Deficiency Index

Every finding on record at Unlimited Healthcare Provider LLC

Desoto, Texas · CCN 747519

3 findings across 1 survey, in the inspector's own words.

The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.

Survey of July 7, 2023

3 findings
E0000

A recertification survey was conducted on 06/30/2023. The census was 0 Licensed and Certified patients. An exit conference was conducted on 7/07/2023.

G0000

A recertification survey was conducted on 06/30/2023. The census was 0 Licensed and Certified patients. An exit conference was conducted on 7/07/2023.

G0446

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients’ right to be advised of the contact information for the following Federally - funded and state-funded entities: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. The failure placed patients at risk of missing out on resources in the area that might assist them in maintaining their health and well- being and to be able to appeal discharge decisions by the agency. Review of the undated sample patient admission folder provided by the Administrator on 07/06/2023 at 1:15 PM revealed no information for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center. The review found an outdated and incorrect phone number for the Quality Improvement Organization. During an interview with the Administrator 07/07/2023 at 3:30 pm the surveyor reviewed the findings of the review of the sample admission folders provided by the Administrator. The surveyor asked why the admission folders did not contain the required federally - funded and state - funded resources contact information. The Administrator stated that they did not have the lists of the resources. The Administrator stated: “I should have pulled and updated the forms from the Policy Provider AA and updated the admission packets.” The surveyor asked why the Quality Improvement Organization contact information had not been updated. The Administrator stated: “It was an oversight.” Review of the agency policy titled: “Rights and Responsibilities RI.5” dated 11/16/2022 read in part: Purpose – To ensure all patients/clients, representatives (if any), and agency staff acknowledge, observe, and implement the patient’s/client’s rights and responsibilities… Agency staff will be responsible for knowing, observing, and implementing the patient’s / client’s rights … The Patient / Client has the right to: … Be advised of the names, addresses, and telephone numbers of the following federally funded and state-funded entities that serve the area where the patient/client resides: Area on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, Quality Improvement Organization…”

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Federal survey findings only. State licensure findings for home health agencies are not shown.

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