Note: Fiscal year (FY) 2013 began Sept. 1, 2012, and ended Aug. 31, 2013. Source: Texas Department of Aging and Disability Services Regulatory Services Fiscal Year 2013 Annual Report.

Top 10 Most Frequent Complaint Intake Reasons

  1. Administration — Failure to ensure responsible management of agency operations to ensure compliance with policies and procedures and/or applicable state and federal regulations. (Ranked No. 1 in fiscal year 2012)

  2. Resident Rights/Client Protection — Failure to ensure client/patient rights are protected under applicable laws. (Ranked No. 2 in fiscal year 2012)

  3. Care/Services — Failure to provide care, including care coordination, assessments, medication/treatment orders, etc., in accordance with a client's care/service plan.(Ranked No. 3 in fiscal year 2012)

  4. Neglect — Failure to provide for one's self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain, or the failure of a caretaker to provide such goods or services. (Ranked No. 4 in fiscal year 2012)

  5. Misappropriation/Exploitation — Failure to ensure clients' resources were not exploited for personal benefit, profit or gain by agency staff that have an ongoing relationship with the client. (Ranked No. 6 in fiscal year 2012)

  6. Clinical Records — Failure to maintain current and accurate client records; failure to treat records with confidentiality and maintain according to professional standards of practice. (Ranked No. 5 in fiscal year 2012)

  7. Compliance with Federal, State and Local Laws — Failure to adopt/enforce policy to ensure compliance with the Occupations Code, Chapter 102 (concerning the solicitation of patients); or, the agency was operating in violation of Chapter 142 of the Health and Safety Code by providing home health and/or personal assistance services, or representing to the public that the person is a provider of home health and/or personal assistance services, for pay without an appropriate license. (Ranked No. 10 in fiscal year 2012)

  8. Billing Irregularities — Failure to ensure accuracy of billing/insurance claims.(Ranked No. 8 in fiscal year 2012)

  9. Financial Solvency — An agency's financial inability to carry out its functions as written at 97.252 Financial Solvency and Business Records. An agency must not intentionally or knowingly pay employees with checks from accounts with insufficient funds. An agency must have sufficient funds to meet payroll. An agency must make available for DADS review any and all financial records. An agency must maintain business records in their original state that are accurate, dated with the date of entry, and identified corrections are made in accordance with standard accounting practices. (Ranked No. 7 in fiscal year 2012)

  10. Staff Training — Failure to ensure adequate staff orientation, training, and education to include the hospice philosophy. (Not ranked in fiscal year 2012)

Top 10 Deficiencies Cited During Inspections (Certification)

  1. Acceptance of Patients, POC, Medical Supervision: 42 CFR 484.18, TAG 0158 — The agency failed to ensure that client care followed a written plan of care periodically reviewed by a properly qualified physician. (Ranked No. 1 in fiscal year 2012)

  2. Administrator: 42 CFR 484.14(c), TAG 0133 — The administrator failed to organize and direct the agency's ongoing functions and/or maintain communication between the agency's governing body, professional personnel and staff. (Ranked No. 6 in fiscal year 2012) [TIE]

  3. Clinical Records: 42 CFR 484.48, TAG 0236 — The agency failed to maintain client clinical records that met accepted professional standards and included all the required information about the client's care and service plan. (Ranked No. 2 in fiscal year 2012) [TIE]

  4. Coordination of Patient Services: 42 CFR 484.14(g), TAG 0143 — The agency failed to ensure that all personnel providing client services coordinated effectively and in support of the objectives in each client's plan of care. (Ranked No. 3 in fiscal year 2012)

  5. Plan of Care: 42 CFR 484.18(a), TAG 0159 — The agency failed to ensure that each client had a comprehensive plan of care that addressed the client's needs.(Ranked No. 4 in fiscal year 2012)

  6. Encoding OASIS Data: 42 CFR 484.20(a), TAG 0321 — The agency failed to encode and be capable of transmitting OASIS data for each agency patient within 7 days of completing an OASIS data set. (Ranked No. 5 in fiscal year 2012)

  7. Skilled Nursing Services: 42 CFR 484.30, TAG 0170 — The agency failed to furnish skilled nursing services in accordance with the plan of care. (Ranked No. 7 in fiscal year 2012)

  8. Drug Regimen Review: 42 CFR 484.55(c), TAG 0337 — The agency failed to maintain a comprehensive assessment which must include a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. (Ranked No. 10 in fiscal year 2012)

  9. Coordination of Patient Services: 42 CFR 484.14(g), TAG 0144 — The agency failed to ensure that its clinical records or case conference meetings showed that there was effective interchange, reporting and coordination of client care. (Ranked No. 9 in fiscal year 2012)

  10. Duties of the Registered Nurse: 42 CFR 484.30(a), TAG 0176 — The registered nurse failed to prepare clinical and progress notes, coordinate services, inform the physician and other personnel of changes in the patient's condition and needs.(Not ranked in fiscal year 2012)

Top 10 Deficiencies Cited During Inspections (Licensure Violations)

  1. Management Responsibilities: Supervising Nurse — Level B: 40 TAC §97.243(c)(2)(A)(iii) — The supervising nurse or the alternate supervising nurse failed to make sure that care was provided according to clients' needs as written in the plan of care or care plan. (Ranked No. 1 in fiscal year 2012)

  2. Management Responsibilities Administrator — Level A and Level B: 40 TAC §97.243(b)(1)(B) — The agency administrator failed to carry out, organize, and supervise ongoing work under the agency's administrative policies. (Not ranked in fiscal year 2012)

  3. Self-Reported Incidents of A, N & E — Level B: 40 TAC §97.249(c) — The agency failed to immediately report, within 24 hours, knowledge of an alleged act of abuse, neglect or exploitation of a client by an agency employee, contractor or volunteer, to the Texas Department of Family and Protective Services and to DADS. (Ranked No. 4 in fiscal year 2012)

  4. Coordination of Services — Level A and Level B: 40 TAC §97.288(a) — The agency failed to have a written policy to make sure client care was coordinated among all service providers to promote optimal client outcomes. (Ranked No. 3 in fiscal year 2012)

  5. Management Responsibilities Administrator — Level A and Level B: 40 TAC §97.243(b)(1)(A) — The agency administrator failed to carry out, organize and supervise ongoing work under the agency's administrative policies. (Ranked No. 2 in fiscal year 2012)

  6. Quality Assess/Performance Improvement — Level B: 40 TAC §97.287(a)(1) — The agency failed to have, implement, and review a quality assessment and performance improvement program consistent with state requirements. (Ranked No. 5 in fiscal year 2012)

  7. Personnel Records — Level A: 40 TAC §97.246(a)(3) — The agency failed to include in its personnel records verification of license, permits, reference(s), job experience, or educational requirements to verify qualifications for each position a person accepted. (Not ranked in fiscal year 2012)

  8. Emergency Preparedness Planning & Implementation- Level A and Level B: 40 TAC §97.256(k) — The agency failed to test the response phase of its emergency preparedness and response plan by conducting a planned drill consistent with state licensing rules as part of its annual review of the plan. (Ranked No. 8 in fiscal year 2012)

  9. Continuing Education In Agency Administrator — Level B: 40 TAC §97.260(a) — The agency's administrator or alternate administrator failed to complete 12 hours of continuing education in the required topics within each 12 months in that job as required for the position of the administrator or administrator of an agency. (Ranked No. 9 in fiscal year 2012)

  10. Verify Employability/Use Unlicensed Personnel — Level B: 40 TAC §97.247(a)(3) — The agency employed an unlicensed person with face-to-face client contact before it searched the nurse aide and employee misconduct registries as required or employed an unlicensed person who was listed in either registry as unemployable. (Ranked No. 6 in fiscal year 2012)

top of page

Updated: August 21, 2015