Every finding on record at V-Care Home Health Inc

A recertification survey was conducted on 8/11/2023. The census was 152. 152 Licensed and Certified patients and O Licensed Home Health patients. An exit conference was conducted on 8/28/2023. The agency was in compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted on 8/11/2023. The census was: 152 Licensed and Certified patients and O Licensed Home Health patients. An exit conference was conducted on 8/28/2023. Abbreviations: DON – Director of Nurses POC – Plan of care RN – Registered Nurse LVN – Licensed Vocational Nurse NP – Nurse Practitioner IV- Intravenous SOC – Start of Care SN-Admit – Elite Care Physician’s Skilled Nurse Admission

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to include a description of the patient's risk for emergency department visits and hospital re-admission on the Plan of Care for 7 (Patient 2,3,4,5,6.7, and 8) 10 of active patients and 3 (9,10, and 11) of 4 Discharged patients. The failure to include all the required information on the plan of care meant the patients were subjected to an increased risk for emergency care and hospitalization when the agency failed to identify and mitigate the patients’ risk factors. A review of the Plan of Care for Patient 2 revealed a start of care of 06/26/2023 and a certification period of 06/26/23 to 08/24/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. On 08/10/23 the patient reported suicidal thoughts to the Physical therapist during a therapy visit. A review of the Plan of Care for Patient 3 revealed a start of care of 05/25/2023 and a certification period of 05/25/23 to 07/23/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. A review of the Plan of Care for Patient 4 revealed a start of care of 01/12/2023 and a certification period of 05/12/23 to 07/10/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. A review of the plan of Care for Patient 5 revealed a start of care of 06/19/2023 and a certification period of 06/19/2023 to 08/17/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. A review of the plan of Care for Patient 6 revealed a start of care of 11/08/2022 and a certification period of 05/07/2023 to 07/05/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. A review of the plan of Care for Patient 7 revealed a start of care of 11/08/2022 and a certification period of 05/07/2023 to 07/05/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. A review of the plan of Care for Patient 8 revealed a start of care of 05/24/2022 and a certification period of 07/18/2023 to 09/15/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. A review of the plan of Care for discharged Patient 9 revealed a start of care of 06/16/20223 and a certification period of 06/16/2023 to 08/14/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. A review of the plan of Care for discharged Patient 10 revealed a start of care of 05/12/2023 and a certification period of 05/12/2023 to 07/10/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. Patient 10 was readmitted to the hospital on 05/15/2023 for complications from surgery. A review of the Plan of Care for Patient 11 revealed a start of care of 06/21/2022 and a certification period of 06/21/22 to 08/19/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. An interview was conducted with the Administrator and the Director of Nurses on 08/28/2023 at 11:00 AM. The surveyor reviewed the findings from the record reviews and asked why the plans of care for the patients failed to include the patient’s risks for emergency room visits and hospitalization. The Director of Nurses said she did not know why it wasn’t there. The DON stated: “We can have them (the nurses) put a statement in the box labeled ‘Other’ (on the POC). The surveyor asked how the review of the assessments and plans of care was conducted. The Administrator stated the assessments went through a “scrubber,” were reviewed by a contracted quality assurance reviewer who recommended changes back to the assessing RN who reviewed and made changes as needed. A review of the agency policy titled 4.4 Patient Reassessment dated 01/29/2020 read in part: “Each patient must receive the home health services that are written in an individualized plan of care … The individualized plan of care must include the following: … A description of the patient’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors…”

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on record review and interview the Clinical Manager failed to provide oversight of all patient care services and personnel. 1.The Clinical Manager failed to ensure compliance with the Nursing Assessment policy (which outlined all required items on the Plan of Care) for 7 (Patient 2,3,4,5,6.7, and 8) 10 of active patients and 3 (9,10, and 11) of 4 Discharged patients. 2. The policy for standards of practice for nursing services for 3 (Patient AA, BB, and CC) of 4 Contract Patient records reviewed. 3. The policy outlining the Patient Assessment Guidelines policy (which indicated timeliness of initiation of therapy services) for 2 of 4 (Patient 9 and 10) discharged client records reviewed who had orders for therapy services. These failures could affect all patients and place them at risk for harm when care is not provided timely, when qualified staff are not completing assessments, and are not performing client assessments. Nursing Assessment / Contents of the Plan of Care A review of the agency policy titled 4.4 Patient Reassessment dated 01/29/2020 read in part: “The Start of Care / Resumption of Care Comprehensive Assessment will be completed within 48 hours following a patient’s discharge from the hospital…. An RN or qualified individual may perform the reassessment for a significant change in condition… Each patient must receive the home health services that are written in an individualized plan of care … The individualized plan of care must include the following: … A description of the patient’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors…” A review of the Plan of Care for Patient 2 revealed a start of care of 06/26/2023 and a certification period of 06/26/23 to 08/24/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. On 08/10/23 the patient reported suicidal thoughts to the Physical therapist during a therapy visit. A review of the Plan of Care for Patient 3 revealed a start of care of 05/25/2023 and a certification period of 05/25/23 to 07/23/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. A review of the Plan of Care for Patient 4 revealed a start of care of 01/12/2023 and a certification period of 05/12/23 to 07/10/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. A review of the plan of Care for Patient 5 revealed a start of care of 06/19/2023 and a certification period of 06/19/2023 to 08/17/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. A review of the plan of Care for Patient 6 revealed a start of care of 11/08/2022 and a certification period of 05/07/2023 to 07/05/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. A review of the plan of Care for Patient 7 revealed a start of care of 11/08/2022 and a certification period of 05/07/2023 to 07/05/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. A review of the plan of Care for Patient 8 revealed a start of care of 05/24/2022 and a certification period of 07/18/2023 to 09/15/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. A review of the plan of Care for discharged Patient 9 revealed a start of care of 06/16/20223 and a certification period of 06/16/2023 to 08/14/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. A review of the plan of Care for discharged Patient 10 revealed a start of care of 05/12/2023 and a certification period of 05/12/2023 to 07/10/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. Patient 10 was readmitted to the hospital on 05/15/2023 for complications from surgery. A review of the Plan of Care for Patient 11 revealed a start of care of 06/21/2022 and a certification period of 06/21/22 to 08/19/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. An interview was conducted with the Administrator and the Director of Nurses on 08/28/2023 at 11:00 AM. The surveyor reviewed the findings from the record reviews and asked why the plans of care for the patients failed to include the patient’s risks for emergency room visits and hospitalization. The Director of Nurses said she did not know why it wasn’t there. The DON stated: “We can have them (the nurses) put a statement in the box labeled ‘Other’ (on the POC). [HC(3] The surveyor asked how the review of the assessments and plans of care was conducted. The Administrator stated the assessments went through a “scrubber,” were reviewed by a contracted quality assurance reviewer who recommended changes back to the assessing RN who reviewed and made changes as needed. Standards of Practice Review of agency policy 1.7 Responsibilities of the Director of Nurses dated 01/29/2020 read in part: The agency defines the responsibilities of the director of Nurses to include, but not be limited to: Participating in activities relevant to the services furnished, including development of qualifications and assignment of personnel … Coordinating and integrating care provided by Agency staff… Participating in activities relevant to professional services furnished including the development of qualifications and assignment of agency personnel…Ensuring a reassessment of a patient’s needs is performed by the appropriate healthcare professional: when there is a significant health status change in the patient’s condition…” Review of agency policy 4.3 Initial Patient Assessment / Patient Admission dated 01/29/2020 read in part: “Each patient will receive a patient specific, comprehensive assessment … completed by a Registered Nurse to determine the immediate care and support needs of the patient… A Registered Nurse and/or other professional disciplines will evaluate data/information gathered at the time of their initial assessment and consult with the patient’s physician to determine and approve the Plan of Care…” Review of agency policy 5.1 Standards of Practice dated 01/29/3030 read in part: The agency will provide patient care in accordance with the professional staff’s State Practice Act for acceptable standards of practice and as defined in the Agency’s policies and procedures… Patient care staff will adhere to the respective State Practice Acts and all policies and procedures established by Agency during patient visits. Review of Contract Client AA revealed a Skilled Nurse Start of Care assessment dated 08/23/23 by LVN F. The visit note titled: ECP-SN-Admit documented: “Patient SOC completed today…” Review of Contract Client BB revealed a Skilled Nurse Resumption of Care assessment dated 08/04/23 by LVN G who documented the patient was recovering from brain surgery and was resuming home health care post rehospitalization for complication with Chronic Obstructive Pulmonary Disease (lung disease that makes it difficult to breathe) and lung cancer. Review of Contract Client BB revealed a Skilled Nurse Reassessment for Recertification visit on 08/24/23 by LVN G. Review of Contract Client CC revealed a Skilled Nurse Start of Care assessment dated 07/20/23 by LVN G. The visit note titled: ECP-SN-Admit documented the patient was weak and had mobility issues due to multiple ankle replacement surgeries with infections following and the patient needed wound care. The schedule calendar for Client CC had LVN G scheduled for a Skilled Nurse Reassessment for Recertification on 09/15/2023. During an interview on 08/17/2023 at 5:30 PM Confidential RN B stated the agency was using LVN staff to admit clients, do the initial comprehensive assessments, asking LVNs to complete resumption of care post hospitalization, and recertification (comprehensive assessments every 60 days of care). RN B stated: The only RN who sees these clients is a nurse practitioner who has a video visit with some of the clients that often occurs after the LVN admits the clients for home health services. During an interview on 08/21/2023 at 1:56 PM Confidential LVN B stated: the agency had asked the LVN to do start of care admission and assessment visits when the client has come home from the hospital for certain insurance companies, and “I don’t like to do them. I am not used to that paperwork.” LVN B also stated: The agency asks the LVNs to upload a clinical summary and determine what kinds of disciplines and the frequency of nursing visits the client needs after the start of care visit. During an interview on 08/21/2023 at 2:00 PM Confidential LVN C stated the agency pays extra when they ask the LVNS to go out and complete a start of care assessment for a client. LVN C stated they pay “$60 for opens and mileage,“ instead of the usual $35 for visits. Some of the contract clients don’t have RN’s go out. LVN C stated they have completed start of care and the resumption of care assessments when the clients started on service and came out of the hospital. LVN C stated the client has a virtual visit with the Nurse Practitioner provider. LVN C stated: ”I have only done a couple of handfuls of these” (starts of care and resumption of care assessments). “I don’t feel like it’s in my scope (of nursing practice)… I am used to having RN support.” LVN C stated: “I don’t really understand why we (LVNs) do this.” The surveyor asked how it works when the agency requests these types of visits. LVN C stated the scheduler calls and says “Hey, I have a start of care, can you do it.” The surveyor asked why LVN C agreed to do these start of care, resumption of care, and reassessment assessment visits. LVN C stated: The agency tells the LVN if they don’t do this visit, the client won’t have anyone to take care of them. The surveyor asked what the LVN does during these visits. LVN C stated they fill out a skilled nursing assessment, write a clinical summary, determine what other types of disciplines the client needs, fill out the medication list, and the consent forms on the start of care visits. During an interview on 08/24/2023 at 2:17 PM Confidential LVN A the surveyor asked if the LVN was completing start of care visits. LVN A stated they had been asked to do start of care assessments for clients’ multiple times and were told it was “OK” to do the initial assessment, get the consents signed, and complete the medication list. LVN A stated: ‘I’ve only done one (start of care assessment and admission), for a regular insurance patient.” During an interview with the Administrator on 08/28/2023 at 11:12 AM the surveyor asked about sending the LVNs out to see the contract clients. The Administrator stated the contractor uses Nurse Practitioners who are seeing the clients, and the agency’s “LVNs will see the client’s first if the Nurse practitioners don’t get there first.” The Administrator stated the LVNs are usually “just going out to set up home IV therapy services or wound care,” then the Nurse Practitioners will see the clients. The surveyor asked why the agency was sending RNs on some clients and LVNs on others. The Administrator stated “They (the contractor) have told us that an LVN is enough, and we don’t always have an RN.” The surveyor asked the Administrator about the contract statements that require the agency to comply with state and federal laws and regulations, and to comply with the conditions of participation for home care agencies. The Administrator stated they would review the contract. During an interview with the Director of Nurses on 08/28/2023 at 1:00 pm the surveyor asked about the LVNs seeing the contract clients before an RN assesses the client. The DON stated: “That was not supposed to happen.” The DON stated the NP (from the contractor) is supposed to go out before the LVN, “but we don’t know if that happens all the time.” The surveyor asked why the DON allowed the LVNs to go first when the client was discharged from the hospital and admitted or readmitted for new / resuming home care services. The DON stated: “They were already doing that when I came. The LVNs tell me when they are uncomfortable.” Patient Assessment Guidelines / Initiation of Therapy Services Review of agency policy 4.2 Patient Assessment Guidelines dated 01/29/2023 read in part: The Agency will utilize and adhere to a defined comprehensive assessment in order to identify the patient’s needs for home care and that meets the patient’s medical, nursing, rehabilitative, social and discharge planning needs. The Comprehensive Assessment … will be completed by primary provider – a Registered Nurse…Each discipline’s standards of practice will be referenced for decision making when assessing… Other qualified Agency professional who have the necessary skills and training and comply with all federal and state laws and regulations, will perform applicable assessments per discipline, as ordered by a physician… An assessment performed due to an intra-agency referral will be completed as follow: Nursing 48 hours, Physical Therapy 4 days, Occupational Therapy 4 days, Speech Therapy 4 days, and Medical Social Worker 4 Standards of Practice Review of Patient 9’s record revealed a start of care of 06/16/2023 with orders for Physical and Occupational therapy to evaluate and treat on the Plan of Care dated 06/16/2023 to 08/14/2023. The record found a Physical Therapy evaluation did not occur until 06/26/2023 (a 10-day delay in initiation of physical therapy services.) The record review found the Occupational Therapy evaluation did not occur until 06/23/2023 (a 7-day delay in initiation of occupational therapy services). Review of the record and coordination of care notes provided failed to find notification to the physician of the delays in therapy services. Review of Patient 10’s record revealed a start of care of 05/12/2023 with orders for Physical and Occupational therapy to evaluate and treat on the Plan of Care dated 05/12/2023 to 07/10/2023. The record found a Physical Therapy evaluation did not occur until 05/22/2023 (a 10-day delay in initiation of physical therapy services.) The record review found the Occupational Therapy evaluation did not occur until 05/22/2023 (a 10-day delay in initiation of occupational therapy services). Review of the record revealed the client was hospitalized on 05/15/2023 and home care was resumed on 05/18/2023. Review of the record and coordination of care notes provided failed to find notification to the physician of the delays in therapy services. During an interview with LVN G on 08/24/23 at 4:30 PM the surveyor asked about the therapy services for Patient 9. LVN G stated the patient reported falling several times while waiting for therapy services to begin. LVN G stated the patient was falling prior to home health admission and was admitted for assistance with preventing falls. During an interview with RN D on 08/24/2023 at 4:15 PM the surveyor asked about the delay in therapy services for Patient 9. RN D stated Patient 9 was admitted to home health primarily for therapy services as he used a rollator walker and reported falling while using the walker to agency staff. An interview was conducted with the previous Alternate Director of Nurses (RN B) on 08/24/2023 at 3:30 PM. The surveyor asked if there were delays in initiation of therapy services. RN B stated: “Yes.” RN B stated: “I would tell them we shouldn’t take them (admit the clients) if we can’t see them timely.” An interview was conducted with Confidential RN C on 08/24/2023 at 3:25 PM. RN C stated they had several clients who had experienced long delays in getting ordered therapy services started. The RN stated they had reported this to management. An interview was conducted with the Administrator and DON on 08/28/23 at approximately 10:21 AM. The surveyor asked about the policy for initiation of services. The Administrator stated they had 48 hours to conduct the start of care and 5 days to start therapy services. The surveyor reviewed the findings from the record reviews and asked about the delay in initiation of therapy services for the clients. The Administrator stated: “We see delays in areas of no coverage.” The surveyor asked what areas. The Administrator stated they had seen delays in Fort Worth and in Terrell areas. The surveyor asked what the agency did when they did not have a therapist to start services in a timely manner. The Administrator stated: “We inform the physician and the patient, and we can find them another agency.” The surveyor asked why there was no documentation of these notifications to the physician and the patient in the client records. The Administrator stated they would look for the notice and provided what they found. Additional information to explain or correct the deficiency was not provided by the end of the survey.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on record review, and interview the agency failed to ensure all HHA services were provided in accordance with current clinical practice guidelines and accepted professional standards of practice for nursing. The agency’s failed to enforce their written policy to ensure compliance with the rules of the Texas Board of Nursing adopted in 22 TAC Chapters 211-226 (relating to Nursing Continuing Education, Licensure, and Practice in the State of Texas) by assigning Licensed Vocational Nurses to complete comprehensive assessments of clients who were discharged from the hospital and referred to the agency under a staffing agreement for nursing care to home health patients for 3 (Patient AA, BB, and CC) of 4 Contract Patient records reviewed. The failure to comply meant the standards of practice that required comprehensive assessments by Registered Nurses prior to care by Licensed Vocational Nurses were not enforced, and Licensed Vocational Nurses provided nursing services that were not in compliance with the with the Texas Board of Nursing. Record review Review of Contract Client AA revealed a Skilled Nurse Start of Care assessment dated 08/23/23 by LVN F. The visit note titled: ECP-SN-Admit documented: “Patient SOC completed today…” Review of Contract Client BB revealed a Skilled Nurse Resumption of Care assessment dated 08/04/23 by LVN G who documented the patient was recovering from brain surgery and was resuming home health care post rehospitalization for complication with Chronic Obstructive Pulmonary Disease (lung disease that makes it difficult to breathe) and lung cancer. Review of Contract Client BB revealed a Skilled Nurse Reassessment for Recertification visit on 08/24/23 by LVN G. Review of Contract Client CC revealed a Skilled Nurse Start of Care assessment dated 07/20/23 by LVN G. The visit note titled: ECP-SN-Admit documented the patient was weak and had mobility issues due to multiple ankle replacement surgeries with infections following and the patient needed wound care. The schedule calendar for Client CC had LVN G scheduled for a Skilled Nurse Reassessment for Recertification on 09/15/2023. Interviews During an interview on 08/17/2023 at 5:30 PM Confidential RN B stated the agency was using LVN staff to admit clients, do the initial comprehensive assessments, asking LVNs to complete resumption of care post hospitalization, and recertification (comprehensive assessments every 60 days of care). RN B stated: The only RN who sees these clients is a nurse practitioner who has a video visit with some of the clients that often occurs after the LVN admits the clients for home health services. During an interview on 08/21/2023 at 1:56 PM Confidential LVN B stated: the agency had asked the LVN to do start of care admission and assessment visits when the client has come home from the hospital for certain insurance companies, and “I don’t like to do them. I am not used to that paperwork.” LVN B also stated: The agency asks the LVNs to upload a clinical summary and determine what kinds of disciplines and the frequency of nursing visits the client needs after the start of care visit. During an interview on 08/21/2023 at 2:00 PM Confidential LVN C stated the agency pays extra when they ask the LVNS to go out and complete a start of care assessment for a client. LVN C stated they pay “$60 for opens and mileage,“ instead of the usual $35 for visits. Some of the contract clients don’t have RN’s go out. LVN C stated they have completed start of care and the resumption of care assessments when the clients started on service and came out of the hospital. LVN C stated the client has a virtual visit with the Nurse Practitioner provider. LVN C stated: ”I have only done a couple of handfuls of these” (starts of care and resumption of care assessments). “I don’t feel like it’s in my scope (of nursing practice)… I am used to having RN support.” LVN C stated: “I don’t really understand why we (LVNs) do this.” The surveyor asked how it works when the agency requests these types of visits. LVN C stated the scheduler calls and says “Hey, I have a start of care, can you do it.” The surveyor asked why LVN C agreed to do these start of care, resumption of care, and reassessment assessment visits. LVN C stated: The agency tells the LVN if they don’t do this visit, the client won’t have anyone to take care of them. The surveyor asked what the LVN does during these visits. LVN C stated they fill out a skilled nursing assessment, write a clinical summary, determine what other types of disciplines the client needs, fill out the medication list, and the consent forms on the start of care visits. During an interview on 08/24/2023 at 2:17 PM Confidential LVN A the surveyor asked if the LVN was completing start of care visits. LVN A stated they had been asked to do start of care assessments for clients’ multiple times and were told it was “OK” to do the initial assessment, get the consents signed, and complete the medication list. LVN A stated: ‘I’ve only done one (start of care assessment and admission), for a regular insurance patient.” During an interview with the Administrator on 08/28/2023 at 11:12 AM the surveyor asked about sending the LVNs out to see the contract clients. The Administrator stated the contractor uses Nurse Practitioners who are seeing the clients, and the agency’s “LVNs will see the client’s first if the Nurse practitioners don’t get there first.” The Administrator stated the LVNs are usually “just going out to set up home IV therapy services or wound care,” then the Nurse Practitioners will see the clients. The surveyor asked why the agency was sending RNs on some clients and LVNs on others. The Administrator stated “They (the contractor) have told us that an LVN is enough, and we don’t always have an RN.” The surveyor asked the Administrator about the contract statements that require the agency to comply with state and federal laws and regulations, and to comply with the conditions of participation for home care agencies. The Administrator stated they would review the contract. During an interview with the Director of Nurses on 08/28/2023 at 1:00 pm the surveyor asked about the LVNs seeing the contract clients before an RN assesses the client. The DON stated: “That was not supposed to happen.” The DON stated the NP (from the contractor) is supposed to go out before the LVN, “but we don’t know if that happens all the time.” The surveyor asked why the DON allowed the LVNs to go first when the client was discharged from the hospital and admitted or readmitted for new / resuming home care services. The DON stated: “They were already doing that when I came. The LVNs tell me when they are uncomfortable.” Policy Review of agency policy 5.1 Standards of Practice dated 01/29/3030 read in part: The agency will provide patient care in accordance with the professional staff’s State Practice Act for acceptable standards of practice and as defined in the Agency’s policies and procedures… Patient care staff will adhere to the respective State Practice Acts and all policies and procedures established by Agency during patient visits. Review of agency policy 1.7 Responsibilities of the Director of Nurses dated 01/29/2020 read in part: The agency defines the responsibilities of the Director of Nurses to include, but not be limited to: Participating in activities relevant to the services furnished, including development of qualifications and assignment of personnel … Coordinating and integrating care provided by Agency staff… Participating in activities relevant to professional services furnished including the development of qualifications and assignment of agency personnel…Ensuring a reassessment of a patient’s needs is performed by the appropriate healthcare professional: when there is a significant health status change in the patient’s condition…” Review of agency policy 4.2 Patient Assessment Guidelines dated 01/29/2023 read in part: The Agency will utilize and adhere to a defined comprehensive assessment in order to identify the patient’s needs for home care and that meets the patient’s medical, nursing, rehabilitative, social and discharge planning needs. The Comprehensive Assessment … will be completed by primary provider – a Registered Nurse…Each discipline’s standards of practice will be referenced for decision making when assessing… Review of agency policy 4.3 Initial Patient Assessment / Patient Admission dated 01/29/2020 read in part: “Each patient will receive a patient specific, comprehensive assessment … completed by a Registered Nurse to determine the immediate care and support needs of the patient… A Registered Nurse and/or other professional disciplines will evaluate data/information gathered at the time of their initial assessment and consult with the patient’s physician to determine and approve the Plan of Care…” Review of agency policy 4.4 Patient Reassessment dated 01/29/2020 read in part: “The Start of Care / Resumption of Care Comprehensive Assessment will be completed within 48 hours following a patient’s discharge from the hospital…. An RN or qualified individual may perform the reassessment for a significant change in condition…” Review of the Texas Board of Nursing Practice Act on 08/23/2023 at 11:00 am read in part: “The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;… (K) Comply with mandatory reporting requirements of Texas Occupations Code Chapter 301 (Nursing Practice Act), Subchapter I, which include reporting a nurse: … (iv) whose actions indicate that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse's continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior. (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse… (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: (i) collecting data and performing focused nursing assessments; … (3) Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall: (A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by: (i) performing comprehensive nursing assessments regarding the health status of the client;…”