Every finding on record at Absolutely Angels Inc

A recertification survey was conducted on 06/02/2026. Census: LCHH: 122 LHH: 3 Abbreviations: Adm: Administrator Alt Adm: Alternate Administrator EC: Environment Safety & Equipment Management EP: Emergency Preparedness LHH: Licensed Home Health LCHH: Licensed and Certified Home Health TX: Texas

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain an EP plan that was reviewed and updated at least every two years to evaluate its effectiveness and update the plan as needed. The plan had not been reviewed and updated in three of three years reviewed (2023, 2024, and 2025). This failure placed clients at risk of harm in the event of an emergency or disaster if the agency’s emergency plan was not effective. Findings include: Record review of the agency’s EP binder (undated) did not contain an internal review of the emergency response plan to evaluate its effectiveness and to update the plan as needed for calendar years 2023, 2024, or 2025. During an interview with the Adm on 6/1/2026 at 11:20 AM, Surveyor 2 asked if the binder contained all the EP information for the agency to which the Adm replied “Yes.” During an interview with the Adm and Alt Adm on 6/2/2026 at 2:00PM, Surveyor 2 asked why the EP binder did not contain an annual internal review of the plan for calendar years 2023, 2024, or 2025. The Adm responded that he did not know they had to do an annual review of the plan. Surveyor 2 asked why agency policies were not followed, the Adm stated he did not know the agency had to review the EP plan annually. Review of agency policy EC.40, titled, “Emergency Preparedness and Response Plan”, revised 7/1/2020, read in part… “Purpose…II. To ensure the agency develops, establishes, and maintains…emergency preparedness policies and procedures…emergency plan, and communication plan…will be reviewed and updated at least every two years...” Review of agency policy EC.40-TX, titled “Emergency Preparedness and Response Plan-Addendum”, revised 4/14/2023, read in part… “Policy I…A. The plan...must be reviewed and updated at least annually...”

A recertification survey was conducted on 06/02/2026. Census: LCHH: 122 LHH: 3 The agency was in compliance with no deficiencies cited.