Every finding on record at Tx Prestige Home Health, Incorporated

Purpose of the visit: Recertification survey. Entrance conference date 07/22/2025 The census was 11. 9 Licensed and Certified, 0 Licensed Home Health, and 2 Personal Assistance Services clients. Purpose of the visit: Recertification and dropped deemed survey. The agency was in substantial compliance with the emergency preparedness conditions of participation.

Purpose of the visit: Recertification survey. Entrance conference date 07/22/2025. The census was 11. 9 Licensed and Certified, 0 Licensed Home Health, and 2 Personal Assistance Services clients. Abbreviations: HHA – Home Health Agency IQIES - Quality Improvement Evaluation System CMS – Centers for Medicare and Medicaid Services OASIS – Outcome and Assessment Information Set QAPI – Quality Assurance Performance Improvement PIP- Performance Improvement Project DON – Director of Nurses / Supervising Nurse PAS – Personal Assistance Services POC- Plan of Care RN – Registered Nurse PICC (Peripherally Inserted Central Catheter HHA- Home Health Agency COC / COS- Coordination of care / Coordination of Services

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 HHA failed to encode and electronically transmit 19 of 117 (16 percent of assessments submitted over the previous 12 months) completed OASIS assessments to the CMS system within 30 days of completing the assessment of the beneficiary (patient). This failure meant the agency and CMS was unable to evaluate timely outcomes of care provided by the agency and potentially subjected patients to poor health outcomes and a lack of quality care. Review of the agencies HHA error summary report (produced by CMS for all certified agencies nationwide after agencies submit patient assessment data) for 07/01/2024 to 07/2102025 on 07/22/2025 revealed 19 of the 117 assessments processed were submitted late (CMS defines this as more than 30 days after the date of the assessment.) During the entrance conference the surveyor reviewed the late submission date error report findings with the Administrator on 07/22/2024 at 12:20PM. The Administrator / DON stated “When we got certified we had to resubmit assessments. The surveyor asked when the agency was recertified. The Administrator / DON stated in 2019. The surveyor explained the report findings only included July 2024 to July 2025 - only the last 12 months assessments. The surveyor asked the Administrator / DON to describe the OASIS procedures for the agency. The Administrator /DON stated: “the nurse or therapist has at least 5 days to complete (the assessment), the DON reviews, then we export after any changes needed are made.” The surveyor asked who was responsible for exporting the completed OASIS assessments. The Administrator/DON stated that he “does the export.” The surveyor asked how often the Administrator/DON exported OASIS assessments. The Administrator / DON stated: “at least once a week, and we export when they (the assessments) are finished.” The surveyor asked why 16 percent were submitted late, more than 30 days after completion. The Administrator stated he was “kind of surprised.” The surveyor asked if the agency reviewed OASIS transmission as part of QAPI. The Administrator stated they used a contractor for QAPI and that “yes, sometimes” the agency reviewed the OASIS transmission information. The surveyor asked for OASIS policy and procedures, the validation reports (completed after submission of the OASIS, and any other information the Administrator had regarding the late transmissions. The Administrator stated he would provide whatever he could to explain anything he might remember to explain the findings. The surveyor asked how this failure affected the agency. The Administrator stated: “our reimbursement goes down, and it takes away from where we need to be which is focus on the patient.” On July 24,2025 the surveyor reviewed a white three ring binder with the validation reports (reports generated by CMS after submission of the OASIS data) provided by the administrator. The binder contained 4 validation reports. Two of the four were submitted more than 30 days after completion of the OASIS assessment. One for Patient #1 documented the date of completion of the OASIS assessment was 03/21/2025 and the date of submission to CMS was 05/29/2025. The second for Patient #2 documented the date of completion of the OASIS assessment was 05/03/2025 and the date of submission to CMS was 07/15/2025. Both validation reports included the warning error 3330 (Record submitted late: The submission date is more than 30 days after M0090). During an interview on 07/24/2025 at 11:47 AM with the Administrator/DON and the Office Manager / RN/ previous DON A the surveyor asked about the 2 examples of recent validation reports with late transmissions to CMS. The Administrator stated if “there is a mistake on the documentation or maybe something that we have to reopen some assessment and make an update, it makes the date submitted late.” The Administrator stated the software the agency was using was not catching all the areas were not completed (by the practitioner during the assessment) and allowed the first submission (that was incomplete) to be transmitted to CMS. Then later when the assessment was rejected by CMS, and when corrections were made the date submitted was recorded as late. Agency policy titled “Timelines IM.35… last reviewed:070125” read in part: “Policy -The Agency will ensure timely provision of care and services to meet the patient’s/client’s needs in compliance with all federal and state laws and regulations… All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set and the CMS assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with the Federal Information Processing Standard (FIPS 140-2, issued May 25, 2001) from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date” (the date the assessment was completed.)

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (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 HHA failed to assure communication with all physicians or allowed practitioners involved in the plan of care to ensure the effective exchange of information, reporting, and coordination of care with all service providers involved in the care of a patient for 1 (Patient 3) of 2 discharged records. The agency failed to assure communication with Patient 3’s wound care practitioner. This failure placed the Patient at risk of duplicate or missing care and poor outcomes. Review of Patient 3’s POC revealed diagnoses of: Osteomyelitis of Right Foot and Ankle (infection of the bone and surrounding tissues), Methicillin Resistant Staphylococcus Aureus Infection (infections caused by a type of bacteria that are resistant to many common antibiotics making them harder to treat), Type 2 Diabetes Mellitus with Foot Ulcer (open sore or wound on the foot of a person with diabetes – a disorder of managing blood sugar), Encounter for Adjustment and management of Vascular Access Device (billing code for care of tubes inserted into blood vessels generally used to access blood for lab tests and deliver medications directly into the blood stream over weeks of time), Long Term Current Use of Antibiotics (treatment with medications to treat severe infections over weeks of time). The POC included orders for skilled nursing one time a week for 9 weeks and three visits as needed. Orders were for lab draws, administration of Intravenous medication if patient or caregiver were unable, weekly dressing changes of the PICC (tube left in the body to allow for lab draws and administration of medications directly to the blood stream). The POC did not contain information or orders for wound care for the infected foot and ankle. Review of Patient 3’s start of care assessment dated 06/11/2024 and signed by the Administrator / DON documented Patient 3 had a wound on the Right foot covered with a dressing. The Administrator / DON documented Patient 3 was seen by a wound care provider. No evidence of coordination of services with the wound care provider were found in the review of the patient’s record. No name or information for the wound care provider were found in the review of the patient’s record. Review of Patient 3’s discharge summary dated 09/10/2024 and signed by the Administrator / DOC documented the patient’s admission problem was osteomyelitis of his right foot and Patient 3 received care for his PICC line and IV medications. The infectious disease doctor sent the orders to us for the PICC care and lab draws. There was no coordination of services with a wound care practitioner was found on the discharge summary and no outcome for Patient 3’s infection of the right foot. Further review of Patient #3’s record revealed no communication notes that served as coordination of care from the wound care provider. An interview was conducted with the Administrator / DON on 02/24/2025 at 2PM. The surveyor shared the findings of the record review for Client 3. The surveyor asked about the agency policy for coordination of services with other providers involved in the client’s care. The Administrator / DON stated they didn’t do any coordination with the wound care provider, and he wasn’t sure the name of the wound care provider. The Administrator / DON stated the agency was referred to provide PICC line care by the infectious disease doctor with the infusion company providing the supplies and were not providing wound care. The surveyor asked who was responsible to coordinate care and the Administrator / DON stated he was as he admitted the client and provided the care. The Administrator /DON stated he understood now the need to coordinate with the wound care center to ensure the client was cared for. Agency policy titled: “Monitoring Patient / Client / Coordination of Care PC.45 … Last Reviewed 05012024” read in part: Policy I. The Agency will monitor, evaluate, and report to the patient’s/client’s physician and/or nonphysician practitioner regarding the patient’s/client’s progress toward achieving goals established on the plan of care. II. The Agency will collaborate with other organizations providing services (i.e., medical equipment, other home health agencies, out-patient clinics, etc.), the patient/client, and their representative (if applicable) to ensure appropriate coordination of care. Procedure I. The Agency will: A. Assure effective communication with all physicians and/or non-physician practitioners involved in the plan of care. B. Integrate orders from all physicians and/or non-physician practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient/client. C. Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient/client needs and factors that could affect patient/client safety and treatment effectiveness and the coordination of care provided by all disciplines. D. Coordinate care delivery to meet the patient’s/client’s needs, and involve the patient/client, representative, and caregiver(s), as appropriate, in the coordination of care activities. E. Ensure that each patient/client, and the caregiver(s) where applicable, receive ongoing education and training provided by the Agency, as appropriate, regarding the care and services identified in the plan of care. The Agency must provide training, as necessary, to ensure a timely discharge. II. When other organizations are involved in the patient’s/client’s care, agency staff members will notify them of significant changes in the patient’s/client’s overall care. This communication will be documented in the medical record. III. Agency staff are expected to contact the Agency to report patient/client needs and changes. This will be documented on a communication note and will serve as coordination of care. IV. Skilled professionals who provide services to agency patients/clients directly or under arrangement.”

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to conduct Performance improvement projects for 2 (2022 and 2024) of three years of the survey review period. The HHA failed to document the quality improvement projects undertaken for 2022 and 2024, the reasons for conducting projects, and the measurable progress achieved on projects. This failure meant the agency was unable to use performance improvement projects to document improvements undertaken to correct identified problems and, if necessary, to revise policies. Patients were potentially subjected to poor quality care. During the entrance conference on 07/22/2025 the surveyor requested all QAPI documents including the Performance Improvement Projects for 2022, 2023, and 2024. Review of the white three ring binder that was undated provided by the Administrator on 07/22/2025 revealed only one PIP completed in 2023 and no PIPS for 2022 and 2024. The surveyor requested PIPS on 07/24/2025. No other PIPs were provided by the end of the survey. During an interview with the Administrator / DON and the Office Manager / Previous DON A on 07/24/2025 at 2PM. The surveyor clarified the Office Manager / Previous DON A was the DON for the agency in 2022, 2023, and 2024. The surveyor asked about the agency’s PIPs for 2022 and 2024. The Office Manager / previous DON reviewed the binder documents that the Administrator had provided to the surveyor and stated: “I only see one (PIP) for 2023.” The Administrator stated they had not done any others for 2022 and 2024. The surveyor asked about the agency’s PIP policies and procedures. The Administrator stated they used a consultant to review records, and they hadn’t done the PIPs. The surveyor asked who was responsible for the QAPI program. The Administrator stated he was responsible. The surveyor asked about the effect of not doing the PIPS on the agency services to the patients. The Administrator stated they should be doing them to improve services. Agency policy titled “Performance Improvement Process: Improvement Activities QAPI.25 … last reviewed: 050124” read in part: “Purpose To establish a standard for achieving and sustaining improved performance. Policy I. The Governing Body will be responsible for setting the priorities for improvement activities or projects based on Agency functions, the defined data collection, the resources required to facilitate the improvement, and the organization's mission. II. The Governing Body will determine the number and scope of distinct Performance Improvement Projects (PIP) conducted annually… All performance improvement activities/projects undertaken will be documented and include the reasons for conducting and the measurable progress achieved. “