Every finding on record at Winghing Chun Inc

An entrance conference was conducted with the Alternate Administrator/Alternate DON on 2/1/2022 at 12:15 PM. The Alternate Administrator/Alternate DON was informed the purpose of the visit was to conduct a recertification survey and investigation of Intakes #231720, #183564 and #186618. The "HCSSA's, What To Expect During Your Agency's Survey" was provided and explained. Written information was provided with instructions on how to complete the on-line "Comment Card Survey. On 2/18/2022 at 2:00 PM, the Alternate Administrator/Alternate DON was informed the self-reported Intake #333556 had an allegation of Infection Control and an Infection Control survey would be conducted, in addition to the current recertification survey. Census: Parent location: Richardson Licensed and Certified Home Health - 19 Branch location: North Richland Hills Licensed and Certified Home Health - 0 An exit conference was conducted on 2/28/22 at 3:20 PM, with the Alternate Administrator/Alternate DON, and office staff member, RN M. Also present, via telephone call, were office staff members, manager/scheduler, Employee A, and LVN C. The preliminary findings of the survey were discussed and a written copy was provided. The agency representatives were afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Deficiencies. The agency representatives were informed Intake #186681 would be re-assigned. Intakes #231720, #183564, and #333556 were substantiated with deficiencies.

An entrance conference was conducted with the Alternate Administrator/Alternate DON on 2/1/2022 at 12:15 PM. The Alternate Administrator/Alternate DON was informed the purpose of the visit was to conduct a recertification survey and investigation of Intakes #231720, #183564 and #186618. The "HCSSA's, What To Expect During Your Agency's Survey" was provided and explained. Written information was provided with instructions on how to complete the on-line "Comment Card Survey." On 2/18/2022 at 2:00 PM, the Alternate Administrator/Alternate DON was informed the self-reported Intake #333556 had an allegation of Infection Control and an Infection Control survey would be conducted, in addition to the current recertification survey. Census: Parent location: Richardson Licensed and Certified Home Health - 19 Branch location: North Richland Hills Licensed and Certified Home Health - 0 An exit conference was conducted on 2/28/22 at 3:20 PM, with the Alternate Administrator/Alternate DON, and office staff member, RN M. Also present, via telephone call, were office staff members, manager/scheduler, Employee A, and LVN C. The preliminary findings of the survey were discussed and a written copy provided. The agency representatives were afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Deficiencies. The agency representatives were informed Intake #186681 would be re-assigned. Intakes #231720, #183564, and #333556 were substantiated with violations. Abbreviations: HCSSA (Home and Community Support Services Agencies) HHSC (Health and Human Services Commission) OASIS (Outcome and Assessment Information Set) DON (Director of Nursing) POC (Plan Of Care) SOC (Start Of Care) RN (Registered Nurse) LVN (Licensed Vocational Nurse) PT (Physical Therapy) PTA (physical therapy assistant) OT (Occupational Therapy) MSW (Masters Social Worker) SN (skilled nursing) MD (medical doctor) pt (patient) PCP (primary care physician) PRN (as needed) RLE (right lower extremity) LLE ( left lower extremity) CHF (congestive heart failure) COPD (chronic obstructive pulmonary disease) PVD (peripheral vascular disease) L (length) W (width) D (depth) cm (centimeters) mg (milligram) NS (normal saline) TAO (triple antibiotic ointment) V/S (vital signs TX BON (Texas Board of Nursing ADLs- activities of daily living O2 -oxygen LPM -liter per minute HHC - home health care CMS- center medicare/medicaid services BNI - CMS beneficiary Notices Initiatives UNNA- type of bandaging used in wound care A-fib - cardiac condition QIO-Quality Improvement Organization in the Centers for Medicare and Medicaid Services (CMS), Area 3: including Texas. OMB- Office of Management and Budget

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 home health agency failed to protect the patient's rights by not ensuring 6 (Patients 11, 12, 13, 14, 15 and 16 ) of 6 discharged patients whose records were reviewed did not receive written notice of discharge, the Notice of Medicare Non-Coverage (NOMNC), that included the Quality Improvement Organization (QIO) contact information, in time for them to appeal a discharge decision. This failure prevented the patients from exercising their rights to appeal a discharge decision for reconsideration. Findings include: A list of patients who were discharged between 1/01/21 to 2/01/22 was provided by the Alternate Administrator/Alternate DON, on 2/8/22 at 11:45 am. The list provided the dates and reason for discharge, including those patients that were discharged with their goals met.Review of the discharged list:Discharged Patient 11: revealed a discharge date 1/31/22 with discharge reason "Goals Met".Discharged Patient 12: revealed a discharge date 9/13/21 with discharge reason "Goals Met".Discharged Patient 13: revealed a discharge date 10/11/21 with discharge reason "Goals Met".Discharged Patient 14: revealed a discharge date 5/27/21 with discharge reason "Goals Met".Discharged Patient 15: revealed a discharge date 1/5/21 with discharge reason "Goals Met".Discharged Patient 16: revealed a discharge date 8/2/21 with discharge reason "Goals Met".Review of discharge records:Discharged Patient 11, with a discharge date of 1/31/22. Review of the patient's entire record did not include the Medicare/ Medicaid Services (CMS) form titled, "Notice of Medicare Non-Coverage." Patient 11 should have received and signed the "Notice of Medicare Non-Coverage," to indicate the patient received the form, with in 2 days before discharge, on 1/29/22. Discharged Patient 12, with a discharge date of 9/13/21. Review of the discharge record revealed a Center for Medicare/ Medicaid Services (CMS) form titled, "Notice of Medicare Non-Coverage" was signed by Patient 12 on 9/13/21. Patient 12 should have received and signed the "Notice of Medicare Non-Coverage," to indicate the patient received the form, with in 2 days before discharge, on 9/11/21. Discharged Patient 13, with a discharge of 10/11/21.Review of the patient's entire record did not include the Medicare/ Medicaid Services (CMS) form titled, "Notice of Medicare Non-Coverage." Patient 13 should have received and signed the "Notice of Medicare Non-Coverage," to indicate the patient received the form, with in 2 days before discharge, on 10/9/21. Discharged Patient 14, with a discharge date 5/27/21. Review of the patient's entire record did not include the Medicare/ Medicaid Services (CMS) form titled, "Notice of Medicare Non-Coverage." Patient 14 should have received and signed the "Notice of Medicare Non-Coverage," to indicate the patient received the form, with in 2 days before discharge, on 2/25/21. Discharged Patient 15, with a discharge date of 1/5/21. Review of the discharge record revealed a Center for Medicare/ Medicaid Services (CMS) form titled, "Notice of Medicare Non-Coverage" was signed by Patient 15 on 1/6/21. 1 day after the documented discharge date. Patient 15 should have received and signed the "Notice of Medicare Non-Coverage," to indicate the patient received the form, with in 2 days before discharge, on 1/3/21. Discharged Patient 16, with a discharge date of 8/2/21. Review of the discharge record revealed a Center for Medicare/ Medicaid Services (CMS) form titled, "Notice of Medicare Non-Coverage" was signed by Patient 16 on 8/2/16. Patient 16 should have received and signed the "Notice of Medicare Non-Coverage," to indicate the patient received the form, with in 2 days before discharge, on 7/31/21. An interview was conducted on 2/28/22 at 1;00 PM, with the Alternate Administrator/Alternate DON. The surveyor reviewed and discussed the findings regarding the discharged Patients 11, 12, 13, 14, 15, and 16. The surveyor asked why the discharged patients had not been given the "Notice of Medicare Non-Coverage (NOMNC)", that included the Quality Improvement Organization (QIO) contact information so the patients had an opportunity to appeal the discharge decision prior to when home health services ended, within 2 days of discharge. The surveyor and the Alternate Administrator/Alternate DON reviewed the discharges. The Alternate Administrator/Alternate DON was unable to locate the the forms for patient's 11, 13 and 14 and said if they were not in the patient's record she did not know where they would be and may not have been done. She said she did not know why patient 12, 15 and 16 did not sign the forms at least 2 days before discharge. She said she had discussed this with agency nurses and it was not that hard to make sure the patients received the form within 2 days before discharge. She did not dispute the surveyor's findings. No further documentation was provided. Agency Policy, quoted in part, Revised date 120118 ..."PATIENT/CLIENT TRANSFER AND DISCHARGE NOTICES PE. 6, ...Purpose: To provide guidance on completion of the required transfer and discharge notices...Policy ...IV. The Agency will deliver a Detailed Explanation of Non-Coverage (an OMB-approved Medicare form) to the patient/client and the appropriate Quality Improvement Organization (QIO) if the patient/client requests an expedited review by the QIO of the decision that coverage for items and/or services should end..... Procedure II. Notice of Medicare Non-Coverage (NOMNC) and Detailed Explanation of Non-Coverage (DENC)...A. Agency staff will provide valid delivery notice (involves both delivery and completion) of the NOMNC to the patient/client (or their representative) when the end of all covered care is foreseen, even if the patient/client agrees with the discharge. B. At least two (2) calendar days before Medicare covered services end or the second to last day of service if care is not provided daily, the Agency representative will provide the NOMNC to the patient/client (or their representative) when providing the five (5) day notice of discharge...."Regulation: July 1, 2005, the new Medicare regulations (Benefits Improvement and Protection Act) BNI gave beneficiaries access to the new expedited determination process when their home health agency services are ending. There are two notices required by these regulations. The first is a generic notice (called a Notice of Medicare Provider Non-coverage) that the provider will deliver at least two days prior to when a beneficiary's Medicare coverage of services is ending. The phone number for the Quality Improvement Organization (QIO) should be included in this notice (XXX-XXX-9504). The second is a detailed notice (called a Detailed Explanation of Provider Non-Coverage) that the provider will deliver to the beneficiary and the appropriate QIO only if the beneficiary requests an expedited review by the QIO of the decision that coverage for items and/or services should end.

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 record review and interview, the agency failed to ensure a patients received the services written in the plan of care as ordered by the physician for 3 (Patients 1, 2 and 3) of 10 patients records reviewed. Patient 1 and 2 did not receive wound care or skilled visits as ordered. Patient 3 did not receive skilled visits as ordered. This failure placed the patients at risk of significant changes in health status to go unreported, and caused a decline in Patient 1, 2, and 3's health status, that included wound infection, and harm. Findings include: Patient 1: Review of the patient’s record revealed a POC with an episode period of 09/22/21 to 11/20/21 and included a SOC date of 05/25/21. The POC included a primary diagnosis of Hemiplegia and hemiparesis [muscle weakness or partial paralysis] following cerebral infarction [lack of blood flow to the brain] affecting left non-dominant side. Other diagnoses included Diabetes Mellitus, history of falling, and bed confinement. The POC included orders for SN frequency of one time a week for four weeks starting 09/29/21, one time a week for one week starting 10/31/21, and one time a week for one week starting 11/14/21. The POC included orders for SN to perform inspection of patient’s lower extremities every visit and report any alteration in skin integrity to the physician. Client 1’s record included skilled nurse notes for the first two visits of the treatment period. RN K signed and dated the notes on 9/30/21 and 10/7/21. RN K's documentation indicated the patient did not have a wound or wound care orders during this time. RN K documented the patient’s skin was intact. The record included an “Oasis – Transfer to Inpatient Facility” dated 10/11/21 and listed the date of the patient’s transfer to the facility as 10/11/21. The Oasis included the Client 1’s physical condition, at the time of the transfer, was unknown and no visit was made. The record included an “office communication” signed and dated on 10/13/21, by LVN C, that read “patient discharging home today... resumption order 10/13/21….” The record included an “Oasis – Resumption of Care” assessment signed and dated by RN K on 10/14/21. RN K documented, in the “Integumentary Status” section of the assessment, the patient had a “Stage 1 pressure injury” and “DM foot assessment performed; no abnormalities noted, has stage 1 pressure sore to heel; no dressing/wound care provided this skilled nurse visit; pt [patient] to keep her foot elevated & no pressure on it.” RN K’s wound documentation, in the “Wound Assessment” section included a description of Wound #1, location left heel, date of onset 10/11/21, measurement of L-4.5 cm, W-4 cm, D-0.0 cm. Patient 1’s record included a skilled nurse visit note for the next weekly visit, signed and dated by RN K, on 10/21/21. There was no documentation regarding the status of the "Stage 1 pressure injury" to Patient 1’s left heel. RN K documented, in the “Skin” section of the note, “skin integrity intact.” The record indicated there were no further weekly skilled nurse visits for 3 consecutive weeks. The record included 3 “Missed Visits Notes,” signed and dated by manager/scheduler, Employee A. The missed visit note dated 10/29/21 read, “…service…LVN…skilled nursing…pt refused staff….” The missed visit note dated 11/5/21 read, “…service…LVN…skilled nursing…pt refused staff….” The missed visit note dated 11/12/21 read, “…service…LVN…skilled nursing…pt refused staff…. ” Client 1’s record revealed another “Missed Visit Note” signed and dated by manager/scheduler, Employee A, on 11/16/21. The missed visit note read, “service… PTA… [family member] called, and cancelled stating patient heel blister had opened and was bleeding. Stated she was planning to take patient to the hospital….” Patient 1’s record included an “Oasis – Transfer to Inpatient Facility” dated 11/16/21. Review of the entire record, revealed no documentation that indicated the agency attempted to reschedule or make-up the missed visits. Review of Patient 1's record included a hospital record that revealed Patient 1 was hospitalized on 11/16/21 with a wound infection. Review of Patient 1’s hospital records dated 11/17/2021 revealed Patient 1 was admitted to the emergency department on 11/16/21 at 12:00 noon. The hospital record read, …”74 year old F [female] w/h/o [with history of] stroke presents to the ED [emergency department] for evaluation of pain from L [left] foot wound. Patient states she has had the foot pain for a long time…. Skin:… L- 3.5 cm, W- 3.5 cm, wound to left heel. Break in skin and mild amount cellulitis [swelling]. Mild amount of erythema [redness] noted at this time. No discharge and pungent odor noted…. Clindamycin (Cleocin) [antibiotic] 150 mg capsule, take 1 capsule (150 mg total) by mouth 3 times a day, starting 11/16/21…. Home health to arrange for visits and have wound care evaluate as well. Pt stable for discharge at this time…. Pt is bed bound – in hospital bed at home.“ An interview was conducted with the Alternate Administrator/ Alternate DON on 2/22/22, at 2:00 pm. The surveyor reviewed the missed visits and asked why the skilled nursing visits were not completed. The Alternate Administrator/Alternate DON stated she thought the reason the visits were refused was because RN K was out of town and the patient’s family member did not want another nurse. The surveyor asked for documentation of the agency’s efforts to reschedule and provide a nursing visit. The Alternate Administrator/Alternate DON said the agency was probably not able to reschedule the visit with the nurse and /or the patient at the time. No further documentation was provided. Patient 2: Review of the patient’s record revealed a POC with an episode period of 10/5/21 to 12/3/21 and included a SOC date of 10/5/21. The POC included a primary diagnosis of “Peripheral vascular disease” [a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs]. Other diagnoses included, “Non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin, non-pressure chronic ulcer of other part of left lower leg limited to breakdown of skin….“ The POC included orders for a SN frequency of two times a week for four weeks, and one time a week for 5 weeks, starting 10/5/21, with 1 PRN for wound care needs. The POC included orders for skilled nursing to assess and evaluate wounds at each dressing change and PRN for signs and symptoms of infection. Report to physician increased temp…, chills, increase in drainage, foul odor, redness, unrelieved pain greater that 7 on a 0-10 scale, and any other significant change. The POC included orders for skilled nursing to perform wound care as follows: using aseptic technique, SN to clean with normal saline, pat dry with gauze, apply 3 layer UNNA Boot System [a special gauze bandage, which can be used in the treatment of venous stasis ulcers and other venous insufficiencies of the leg] from just before the toes up to just below the knee. Patient 2’s record included a SOC signed and dated by the Administrator/DON, on 10/5/2021. The Administrator/DON's documentation, in the “Wound Assessment” section included the following, “Wound #1… venous stasis… L-1.7 cm, W-1.7 cm, D-0.2 cm, small amount serosanguinous [blood tinged] drainage. Using aseptic technique, skilled nurse cleaned RLE with NS, patted dry with gauze, applied TAO, then Vaseline gauze (cut to size), then wrapped with Kerlix [a soft type of gauze used for bandaging]. Wound #2, venous stasis, L-1.7 cm, W-1.7 cm, D-0.2 cm depth, with a small amount serosanguinous drainage, using aseptic technique, skilled nurse cleaned LLE with NS, patted dry with gauze, applied TAO, then Vaseline gauze (cut to size), then wrapped with Kerlix. The record revealed a “Missed Visit Note” signed and dated by RN C on 10/8/21. RN C’s skilled note included, “…service: SN Wound Care…patient [family member] unable to be there for the visit, requests visits to start on Monday.” Review of the record revealed there were 6 days until the next wound care visit. Patient 2’s record revealed a skilled nurse visit note signed and dated by RN C on 10/11/21. RN C’s note included wound care documentation that read, “Wound #1, venous stasis, L 1.7 cm, W 1.7 cm, D 0.2 cm, small amount serosanguinous drainage, SN cleansed wound with wound cleanser, patted dry with gauze, applied zinc [barrier cream for cuts, scrapes and burns] wrap, covered with Coban [a cohesive bandage commonly used to wrap on limbs]. The record revealed a “Missed Visit Note” signed and dated by RN C on 10/14/21. RN C’s skilled note included, “…service: SN Wound Care… [family member] canceled visit. They have errands to run.” Review of the record revealed there were 7 days until the next wound care visit. Patient 2’s record revealed a skilled nurse visit note signed and dated by RN C on 10/18/21. RN C’s note read, “SN cleansed wound with wound cleanser, patted dry with gauze, applied zinc wrap, covered with Coban.” Review of Patient 2’s record contained a calendar with a schedule of wound care visits to be provided. There were no completed skilled nurse visit notes documented, for 22 days, from 10/18/21 until 11/9/21. The record revealed Patient 2 had a wound clinic appointment on 11/9/21. The following missed visit notes were included in the record, The calendar included a visit was scheduled for 10/21/21, and revealed documentation that read, “clinician RN C, SN Wound Care, Planned.“ There was no visit completed and no missed visit note documented. A missed visit note signed and dated by RN C on 10/25/21 read, “No answer to locked door and no answer to multiple phone calls.” The calendar included a visit was scheduled for 10/28/21, and revealed documentation that read, ”clinician RN C, SN Wound Care, missed visit.“ Scheduled visit dated 11/1/21, revealed a missed visit note, signed and dated by RN C and read, “Pt has MD appointment.“ The record revealed the patient went 22 days with no wound care visit by an agency nurse. Patient 2’s record revealed a wound clinic visit note dated 11/9/21. The note revealed the following, “This 76 year old female, Non Diabetic patient with a history of CHF, COPD, AFIB and PVD presents as new patient today with a referral from… for open ulcers to bilateral lower extremities…She has recently started HHC [home health care] but for some reason they have stopped coming. Pt is unable to provide the name of the HHC, she will call back with this information. We will fax wound care orders to them to start assisting with dressing changes. Pt comes in today with UNNA boots bilaterally…there was nothing covering the wounds…the Unna calamine layer was stuck to the ulcers. Pt reported family member applied them for her….The wounds today were cleansed, applied Santyl [barrier cream] ointment, Hydrofera blue ready [foam dressing] and wrapped legs with Kerlix and loose Coban….” The note continues, “…Wound #1, left lateral lower leg…ulcer… not healed… 3 cm length, 3 cm width, 0.1 cm depth…periwound [tissue around the wound] skin presents with signs and symptoms of infection…. A debridement was performed…non-viable tissue removed…procedure tolerated well…applied Santyl ointment debriding agent to wound bed.” “Wound #2, right lateral lower leg… full thickness venous ulcer…not healed…4.76 cm length, 2.54 cm width, 0.1 depth…periwound skin presents with signs and symptoms of infection…. A debridement was performed…non-viable tissue removed…procedure tolerated well…applied Santyl ointment debriding agent to wound bed.” “Home Health Wound Care Orders: Please visit M-W-F, remove bilateral lower leg dressings, cleanse open ulcers with Vashe [wound cleanser] or normal saline, pat dry, apply Santyl ointment …to all open ulcers, cover with Hydrofera blue ready, then loosely wrap both legs with gauze kerlix roll, then loose Coban. Patient and /or family can assist with dressing changes the other days. Santyl ointment is daily….” There was nothing in the record that indicated the agency’s attempts to reschedule and make the nursing visits. The surveyor conducted a home visit with Patient 2 on 2/7/22, at approximately 2:00 pm. Patient 2 said she did have problems scheduling with one of the nurses that came in the beginning. Patient 2 said the nurses name was [RN C]. Patient 2 said the nurse hardly ever made the visits and said the nurse always had excuses. She said she told the Alternate Administrator/Alternate DON about it, and she took care of it. Patient 2 said she liked the nurse she currently had and the nurse conducted all the visits. Review of the agency’s complaint binder revealed Patient 2’s wound clinic physician called the agency on 11/10/21 and reported a complaint about the condition of Patient 2’s wounds. The complaint read as follows, “Patient Complaint Form” signed and dated on 11/10/21 by LVN C. “…Person registering complaint: [Physician A] @ wound center... Employee involved: [RN C] … Physician: PCP: [ Physician B] … Description of Complaint… HH [home health] stopped coming. Unna boot dressing stuck to wound (ulcer), family member was applying dressing….” “Action taken” LVN C documented she notified Employee A, manager/scheduler, and “…will have the Alternate Administrator/Supervising Nurse follow up….” The complaint form continued, “…Resolution Follow Up….” The complaint form included the Alternate Administrator/Alternate DON's signature, dated 11/12/21 and indicated she attempted to visit and call to follow up with Patient 2 on 11/11/21, and was unsuccessful. The Alternate Administrator/Alternate DON documented she received a phone call from Patient 2 and the patient reported she had been at the hospital with a family member and may have missed calls from the agency. An interview was conducted with the Alternate Administrator/ Alternate DON on 2/22/22 at 2:00 pm. The surveyor reviewed Patient 2’s missed visits, the complaint from the wound clinic and asked why RN C did not complete scheduled nursing visits. The Alternate Administrator/ Alternate DON said she thought the reason the visits were missed was because the client was living with another family member, so the patient was very hard to get in touch with. The surveyor requested documentation of the agency’s efforts to provide the ordered visits and documentation of coordination with the patient’s physician. The Alternate Administrator/Alternate DON said she was not sure why the visits were not completed and RN C had not returned her calls. No other documentation was provided to the surveyor. Patient 3. Review of the patient’s record revealed a POC with an episode period of 12/28/21 to 2/25/22 and included a SOC date of 12/28/21. The POC included a primary diagnosis of Pneumonia. Other diagnoses included Chronic Obstructive Pulmonary Disease and Chronic diastolic (congestive) heart failure and Type II Diabetes Mellitus. The POC included “…SN frequency 2W1 [two times a week for one week] 1W8 [one time a week for 8 weeks] starting 12/28/21, PT frequency 1W1, 2W4, 1W1…for weak/unsteady gait with a history of falls, OT frequency 1W1, 2W3, 1w1… for ADL’s, MSW frequency 1-3 Q 60 days [1-3 times every 60 days] for community resources, long term planning, provider services….” The POC included orders for “SN to perform finger stick for fasting blood sugar/random blood sugar during the visit if it has not been done or if patient reports signs and symptoms of hypo/hyperglycemia…Clinician to assess and instruct patient and caregiver on signs/symptoms of heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain)…SN to inspect patient’s lower extremities every visit and report any alteration in skin integrity to the physician…SN to assess O2 saturation [oxygen level reading] on O2 @ 2 LPM [liters per minute]/every visit....” Review of Patient 3’s record revealed a SN visit dated 1/7/22, documented by RN C. RN C documented labs were ordered and drawn during the visit. Review of the entire record did not include any further documented SN visits. Review of the record included “Missed Visit Order” notes, all signed and dated by RN C, that read, “Missed Visit Order… 12/30/2021…No answer to multiple phone calls.” “Missed Visit Order… 01/14/2022…No answer to multiple phone calls.” “Missed Visit Order… 01/18/2022…No answer to call.” “Missed Visit Order… 01/25/2022…No answer to locked door and multiple phone calls, drove by her home and no one answered the door.” “Missed Visit Order… 02/04/2022…Visit cancelled due to severe weather, visit rescheduled for Friday” “Missed Visit Order… 02/08/2022…Staff sick, unable to make visit due to illness this week.” “Missed Visit Order… 02/18/2022…No answer to multiple phone calls.” Review of Patient 3’s record revealed all PT, OT and MSW visits were made to Patient 3 as scheduled for the episode period. The surveyor conducted an interview on 2/22/22 at 2:00 pm with the Alternate Administrator/Alternate DON. The surveyor asked why RN C had not done the ordered visits for Patient 3. The Alternate Administrator/Alternate DON said she thought RN C had done the visits, She said RN C was behind on getting her notes in and thought she had not documented the visits. The surveyor reviewed the missed visit notes from RN C and the complaint from Client 2 about RN C not doing her scheduled visits. The Alternate Administrator/Alternate DON said this was an ongoing problem and the nurse was jeopardizing the patients. She said she had tried to call RN C, but she was not returning her calls. The surveyor requested documentation of the agency’s efforts to reschedule the visits as soon as the agency was made aware of the missed visits. The Alternate Administrator/Alternate DON said the agency was probably not able to reschedule the visit with the nurse and /or the patient at the time. No documentation of the agency’s attempt to provide the visits was provided. The surveyor conducted a phone interview with Patient 3 on 2/25/22 at 5:10 pm. Patient 3 told the surveyor she was happy with the therapy services, but not with the nursing services. She said she never had a nurse come except one time. She said a nurse came once and drew blood for lab work and never came again. She told the surveyor the agency never offered to provide home health aide services to assist her with her ADL's. She thanked the surveyor for the call. The surveyor conducted an exit interview on 2/28/22 at 3:30 pm with the Alternate Administrator/Alternate DON and RN M. LVN C and manager/scheduler, Employee A, were in attendance via telephone. The surveyor reviewed Patient 3’s record and asked if anyone had spoken with Patient 3 regarding the missed visits. LVN C said she called Patient 3 on 2/23/22, to check on her because of the winter weather. LVN C said Patient 3 reported to her that the nurse, RN C never made her visits. LVN C said the patient requested to be discharged. LVN C said Patient 3 told her she was very unhappy with the nursing services but was happy with the therapy services. The Alternate Adm/Alt DON told the surveyor that now that she knows about the missed visits she would make a referral to the Texas Board of Nursing. The surveyor asked why the patient did not have home health aide services provided to the patient. The Alternate Administrator/Alternate DON said the nurse, RN C, should have identified the patient needed assistance and assisted in arranging home health aide services. She said the nurse should have completed the visits and RN C would be terminated immediately. The surveyor asked if the neglect had been self-reported to HHSC and DFPS. She said it had not been reported. No documentation of the agency’s attempts to reschedule the missed visits was provided. Agency policy, with a revised date of 011318 read in part:..."Responsibilities of the Supervising Nurse", LD.6 ...H. Ensuring that a patient's/client's Plan of Care or care plan is executed as written...."

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the Alternate Administrator/Alternate DON, and the agency’s clinical staff, failed to ensure coordination with physicians, involved in the plans of care for 3 (Patients 1, 2, and 3 ) of 3 patient records reviewed, in that: The physician was not notified of Patient 1's "Stage 1 pressure injury" and missed skilled nursing visits. The physician was not notified of Patient 2's missed wound care visits or the status of the patient's wounds. the physician was not notified of missed skilled nursing visits for Patient 3. These failures resulted in the hospitalization of Patient 1, wound infection for Patient 2, and placed Patient 3 at risk for a decline in health status. Findings include: Patient 1: Review of the patient’s record revealed a POC with a treatment period of 09/22/21 to 11/20/21 and included a SOC date of 05/25/21. The POC included a primary diagnosis of Hemiplegia and hemiparesis [muscle weakness or partial paralysis] following cerebral infarction [lack of blood flow to the brain] affecting left non-dominant side. Other diagnoses included Diabetes Mellitus, history of falling, and bed confinement. The POC included orders for SN frequency of one time a week for four weeks starting 09/29/21, one time a week for one week starting 10/31/21, and one time a week for one week starting 11/14/21. The POC included orders for SN to perform inspection of patient’s lower extremities every visit and report any alteration in skin integrity to the physician. Patient 1’s record included SNV notes for the first two visits of the treatment period. The notes were signed and dated by RN K on 9/30/21 and 10/7/21. RN K's documentation did not indicate the patient had a wound or wound care orders during this time. RN K documented the patient’s skin was intact. Patient 1’s record included skilled nurse visit notes for the first two visits of the treatment period. The notes were signed and dated by RN K on 9/30/21 and 10/7/21. RN K's documentation did not indicate the patient had a wound or wound care orders during this time. RN K documented the patient’s skin was intact. The record included an “Oasis – Transfer to Inpatient Facility” dated 10/11/21 and listed the date of the patient’s transfer to a facility as 10/11/21. The Oasis included the Patient 1’s physical condition, at the time of the transfer, was unknown and no visit was made. Review of the record revealed Patient 1 was transferred to the hospital for encephalopathy [some type of viral or infection that can affect the brain functions and can cause confusion]. The record included an “office communication” signed and dated on 10/13/21, by LVN C, that read “patient discharging home today... resumption order 10/13/21….” The record included an “Oasis – Resumption of Care” assessment signed and dated by RN K on 10/14/21. RN K documented, in the “Integumentary Status” section of the assessment, the patient had a “Stage 1 pressure injury” and “DM foot assessment performed; no abnormalities noted, has stage 1 pressure sore to heel; no dressing/wound care provided this SNV [skilled nurse visit]; pt [patient] to keep her foot elevated & no pressure on it.” RN K’s wound documentation, in the “Wound Assessment” section included a description of Wound #1, location left heel, date of onset 10/11/21, measurement of L-4.5 cm, W-4 cm, D-0.0 cm. Review of the patient's entire record did not include coordination of care from RN K to the patient’s physician regarding the patient's "Stage 1 pressure injury" to the left heel. Patient 1’s record included a skilled nurse visit note for the next weekly visit, signed and dated by RN K, on 10/21/21. There was no documentation regarding the status of the wound to Patient 1’s "Stage 1 pressure injury" to the left heel. RN K documented, in the “Skin” section of the note, “skin integrity intact.” Review of the patient's entire record did not include coordination of care from RN K to the patient's physician regarding the "Stage 1 pressure injury" and condition of the patient's left heel. The record indicated there were no further weekly skilled nurse visits for 3 consecutive weeks. The record included 3 “Missed Visits Notes,” signed and dated by Manager/scheduler, Employee A. The missed visit note dated 10/29/21 read, “…service…LVN…skilled nursing…pt refused staff….” The missed visit note dated 11/5/21 read, “…service…LVN…skilled nursing…pt refused staff….” The missed visit note dated 11/12/21 read, “…service…LVN…skilled nursing…pt refused staff…. ” Patient 1’s record revealed another “Missed Visit Note” signed and dated by Manager/scheduler, Employee A, on 11/16/21. The missed visit note read, “service… PTA… [family member] called, and cancelled stating patient heel blister had opened and was bleeding. Stated she was planning to take patient to the hospital….” Patient 1’s record included an “Oasis – Transfer to Inpatient Facility” dated 11/16/21. Review of the entire record did not included coordination of care from RN K, manager/scheduler, Employee A, or the Alternate Administrator/DON, to the patient’s physician, regarding the status of Patient 1's "Stage 1 pressure injury" to the left heel, or the failure to conduct SN visits and assess the patient for 26 days. There was no record the agency attempted to reschedule or make-up the missed visits. Further review of the record, included a hospital clinical record that revealed Patient 1 was hospitalized on 11/16/21 with a wound infection. Review of Patient 1’s hospital records dated 11/17/2021 revealed Patient 1 was admitted to the emergency department on 11/16/21 at 12:00 pm. The hospital record read, …”74 year old F [female] w/h/o [with history of] stroke presents to the ED [emergency department] for evaluation of pain from L [left] foot wound. Patient states she has had the foot pain for a long time…. Skin:… L- 3.5 cm, W- 3.5 cm, wound to left heel. Break in skin and mild amount cellulitis [swelling]. Mild amount of erythema [redness] noted at this time. No discharge and pungent odor noted…. Clindamycin (Cleocin) [antibiotic] 150 mg capsule, take 1 capsule (150 mg total) by mouth 3 times a day, starting 11/16/21…. Home health to arrange for visits and have wound care evaluate as well. Pt stable for discharge at this time…. Pt is bed bound – in hospital bed at home.“ An interview was conducted with the Alternate Administrator/ Alternate DON on 2/22/22, at 2 pm. The surveyor reviewed the missed visits and asked why the skilled nursing visits were not completed. The Alternate Administrator/Alternate DON told the surveyor she thought the reason the visits were refused was because RN K was out of town and the patient’s family member did not want another nurse. The surveyor asked for documentation the agency notified Patient 1’s physician that ordered skin assessments and wound care visits had not been made. The Alternate Administrator/Alternate DON said the coordination with the physicians should be included in the SNV notes, and she did not think there was any other coordination about the wound care. No other coordination was provided to the surveyor. Patient 2: Review of the patient’s record revealed a POC with a treatment period of 10/5/21 to 12/3/21 and included a SOC date of 10/5/21. The POC included a primary diagnosis of “Peripheral vascular disease” [a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs]. Other diagnoses included, “Non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin, non-pressure chronic ulcer of other part of left lower leg limited to breakdown of skin….“ The POC included orders for a SN frequency of two times a week for four weeks, and one time a week for 5 weeks, starting 10/5/21, with 1 PRN for wound care needs. The POC included orders for skilled nursing to assess and evaluate wounds at each dressing change and PRN for signs and symptoms of infection. Report to physician increased temp…, chills, increase in drainage, foul odor, redness, unrelieved pain greater that 7 on a 0-10 scale, and any other significant change. The POC included orders for skilled nursing to perform wound care as follows: using aseptic technique, SN to clean with normal saline, pat dry with gauze, apply 3 layer UNNA Boot System [a special gauze bandage, which can be used in the treatment of venous stasis ulcers and other venous insufficiencies of the leg] from just before the toes up to just below the knee. Patient 2’s record included a SOC SNV signed and dated by the Administrator/DON, on 10/5/2021. The Administrator/DON's documentation, in the “Wound Assessment” section included the following, “Wound #1… venous stasis… L-1.7 cm, W-1.7 cm, D-0.2 cm, small amount serosanguinous [blood tinged] drainage. Using aseptic technique, skilled nurse cleaned RLE with NS[normal saline], patted dry with gauze, applied TAO, then Vaseline gauze (cut to size), then wrapped with Kerlix [a soft type of gauze used for bandaging]. Wound #2, venous stasis, L-1.7 cm, W-1.7 cm, D-0.2 cm depth, with a small amount serosanguinous drainage, using aseptic technique, skilled nurse cleaned LLE with NS, patted dry with gauze, applied TAO, then Vaseline gauze (cut to size), then wrapped with Kerlix. The record revealed a “Missed Visit Note” signed and dated by RN C on 10/8/21. RN C’s skilled note included, “…service: SN Wound Care…patient [family member] unable to be there for the visit, requests visits to start on Monday.” Patient 2’s record revealed a skilled nurse visit note signed and dated by RN C on 10/11/21. RN C’s note included wound care documentation that read, “Wound #1, venous stasis, L 1.7 cm, W 1.7 cm, D 0.2 cm, small amount serosanguinous drainage, SN cleansed wound with wound cleanser, patted dry with gauze, applied zinc [barrier cream for cuts, scrapes and burns] wrap, covered with Coban [a cohesive bandage commonly used to wrap on limbs]. The record revealed a “Missed Visit Note” signed and dated by RN C on 10/14/21. RN C’s skilled note included, “…service: SN Wound Care… [family member] canceled visit. They have errands to run.” Patient 2’s record revealed a skilled visit note signed and dated by RN C on 10/18/21. RN C’s note did not include any wound measurements or descriptions of the wounds. RN C’s note read, “SN cleansed wound with wound cleanser, patted dry with gauze, applied zinc wrap, covered with Coban.” Review of Patient 2’s record contained a calendar with a schedule of wound care visits to be provided. There were no completed skilled nurse visits documented, for 22 days, from 10/18/21 until 11/9/21. The record revealed Patient 2 had a wound clinic appointment on 11/9/21. The following missed visit notes were included in the record, The calendar included a visit was scheduled for 10/21/21, and revealed documentation that read, “clinician RN C, SN Wound Care, Planned.“ There was no visit completed and no missed visit note documented. A missed visit note signed and dated by RN C on 10/25/21 read, “No answer to locked door and no answer to multiple phone calls.” The calendar included a visit was scheduled for 10/28/21, and revealed documentation that read, ”clinician RN C, SN Wound Care, missed visit.“ Scheduled visit dated 11/1/21, revealed a missed visit note, signed and dated by RN C and read, “Pt has MD appointment.“ Patient 2’s record revealed a wound clinic visit note dated 11/9/21. The note revealed the following, “This 76 year old female, Non Diabetic patient with a history of CHF, COPD, AFIB and PVD presents as new patient today with a referral from… for open ulcers to bilateral lower extremities…She has recently started HHC [home health care] but for some reason they have stopped coming. Pt is unable to provide the name of the HHC, she will call back with this information. We will fax wound care orders to them to start assisting with dressing changes. Pt comes in today with UNNA boots bilaterally…there was nothing covering the wounds…the Unna calamine layer was stuck to the ulcers. Pt reported family member applied them for her….The wounds today were cleansed, applied Santyl [barrier cream] ointment, Hydrofera blue ready [foam dressing] and wrapped legs with Kerlix and loose Coban….” The note continues, “…Wound #1, left lateral lower leg…ulcer… not healed… 3 cm length, 3 cm width, 0.1 cm depth…periwound [tissue around the wound] skin presents with signs and symptoms of infection…. A debridement was performed…non-viable tissue removed…procedure tolerated well…applied Santyl ointment debriding agent to wound bed.” “Wound #2, right lateral lower leg… full thickness venous ulcer…not healed…4.76 cm length, 2.54 cm width, 0.1 depth…periwound skin presents with signs and symptoms of infection…. A debridement was performed…non-viable tissue removed…procedure tolerated well…applied Santyl ointment debriding agent to wound bed.” “Home Health Wound Care Orders: Please visit M-W-F, remove bilateral lower leg dressings, cleanse open ulcers with Vashe [wound cleanser] or normal saline, pat dry, apply Santyl ointment …to all open ulcers, cover with Hydrofera blue ready, then loosely wrap both legs with gauze kerlix roll, then loose Coban. Patient and /or family can assist with dressing changes the other days. Santyl ointment is daily….” Review of the patient's entire record did not included coordination of care from RN C to the patient’s physician regarding the change in the wound care visit schedule and that wound care was not provided. There was no record that any of the missed visits were attempted to be rescheduled or coordination with the physician that visits were missed. The surveyor conducted a home visit with Patient 2 on 2/7/22, at approximately 2:00 pm. Patient 2 said she had problems scheduling with one of the nurses that came in the beginning. Patient 2 said the nurses name was [RN C]. Patient 2 said the nurse hardly ever made the visits and said the nurse always had excuses. She said she told the Alternate Administrator/Alternate DON about it, and she took care of it. Patient 2 said she liked the nurse she currently had and the nurse she conducted the visits. Review of the agency’s complaint binder revealed Patient 2’s wound clinic physician called the agency on 11/10 and reported a complaint about the condition of Patient 2’s wounds. The complaint read as follows, “Patient Complaint Form” signed and dated on 11/10/21 by LVN C. “…Person registering complaint: [Physician A] @ wound center... Employee involved: [RN C] … Physician: PCP: [ Physician B] … Description of Complaint… HH [home health] stopped coming. Unna boot dressing stuck to wound (ulcer), family member was applying dressing….” “Action taken” LVN C documented she notified Employee A, manager/scheduler, and “…will have the Alternate Administrator/Supervising Nurse follow up….” The complaint form continued, “…Resolution Follow Up….” The complaint form included the Alternate Administrator/Alternate DONs signature, dated 11/12/21 and indicated she attempted to visit and call to follow up with the patient on 11/11/21, and was unsuccessful. The Alternate Administrator/DON documented she received a phone call from Patient 2 and the patient reported she had been at the hospital with a family member and may have missed calls from the agency. An interview was conducted with the Alternate Administrator/ Alternate DON on 2/22/22 at 2:00 pm. The surveyor reviewed Patient 2’s missed visits, the complaint from the wound clinic and asked why RN C did not complete scheduled nursing visits and why wasn't the physician notified of the missed wound care visits. The Alternate Administrator/ Alternate DON stated she thought the reason the visits were missed was because the patient was living with another family member, and the patient was very hard to get in touch with. The surveyor requested documentation of the agency’s efforts to provide the ordered visits and requested documentation of coordination with the patient’s physician to inform wound care was not provided. The Alternate Administrator/Alternate DON said coordination with the physician should have been documented in the skilled nurse visit notes, and she did not think there was any other documentation of coordination to the physician about the wound care. No other coordination was provided to the surveyor. Patient 3. Review of the patient’s record revealed a POC with a treatment period of 12/28/21 to 2/25/22 and included a SOC date of 12/28/21. The POC included a primary diagnosis of Pneumonia. Other diagnoses included Chronic Obstructive Pulmonary Disease and Chronic diastolic (congestive) heart failure and Type II Diabetes Mellitus. The POC included “…SN frequency 2W1 [two times a week for one week] 1W8 [one time a week for 8 weeks] starting 12/28/21, PT frequency 1W1, 2W4, 1W1…for weak/unsteady gait with a history of falls, OT frequency 1W1, 2W3, 1w1… for ADL’s, MSW frequency 1-3 Q 60 days [1-3 times every 60 days] for community resources, long term planning, provider services….” The POC included orders for “SN to perform finger stick for fasting blood sugar/random blood sugar during the visit if it has not been done or if patient reports signs and symptoms of hypo/hyperglycemia…Clinician to assess and instruct patient and caregiver on signs/symptoms of heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain)…SN to inspect patient’s lower extremities every visit and report any alteration in skin integrity to the physician…SN to assess O2 saturation [oxygen level reading] on O2 @ 2 LPM [liters per minute]/every visit....” Review of Patient 3’s record revealed a SN visit dated 1/7/22, documented by RN C. RN C documented labs were ordered and drawn during the visit. Review of the patient's entire record did not include any further documented SN visits. Review of the record included “Missed Visit Order” notes, all signed and dated by RN C. The "missed visit order" read, “Missed Visit Order… 12/30/2021…No answer to multiple phone calls.” “Missed Visit Order… 01/14/2022…No answer to multiple phone calls.” “Missed Visit Order… 01/18/2022…No answer to call.” “Missed Visit Order… 01/25/2022…No answer to locked door and multiple phone calls, drove by her home and no one answered the door.” “Missed Visit Order… 02/04/2022…Visit cancelled due to severe weather, visit rescheduled for Friday” “Missed Visit Order… 02/08/2022…Staff sick, unable to make visit due to illness this week.” “Missed Visit Order… 02/18/2022…No answer to multiple phone calls.” Review of Patient 3’s record revealed all PT, OT and MSW visits were made to Patient 3 as scheduled. The surveyor conducted an interview on 2/22/22 at 2:00 pm with the Alternate Administrator/Alternate DON. The surveyor requested documentation of coordination with the physician that weekly visits were not completed as ordered and documentation of the agency’s efforts to reschedule the visits. The Alternate Administrator/Alternate DON told the surveyor coordination would be documented in the Patient’s record if it was done. No further coordination with the patient’s physician was provided. The surveyor conducted a phone interview with Patient 3 on 2/25/22 at 5:10 pm. Patient 3 told the surveyor she was happy with the therapy services, but not with the nursing services. She said she never had a nurse come except one time. She said a nurse came once and drew blood for lab work and never came again. The surveyor conducted an exit interview on 2/28/22 at 3:30 pm with the Alternate Administrator/Alternate DON and RN M. LVN C and manager/scheduler, Employee A, were in attendance via telephone. The surveyor reviewed Patient 3’s record and asked if anyone had spoken with Patient 3 regarding the missed visits. LVN C said she called Patient 3 on 2/23/22, to check on her because of the winter weather. LVN C said Patient 3 reported to her that the nurse, RN C never made her visits. LVN C said Patient 3 told her she was very unhappy with the nursing services and that a nurse came one time and never came back. LVN C said the patient told her she was happy with the therapy services. The surveyor asked the Alternate Administrator/Alternate DON if she had reported this to the patient’s physician. She said it had not been reported to the physician. The surveyors findings were not disputed and no further documentation of coordination to the physician was provided. Agency policy, “Monitoring Patient Care/Coordination of Care,” with a revised date of 080120 read in part:"…The agency will collaborate with other providers of health care services involved in the care of a patient/client, if known by the agency, and the patient/client and their representative (if any), to ensure appropriate coordination of care…The agency will ensure communication with all physicians and/or non-physician practitioners involved in the plan of care. Agency Policy, “Implementing Care and Treatment,“ with a revised date of 080120 read in part:”…VII. When the provision of care and treatment cannot be implemented as established on the care planning documents, the patient’s/client’s physician or non-physician practitioner will be notified If the agency missed visits or services as required by the plan of care, it must notify the responsible physician …of the missed visit if there is any potential for clinical impact upon the patient/client. The physician …will decide whether the patient/client visit may be skipped, or additional intervention is required by the agency due to the impact on the client. The appropriate documentation will be completed and submitted by the discipline or the nursing supervisor.