The following plan of correction was deemed acceptable to …



The following plan of correction was deemed unacceptable to HHSC. The survey exit date was 6/27/19. Some identified problems with the plan of correction follow the plan of correction.

|State Tag |Summary Statement of Licensing Violations |State Tag |Facility's Plan of Correction |Completion Date |

|ID | |ID | | |

|Z358 |§558.282(d) Client Conduct, Responsibility & Rights |Z358 |§558.282(d) Client Conduct, Responsibility & Rights |7/10/19 |

| | | | | |

| |At the time of admission, an agency must provide each person who receives licensed| |Agency will provide all future clients with a written statement that informs the | |

| |home health services, licensed and certified home health services, hospice | |client that a complaint against the agency may be directed to HHSC. This | |

| |services, or personal assistance services with a written statement that informs | |statement will also include that a client can lodge a complaint with HHSC without | |

| |the client that a compliant against the agency may be direct to the HHSC Consumer | |notifying the agency. Greg Smith will update the statement. Once completed, he |7/14/19 |

| |Rights and Services Division, P.O. Box 149030, Austin, Texas 78714-9030, toll free| |will review policies every six months to ensure they are kept up-to-date with | |

| |1-800-458-9858. The statement also may inform the client that a complaint against| |HHSC. The alternate administrator will be monitoring the procedure. | |

| |the agency may be directed to the administrator of the agency. The statement | | | |

| |about complaints directed to the administrator also must include the time frame in| |Additionally, the statement will include HHS contact info, how to contact the | |

| |which the agency will review and resolve the complaint. | |administrator and the time frame in which the agency will review and resolve the | |

| | | |complaint. | |

| |This is a Severity Level B violation. | | | |

| | | |All future clients will initial a copy of "A Client's Guide to Quality Care" and | |

| |This REQUIREMENT is not met as evidenced by: | |"Important Telephone Numbers," stating they have received this information. | |

|State Tag |Summary Statement of Licensing Violations |State Tag |Facility's Plan of Correction |Completion Date |

|ID | |ID | | |

|Z358 |Based on record review and interviews, the agency failed to ensure that 2 of 2 |Z358 | |7/10/19 |

| |sampled clients were given accurate information related to their rights to | | | |

| |complain, in that the complaint procedure provided did not clearly inform clients | | | |

| |of their right to complain HHS without calling or notifying the agency (Clients #1 | | | |

| |and #2). | | | |

| | | | | |

| |The findings included: | | | |

| |A. During the entrance conference on 6/25/19 at 12:15 p.m., the agency's | | | |

| |administrator was asked to provide an admission packet that would be used to admit | | | |

| |a client for services. Review of the provided packet identified a form titled, "A | | | |

| |Client's Guide to Quality Care" (page 2, 2004). The form indicated a communication| | | |

| |guide of when to communicate with the office that included "complaints and | | | |

| |grievances." The packet also included a form entitled, "Important Telephone | | | |

| |Numbers" (no form number or date), which indicated, "Should you make a complaint to| | | |

| |our agency and not receive a written response within 14 days, contact HHSC at | | | |

| |1-800-458-9858." | | | |

|State Tag |Summary Statement of Licensing Violations |State Tag |Facility's Plan of Correction |Completion Date |

|ID | |ID | | |

|Z358 |B. During an interview on 6/27/19 at 12:45 p.m., the administrator was asked to |Z358 | |7/10/19 |

| |review the forms titled, "A Client's Guide to Quality Care" and "Important | | | |

| |Telephone Numbers" and was asked to identify whether the forms notified the clients| | | |

| |that a complaint could be lodged with HHS without notifying the agency. The | | | |

| |administrator verified the forms did not indicate the clients could lodge a | | | |

| |complaint with HHS without notifying the agency and that there were no additional | | | |

| |forms that clearly informed clients of their right to complain to HHS at | | | |

| |1-800-458-9858. | | | |

Reasons why the PoC was unacceptable:

• Two different dates of correction were given.

• The agency gave a person's name (Greg Smith) rather than position as being responsible for monitoring the implementation of the PoC.

• The PoC did not address current clients who received the erroneous information. While the prevention of future problems is important, the agency also needs to include a mechanism for identifying other current clients affected by the deficient practice.

The following plan of correction was deemed acceptable to HHS. The survey exit date was 7/20/19.

|State Tag |Summary Statement of Licensing Violations |State Tag |Facility's Plan of Correction |Completion Date |

|ID | |ID | | |

|Z196 |§558.247 Verification of Employability and Use of Unlicensed Persons |Z196 |§558.247 Verification of Employability and Use of Unlicensed Persons |7/27/19 |

| | | | | |

| |§558.247(a)(3) | |In accordance with TAC §558.247(a)(3), Administrator/DON conducted a | |

| |Before the agency hires an unlicensed applicant, or before an unlicensed | |search of the Nurse Aide Registry and the Employee Misconduct | |

| |employee's first face-to-face contact with a client, the agency must search the | |Registry. The search revealed no findings of misconduct and that | |

| |nurse aide registry (NAR) and the employee misconduct registry (EMR) using the | |Employees "A" and "E" were eligible for hire. These findings were | |

| |HHS Internet website to determine if the applicant or employee is listed in | |documented in each employee's personnel file. | |

| |either registry as unemployable. The agency must not employ an unlicensed | | | |

| |applicant who is listed as unemployable in either registry. | |Agency policy on "Criminal History and Background Checks" was revised| |

| | | |to meet the requirements of TAC §558.247(a)(3). The policy has been | |

| |This is a Severity Level B violation. | |reviewed by the Quality Assurance/Performance improvement Committee | |

| | | |(QAPI) and approved by the Board of Directors. The Administrator/DON | |

| | | |in-serviced all staff on proper procedure to perform criminal history| |

| | | |and background checks on unlicensed persons and policy revisions. | |

|State Tag |Summary Statement of Licensing Violations |State Tag |Facility's Plan of Correction |Completion Date |

|ID | |ID | | |

|Z196 |This REQUIREMENT is not met as evidenced by: |Z196 |§558.247 Employability of Unlicensed Persons |7/27/19 |

| | | | | |

| |Based on record review and interview, the agency failed to search the Nurse Aide | |Compliance will be monitored by the Administrator at least quarterly | |

| |Registry (NAR), for 2 of 5 sampled unlicensed staff who had face-to-face contact | |and reported to the QA/PI Committee. All policies will be evaluated | |

| |with clients (HHA-A and Staff E). | |for compliance with all applicable rules and regulations by the QAPI | |

| | | |Committee, and presented to the Board of Directors for review and | |

| |Findings included: | |approval at least annually and as deemed appropriate by the | |

| | | |Administrator/DON. | |

| |A. Review of the personnel file of Home Health Aide-A identified no | | | |

| |documentation of a search of the Nurse Aide Registry (NAR). | |An agreement has been reached and approved by the Board of Directors | |

| | | |for third party objective review of agency operations and compliance | |

| |During an interview on 7/20/19 at 3:45 p.m., the CEO/CFO verified that she | |by Allgood Consultants, LLC. | |

| |"checked the employee misconduct registry online but didn’t check the NAR online | | | |

| |as part of the background check." | | | |

|State Tag |Summary Statement of Licensing Violations |State Tag |Facility's Plan of Correction |Completion Date |

|ID | |ID | | |

|Z196 |B. Review of the agency-provided "Employee Roster" identified Staff-E as |Z196 | |7/27/19 |

| |"Administrative Assistant." In an interview on 07/20/19 at 1:15 p.m., Staff-E | | | |

| |stated that she had accompanied the former Administrator/Supervising Nurse to the | | | |

| |home of discharged Client #15 to provide translation on 01/11/19, 02/14/19, and | | | |

| |03/13/19. Upon review, the personnel file of Staff E did not include | | | |

| |documentation that a search of the NAR had been conducted. | | | |

| | | | | |

| |During an interview on 07/20/19 at 3:45 p.m., the CEO/CFO verified that Staff-E | | | |

| |had translated for the former Administrator/Supervising Nurse in Client #11's home| | | |

| |and that a check of Staff E through the NAR had not been done. | | | |

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