Every finding on record at Dimension Healthcare Services, Inc.

A recertification survey was conducted on 06/13/2025. The census was 15 (L&C), 2 (LHHS), and 13 (PAS). The agency was in compliance with no deficiency cited. Abbreviations used: L&C = Licensed and Certified LHHS = Licensed Home Health Services PAS = Personal Assistance Services

A recertification survey was conducted on 06/13/2025. The census was 15 (L&C), 2 (LHHS), and 13 (PAS). Abbreviations used: Adm = Administrator AA/DON = Alternate Administrator/Director of Nursing CMS = Centers for Medicare and Medicaid Services CR = Clinical Record DME = Durable Medical Equipment HHA = Home Health Agency L&C = Licensed and Certified LHHS = Licensed Home Health Services OASIS = Outcome Assessment Information Set PAS = Personal Assistance Services POC = Plan of Care RN = Registered Nurse SN= Skilled Nurse SOC = Start of Care

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 review and interview, the agency failed to transmit completed OASIS (group of standard data HHAs integrate into their comprehensive assessment, to collect and report quality data to the CMS) assessments within 30 days of completion date in 6 of 6 (January 2024 through June 2024) months of transmissions reviewed. This failure prevented the patients’ data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. During pre-survey surveyor reviewed reports ran on 06/09/2025, titled “HHA ERROR Summary by Agency” for the following reporting periods reviewed: Period 06/01/23 to 06/30/24 revealed 259 assessments were processed with 143 (55.21%) of assessments with error warning -3330 with error description that read, “Record Submitted late: The submission date was more than 30 days after M0090 (assessment) on this new record.” Period 01/01/24 to 06/20/24 revealed 139 assessments were processed with 70 (50.36%) of the assessments with error warning -3330. Period 06/09/24-06/09/25 revealed 130 assessments were processed with 116 (89.23%) of the assessments with error warning -3330. On 06/10/25 surveyor requested OASIS Validation Reports from Adm for 6-month period from 01/01/24- 06/30/24. Record review of OASIS validation reports for date range 01/19/24 to 06/27/24 revealed 109 assessments were processed with 61(55.96%) of the assessments with error warning -3330. Reports for the OASIS Agency Final Validation report revealed submission date of 01/19/24 with 3 assessments submitted and showed all 3 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 01/31/24 with 4 assessments submitted and showed 2 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 02/20/24 with 8 assessments submitted and showed 4 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 02/20/24 with 9 assessments submitted and showed 5 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/01/24 with 8 assessments submitted and showed 7 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/12/24 with 13 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/22/24 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/29/24 with 6 assessments submitted and showed 2 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 04/05/24 with 7 assessments submitted and showed 2 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 04/12/24 with 5 assessments submitted and showed all 5 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/03/24 with 9 assessments submitted and showed 6 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/10/24 with 2 assessments submitted and showed 2 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/16/24 with 10 assessments submitted and showed 4 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/31/24 with 12 assessments submitted and showed 4 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/14/24 with 4 assessments submitted and showed all 4 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/27/24 with 19 assessments submitted and showed 11 of the assessments had -3330 warning code. During interview with Adm conducted on 06/12/25 at 11:25 a.m. the surveyor asked the Adm who did the OASIS submissions for the HHA. The Adm said the PAS Coordinator did the OASIS submissions for the agency. When the surveyor asked the Adm if anyone else at the HHA helped with the OASIS submissions, the Adm said no. During interview with PAS Coordinator conducted on 06/12/25 at 12:05 p.m., when the surveyor asked if the PAS Coordinator did the OASIS assessment submissions for the HHA the PAS Coordinator said yes. The surveyor asked the PAS Coordinator how long the PAS Coordinator had been doing the OASIS assessment submissions for the HHA the PAS Coordinator said for about 2 years. The surveyor asked the PAS Coordinator how often did the PAS Coordinator do OASIS submissions, the PAS Coordinator said she tried to do them weekly, but the assessments were not always ready to be submitted. When the PAS Coordinator was asked when the OASIS assessments have to be submitted by the PAS Coordinator said by the thirtieth day. The surveyor asked why the OASIS assessments were being submitted after 30 days, the PAS Coordinator said when the assessments were returned to the nurses after QA reviewed them to make corrections the nurses did not make corrections right away and the PAS Coordinator could not submit the assessments. The surveyor asked what process the HHA had in place for submitting the OASIS assessment, the PAS Coordinator said once the nurse completed the assessment, the assessment was reviewed by QA then if corrections were needed the assessment was returned to the nurse to correct and then to PAS Coordinator to be submitted. When PAS Coordinator was asked how submitting the OASIS assessments could harm the patients, the PAS Coordinator said she did not think there would be any harm to patients. When PAS Coordinator was asked what the purpose was for submitting the OASIS assessments, the PAS Coordinator said the assessments were used to show comparisons with other agencies on how the HHA was doing and to get patient information for the state. The PAS Coordinator acknowledged that she was responsible for submitting the OASIS assessments on time. During a continued interview with Adm conducted on 06/12/25 at 12:20 p.m., the surveyor asked the Adm how often OASIS assessment was submitted for HHA. The Adm said she did not know, and the PAS Coordinator took care of submitting the OASIS assessments. The surveyor asked when did the OASIS assessment have to be submitted according to CMS. The Adm said no later than 30 days. The surveyor asked what process the HHA had in place for submitting OASIS assessments. The Adm said once the nurse completed the assessment it went to QA then back to nurse if corrections needed to be made then to PAS Coordinator to submit. The surveyor asked why the OASIS assessments were being transmitted late as in greater than 30 days. The Adm said the nurses did not return the assessment back in when corrections needed to be made. The Adm said she had to keep calling the nurses to tell them to complete corrections and submit for transmission. When the surveyor asked the Adm what problems or harm does transmitting OASIS assessments late impose on patients, the Adm said information not timely. The surveyor asked why are OASIS assessments transmitted. The Adm said for information about the patients and how the HHA compares to other agencies. Review of HHA’s policy titled “OASIS- Accuracy of Encoded Data, OASIS Transmittal, Release of Identifiable OASIS Information,” dated 11/2006, read in part, “Procedure: Transmittal of OASIS Data: 2. The Agency may transmit all monthly or more frequently as they choose.”

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that initial assessment visits were conducted within 48 hours of the referral for 5 of 7 patients (#1, #3, #4, #6, and #7) whose records were reviewed. This failure resulted in the care and treatment of patients #1, #3, #4, #6 and #7 being delayed. This failed practice potentially placed the patients at risk for negative outcomes resulting from the patients not having their nursing and rehabilitative needs met timely. Findings included: Review of patient #1's CR showed a referral date of 07/25/24. The initial assessment was completed on 07/31/24, 6 days after the referral. There was no documentation of the reason for the delay in SOC found in the CR. Review of patient #3's CR showed a referral date of 05/29/25. The initial assessment was completed on 06/02/25, 4 days after the referral. There was no documentation of the reason for the delay in SOC found in the CR. Review of patient #4's CR showed a referral date of 08/01/24. The initial assessment was completed on 08/13/24, 12 days after the referral. There was no documentation of the reason for the delay in SOC found in the CR. Review of patient #6's CR showed a referral date of 06/27/24. The initial assessment was completed on 07/11/24, 14 days after the referral. There was no documentation of the reason for the delay in SOC found in the CR. Review of patient #7's CR showed a referral date of 08/14/23. The initial assessment was completed on 08/23/23, 9 days after the referral. There was no documentation of the reason for the delay in SOC found in the CR. During an interview with AA/DON conducted on 06/13/25 at 11:55 a.m., the surveyor asked when the HHA was to do initial assessment on patients when referral received. The AA/DON said she thought within 48 to 72 hours. The AA/DON also said for their HHA the initial assessment was the SOC. When the AA/DON was asked why the initial assessments for patients #1, #3, #4, #6 and #7 were not done within 48 hours of receiving the referral she said she did not know. The surveyor asked what harm could have come to patients if the initial assessment was not done within 48 hours of the referral for care. The AA/DON said patients would have a delay in care, may end up in the hospital for worsening condition, and delay in payment from insurance. When asked who was responsible for making sure the initial assessment was done on time, the AA/DON said she was. During an interview with Adm conducted on 06/13/25 at 12:55 a.m., the surveyor asked when the HHA was to do initial assessment on patients when referral received. The Adm said the initial assessment was to be done in 2 days from the referral. The Adm continued and said when a referral comes to the HHA staff were scheduled to go out the same day if possible. When the Adm was asked why the initial assessments for patients #1, #3, #4, #6 and #7 were not done within 48 hours of receiving the referral she said she did not know the staff needed to put communication of why SOC delayed in the CR when the assessment cannot be done in 2 days. When the Adm was asked, what harm could come to the patient if the initial assessment was not done within 48 hours of the referral, the Adm said the patient may not get correct care. Review of HHA’s policy titled, “Initial Patient Comprehensive Assessment,” dated 01/11/05, read in part, “Procedure A. Admission 2. The initial assessment will be conducted within 48 hours of the referral or on the physician ordered start of care.”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview the HHA failed to ensure the POCs for 5 of 7 patients (#2, #3, #4, #5, and #6) that received skilled services, included DME and supplies, safety measures, and medications. This failure had the potential for placing patients’ #2, #3, #4, #5, and #6 at risk of not receiving adequate care that could have affected patient outcomes, exacerbated their disease processes, or not being properly monitored by the physicians overseeing their care. Findings included: Review of patient #2's CR included POC for certification period 05/05/25- 07/03/25 that was digitally signed and dated on 05/05/25 by RN B. The POC had SOC date listed as 05/05/25 with primary diagnoses of type 2 diabetes (A gland that makes insulin, called the pancreas, cannot make enough to keep blood sugar levels in a healthy range) and high blood pressure. Further review of the POC showed a section for DME and supplies. No DME and supplies were listed for patient #2; that section on the POC was left blank. Review of patient #3's CR included POC for certification period 06/02/25- 07/31/25 that was digitally signed and dated on 06/02/25 by RN B. The POC had SOC date listed as 06/02/25 with primary diagnoses of type 2 diabetes and high blood pressure. The POC had a section for DME and supplies. No DME and supplies were listed for patient #3; the area on the POC was left blank. Review of patient #4's CR included POC for certification period 05/01/25-06/29/25 that was not signed by a RN. The POC had SOC date listed as 08/13/24 with primary diagnosis of bilateral osteoarthritis (a condition that causes pain and stiffness in the joints on both sides of the body). The POC had a section to list DME and supplies. No DME and supplies were listed for patient #4. The area on the POC was left blank. Review of patient #5's CR included POC for certification period 03/02/25-04/30/25 that was digitally signed and dated on 02/26/25 by RN A. The POC had SOC date listed as 03/07/24 with primary diagnosis of heart failure (the heart cannot pump enough blood to meet the body’s need). The POC had a section for safety measures. No safety measures were listed for patient #5. The area on the POC was left blank. Review of patient #6's CR included POC for certification period 09/09/24 -11/07/24 that was digitally signed and dated on 09/06/24 by RN A. The POC had SOC date listed as 07/11/24 with primary diagnoses of chronic ulcer of right leg and type 2 diabetes. The POC had sections to list the medications and DME and supplies. No medications, DME or supplies were listed for patient #6. The areas on the POC were left blank. During an interview with AA/DON conducted on 06/13/25 at 11:55 a.m., the surveyor asked what goes on the POC. The AA/ DON said vital signs, nurse visits and other essential information that the patient needs. The surveyors asked why it was important to have all necessary information on the POC. The AA/DON said if all information were not on the POC it could cause harm to patient or cause the patient not to get care that they need and could lead to emergency room visit or patient getting sick. The surveyor asked why the POCs reviewed for patients #2, #3, #4, #5, and #6 did not have all the pertinent information on them. The AA/DON said she was unsure what happened. When asked if she thought DME and supplies, safety measures and medications should go on the POC the AA/DON said yes. When asked what harm could come to patients if all pertinent information were not placed on the POC the AA/DON said missing information on POC could cause significant harm to patients, they could get sick, go to emergency room, or end up in the hospital. The surveyor asked who oversees the POC to make sure they are correct and have all information needed on them. The AA/DON said the case managers assigned to the patient and she did. The AA/DON said she would go through the POCs to make sure nothing was missing. Review of HHA’s policy titled, “Plan of Care,” dated 03/16/04, read in part, “Purpose To ensure that care provided is appropriately planned in a timely manner to meet the patient’s specific needs and problems…” Review of HHA’s policy titled, Responsibilities of the Director of Home Health Services,” dated 09/21/04, read in part, “Purpose To define the responsibilities of the Director of Home Health Services to ensure safe, appropriate delivery of care… Policy Director of Home Health Services… is responsible for the daily direction of patient care and participates in activities relevant to professional services furnished.”

An entrance conference was conducted on 05/24/2022 with ADM at 12:01PM. The ADM was informed that the purpose of the survey was to conduct a re-certification survey. Agency Census L&C: 21 LHHS: 0 PAS: 167 An exit conference was conducted on 06/14/2022 at 10:50AM with the ADM and PAS SUP. The preliminary findings were discussed. The agency was given the opportunity to provide additional information. Written instructions were provided for submitting a Plan of Corrections within 10 days of the receipt of the Statement of Deficiencies. Abbreviations ADM (Administrator) Alt ADM (Alternate Administrator) EPRP (Emergency Preparedness and Response Plan) HHA (Home Health Aide) HCSSA (Home and Community Support Services Agency) HHSC (Health and Human Services Commission) L&C (Licensed and Certified Home Health Services) LHHS (Licensed Home Health Services) PAS (Personal Assistance Services) QAPI (Quality Assessment and Performance Improvement Program) TULIP (Texas Unified Licensure Information Portal) PAS SUP (PAS Supervisor)

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on observation, record review and interviews, the agency failed to develop, establish or maintain its own Emergency Preparedness Plan, and ensure that it was reviewed at least every two years, for 3 of 3 years reviewed (2019, 2020 and 2021) in that the agency did not have an Emergency Preparedness Plan for itself; it was using the Plan for Agency 2. This failure could affect the agency's ability to direct the provision of care and services to patients during and after a disaster. Refer to E0004 Refer to E0004

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), §485.625(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 observation, record review and interviews, the agency failed to develop, establish or maintain its own Emergency Preparedness Plan, and ensure that it was reviewed at least every two years, for 3 of 3 years reviewed (2019, 2020 and 2021) in that the agency did not have an Emergency Preparedness Plan for itself; it was using the Plan for Agency 2. This failure could affect the agency's ability to direct the provision of care and services to patients during and after a disaster. Findings Record review of TULIP (a database utilized by the state to maintain licensing, demographic information, complaints and self-reported incidents on Home Health and Hospice agencies for the State of Texas) revealed that agency provided services to the following counties: Region 1 Counties Served ARMSTRONG;BAILEY;BRISCOE;CARSON;CASTRO;CHILDRESS;COCHRAN;COLLINGSWORTH;CROSBY;DALLAM;DEAF SMITH;DICKENS;DONLEY;FLOYD;GARZA;GRAY;HALE;HALL;HANSFORD;HARTLEY;HEMPHILL;HOCKLEY;HUTCHINSON;KING;LAMB;LIPSCOMB;LUBBOCK;LYNN;MOORE;MOTLEY;OCHILTREE;OLDHAM;PARMER;POTTER;RANDALL;ROBERTS;SHERMAN;SWISHER;TERRY;WHEELER;YOAKUM Region 2 Counties Served ARCHER;BAYLOR;BROWN;CALLAHAN;CLAY;COLEMAN;COMANCHE;COTTLE;EASTLAND;FISHER;FOARD;HARDEMAN;HASKELL;JACK;JONES;KENT;KNOX;MITCHELL;MONTAGUE;NOLAN;RUNNELS;SCURRY;SHACKELFORD;STEPHENS;STONEWALL;TAYLOR;THROCKMORTON;WICHITA;WILBARGER;YOUNG Region 3 Counties Served COLLIN;COOKE;DALLAS;DENTON;ELLIS;ERATH;FANNIN;GRAYSON;HOOD;HUNT;JOHNSON;KAUFMAN;NAVARRO;PALO PINTO;PARKER;ROCKWALL;SOMERVELL;TARRANT;WISE Region 4 Counties Served ANDERSON;BOWIE;CAMP;CASS;CHEROKEE;DELTA;FRANKLIN;GREGG;HARRISON;HENDERSON;HOPKINS;LAMAR;MARION;MORRIS;PANOLA;RAINS;RED RIVER;RUSK;SMITH;TITUS;UPSHUR;VAN ZANDT;WOOD Region 5 Counties Served ANGELINA;HARDIN;HOUSTON;JASPER;JEFFERSON;NACOGDOCHES;NEWTON;ORANGE;POLK;SABINE;SAN AUGUSTINE;SAN JACINTO;SHELBY;TRINITY;TYLER Region 6 Counties Served AUSTIN;BRAZORIA;CHAMBERS;COLORADO;FORT BEND;GALVESTON;HARRIS;LIBERTY;MATAGORDA;MONTGOMERY;WALKER;WALLER;WHARTON Region 7 Counties Served BASTROP;BELL;BLANCO;BOSQUE;BRAZOS;BURLESON;BURNET;CALDWELL;CORYELL;FALLS;FAYETTE;FREESTONE;GRIMES;HAMILTON;HAYS;HILL;LAMPASAS;LEE;LEON;LIMESTONE;LLANO;MCLENNAN;MADISON;MILAM;MILLS;ROBERTSON;SAN SABA;TRAVIS;WASHINGTON;WILLIAMSON Region 8 Counties Served ATASCOSA;BANDERA;BEXAR;CALHOUN;COMAL;DEWITT;DIMMIT;EDWARDS;FRIO;GILLESPIE;GOLIAD;GONZALES;GUADALUPE;JACKSON;KARNES;KENDALL;KERR;KINNEY;LA SALLE;LAVACA;MAVERICK;MEDINA;REAL;UVALDE;VAL VERDE;VICTORIA;WILSON;ZAVALA Region 9 Counties Served ANDREWS;BORDEN;COKE;CONCHO;CRANE;CROCKETT;DAWSON;ECTOR;GAINES;GLASSCOCK;HOWARD;IRION;KIMBLE;LOVING;MCCULLOCH;MARTIN;MASON;MENARD;MIDLAND;PECOS;REAGAN;REEVES;SCHLEICHER;STERLING;SUTTON;TERRELL;TOM GREEN;UPTON;WARD;WINKLER Region 10 Counties Served BREWSTER;CULBERSON;EL PASO;HUDSPETH;JEFF DAVIS;PRESIDIO Region 11 Counties Served ARANSAS;BEE;BROOKS;CAMERON;DUVAL;HIDALGO;JIM HOGG;JIM WELLS;KENEDY;KLEBERG;LIVE OAK;MCMULLEN;NUECES;REFUGIO;SAN PATRICIO;STARR;WEBB;WILLACY;ZAPATA Record review of a binder presented by the agency as the agency’s “Emergency Preparedness Plan” contained documentation with a different agency’s name (Agency 2). Further review of the Emergency Preparedness binder documentation revealed that the agency did not have a Plan and did not have any documented evidence of the following: A risk assessment that identified natural and man-made disasters likely to occur in the agency's service area.A continuity of operations business plan to address emergency financial needs, essential functions for patient services, critical personnel, and how to return to normal operations as quickly as possible.How the agency will monitor disaster-related news and information, including after hours, weekends, and holidays, to receive warning of imminent and occurring disasters.The procedures to release patient information in the event of a disaster.The actions/responsibilities for agency staff in each phase of emergency planning, including mitigation, preparedness, response, and recovery.The actions and responsibilities of agency staff when a warning is not provided.What staff member at the agency would initiate each phase.A primary mode of communication and alternate communication or alert systems in the event of a telephone or power failure.The procedures for communicating with staff, patients, or persons responsible for a patient's emergency plan, local, state, and federal emergency agencies, and other entities.The procedures to follow to orient and train employees, volunteers, and contractors about their responsibilities in the agency's EPRP upon hire and annually thereafter.No documentation to show that the agency had actual activated a response phase of the EPRP for 2019, 2020, and 2021 for any of the flooding, COVID Pandemic, state wide freeze or other emergencies/disasters that affected the State of Texas in 2019, 2020 or 2021.No evidence of a Plan that had been reviewed / updated every 2 years in the three years reviewed.. During an interview with ADM and PAS SUP 05/27/2022 at 3:22 PM, the surveyor presented the above findings of no documents in the EPRP binder listed under the agency’s name and asked why the EPRP binder lacked documentation of the above details. PAS SUP stated, “[Agency 2] owns [Agency 1] completely, so we do a joint operation. [Agency 2] also owns [Agency 3] as well. But in the future, we will have different binders for them both as part of our plan of corrections.” During an interview with ADM and PAS SUP 05/27/2022 at 3:29 PM, the PAS SUP stated, “…if it wasn’t done, then it would have a negative impact on the patients as a whole.” Record review of agency’s policy titled, “Addendum To Emergency Preparedness Plan” unpaged reads in part, “It is the policy of [Agency 2], to educate patients/clients about procedures to follow if care or services are disrupted due to natural disaster or other emergency… the office manager shall serve as the Disaster Coordinator and the Alternate PAS Administrator shall serve as the Alternate Disaster Coordinator, supervised by the Administrator…The Disaster Coordinator shall evaluate the plan at least annually and after each actual emergency response. As part of the annual review, the agency shall test the response phase of the emergency preparedness and response plan in a planned drill if not tested during an actual emergency…” Record review of another agency’s policy titled, “Emergency Preparedness and Response Plan” page 2 of 16 reads in part, “… Agency will conduct a risk assessment analysis to identify potential disasters from natural and man-made causes in Agency’s service area. Agency will develop a continuity of operations business plan, based on the risk assessment to address emergency financial needs, essential functions for patient services, critical personnel, and how to return to normal operations as quickly as possible. Agency will describe the actions and responsibilities for agency staff in each phase of emergency planning, including mitigation, preparedness, response, and recovery. Agency will initiate a plan for monitoring disaster-related news and information, including after hours, weekends, and holidays, to receive warnings of imminent and occurring disasters. Agency will utilize an Emergency Preparedness and Response Plan in the event a disaster occurs that could potentially interrupt the provision of patient care…” Record review of another agency’s policy titled, “Emergency Preparedness and Response Plan” page 3 of 16 reads in part, “… The effectiveness of the Emergency Preparedness and Response Plan will be evaluated at annually and after each actual emergency response…”

An entrance conference was conducted on 05/24/2022 with ADM at 12:01PM. The ADM was informed that the purpose of the survey was to conduct a re-certification survey. Agency Census L&C: 21 LHHS: 0 PAS: 167 An exit conference was conducted on 06/14/2022 at 10:50AM with the ADM and PAS SUP. The preliminary findings were discussed. The agency was given the opportunity to provide additional information. Written instructions were provided for submitting a Plan of Corrections within 10 days of the receipt of the Statement of Deficiencies. Abbreviations ADM (Administrator) Alt ADM (Alternate Administrator) EPRP (Emergency Preparedness and Response Plan) HHA (Home Health Aide) HCSSA (Home and Community Support Services Agency) HHSC (Health and Human Services Commission) L&C (Licensed and Certified Home Health Services) LHHS (Licensed Home Health Services) PAS (Personal Assistance Services) QAPI (Quality Assessment and Performance Improvement Program) TULIP (Texas Unified Licensure Information Portal) PAS SUP (PAS Supervisor)