Every finding on record at Victory Institute Inc

PURPOSE OF VISIT: Recertification and relicensure survey ENTRANCE CONFERENCE DATE: 03.05.2026 CENSUS: Total 16, Licensed & Certified– 16 The agency is in compliance with the Emergency Preparedness Conditions of Participation for Home Health Agencies.

PURPOSE OF VISIT: Recertification and relicensure survey ENTRANCE CONFERENCE DATE: 03.05.2026 CENSUS: Total 16 Licensed & Certified– 16 Abbreviations: CHAP – Community Health Accreditation Partner RN – Registered Nurse DON – Director of Nursing ST – Speech Therapy OT- Occupational Therapy TX – Treatment HHA – Home Health Agency QAPI – Quality Assurance and Performance Improvement

Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient's legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to provide a patient and the patient’s or legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: patient conduct, patient responsibility, and patient rights in 3 (#1, #2, and #3) of 3 home visits completed by the nurse surveyor. Failure to provide written notice of patient rights and responsibilities meant patients may be unaware of their rights, responsibilities, and the process for filing grievances, which may impact their ability to participate in the provision of safe care and placed the clients at risk of receiving inadequate care. Record review of the sample home admission packet information requested on 03.05.2026 at 2pm revealed no printed version of the following required documents: Client Rights and Responsibilities and The Rights of the Elderly. Due the items being missing in the sample home admission packet, there is no date the items were made. Interview and record review on 03.10.2026 during the home visit of Patient 1 at 1pm, revealed that the there were no client “Rights and Responsibilities” nor “The Rights of the Elderly” documents in the home packet as required by agency policy. The surveyor asked if the patient had removed any of the documents in the home folder provided by the agency and Patient 1 stated they had not removed anything and did not recall seeing a document about these rights. Interview and record review on 03.10.2026 during the home visit of Patient 2 at 11:30am, revealed there were no client “Rights and Responsibilities” nor “The Rights of the Elderly” documents in the home packet as required by agency policy. The surveyor asked if the patient had removed any of the documents in the home folder provided by the agency and Patient 2 stated they had not removed anything and did not recall seeing a document about these rights. Interview and record review on 03.10.2026 during the home visit of Patient 3 at 10:00am, revealed there were no client “Rights and Responsibilities” nor “The Rights of the Elderly” documents in the home packet as required by agency policy. The surveyor asked if the patient had removed any of the documents in the home folder provided by the agency and Patient 3 stated they had not removed anything and did not recall seeing a document about these rights. An interview was conducted with the Administrator and Director of Nursing on 3.11.2026 at 3:15pm regarding the home admission packet. The Administrator reported that the “copy people, our administrative staff makes the home packets in the office, and the numbers and rights should be in the home packet. I will make sure it will be there; we have it.” The Director of Nursing reported that the home packets are given to the admission nurses, and they go over the packets in the home prior to the initiation of care. She stated, “we have six home care [agencies] and they should all be there, the resource list and rights of the elderly.” Record review completed on 3.11.2026 at 3pm of the agency policy dated, 09.13.2011, titled, “Client Bill of Rights and Responsibilities: Rights of the Elderly” states, “The Agency will provide information regarding Client Bill of Rights and Client Responsibilities, Client Conduct, and The Rights of the Elderly (to persons age 60 and over) both verbally and in writing (in a manner that the client / guardian can understand) to each client or legal guardian in advance of furnishing care or during the initial evaluation visit before the initiation of treatment… agency will comply with the provisions of Human Resources Code, Chapter 102, concerning the rights of the elderly.” In the section titled, “Procedure”, B. “Agency staff will be responsible for knowing, observing, and implementing the client’s rights, client conduct, and client responsibilities on an ongoing basis… Section C. The Client Bill of Rights and Responsibilities and the Rights of the Elderly for those 60 years of age and older will be given to the client verbally and in writing at the time of the client’s assessment, prior to admission…”

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 interview, and record review, the agency failed to ensure patients were advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patients 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 for 3 of 3 patients (#1, #2, #3) who completed home visits with the nurse surveyor. This failure meant patients lacked information to ensure access to services as needed and to request an expedited review of changes in services provided by the agency. The agency did not follow policy to ensure the patients had the required numbers as required by regulation, placing clients at risk of receiving inadequate care. Review of the sample home admission packet information requested on 03.05.2026 at 2pm revealed no list of the required Federally funded and state-funded entities that included the names, addresses, and telephone numbers for the following: (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. Interview and record review on 03.10.2026 during home visit of Patient 1 at 1pm revealed no list of the required Federally funded and state-funded entities that included the names, addresses, and telephone numbers for the following: (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 In the home admission packet. The surveyor asked if the patient had removed any of the documents in the home folder provided by the agency and Patient 1 stated they had not removed anything and had not been provided with a list of resources other than what was in the home folder. Interview and record review on 03.10.2026 during home visit of Patient 2 at 11:30 am revealed no list of the required Federally funded and state-funded entities that included the names, addresses, and telephone numbers for the following: (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 In the home admission packet. The surveyor asked if the patient had removed any of the documents in the home folder provided by the agency and Patient 2 stated they had not removed anything and had not been provided with a list of resources other than what was in the home folder. Interview and record review on 03.10.2026 during home visit of Patient 3 at 10:00 am revealed no list of the required Federally funded and state-funded entities that included the names, addresses, and telephone numbers for the following: (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 In the home admission packet. The surveyor asked if the patient had removed any of the documents in the home folder provided by the agency and Patient 3 stated they had not removed anything and had not been provided with a list of resources other than what was in the home folder. An interview was conducted with Registered Nurse A on 3.11.2026 at 12:02pm. Registered Nurse A stated that she reviewed everything in the home packets with the clients at the time of admission verbally and then has the patient sign the forms. She stated, “the packet is handed to me already put together by office staff. I just go through the list of stuff; I should have been more aware they [the resource telephone numbers] were not there.” An interview was conducted with the Administrator and Director of Nursing on 3.11.2026 at 3:15pm regarding the home admission packet. The Administrator reported that the “copy people, our administrative staff makes the home packets in the office, and the numbers and rights should be in the home packet. I will make sure it will be there; we have it.” The Director of Nursing reported that the home packets are given to the admission nurses, and they go over the packets in the home prior to the initiation of care. She stated, “we have six home care [agencies] and they should all be there, the resource list and rights of the elderly.” Record review of the agency policy dated, 09.13.2011, titled, “Resolution of Client Conflicts, Grievances or Complaints” Section C states, “The client Bill of Rights and Responsibilities and the Rights of the Elderly for those 60 years of age and older will be given to the client verbally and in writing at the time of the client’s assessment, prior to admission to the agency and prior to the initiation of care. Client will be informed of their right to make a complaint to the administrator of the Home Health agency and to the following: Department of Aging and Disability Services (DADS), Consumer Rights and Services Division… Toll Free 1-800-656-9656 24-hour hotline.” The telephone number is correct, but the policy is not updated to show the correct name: Texas Health and Human Services. Section D of policy states, “Once this agency is CHAP accredited, the client and/or family may contact CHAP regarding a complaint…” Record review of the agency policy dated, 09.13.2011, titled, “Client Bill of Rights and Responsibilities: Rights of the Elderly” Section C states, “The client Bill of Rights and Responsibilities and the Rights of the Elderly for those 60 years of age and older will be given to the client verbally and in writing at the time of the client’s assessment, prior to admission to the agency and prior to the initiation of care…” Section D states, “Prior to the start of care, agency will provide the client the toll-free Home Health Hotline… Client will receive in writing the telephone numbers for the state Home Health Hotline and the accreditation agency hotline…”

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 observation, record review, and interview, the agency failed to ensure 2 of 7 patients (#1, #4) received the home health services that were written in the individualized plan of care which was established by a Doctor of Medicine. The agency failed to ensure the client's received the therapy services as ordered on the Plan of Care. This failure meant that Clients #1 and #4 were subjected to poor quality care, poor health outcomes, and inadequate care. Review of Patient 1’s Plan of Care for the certification period 02/23/2026 to 04/23/2026 revealed diagnoses of Cellulitis of Right Lower Limb (infection of right leg), Dementia, Moderate, with Agitation (a behavioral syndrome in cognitive decline affecting memory, motor activity, and emotional distress), Diabetes Mellitus with Diabetic Polyneuropathy (a chronic complication of impaired blood sugar metabolism leading to damage to peripheral nerves), Repeated Falls (2 or more unintentional landings on the floor within a 12 month period), Dependence on Wheelchair (necessary reliance on a wheelchair for mobility), and Long Term use of Anticoagulants (medication given beyond 6 months to prevent blood clots and stroke). Orders for care included nursing twice a week for nine weeks, physical therapy once a week for one week, twice a week for five weeks, and once a week for one week, and speech therapy once a week for one week, twice a week for four weeks, and once a week for one week. Review of Patient 1’s clinical record revealed no speech therapy services were provided as of the exit date of 03/11/2026. Review of the entire record found no evidence the physician was notified of the lack of services as ordered. An interview was conducted on 03.10.2026 at 1 pm during a home visit with Patient 1 and his family member (Identifier AA.) Patient 1 did not speak during the home visit to the surveyor. Patient 1’s Family Member AA stated no speech therapy had been provided by the agency, and Family Member AA had contacted the agency the week before the surveyor visit to ask when the speech therapy was going to be provided. Family Member AA stated Patient 1 needed more reminders to speak. Family Member AA stated Patient 1 had speech therapy with the previous home health agency and was concerned there had been no speech therapy provided since admission on 02/23/2026. Review of Patient 4’s Plan of Care for the certification period 01/12/2026 to 03/12/2026 revealed diagnoses of Nonrheumatic Aortic (valve) Stenosis (heart valve disease where the valve between the left ventricle and aorta cannot open fully, forcing the heart to work harder), Dissection of iliac artery (tear in the inner layer of the artery), Atrial Fibrillation (rapid, irregular heartbeats in the upper chambers of the heart), Diabetes Mellitus II (impaired blood sugar metabolism), Acute Respiratory Failure (lungs cannot adequately oxygenate the blood or remove carbon dioxide, Chronic Kidney Failure 3a (mild to moderate kidney failure where kidneys struggle to filter waste and fluid). Orders for care included nursing twice a week for two weeks and once a week for seven weeks, physical therapy once a week for one week, twice a week for five weeks, physical therapy once a week for one week to evaluate week of 01/12/2026, then twice a week for four weeks, and once a week for one week, and occupational therapy once a week for one week, to evaluate week of 01/12/2026 then twice a week for three weeks and once a week for one week. Review of Patient 4’s clinical record revealed no occupational therapy services were provided from the start of care of 01/12/2026 to discharge on 01/22/2026 when the patient was transferred and admitted to the hospital. Review of the entire record found no evidence the physician was notified of the lack of services as ordered. An interview was attempted with Patient 4 on 03/11/2026 at 2:13 PM and again at 3:00 PM. An interview was conducted on 03/11/2026 at 12:02 PM with RN A. RN A stated she evaluated Patient 1 during the start of care visit and determined the referral and order for speech therapy was appropriate for problems speaking clearly and in complete sentences, and memory issues. RN A stated the process of starting or providing therapy services is handled by the office staff. RN A stated she notified office staff of the patient’s needs after assessment and sometimes the agency only provided one therapy when 2 were ordered. RN A stated that was out of their “hands” after assessment and reporting into the office staff. An interview was conducted on 03/11/2026 at 3:45 PM with Office Manager B, Scheduler C, the Director of Nurses, and the Administrator. The surveyor reviewed the findings of the record reviews and home visits. The surveyor asked about the lack of ST and OT services for patients 1 and 4. Scheduler C stated she received the information from RN A and the procedure was to forward to administration who approved the therapy referrals to the contractors. Office Manager B stated they checked to be sure insurance authorization wasn’t an issue and to determine the number of visits needed. The Office Manager stated the policy was to send the referral to the therapy providers in 4 days after insurance verification and administration approval. Office Manger B stated there was no insurance authorization needed for Patient’s 1 and 4, and the administration made the decision to send only one therapy at a time. The Administrator stated they provided one therapy at a time because sometimes the patients don’t want so many people in their homes. The Administrator stated they would sometimes provide one therapy for the first month and the second for the second month of the certification period. The surveyor asked about the effect on the patients of the deficient practice. Office Manager B stated Patient 1’s family member AA called and complained about the lack of therapy services and the office manager took the information to the Administrator for approval to refer the patient for speech therapy services. The surveyor confirmed no speech therapy services had been provided as of the exit date of 03/11/2026 for Patient 1 with Office Manager B and the DON. Review of Agency policy titled: “Plan of Care TX.6” dated with a revision date of 04/04/2011 read in part: Purpose- To develop an individual Plan of Care to ensure client specific needs are met appropriately according to state and federal regulations. Policy – Agency will utilize data/information gathered during client assessments in the care planning process which involves the identification of client goas, actions or interventions that will resolve or alleviate the client’s problems and / or needs… The client/caregiver, as well as the client’s physician, will be encouraged to participate in the client’s care planning process to determine mutually agreed upon goals… Physician orders to include the discipline to render the services/treatments, the services or therapy modalities to be rendered and the frequency and duration of the visits to be made; specific procedures/treatments to be performed, including amount, frequency and duration…

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 3 (2023, 2024, and 2025) of three years of the survey review period. The HHA failed to document the quality improvement projects undertaken for 2023, 2024, and 2025 and 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 of care, poor health outcomes, and inadequate care. Findings: During the entrance conference interview on 03/05/2026 the surveyor requested all QAPI documents including the Performance Improvement Projects for 2023, 2024, and 2025. Review of the white three ring binder that was undated provided by the agency on 03/11/2026 revealed no Performance Improvement Projects were documented. The surveyor requested additional performance improvement documentation on 03/11/2026. No performance improvement project documentation was provided by the end of the survey. An interview was conducted with the Administrator and DON and the Office Manager B on 03/11/2026 at 3:45 PM. The surveyor asked who was responsible for the agency’s Quality Improvement program and the agency’s lack of performance improvement projects. The Administrator stated Office Manager B was responsible. The Administrator stated he could email something to the surveyor tomorrow from his home computer. The surveyor asked the agency staff to identify any performance improvement projects the agency had documented. There was no response from the agency staff. The surveyor repeated the question. Office Manager B finally stated they were only copying The QAPI information from previous reports. The Administrator stated they should be doing them to improve services and the agency used to use a consultant to help with QAPI and since dropping accreditation in 2022 they did not. Agency policy review revealed a policy titled: “Performance Improvement Process: Data Collection revised 121108” which read in part: “Purpose -To collect data for priorities identified by Agency leaders…Policy – Agency will collect data to monitor performance of areas targeting for study and to determine effectiveness of change…” No agency policy was provided for Performance Improvement Projects.

A recertification inspection survey was conducted on 02/21/2023. L & CHHS census was 18. No deficiency was cited.

A recertification inspection survey was conducted on 02/21/2023. L & CHHS census was 18. Abbreviations/Acronyms: Adm-Administrator DON-Director of Nursing Office Mgr.-Office Manager L & C- Licensed and Certified LHH- Licensed Home Health EHR- Electronic Health Record PT- Physical Therapist OT-Occupational Therapist RN-Register Nurse LVN-Licensed Vocational Nurse POC- Plan of Care SOC- Start of Care HHA- Home Health Agency OASIS- Outcome and Assessment Information Set CFR-Code of Federal Regulations CMS- Center for Medicare and Medicaid Services 485-Plan of Care SN- Skilled Nursing UTI-Urinary Tract Infection PCP-Primary Care Physician NOMNC- Notice of Medicare Non-Coverage Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)

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 ensure proper written notice was provided, in advance of terminating on-going care in five (Patients # 6, # 7, # 8, # 9, AND # 10) of five discharged patient records reviewed. The agency failed to provide Patients # 6 through # 10 with the Centers for Medicare and Medicaid form titled Notice of Medicare Non-Coverage. The failure could affect patients’ health and safety and result in harm due to lack of timely discharge planning in the patients post discharge needs. FINDINGS INCLUDED: “HHAs…are required to provide a Notice of Medicare Non-Coverage (NOMNC) to beneficiaries when their Medicare covered service(s) are ending. The NOMNC informs beneficiaries on how to request an expedited determination from their Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) and gives beneficiaries the opportunity to request an expedited determination from a BFCC-QIO. A Detailed Explanation of Non-Coverage (DENC) is given only if a beneficiary requests an expedited determination. The DENC explains the specific reasons for the end of covered services…” https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-Expedited-Determination-Notices According to the NOMNC form, labeled "FORM CMS 10123- NOMNC," instructions, the HHA “…must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily…This notice fulfills the requirement at 42 CFR 405.1200(b)(1) and (2) and 42 CFR 422.624(b)(1) and (2)…” https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/Instructions-for-Notice-of-Medicare-Non-Coverage-NOMNC.pdf Clinical Record # 6: Record review of the EHR for Patient # 6 revealed a POC with a SOC date of 10/13/2022 and a certification period 10/13/2022 to 12/11/2022. The POC had a primary diagnosis of Cutaneous abscess of abdominal wall, was dated 10/13/2022 and signed by RN A. Continued review of Patient # 6’s record revealed a discharge OASIS/Summary that had a discharge date of 11/03/2022. The discharge summary listed the reason for discharge as goals met. The clinical record included a “Patient Choice Statement” and page 2 of the NOMNC. Review of the choice statement and the NOMNC page 1 did not reveal the contact information for the BFCC-QIO, which is listed on page 1 of the NOMNC form. Further review of Patient # 6's record did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 11/03/2022. The record did not include a completed written NOMNC. Clinical Record # 7: Record review of the EHR for Patient # 7 revealed a POC with a SOC date of 08/16/2022 and a certification period 08/16/2022 to 10/14/2022. The POC had a primary diagnosis of Disruption of external operation, surgical wound, was dated 08/16/2022 and signed by RN B. Continued review of Patient # 7’s record revealed a discharge physician’s order that had a discharge date of 09/21/2022. The discharge order listed the reason for discharge as goals met. Further review of Patient # 7's record did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 09/21/2022. The record did not include a written NOMNC. Clinical Record # 8: Record review of the EHR for Patient # 8 revealed a POC with a SOC date of 04/29/2022 and a certification period 06/28/2022 to 08/26/2022. The POC had a primary diagnosis of Trauma subarachnoid hemorrhage with loss of consciousness of 30 minutes or less., was dated 06/28/2022 and signed by the DON. Continued review of Patient # 8’s record revealed a discharge OASIS/Summary that had a discharge date of 08/22/2022. The discharge summary listed the reason for discharge as goals met. Further review of Patient # 8's record did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 08/22/2022. The record did not include written NOMNC. Clinical Record # 9: Record review of the EHR for Patient # 9 revealed two POC(s) with a SOC date of 07/22/2022 and a certification periods of 09/20/2022 to 11/18/2022 and 11/19/2022 to 01/17/2023. The POC(s) had a primary diagnosis of Chronic obstructive pulmonary disease with acute exacerbation, was dated 09/20/2022 and 11/14/2022 and signed by RN C. Continued review of Patient # 9’s record revealed a discharge OASIS/Summary that had a discharge date of 12/20/2022. The discharge summary listed the reason for discharge as goals met. The clinical record revealed a “2 Day Discharge Notice.” The 2-day discharge notice was not the required Form CMS 10123-NOMNC. Further review of Patient # 9's record did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 12/20 2022. The record did not include a written NOMNC. Clinical Record # 10: Record review of the EHR for Patient # 10 revealed a POC with a SOC date of 04/28/2022 and a certification period 04/28/2022 to 06/26/2022. The POC had a primary diagnosis of Hemiplegia following cerebral infarction affecting right dominant side, was dated 04/28/2022 and signed by RN B. Continued review of Patient # 10’s record revealed a discharge OASIS/Summary that had a discharge date of 06/23/2022. The discharge summary listed the reason for discharge as goals met. Further review of Patient # 10's record did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 06/23/2022. The record did not include a written NOMNC. In an interview on 02/28/2023 at 11:05 a.m. with the Adm and DON the surveyor discussed the above findings and asked why the agency had not provided proper written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for Patients # 6, # 7, # 8, # 9, and # 10. The Adm replied, “I think we have a misunderstanding, that it is just for traditional Medicare [patients]. I think if they are Medicare Advantage [insurance plan], they are not Medicare.” Review of agency policy titled “PE.6 Patient Discharge/Discharge Planning” dated 031518 read in part: “…POLICY…J. Agency will deliver the generic CMS notice…Notice of Medicare Non Coverage [form] to the patient (or authorized representative), no less than…2 days prior to the day of anticipated discharge, or as soon as the Agency determines coverage will end. K. The NOMNC must remain two pages. The notice can be two sides of one page or one side of two separate pages, but must not be condensed to one page…The CMS form number and OMB control number must be displayed on the notice…”

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review, observations, and interviews, the agency failed to provide written information in three (Patients # 1, # 2 and # 5) of three patients who received a home visit. The HHA failed to provide the patient and caregiver with a written visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. The failure could place the patients at risk of being uninformed and/or unable to identify the staff scheduled to provide care and services on behalf of the agency. FINDINGS INCLUDED: Review of the agency's sample "Medicare" admission packet revealed that the admission packet included a form for visit schedules. Clinical Record # 1: Record review of the EHR for Patient # 1 revealed a POC with a SOC date of 11/18/2022. The POC had a certification period 11/18/2022 to 01/16/2023 and a primary diagnosis of Type 2 diabetes mellitus with diabetic chronic kidney disease and a secondary diagnosis of Dependence on renal dialysis. The POC was signed PT A and dated 11/18/2022. The POC contained an order for SN visits one time per week for eight weeks effective week of 11/21/2022 for medication management. The POC also included an order for PT visits for one time per week for one week, three times per week for three weeks, two times per week for four weeks and one time per week for one week and for OT to evaluate and treat. During a home visit with Patient # 1 on 02/23/2023 at 12:30 p.m., the surveyor observed, and reviewed Patient # 1's home admission folder. The folder did not include a written visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA (PT and OT). The folder included the blank (was not completed with a schedule) visit schedule that was in the agency’s sample admission packet. Clinical Record # 2: Review of Patient # 2’s EHR revealed a POC with a SOC date of 04/13/2021. The POC had a certification period 12/04/2022 to 02/01/2023 and a primary diagnosis of “Pressure ulcer of right buttock, stage 4.” The POC was signed the DON and dated 12/04/2022. The POC contained an order for SN visits one time per week for one week two times per week for eight weeks and one time per week for one week for wound care. During a home visit with Patient # 2 on 02/22/2023 at 3:00 p.m., the surveyor observed, and reviewed Patient # 2's home admission folder. The folder did not include a written visit schedule that included frequency of visits by HHA personnel. The folder included the blank (was not completed with a schedule) visit schedule that was in the agency’s sample admission packet. Clinical Record # 5: Review of Patient # 5’s revealed a POC with a SOC date of 02/09/2023 for the certification period of 02/09/2023 to 04/09/2023. The POC contained an order for SN visits one time per week for nine weeks with as needed visits. The POC also contained and order for PT and OT to evaluate and treat. The individualized POC was not signed and dated by an agency nurse. During a home visit with Patient # 5 on 02/23/2023 at 1:00 p.m., the surveyor observed, and reviewed Patient # 5's home admission folder. The folder did not include a written visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA (PT and OT). The folder included the blank (was not completed with a schedule) visit schedule that was in the agency’s sample admission packet. During an interview with the Adm and DON on 02/28/2022 at approximately 10:15 a.m., the surveyor discussed the above findings of why the agency had not provided a current written visit schedule to Patients # 1, # 2 and # 5. The Adm replied, “I think we probably forgot about it. I will make sure we get it done.”

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 coordinate patient care and services with a physician and an outpatient dialysis facility for two (Patients #1 and # 2) of three patients record reviewed who received a home visit. The failure could place the patient 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: Clinical Record # 1: Record review of the EHR for Patient # 1 revealed a POC with a SOC date of 11/18/2022. The POC had a certification period 11/18/2022 to 01/16/2023 and a primary diagnosis of Type 2 diabetes mellitus with diabetic chronic kidney disease and a secondary diagnosis of Dependence on renal dialysis. The POC was signed PT A and dated 11/18/2022. The POC contained an order for SN visits one time per week for eight weeks effective week of 11/21/2022 for medication management. The POC also included an order for PT visits for one time per week for one week, three times per week for three weeks, two times per week for four weeks and one time per week for one week and for OT to evaluate and treat. Continued review of the record revealed missed visit notes dated 01/16/2023 and 01/20/2023 and signed by OT A that documented Patient # 1 had dialysis and was only available on Tuesdays and Thursdays. Further review of Patient # 1’s clinical record did not reveal any documentation that indicated the agency had coordinated services with the outpatient dialysis center. During a home visit and interview with Patient # 1 on 02/23/2023 at 12:30 p.m., Patient # 1 stated that she received dialysis treatment three times per week at dialysis center (Identifier 100). During an interview on 02/28/2023 at 10:55 a.m., the surveyor discussed the above findings and asked the DON and Office Mgr. why there no coordination of patient care and no documentation in Patient # 1's record of coordination of services between the agency and the dialysis center. The Office Mgr. replied, “That’s a good question. It was the therapy.” The DON replied, “I think they [PT] forgot.” Clinical Record # 2: Review of Patient # 2’s EHR revealed a POC with a SOC date of 04/13/2021. The POC had a certification period 12/04/2022 to 02/01/2023 and a primary diagnosis of “Pressure ulcer of right buttock, stage 4.” The POC was signed the DON and dated 12/04/2022. The POC contained an order for SN visits one time per week for one week two times per week for eight weeks and one time per week for one week for wound care. Continued review of the record revealed a laboratory result for a urine specimen culture dated 12/31/2022. The urine culture was collected on 12/28/2022 and was faxed to the agency on 12/31/2022. The urine culture showed that the results were “abnormal” with an identified bacterium. Further review of the record did not reveal that the agency notified the primary physician (Identifier 200) of the abnormal results until 01/10/2023. Review of Patient # 2’s SN visit notes revealed the following: SN visit note dated 01/10/2023 and signed by LVN A read in part, “…Patient has a fever today 100.2…Patient said that she got her lab results from the [kidney doctor]. SN looked at the results and there was a [urine analysis or test of the urine] and [culture, a test to check for bacteria or other germs in the urine] included and SN asked the patient if the [kidney doctor] went over those results and she said well they asked her if she had any burnoing and she said no. SN said well it shows that she has [E. coli/Escherichia coli, a bacteria that normally live in the intestines of healthy people and animals] UTI. Nurse called Patients PCP Dr. [Identifier 200]…” The SN note further revealed that the patient was stated on an antibiotic. The surveyor conducted an interview with the DON and the Office Mgr. on 02/28/2023 at 10:06 a.m. The surveyor discussed the above findings and asked why the physician was not notified until 10 days after the agency received the laboratory results. The Office Mgr. replied, “Maybe it’s because we trust the lab.” The DON replied, “The lab is supposed to send a copy to the doctor too.” Review of agency policy titled “Coordination of Care TX.8” dated 011318 read in part “…Policy…F. The clinical managers are responsible for the coordination of services. The clinical manager’s oversight will include the following…2. Coordinating patient care…Procedure…A. Effective interchange and reporting, as well as coordination of care will occur between all disciplines providing care, treatment or services…B. Coordination of care will occur between other organizations or programs involved in care including…Dialysis…on admission and ongoing. Other providers of care may also include…an outpatient facility…Communication will be documented in the clinical record on the Coordination of Care form or a communication form…” Review of agency policy titled “TX.7 Implementing Care and Treatment” dated 011318 read in part “…Policy…Agency designates a qualified Clinical Manager(s) who will oversee the following when coordinating the assignments of patient care…2. Coordinating patient care…” Review of agency policy titled “TX.12 Laboratory Testing” dated 011318 read in part: “…Procedure…C. Agency will notify the physician and RN regarding the lab results by fax and/or phone. All panic or critical lab results which are out of acceptable range will be brought to the physician’s attention as soon as possible. Time and date of physician contact is noted in the clinical record…”

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the clinical manager failed to assure the development and implementation of the individualized plan of care in two (Patients # 3 and # 5) of two patient records reviewed for current individualized plans of care. The failure could cause patient harm due to lack of oversight of patient care services by the clinical manager. FINDINGS INCLUDED: On 02/21/2022 the agency provided a current patient roster that listed Patient # 3 as an active patient. The patient roster listed a SOC date for Patient # 3 as 02/08/2023 for the certification period of 02/08/2023 to 04/08/2023. Clinical Record # 3: Record review on 02/21/2023, of the EHR for Patient # 3 did not reveal an individualized plan of care. A review of the “print chart” feature of the EHR revealed under “order” revealed that Patient # 3’s CMS 485/individualized plan of care status was listed as “not started.” A review of Patient # 5’s clinical record on 02/24/2023 revealed an individualized plan of care with a SOC date of 02/14/2023. The plan of care was signed and dated by RN A and dated 02/14/2023. The plan of care listed the DON as the clinical manager. Clinical Record # 5: Record review on 02/21/2023, of the EHR for Patient # 5 revealed an individualized plan of care with a SOC date of 02/09/2023 for the certification period of 02/09/2023 to 04/09/2023. The individualized plan of care was not signed and dated by an agency nurse. The clinical manager listed on the plan of care was LVN B. During an interview on 02/28/2023 with the DON, Office Mgr., and Office staff at approximately 10:58 a.m. the surveyor discussed the above findings and asked why the clinician manager failed to assure that Patients # 3 and # 5 had current individualized plans of care that were developed, completed, signed, and dated by an agency nurse. The Office Mgr. replied, [for Patient # 3] “The RN was late admitting the patient. The RNs are [as needed staff].” The Office Staff replied, [for Patient # 5] “The RN said that her computer wasn’t working or something like that.” The DON just looked at the surveyor and did not answer. Review of agency policy titled “ LD.7 Qualifications and Responsibilities of the Clinical Manager” dated 011318 read in part: “…Policy…Responsibilities of the Clinical Manager include…1. Provide oversight of all patient care services and personnel. Oversight must include…a. Making patient and personnel assignments; b. Coordinating patient care; c. Coordinating referrals; d. Assuring that patient needs are continually assessed and assuring the development, implementation , and updates to the individualized plan of care…”

Clinical Manager CFR(s): 484.115(c) Standard: Clinical manager. A person who is a licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker, or a registered nurse. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical manager was a person who was a licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker, or a registered nurse in two (Patients # 1 and # 5) of three patient records reviewed who received home visits. The failure could cause patient harm due to lack of oversight of patient care services by a qualified clinical manager. FINDINGS INCLUDED: Clinical Record # 1: Record review of the EHR for Patient # 1 revealed a POC with a SOC date of 11/18/2022. The POC had a certification period 11/18/2022 to 01/16/2023 and a primary diagnosis of Type 2 diabetes mellitus with diabetic chronic kidney disease and a secondary diagnosis of Dependence on renal dialysis. The POC was signed by PT A and dated 11/18/2022. The POC contained an order for SN visits one time per week for eight weeks effective week of 11/21/2022 for medication management. The clinical manager was list as the Office Mgr. The POC dated 11/18/2023 was signed by primary physician (Identifier 400) and dated 12/02/2022. The clinical record for Patient # 1 also included a POC for the certification period of 01/17/2023 to 03/17/2023 that was signed by the DON and dated 01/17/2023. The POC dated 01/17/2023 also listed the Office Mgr. as Patient # 1’s clinical manager. Personnel Record: Office Mgr. Record review of the Office Mgr.’s personnel record did not reveal any records that indicated she was a licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker, or a registered nurse. The record contained signed job descriptions for home health aide, data entry clerk and office manager. The Office Mgr.’s job application revealed job experience and certification as an educator. Clinical Record # 5: Record review on 02/21/2023, of the EHR for Patient # 5 revealed a POC with a SOC date of 02/09/2023 for the certification period of 02/09/2023 to 04/09/2023. The POC contained an order for SN visits one time per week for nine weeks with as needed visits. The individualized POC was not signed and dated by an agency nurse. The clinical manager listed on the POC was LVN B. Further review of the clinical record revealed an “Intake referral form” dated 02/07/2023. The intake referral form listed the “Admitting RN” as LVN B. Personnel Record: LVN B Record review of LVN B’s personnel record did not reveal any records that indicated she was a licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker, or a registered nurse. The record contained a signed job description for LVN. The record also included a license verification for LVN. During an interview on 02/28/2023 with the DON and Office Mgr. at approximately 10:58 a.m., the surveyor discussed the above findings and asked why the assigned clinician managers for Patients # 1 and # 5 did not meet the regulatory qualifications. The Office Mgr. stated that it was a mistake. The DON just looked at the surveyor and did not answer. Review of agency policy titled “ LD.7 Qualifications and Responsibilities of the Clinical Manager” dated 011318 read in part: “…Policy… Qualifications of a Clinical manager… A. The Clinical Manager is a qualified licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker, or a registered nurse…C. The role of the Clinical Manager may not be delegated…”