the date the agency was notified of the incident as 03/02/2023. The report read in part: “…[Family member] stated [PT/Former Interim Adm] saw [Patient# 4] on 02/14/2023 and he texted [family member(s)] that [Patient# 4] had an elevated [blood pressure]...[PT/Former Interim Adm] noted [blood pressure 190/104…PT/Former Interim Adm] left message [with] nurse (RN C), thinking nurse would see patient same day. [Family member] sent [patient] to hospital approx. 6pm on 2-14-23 [with] unresponsive episode…” Patient # 4: Review of Patient# 4’s EHR revealed a POC with a start of care date of 02/10/2023 for skilled nursing services. The POC had a treatment period of 02/10/2023 to 04/10/2023 and was signed by the Adm/DON and PT/Former Interim Adm and dated 02/10/2023. The POC included orders for SN visits one time per week for one week, effective 02/14/2023. The POC also included orders for PT visits one time per week for one week, two times per week for three weeks, and one time per week for five weeks. Continued review of Patient # 4’s record did not reveal that the agency had coordinated care and services with the physician (Identifier 200) an elevated blood pressure on 02/14/2023 or with the agency. Further review of Patient # 4’s record revealed a “Patient Information Report” that read in Part: “…2/14/2023…Pt had elevated blood pressure today. 190/104…Nursing was notified of patient status to follow-up during their assessment scheduled for this afternoon…” There were no records that indicated nursing received the message or followed up on Patient # 4’s elevated blood pressure. During an interview on 03/09/2023 at approximately 2:30 p.m. with the Adm/DON and PT/Former Interim Adm, via telephone, the surveyor discussed the above findings and asked the agency why had not enforced it’s written policy to coordinate and document care and services for Clients # 2 and # 4’s. The Adm/DON stated that RN C did not make the visit because she was “calling to schedule the visit” with Patient # 4’s family member and did not get an answer.” The Adm/DON also stated that there was no direct phone conversation between the PT/Former Interim Adm and RN C. For Patient# 2 the Adm/DON stated that the incident occurred before her hire date. Review of agency policy titled “Monitoring Patient Care/Coordination of Care PC.45” last reviewed 060106 read in part: “Purpose To ensure patient/client care/treatment is monitored for the patient’s/client’s response to the care/treatment. Policy I. The Agency will monitor, evaluate and report, as needed to the patient’s/client’s physician, regarding the patient’s/client’s progress toward achieving goals established on the plan of care…Procedure…V. The Agency staff are expected to contact the Agency to inform of patient/client needs and changes. This will be documented on a communication note and will serve as coordination of care.”

Purpose of Visit: Re-certification Survey. Entrance Date: 10/21/2021 An entrance conference was conducted with the Administrator at at 11:50 a.m. The Administrator was informed that the purpose of the survey was for a 36-month recertification survey. The Administrator was provided with the HHS handout, "What to expect during your agency survey." Agency census: Licensed and Certified Home Health - 226 Licensed Home Health - 0 Personal Assistance Services - 0 Exit Date: 10/28/2021 An exit conference was conducted at 3:30 p.m. with the Alternate Administrator, Employee B and the Clinical Manager, Employee D. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional information. Additional information was not provided. Written instructions were provided to the agency for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. The agency was in compliance with 42 CFR part 484.22, Emergency Preparedness Requirements for Home Health Agencies.

Purpose of Visit: Re-certification Survey. Entrance Date: 10/21/2021 An entrance conference was conducted with the Administrator at at 11:50 a.m. The Administrator was informed that the purpose of the survey was for a 36-month recertification survey. The Administrator was provided with the HHS handout, "What to expect during your agency survey." Agency census: Licensed and Certified Home Health - 226 Licensed Home Health - 0 Personal Assistance Services - 0 Exit Date: 10/28/2021 An exit conference was conducted at 3:30 p.m. with the Alternate Administrator, Employee B and the Clinical Manager, Employee D. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional information. Additional information was not provided. Written instructions were provided to the agency for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. Abbreviations: POC - plan of care SOC - start of care EMR - electronic medical record NOMC - Notice of Medicare Non-Coverage CMS - Centers for Medicare and Medicaid Services

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide the NOMNC written notice at least two days in advance of terminating on-going care in 1 (Patient #8) of 3 discharged records reviewed whose reason for discharge was goals met. The failure of the agency to protect the rights of the patient by informing in advance of their right to appeal the discontinuation of home health services prevented the identified patient from exercising their right to appeal the discharge decision, if they chose to appeal. Findings include: DISCHARGED PATIENT 8: Record review of the EMR contained a POC dated 04/07/2021-06/06/2021 with a SOC date of 04/07/2021. The EMR contained the CMS form titled, "Notice of Medicare Non-Coverage." The form read in part, " ...The effective date coverage of your ...services will end: 05/20/2021 ..." The form was signed and dated by Patient 8 on the discharge date of 05/20/2021. The record failed to contain any documentation that patient had been notified in advance that services would be ending and provided with the NOMNC with instruction on how to appeal the discharge decision. During an interview with the Alternate Administrator, Employee B, on 10/27/2021 at approximately 2:19 p.m., the surveyor asked why the NOMNC for Patient 8 was dated the same day as discharge. Employee B stated, “I don’t know.” The Agency policy titled "Patient/Client Transfer and Discharge Notices ...PE.6" read in part: "Purpose ...To provide guidance on completion of the required transfer and discharge notices ...Policy ...I. Prior to transferring or discharging a patient/client, the Agency will provide written notification to the patient/client or the patient's/client's parent, family, spouse, significant other or legal representative, and will notify the patient's/client's attending physician or practitioner if he or she is involved in the Agency's care of the patient/client. Notification will be provided in accordance with state and federal regulations ...III. The Agency will deliver the Notice of Medicare Non-Coverage ...to the patient/client ...at least two (2) calendar days before Medicare covered services end or the second to last day of service if care is not provided daily ...Procedure ...II. Notice of Medicare Non-Coverage (NOMNC) ...A. Agency staff will provide valid delivery notice (involves both delivery and completion) of the NOMNC to the patient/client (or their representative) when the end of all covered care is foreseen, even if the patient/client agrees with the discharge. B. At least two (2) calendar days before Medicare covered services end or the second to last day of service if care is not provided daily, the Agency representative will provide the NOMNC to the patient/client (or legal representative) when provided the five (5) day notice of discharge. C. If the Agency fails to give valid notice, patient/client coverage continues for at least two (2) days after the notice is received ...I. The agency will have the patient/client (or their representative) sign and date two copies, keep one, and return a copy to the Agency

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, policy and procedure review, and interviews, the agency failed to ensure each patient received home health services that were written in an individualized plan of care that identified patient-specific measurable outcomes and goals in that 2 (Patient #5 and #6) of 7 active patient charts reviewed there was no plan of care. Findings include: Patient #5 Review of the Agency's Active Patient list revealed Patient #5 with an "SOC" of "08/05/2021". Review of the Patient #5 record indicated an episode from 08/05/2021 through 10/03/2021. The clinical record failed to include a plan of care had been established for the certification period of 08/05/2021 - 10/03/2021. Review of the record revealed 5 skilled nursing visits were conducted for visits dated 08/05/2021, 08/11/2021 and 09/29/2021 signed by RN E, 09/06/2021, signed by LVN G and 09/26/2021 signed by LVN F. Patient #6 Review of the Agency's Active Patient list revealed Patient #6 with an "SOC" of "08/06/2021". Review of the Patient #6 record indicated an episode from 08/06/2021 through 10/04/2021. The clinical record failed to include a plan of care had been established for the certification period of 08/06/2021 - 10/04/2021. Review of the record revealed skilled nursing visits were conducted on the following dates: 08/06/2021 and 09/30/2021 signed by RN E, 08/13/2021, 08/20/2021, and 09/30/2021 signed by LVN H, 08/27/2021 signed by LVN I, 08/29/2021 signed by RN J and 09/06/2021, 09/10/2021 and 09/17/2021 signed by LVN G. An interview was conducted via phone on 10/26/2021 at 10:35 a.m., the surveyor reviewed the above findings with Vice President of Clinical Operations, Employee C and Clinical Manager, Employee D. The surveyor explained that Patient #5’s and #6’s clinical record failed to include a plan of care, therefore the nurses were providing care without orders. Employee C said, “You are correct.” Employee C and Employee D did not dispute the findings. Agency Policy PC.8 Plan of Care revised 11/01/2020 read in part…”Purpose to ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems…Procedure I. The appropriate licensed professional staff member, with physician and/or physician practitioner participation is responsible for developing the plan of care within three (3) to five (5) days of the initial assessment…”