Every finding on record at Valley Care Home Health Services LLC

Purpose of Visit: To conduct Re-Certification and Re-Licensure Survey. On 12/12/22 at 10:36 a.m., Surveyor conducted an unannounced visit, and an entrance conference was conducted with the Alt Adm. Census: Licensed & Certified- 41 Licensed Home Health Services - 0 Personal Assistance Services – 99 Adm-Administrator Alt-Alternate TAC- Texas Administrative Code An exit conference was conducted on 12/19/22 at 3:20 p.m., with the Adm/ADON and Alt Adm. The preliminary findings were discussed. The agency was given the opportunity to provide additional information. Written instructions were provided for submitting a Plan of Correction within 10 days of receipt of the Statement of Deficiencies.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the emergency preparedness plan was reviewed and updated at least annually in 2020 and 2021. This failure places all agency patients at an increased risk of harm in the event of a disaster. The findings included: Review of the Agency's Disaster Plan manual for 2020 and 2021 failed to include any reviews or updates of the agency's Emergency Preparedness Plan. During an interview on 12/19/22 at 12:37 p.m. with the Alt Adm, Surveyor read Federal Regulation 484.102(b) and asked if the agency's Emergency Preparedness had been reviewed and updated annually in 2020 and 2021. Alt Adm stated, "No.” Review of the agency's policy manual revealed a policy titled "Emergency Preparedness Policy and Plan" number EC.8 and dated 12/16/21. The policy read in part: "Policy... E. An annual review of the Emergency Plan will be documented to include the date of the review and any updates made to the Emergency Plan based on the review.” …

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain 1 of 1 written emergency preparedness plan that included procedures to follow up with on-duty staff and patients to determine services that were needed, in the event that of an interruption in services during or due to an emergency as well as procedures to inform State and local officials of any on[RG(1] -duty staff or patients that they were unable to contact. This failure could place the agency's patients at risk of harm from the possibility of the patient not having continuity of care in the event of a disaster. The findings included: Review of the agency's Disaster Plan Manual identified by the Alt Adm on 12/19/22 at 9:35 a.m. as the agency’s Emergency Preparedness and Response Plan revealed a form titled "Emergency Preparedness Plan" that was revealed to the be the agency's Emergency Preparedness and Response Plan. Review of the agency's Disaster Plan Manual failed to reveal documentation that included procedures to follow up with on-duty staff and patients to determine services that were needed in the event that of an interruption in services during or due to an emergency and procedures to inform State and local officials of any on-duty staff or patients that they were unable to contact. During an interview on 12/19/22 at 12:40 p.m. with the Alt Adm, Surveyor read Federal Regulation TAC 484.102(b)(3) and asked if the agency's Emergency Preparedness and Response Plan included procedures to follow up with on-duty staff and patients that they were unable to contact. The Alt Adm stated, "No, that’s not in here." Review of the agency's policy manual revealed a policy titled "Emergency Preparedness Policy and Plan" number EC.8 and dated 12/16/21. The policy read in part: "Procedure … E. Emergency Preparedness Planning for Natural and Manmade Disasters ... 4. A Communication Plan will be developed and kept accurate and current that includes all of the following: a. Names and contact information for the following: i. Staff (updated with new and terminated staff throughout the year, contacts for staff and family members); … Patient Triage … E. The Patient Information and Emergency/Disaster Preparedness Plan is updated with changes that are pertinent to patient safety including but not limited to:..1. Patient name , age…4. Emergency contact information; ..."

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency's emergency preparedness and response plan failed to include strategies for the use of volunteers or other emergency staffing to address surge needs during an emergency. This failure could place the agency's clients at risk of harm from emergency management personnel who do not have adequate knowledge on the ability of the agency to provide services. The findings included: Review of the agency's Disaster Plan Manual identified by the Alt Adm on 12/19/22 at 9:35 a.m. as the agency’s Emergency Preparedness and Response Plan revealed a form titled "Emergency Preparedness Plan" that was revealed to the be the agency's Emergency Preparedness and Response Plan. Review of the agency emergency preparedness and response plan failed to include strategies for the use of volunteers or other emergency staffing to address surge needs during an emergency. During an interview on 12/19/22 at 12:40 p.m. with the Alt Adm, Surveyor read Federal Regulation TAC 484.102(b) and asked if the agency's Emergency Preparedness and Response Plan included strategies for the use of volunteers or other emergency staffing strategies including process and role of integration with state and federally designated health care professionals addressing surge during an emergency. The Alt Adm stated, "No, we don’t."

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on record review and interview, the agency's 1 of 1 Emergency Preparedness and Response Plan failed to include a communication plan in 2020 and 2021. This failure could place the agency's future patients at risk for harm from the possibility of the agency being uninformed and unprepared for a disaster or emergency. The findings included: Review of the policy titled " Emergency Preparedness Policy and Plan" EC.8 revised on 12/16/21 read in part: "… Policy… D. The effectiveness of the Emergency Preparedness Plan is reviewed, evaluated and update at least annually… The Agency will develop and maintain a Communication Plan that is accurate and current.” … Continued Review of the agency's policy manual revealed a policy titled "Emergency Preparedness Policy and Plan" EC.8 revised on 12/16/21 read in part: "…4. A communication Plan will be developed and kept accurate and current that includes all of the following” … Continued review of the Agency's Disaster Plan Manual failed to reveal documentation that the Agency's Emergency Preparedness Plan included a Communication Plan that included an annual review of the agency’s communication plan in 2020 and 2021. During an interview on 12/19/22 at 12:40 p.m. with the Alt Adm, Surveyor read Federal Regulation TAC 484.102(b) and asked if the agency's Emergency Preparedness and Response Plan included documentation that the communication plan was reviewed annually in 2020 and 2021. Alt Adm stated, “no.”

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency's emergency preparedness and response plan failed to include names and contact information for staff, other entities providing services under arrangement and patients' physicians. This failure could place the agency's patients at risk of harm from the possibility of the patient not having continuity of care in the event of a disaster. The findings included: Review of the agency’s Emergency Preparedness Plan read in Part: “I. Mitigation: …3 Agency will maintain current listings of staff and all applicable contact numbers for use as communication tree.” … Review of the agency's Disaster Plan Manual revealed a policy titled "Emergency Preparedness and Response Plan" number EC.8 with a revision date of 12/16/21. The policy revealed in part: "PROCEDURE...a. Staff and contact information for the following: “i. Staff (updated with new and terminated staff throughout the year, contacts for staff and family members]; ii. Entities identified providing services under arrangement; iii. Patient’s physicians or allowed practitioners involved in POC…” Further review of the agency’s Emergency Preparedness Plan failed to include names and contact information for staff, entities providing services under arrangement and patients' physicians. During an interview on 12/19/22 at 12:40 p.m. with the Alt Adm, Surveyor read Federal Regulation TAC 484.102(b) and asked if the agency's Emergency Preparedness Plan included documentation names and contact information for staff entities providing services under arrangements. Alt Adm stated, “no.”

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on record review and interview, the agency's emergency preparedness and response plan failed to include procedures for providing information regarding the home health agency's needs and its ability to aid the authority having jurisdiction, the Incident Command Center, or designee for all the agency service area. This failure could place the agency patients at risk of harm from the possibility of the patient not having continuity of care in the event of a disaster. The findings included: Review of the agency's Disaster Plan Manual revealed a form titled "Emergency Preparedness Plan " that was revealed to be the agency's Emergency Preparedness and Response Plan. Review of the agency’s Emergency Preparedness Plan failed to include procedures for providing information regarding the home health agency's needs and its ability to aid the authority having jurisdiction, the Incident Command Center, or designee for all the agency service area. Review of the agency's policy manual revealed a policy titled "Emergency Preparedness Policy and Plan" number EC.8 and dated 12/16/21. The policy read in part: "Response to Emergency or Disaster with Fore Warning … E. Response Phase … 6. The authority having jurisdiction varies by local, state and federal emergency management structures as well as the type of disaster and in some cases would take over the Incident Command Center … Agency will collaborate with these authorities with assistance as needed and provide as much information to assist with patient and staff safety. 7. Information about the Agency's needs, and its ability to provide assistance, to the authority having jurisdiction (local and State emergency management agencies, local and state public health departments, the Incident Command Center, the Emergency Operations Center, or designee, will be provided by the Disaster Coordinator or Alternate Disaster Coordinator according to the Communication Plan." During an interview on 12/19/22 at 12:40 p.m. with the Alt Adm, Surveyor read Federal Regulation TAC 484.102(b) and asked if the agency's Emergency Preparedness Plan included documentation of means to provide information about the home health agency’s needs and ability to provide assistance to the author having jurisdiction, the Incident Command or designee. Alt Adm stated, “no, it doesn’t.”

Purpose of Visit: To conduct Re-Certification On 12/12/22 at 10:36 a.m., Surveyor conducted an unannounced visit, and an entrance conference was conducted with the Alt Adm. Census: Licensed & Certified- 41 Licensed Home Health Services - 0 Personal Assistance Services – 99 An exit conference was conducted on 12/19/22 at 3:20 p.m., with the Adm/ADON and Alt Adm. The preliminary findings were discussed. The agency was given the opportunity to provide additional information. Written instructions were provided for submitting a Plan of Correction within 10 days of receipt of the Statement of Deficiencies. Adm- Administrator DON- Director of Nurses LVN- Licensed Vocational Nurse LPN-Licensed Practical Nurse NS-Normal Saline OASIS- Outcome and Assessment Information Set POC- Plan of Care Rt-Right SN- Skilled Nurse

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to perform an initial assessment visit within 48 hours of referral or on the physician ordered start of care date for 1 of 2 discharged patients (#7) whose records were reviewed. This failure has the potential to place the agency's active patients of the agency at risk for failure to have adequate care that is essential to the patient' health provided in a timely manner. The findings included: 1. Review of discharged Patient # 7's clinical record revealed a form titled: "Home Health Care Certification and Plan of Care" that revealed a start of care date as 09/06/22 for the certification period of 09/24/22-11/02/22, that was signed and dated by RN on 09/06/22. Discharged Patient #7's clinical record revealed that patient was referred to agency on 09/02/22. Continued review of Discharged Patient # 7's clinical record revealed a document titled, "OASIS-D1 Start of Care" signed and dated by RN on 09/06/22. Review of Discharged Patient #7’s clinical record revealed no documented evidence that the patient was admitted within 48 hours of receiving the referral. During an interview concurrent with record review on 12/15/22 at 2:47 a.m. with Adm/ DON, surveyor and Adm/DON reviewed the above findings. Surveyor asked Adm/DON on what day was the referral submitted to the agency. Adm/DON stated there was a referral dated on the 2nd of September. The order was dated September 02, 2022. Adm/DON was asked if the patient was admitted within 48 hours of the referral. Adm/DON stated, “she was admitted on the 6th of September, no.” Review of the agency's policy manual included a policy titled "Initial Patient Comprehensive Assessment” PE. 3 dated 03/04/22. The policy revealed, in part: “…2. The initial visit will be conducted within 48 hours of referral or on the physician or allowed practitioner ordered star of care date.…”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals completed clinical notes were accurate and complete for 1 of 7 Active Patients (#1) whose records were reviewed. This failure prevents the agency from ensuring client services are provided and the needs are met and could place all agency patients as risk of harm. The findings included: 1. Review of Patient #1’s electronic record revealed a POC for the period of 10/06/22 to 12/04/22 with a diagnosis of Pressure Ulcer of Right Heel Stage II (also called a bed sore, injury to the skin caused by staying in the same position for a very long time/ hours. Especially for individuals that are not able to move or turn on their own). With SN visit frequency of one visit a week for one week, then three visits a week for eight weeks. Review of record Patient #1’s electronic record revealed the following notes dated 11/16/22,11/18/22, 11/21/22, 11/23/22, 11/25/22, and 11/28/22 in a “Not Yet Started Status” (these notes have not been started by the nurse) which were assigned to LVN E. Continued review of Patient #1’s electronic record revealed a Physician Order with a scheduled date of 11/30/22 for RN C that was in a “Not Yet Started Status” Further review of Patient #1’s electronic record revealed an OASIS-D1 Recertification, LVN/LPN Supervisory Visit and 60 Day Summary Case Conference with a scheduled date of 11/30/22 in a “Not Yet Started Status.” Review of the record failed to reveal documentation that SN note dated the following notes dated 11/16/22,11/18/22, 11/21/22, 11/23/22, 11/25/22, and 11/28/22 10/20/22 were completed and in the clinical record within 14 days. It also failed to reveal documentation of a Physician Order, OASIS-D1 Recertification, LVN/LPN Supervisory Visit and 60 Day Summary Case Conference scheduled for 11/30/22 were completed and in the clinical record within 14 days. During an interview concurrent with record review on 12/15/22 at 1:35 p.m. with Adm/DON and Alt Adm, Surveyor presented the above findings. After review of the documents presented, the Adm/DON acknowledged the SN notes, Physician Order, OASIS -D1 Recertification, LVN/LPN Supervisory Visit and 60 Day Summary Case Conference were not completed and in the clinical record within 14 days. Adm/DON stated, “no, they are not.” 2. Review of Patient #1’s electronic record revealed a POC for the period of 10/06/22 to 12/04/22 with a diagnosis of Pressure Ulcer of Right Heel Stage II (also called a bed sore, injury to the skin caused by staying in the same position for a very long time/ hours. Especially for individuals that are not able to move or turn on their own). With SN visit frequency of one visit a week for one week, then three visits a week for eight weeks. Continued review of Patient #1’s POC for the period of 10/06/22 to 12/04/22 that read in part: “… SN to perform pressure ulcer care to Rt Heel on 10/07/22 and then 3x/week wound [sic]with Betadine solution, apply dry gauze dressing, wrapped with rolled gauze and secure with tape, using aseptic technique.” Review of Patient #1’s electronic record revealed a form titled “[Agency Y] Physician Written Order dated 10/06/22 that read in part: please do betadine cast 3 times a week and full dressing.” Review of Patient #1’s electronic record revealed SN notes dated, 10/07/22, 10/10/22,10/12/22,10/14/22,10/17/22,10/19/22,10/21/22,10/24/22, 10/26/22,10/28/22,10/31/22,11/02/22,11/04/22, 10/17/22,11/09/22,11/11/22, and 11/14/22 “Treatment Performed” read: “Sn performed wound care to Rt. Heel: cleansed with NS, pat dried with 4x4(gauze), applied betadine cast, covered with gauze wrapped with kerlix and secured with tape.” Review of the record revealed no documented evidence that the POC for the period of 10/06/22 to 12/04/22 was accurate. The POC failed to reflect the physicians order to apply a betadine cast with full dressing. During an interview concurrent with record review on 12/15/22 at 1:58 p.m. with Adm/DON present and LVN E on a conference call via telephone, Surveyor presented the above findings. After review of the documents presented, the Adm/DON acknowledged the POC from 10/06/22 to 12/04/22 was inaccurate. LVN C stated, “there is documentation of what I did. Rn gave me report, it was to apply betadine cast. I believe the 485(also known as the POC) is incorrect.” Review of the agency's policy manual included a policy titled "Timelines” IM.10 with a revised date of 05/01/11. The policy revealed, in part: “…1.5 Daily progress notes with correlating time sheets are turned in maximum of 7 calendar … 4. All medical record information will be incorporated into the patient’s medical record within 14 business days.” …