Writing Acceptable Plans of Correction for HCSSAs

The following plan of correction was deemed unacceptable to HHS. The survey exit date was 6/27/17. Some identified problems with the plan of correction follow the plan of correction.

State Tag
ID / Summary Statement of Licensing Violations / State Tag
ID / Facility's Plan of Correction / Completion Date
Z358 / §97.282(d) Client Conduct, Responsibility & Rights
At the time of admission, an agency must provide each person who receives licensed home health services, licensed and certified home health services, hospice services, or personal assistance services with a written statement that informs the client that a compliant against the agency may be direct to the Department of Aging and Disability Services, DADS' Consumer Rights and Services Division, P.O. Box 149030, Austin, Texas 78714-9030, toll free 1-800-458-9858. The statement also may inform the client that a complaint against 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 which the agency will review and resolve the complaint.
This is a Severity Level B violation.
This REQUIREMENT is not met as evidenced by: / Z358 / §97.282(d) Client Conduct, Responsibility & Rights
Agency will provide all future clients with a written statement that informs the client that a complaint against the agency may be directed to HHS. This statement will also include that a client can lodge a complaint with HHS without notifying the agency. Greg Smith will update the statement. Once completed, he will review policies every six months to ensure they are kept up-to-date with HHS. The alternate administrator will be monitoring the procedure.
Additionally, the statement will include HHS contact info, how to contact the administrator and the time frame in which the agency will review and resolve the complaint.
All future clients will initial a copy of "A Client's Guide to Quality Care" and "Important Telephone Numbers," stating they have received this information. / 7/10/17
7/14/17
State Tag
ID / Summary Statement of Licensing Violations / State Tag
ID / Facility's Plan of Correction / Completion Date
Z358 / Based on record review and interviews, the agency failed to ensure that 2 of 2 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 6/25/17 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 HHS at 1-800-458-9858." / Z358 / 7/10/17
State Tag
ID / Summary Statement of Licensing Violations / State Tag
ID / Facility's Plan of Correction / Completion Date
Z358 / B. During an interview on 6/27/17 at 12:45 p.m., the administrator was asked to 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 HHSwithout 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. / Z358 / 7/10/17

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.

Unacceptable and Acceptable PoC

Writing Acceptable Plans of Correction for HCSSAs

The following plan of correction was deemed acceptable to HHS. The survey exit date was 7/20/17.

State Tag
ID / Summary Statement of Licensing Violations / State Tag
ID / Facility's Plan of Correction / Completion Date
Z196 / §97.247 Verification of Employability and Use of Unlicensed Persons
§97.247(a)(3)
Before the agency hires an unlicensed applicant, or before an unlicensed employee's first face-to-face contact with a client, the agency must search the nurse aide registry (NAR) and the employee misconduct registry (EMR) using the HHS Internet website to determine if the applicant or employee is listed in either registry as unemployable. The agency must not employ an unlicensed applicant who is listed as unemployable in either registry.
This is a Severity Level B violation. / Z196 / §97.247 Verification of Employability and Use of Unlicensed Persons
In accordance with TAC §97.247(a)(3), Administrator/DON conducted a search of the Nurse Aide Registry and the Employee Misconduct Registry. The search revealed no findings of misconduct and that Employees "A" and "E" were eligible for hire. These findings were documented in each employee's personnel file.
Agency policy on "Criminal History and Background Checks" was revised to meet the requirements of TAC §97.247(a)(3). The policy has been 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. / 7/27/17
State Tag
ID / Summary Statement of Licensing Violations / State Tag
ID / Facility's Plan of Correction / Completion Date
Z196 / This REQUIREMENT is not met as evidenced by:
Based on record review and interview, the agency failed to search the Nurse Aide Registry (NAR), for 2 of 5 sampled unlicensed staff who had face-to-face contact with clients (HHA-A and Staff E).
Findings included:
A. Review of the personnel file of Home Health Aide-A identified no documentation of a search of the Nurse Aide Registry (NAR).
During an interview on 7/20/17 at 3:45 p.m., the CEO/CFO verified that she "checked the employee misconduct registry online but didn’t check the NAR online as part of the background check." / Z196 / §97.247 Employability of Unlicensed Persons
Compliance will be monitored by the Administrator at least quarterly and reported to the QA/PI Committee. All policies will be evaluated for compliance with all applicable rules and regulations by the QAPI Committee, and presented to the Board of Directors for review and approval at least annually and as deemed appropriate by the Administrator/DON.
An agreement has been reached and approved by the Board of Directors for third party objective review of agency operations and compliance by Allgood Consultants, LLC. / 7/27/17
State Tag
ID / Summary Statement of Licensing Violations / State Tag
ID / Facility's Plan of Correction / Completion Date
Z196 / B. Review of the agency-provided "Employee Roster" identified Staff-E as "Administrative Assistant." In an interview on 07/20/17 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 01/11/17, 02/14/17, and 03/13/17. 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 07/20/17 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. / Z196 / 7/27/17

Unacceptable and Acceptable PoC