Every finding on record at Ariel Amana Healthcare Inc

Purpose of visit: Recertification survey Entrance conference date 7/10/2025 The census was - 198 Licensed and Certified patients – 9 Licensed Home Health patients – 3 Personal Assistance Services - 186 The agency is in compliance with emergency preparedness.

Purpose of visit: Recertification, relicensure survey and Complaint investigation Intake 1020898 Entrance conference date 7/10/2025 The census was - 198 Licensed and Certified patients – 9 Licensed Home Health patients – 3 Personal Assistance Services - 186 Abbreviations: BFCC- Beneficiary and Family Centered Care QIO- Quality Improvement Organization CMS – Centers for Medicare and Medicaid Services Adm- Administrator DON- Director of Nurses or Supervising Nurse Alt DON – Alternate Director of Nurses AAA- Area Agency on Aging OASIS – Outcome and Assessment Information Set IQIES – Internet Quality Improvement and Evaluation System SN – skilled nurse SOC – start of care RN – Registered Nurse PAS – Personal Assistant Services EMR – electronic medical record LVN – Licensed Vocational Nurse

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record reviews and interviews the Home Health Agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary for 4 (Patients 4, 5, 6, and 7) of 9 active and discharge patient’s records reviewed. This failure prevented CMS from analyzing patient’s data and the agency’s performance in comparison to other agencies, which potentially placed patients at risk for substandard care due to inaccurate OASIS information. Review of IQIES on 7/10/2025 revealed “There are no results for this report criteria” when the Potentially Avoidable Event Report, the Potentially Avoidable Event: Patient Listing Report and the Agency Patient Related Characteristics Report were pulled for the report period of 05/2024-04/2025. The OASIS Error Detailed Report had 1 late OASIS submission for period 06/29/2024-06/30/2025. Review of the undated “Active Medicaid Home Health List” provided by the agency on 7/10/2025 contained the names of Patients 4,5 and 6 and their SOC dates. Review of the undated “Medicaid Discharged Patient List” provided by the agency on 7/10/2025 contained the name of Patient 7 and date of service of 5/6/2022-2/04/2025. Record review of Patient 4 revealed a “Home Health Certification and Plan of Care” for period 5/4/2025-10/30/2025 with a SOC date of 2/14/2023, SN frequency 70 hours weekly, and a primary diagnosis (identification of a disease) of “Encounter for attention to gastrostomy (a surgical procedure that creates an opening to the stomach allowing for the insertion of a feeding tube)” electronically signed by the Adm/DON. Records contained a “RN Assessment-Start of Care (Non-OASIS) dated 2/14/2023 and last RN Assessment-Recertification (Non-OASIS) dated 5/2/2025 completed by the Adm/DON. Record review of Patient 5 revealed a “Home Health Certification and Plan of Care” for period 11/18/2024-5/16/2025 with a SOC date of 10/9/2019, SN frequency of 84 hours weekly, and a primary diagnosis of chronic respiratory failure (breathing failure) with hypoxia (low oxygen), electronically signed by the Adm/DON. Records contained a “RN Assessment-Start of Care (Non-OASIS) dated 10/9/2019 and last RN Assessment-Recertification (Non-OASIS) dated 5/17/2025 completed by the Adm/DON. Record review of Patient 6 revealed a “Home Health Certification and Plan of Care” for period 01/31/2025-6/30/2025 with a SOC date of 1/31/2025, SN frequency of 112 hours weekly, and a primary diagnosis of Immunodeficiency (the body’s immune system is unable to effectively protect the body from infections and diseases) unspecified, electronically signed by the Alt DON. Records contained a “RN Assessment-Start of Care (Non-OASIS) dated 1/31/2025 completed by the Alt DON. Record review of discharged Patient 7 revealed a “Home Health Certification and Plan of Care” for period 11/21/2024-5/19/2025 with a SOC date of 05/06/2022, SN frequency of 84 hours weekly, and a primary diagnosis of Presence of Cardiac Pacemaker (a small electronic device implanted in the chest to help regulate a slow or irregular heartbeat), electronically signed by the Adm/DON. Records contained a “RN Assessment-Start of Care (Non-OASIS) dated 5/6/2022, last RN Assessment-Recertification (Non-OASIS) dated 11/20/2024, and a Non-OASIS Discharge dated 1/31/2025 completed by the Adm/DON. An interview was conducted with the Adm/DON on 7/11/2025 at 12:45pm. When asked about the agency’s policy for submitting OASIS data on skilled patients, the Adm/DON stated the agency submitted OASIS data “on Medicare patients only.” The surveyor asked why OASIS data was not submitted on Medicaid patients. The Adm/DON stated the Medicaid patients that received skilled services also received PAS services. The Adm/DON stated OASIS data was not submitted on the Medicaid Patients because of the longer hours of skilled care provided by the agency. The Adm/DON stated the agency bills services provided to the Medicaid patients to Agency D (A managed care company that provides Medicaid to individuals and families). The Adm/DON stated nursing assessments and documentation for patients on Medicaid and private insurance were done on paper, and for Medicare patients it was completed in the agency’s EMR system. The surveyor asked if the agency was registered to receive CMS updates for Home Health Agencies. The Adm/DON stated she received the updates from CMS but did not always read them. An interview was conducted with the Adm/DON on 7/18/2025 at 1:55pm. The surveyor shared the findings of Patients 4 ,5, 6 and 7. When asked about the agency’s policy for submitting OASIS data, the Adm/DON stated, “before I was just doing the Medicare.” The Adm/DON stated she was not aware of the requirements to submit OASIS data on Medicaid patients. The Adm/DON stated she also was not aware of the CMS requirements effective 7/1/2025 to submit OASIS data on all patients regardless of payer source except for maternity patients and patients under the age of 18 prior to the survey. When asked about the potential patient outcome for OASIS data not being submitted when required, the Adm/DON stated, “they (CMS) would not be able to track the effectiveness of the services being provided, they (CMS) use the statistics to be able to generate if there's an outbreak or if there's something we (the agency) are not following in the guidelines. It's (OASIS data is) also used to evaluate the quality of care of the agency.” Review of the agency’s policy “Timelines, IM.35,” revision 05/02/2024, reads in part “The Agency will ensure timely provision of care and services to meet the patient’s/client’s needs in compliance with all federal and state laws and regulations. Procedure: A registered nurse, physical therapist, or speech therapist will complete the Initial Comprehensive Assessment no later than five calendar days after the start of care (SOC) for all patients/clients in a licensed and certified agency. The transmission of the Outcome and Assessment Information Set (OASIS) data excludes the following patients/clients: 1. Patients/Clients under 18 years old; 2. Maternity patients/clients; 3. Homemaker or chore service only patients/clients; 4. Receiving only personal care services (regardless of payor source); 5. Patients/clients for whom Medicare or Medicaid insurance is not billed. All completed and encoded OASIS data will be transmitted via electronic communication software that is available by CMS or software that conforms to CMS electronic record layout…within the 30 days of the M0090 (the last date the comprehensive assessment was completed for a patient in home health care) date.”

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on observations, record reviews and interviews the agency failed to provide the name, address, and phone number for the Agency on Aging and failed to provide the name, address and correct phone numbers for the Quality Improvement Organization (QIO) for 3 (Patients 1,2 and 3) of 7 active home health patients’ records reviewed. This failure potentially placed patients at risk for not receiving information, referrals, and community services through federally funded and state funded agencies. Record review of the Agency’s Home Health folder on 7/10/2025 revealed an undated contact information list for Federal and State Public Agencies with no contact information for the Area Agency on Aging for County E (county where patients reside). The list contained an internet web address “for a list of current BFCC-QIOs (CMS contracted agencies which receive appeals from patients regarding home health discharge decisions)” and the phone number for Agency B (federal insurance program for people aged 65 or older and younger people with disabilities). The list did not contain the name, address and phone number for Agency C (CMS contracted agency which receives appeals from patients regarding home health discharge decisions). Review of the agency’s undated service area map revealed County E as an area the agency serviced. Observation, record review and interview with Patient 1 during a home visit in County E (county where patient resides) on 7/15/2025 at 11:00 am revealed an undated contact information list for Federal and State Public Agencies with no contact information for the Area Agency on Aging for County E (county where patient resides). The list contained an internet web address “for a list of current BFCC-QIOs (CMS contracted agencies which receive appeals from patients regarding home health discharge decisions)” and the phone number for Agency B (federal insurance program for people aged 65 or older and younger people with disabilities).The list did not contain the name, address and phone number for Agency C (CMS contracted agency which receives appeals from patients regarding home health discharge decisions). Review of patient’s plan of care for period 4/7/2025-6/05/2025 showed a start of care date of 04/07/2025. When asked if any pages had been removed from the home health folder, Patient 1 stated “No.” When asked, Did the agency staff advise you of the name, address and telephone numbers of the Agency on Aging and Quality Improvement Organization? Patient 1 stated “No.” Observation, record review and interview with Patient 2 during a home visit in County E (county where patient resides) on 7/15/2025 at 11:46 am revealed an undated contact information list for Federal and State Public Agencies with no contact information for the Area Agency on Aging for County E (county where patient resides). The list contained an internet web address “for a list of current BFCC-QIOs (CMS contracted agencies which receive appeals from patients regarding home health discharge decisions)” and the phone number for Agency B (federal insurance program for people aged 65 or older and younger people with disabilities).The list did not contain the name, address and phone number for Agency C (CMS contracted agency which receives appeals from patients regarding home health discharge decisions). Review of patient’s plan of care for period 5/23/2025-07/21/2025 showed a start of care date of 03/24/2025. When asked if any pages had been removed from the home health folder, Patient 2 stated “No.” When asked, Did the agency staff advise you of the name, address and telephone numbers of the Agency on Aging and Quality Improvement Organization? Patient 2 stated “No.” Observation, record review and interview with Patient 3 during a home visit in County E (county where patient resides) on 7/15/2025 at 10:03 am revealed an undated contact information list for Federal and State Public Agencies with no contact information for the Area Agency on Aging for County E (county where patient resides). The list contained an internet web address “for a list of current BFCC-QIOs (CMS contracted agencies which receive appeals from patients regarding home health discharge decisions)” and the phone number for Agency B (federal insurance program for people aged 65 or older and younger people with disabilities).The list did not contain the name, address and phone number for Agency C (CMS contracted agency which receives appeals from patients regarding home health discharge decisions). Review of patient’s plan of care for period 4/21/2025-6/19/2025 showed a start of care date of 02/20/2025. When asked if any pages had been removed from the home health folder, Patient 3 stated “No.” When asked, Did the agency staff advise you of the name, address and telephone numbers of the Agency on Aging and Quality Improvement Organization? Patient 3 stated “I don’t know.” An interview was conducted with the Adm/DON on 7/18/2025 at 1:55pm. The surveyor shared the above findings of the missing contact information for the Area Agency on Aging for County E (county where patients reside) and QIO contact information for Agency C (CMS contracted agency which receives appeals from patients regarding home health discharge decisions) on the undated contact information list for Federal and State Public Agencies. When asked about the agency’s policy on providing patients with contact information for the Area Agency on Aging (AAA) and Quality Improvement Organization (QIO) the Adm/DON stated, “It’s provided with the policy package and all of these resources (AAA and QIO) are available if needed.” When asked why the information for the AAA for County E and the QIO contact information for Agency C were missing, the Adm/DON stated she was unaware of the missing contact information. When asked about the potential patient outcome for not receiving the AAA and the QIO contact information the Adm/DON stated, the patients “would not be able to contact them (AAA and QIO).” Review of the Agency’s policy “Patient/Client Rights and Responsibilities, RI.5” revision 11/11/2022, reads in part “The patient/client and representative (if any) will be informed of the patient’s/client’s rights and responsibilities in a language and manner the individual understands. The Agency will protect and promote the exercise of these rights. Procedure- Be advised of the names, addresses, and telephone numbers of the following federally-funded and state-funded entities that service the area where the patient/client resides: Agency on Aging…Quality Improvement Organization.”

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interviews the agency failed to ensure required items in the patient’s clinical record including all assessments and clinical notes in 1 (Patient 4) of 7 active home health patients’ records reviewed. This failure places patients at risk for substandard care and poor health outcomes due to healthcare providers not knowing specific clinical information. Record review of Patient 4 revealed a “Home Health Certification and Plan of Care” for period 5/4/2025-10/30/2025 with a SOC date of 2/14/2023, SN frequency 70 hours weekly, and a primary diagnosis of “Encounter for attention to gastrostomy (a surgical procedure that creates an opening to the stomach allowing for the insertion of a feeding tube)” electronically signed by the Adm/DON. The record contained a clear pocket folder with a tab labeled “May 2025.” The pocket folder contained a “Medication Administration Record” for Patient 4 dated “May 2025” with LVN A’s initials entered daily. The folder also contained nursing flowsheets with skilled nursing assessments dated 5/2/24, 5/3/24, 5/4/24, 5/9/24, 5/10/24 and 5/11/24. Patient 4’s records did not contain daily skilled nursing assessments or clinical notes dated for May 2025 or June 2025. An interview was conducted with LVN A on 7/18/2025 at 12:57pm. The surveyor shared the findings on Patient 4. When asked about the frequency of visits and documentation of the visits, LVN A stated Patient 4’s skilled nursing visit frequency was “10 hours daily every day.” LVN A stated she documented on a paper nurse assessment form daily and mailed it to the office weekly “because sometimes the office is far from the patient.” When asked why the documentation in the May 2025 folder was dated 2024, LVN A stated “They (the agency) must have missed filed it.” When asked about the missing skilled nursing assessment documentation for May 2025 and after, LVN A stated she did not know why they were missing “I sent the visit notes to the office by mail.” An interview was conducted with the Adm/DON on 7/18/2025 at 1:55pm. The surveyor shared the findings on Patient 4 and the interview with LVN A. The Adm/DON stated the nurse notes “are sent registered mail” because the nurses are caring for patients for extended hours daily. The Adm/DON stated, “most of the time I picked it (the nursing notes) up myself because there are not many patients.” When asked who was responsible for filing the nursing notes, The Adm/DON stated, “office staff.” When asked about the missing nursing assessment and clinical notes for May 2025 and after in Patient 4’s records, the Adm/DON stated, “I have to check honestly. It (nursing notes) might be there, probably just needs to be filed.” When asked about the agency’s policy on the contents of patient records, the Adm/DON stated “we (the agency) must have the admission, complaints and most notes.” When asked about the potential patient outcome for missing patient records, the Adm/DON stated, “there would be no records of the care we (the agency) provided to the patients.” The Adm/DON did not locate and provide the missing nursing notes to the surveyor. Review of the agency’s policy “Medical Record Contents, IM.25,” revision 07/05/2024 reads in part “The Agency will initiate and maintain a clinical record containing past and current information for every patient/client accepted by the Agency and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) issuing orders for the home health Plan of Care, and appropriate Agency staff. Procedure… Each medical record will contain the following…all the assessments from the most recent home health admission…Clinical notes documenting all actions, interventions, and procedures provided by the agency, including medication administration, treatments, and services, and responses to those interventions, the date and time the care was provided, and the staff member or contractor who provided care. “

Purpose of visit: Recertification/Relicensure/Complaint Survey Entrance: 07/11/2022 The agency's census was: L&C 7 LHHS 0 PAS 111 Complaint Intakes TX#’s 316114, 280060, 273198, 264415, 259899, and 178256. “A recertification survey and complaint investigation (TX#’s 316114, 280060, 273198, 264415, 259899, and 178256) entrance date was conducted on 07/15/22. The census was 118.” Abbreviations: Texas Department of Family and Protective Services (DFPS) Texas Health and Human Services (HHS) Abuse, Neglect, Exploitation (ANE) TULIP (Texas Unified Licensure Information Portal) Emergency Preparedness Plan (EPP) Enhanced Fujita Scale or EF Scale (EF)

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to review the EPP after each actual emergency to evaluate its effectiveness and to update the plan as needed in two of two years reviewed (2021 and 2022) following the Winter Storm Uri that occurred on 02/11/2021, the North Texas snowstorm that occurred 02/03/2022, and the EF-6 tornado on 5/14/2021, and the excessive heat warning on 06/12/22 in the Dallas Fort Worth area. This failure placed the agency clients at risk of harm in the event of an emergency or disaster if the agency's emergency plan was not effective. Findings included: A review of the emergency preparedness plan binder, policies and procedures revealed the following: (1) No evidence of any records to establish the agency conducted an internal review after the Winter Storm Uri that occurred on 02/11/2021, the North Texas snowstorm that occurred 02/03/2022, and the EF-6 tornado on 5/14/2021, and the excessive heat warning on 06/12/22 in the Dallas Fort Worth area. (2) There were no other reports in the binder that indicated that the agency had conducted full-scale community based, full-scale facility-based or table-top exercises or an actual emergency, to test the emergency plan at least annually, for the year 2021. During an interview on 07/15/22 at 12:15 p.m. with the Administrator/Director of Nurses, the surveyor presented the above findings. The Administrator/Director of Nurses confirmed the EPP binder did not contain any drills for 2020, 2021, 2022. She stated there were no internal reviews after the Winter Storm Uri that occurred on 02/11/2021, the North Texas snowstorm that occurred 02/03/2022, and the EF-6 tornado on 5/14/2021, and the excessive heat warning on 06/12/22 in the Dallas Fort Worth area. She agreed the staff and clients might not know what to do in a specific emergency if procedures had changed and the plan was not updated. Agency policy titled "EMERGENCY PREPAREDNESS AND RESPONSE PLAN EC.8" revised 020119 read in part: " PROCEDURE: ... III. Preparedness A. Administrative staff responsibilities .... 2. Training and Testing: a. As part of the annual internal review, the Agency test the response phase of its Emergency Preparedness and Response Plan in two (2) exercises per year, if not tested during an actual emergency response…... e. The Agency will conduct two (2) exercises to test the emergency plan at least annually. The Agency will do the following .... (1) Participate in a full-scale exercise that is community-based. If a community-based exercise is not accessible, an annual individual, facility-based exercise will be conducted every two (2) years. The Agency will document efforts to identify a full-scale community based exercise if they did not participate in one ....(2) Conduct an additional exercise that may include, but is not limited to the following: (3) A second full-scale exercise that is community-based or individual facility-based, or (4) A tabletop exercise or workshop that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan...."

Purpose of visit: Recertification/Relicensure/Complaint Survey Entrance: 07/11/2022 The agency's census was: L&C 7 LHHS 0 PAS 111 Complaint Intakes TX#’s 316114, 280060, 273198, 264415, 259899, and 178256. “A recertification survey and complaint investigation (TX#’s 316114, 280060, 273198, 264415, 259899, and 178256) entrance date was conducted on 07/15/22. The census was 118.” Abbreviations: Texas Department of Family and Protective Services (DFPS) Texas Health and Human Services (HHS) Abuse, Neglect, Exploitation (ANE) TULIP (Texas Unified Licensure Information Portal) Emergency Preparedness Plan (EPP) Enhanced Fujita Scale or EF Scale (EF)

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop, implement, and evaluate performance improvement projects for 2 of 2 (2020 and 2021) years reviewed. This failure could have resulted in the agency failing to identify and address areas of the agency's program for which performance could be improved. The findings included: Review of the documentation regarding the agency's Quality Assessment Performance Improvement Program (QAPI) included no documentation to indicate the agency had developed, implemented, or evaluated a performance improvement project for the years of 2020 and 2021. During an interview on 07/15/2022 at 12:10 p.m., with the Administrator/Director of Nurses, the surveyor discussed the above findings. The Administrator/Director of Nurses said, "It was not done." The Administrator/Director of Nurses stated this failure could place patients at "risk of inadequate care." Agency Policy titled, "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PROGRAM QAPI.1" dated of 011318, read in part, "...Purpose To develop, implement, and maintain an effective, ongoing, Agency-wide data driven Quality Assessment Performance Improvement (QAPI) Program as defined by its QAPI plan...Procedure…Performance improvement projects…1. The number and scope of distinct improvement projects conducted annually…2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects…” [M(1]The surveyor is not required to use abbreviations. However, if used ensure all abbreviations/acronyms are defined in the initial comments and consistent throughout all citations. See IM 20-03 for guidance.