Every finding on record at Garland Home Healthcare Agency Inc

Purpose of visit: Recertification/Re-licensure Survey/Follow-Up Entrance: 11/01/2021 The agency's census was: LC-1; LHHS-0; PAS-20 Exit: 11/03/2021 An entrance conference was conducted on 11/01/2021 at 10:21 AM with the Administrator. The agency was informed that the purpose of the survey was to conduct a Recertification/Re-licensure Survey. The "Home and Community Support Services Agencies (HCSSAs), What To Expect During Your Agency's Survey" was provided and explained. The information card giving instructions on how to complete the on-line comment survey was provided. An exit conference was conducted on 11/03/2021 at 12:22 PM with the Administrator. The preliminary findings of the survey were discussed, and a written copy provided. The agency was informed which records were duplicated. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Violation. Abbreviations: Quality Assessment Performance Improvement Plan (QAPI). Texas Department of Family and Protective Services (TDFPS) Department of Aging and Disability Services (DADS) Health and Human Services Commission (HHSC) Abuse, Neglect, Exploitation (ANE) Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR)

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 test the response phase of its emergency preparedness and response plan in a planned drill if not tested during an actual emergency response for two of three years reviewed (2019 and 2020). This failure placed agency operations and patient lives at risk in the event of a disaster occurring as the agency would not know if the plan was effective or not. Record review of the emergency preparedness plan: Review of the agency's emergency preparedness binder showed no documentation of agency's performance of drills for its emergency preparedness and response plan for years 2019 and 2020. In an interview on 11/01/2021 with the Administrator (Employee A) at 1:40 p.m., the surveyor reviewed the findings regarding the lack of emergency preparedness drills. The surveyor asked did the agency have emergency preparedness drills for the years 2019 and 2020? The Administrator (Employee A) stated, "It was overlooked." Review of the Agency's Policy and Procedure manual included a document titled, " Emergency Preparedness and Response Plan", Numbered: EC.6, Revised date: 100112. The document read in part: "... 11. The agency will complete an internal review of the at least annually, and after each actual emergency response, to evaluate its effectiveness and to update the plan as needed...."

Purpose of visit: Recertification/Re-licensure Survey/Follow-Up Entrance: 11/01/2021 The agency's census was: LC-1; LHHS-0; PAS-20 Exit: 11/03/2021 An entrance conference was conducted on 11/01/2021 at 10:21 AM with the Administrator. The agency was informed that the purpose of the survey was to conduct a Recertification/Re-licensure Survey. The "Home and Community Support Services Agencies (HCSSAs), What To Expect During Your Agency's Survey" was provided and explained. The information card giving instructions on how to complete the on-line comment survey was provided. An exit conference was conducted on 11/03/2021 at 12:22 PM with the Administrator. The preliminary findings of the survey were discussed, and a written copy provided. The agency was informed which records were duplicated. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Violation. Abbreviations: Quality Assessment Performance Improvement Plan (QAPI). Texas Department of Family and Protective Services (TDFPS) Department of Aging and Disability Services (DADS) Health and Human Services Commission (HHSC) Abuse, Neglect, Exploitation (ANE) Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR)

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to report immediately, within 24 hours, to DFPS and HHSC an allegation of ANE by an agency employee. The failure could place clients at risk of further ANE and could also result in the allegations not being investigated or a delay in investigation by the regulatory authorities. On 11/01/2021 the surveyor reviewed the agency's complaint binder. The binder revealed a "Complaint/Grievance Report" dated 05/16/2021. The report stated that discharged Client #DC1 stated she suspected former Attendant (Employee F1) of stealing $60.00 from the client’s bank account. The "Complaint/Grievance Report" was signed and dated 05/16/2021 by the Administrator (Employee A). During an interview on 11/01/2021 at approximately 12:56 p.m. the surveyor presented the above findings to the Administrator. The Administrator replied, "That was a mistake on my part. After I did the investigation and the attendant wasn’t guilty, I didn’t think I had to report.” Review of agency policy revealed: Agency policy titled, TX.2 Abuse, Neglect and Exploitation" dated Rvd 01016 read in part: " ...Policy III... If there is cause to believe abuse, neglect, or exploitation of the patient/client has occurred by an Agency employee ... the incident(s) will be reported to TDFPS and DADS immediately, meaning 24 hours ...upon receipt of the allegation to ...."

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interviews, the agency's governing body failed to ensure that an ongoing program for quality improvement and patient safety was implemented and maintained. The agency failed to address priorities for improved quality of care and patient safety and ensure that: all improvement actions were evaluated for effectiveness; clear expectations for patient safety were established, implemented, and maintained. The QAPI program was not ongoing and focused on patient outcomes that were measurable. The agency failed to maintain a QAPI Program implemented by a QAPI committee. The agency did not review and update or revise the plan of implementation at least once within a calendar year for the years 2019 and 2020. The governing body failed to ensure that the QAPI Committee met at least twice a year in 2019 and 2020 to ensure that an ongoing program for quality improvement and patient safety was defined implemented and maintained. This failure could place the agency's patients at risk of negative patient care outcomes if substandard care was not identified and corrected by the agency during ongoing QAPI evaluations. Record review of the QAPI binder did not contain committee member names. The QAPI binder did not contain any reports, reviews nor documentation that indicated the agency had maintained an agency wide QAPI program that included the federal regulatory requirements, for the years 2019 and 2020. The QAPI Binder did include QAPI committee meetings held once a year in 2019 and 2020. During an interview with the Adm on 11/01/21 at 1:34 PM, the surveyor asked who was on the QAPI Committee. The Administrator stated, "The Director of Nursing because we haven’t used any therapy." The surveyor asked why the agency had not conducted an annual evaluation of the total operation of the agency for 2019 and 2020. The Administrator stated, "It was overlooked." The surveyor asked why the agency had not conducted QAPI meetings twice a year in 2019 and 2020. The Administrator stated, " It was overlooked." Review of agency undated policy titled " ...Quality Assurance Performance Improvement Program QAPI.1 Rvd. 060101" read in part: " ...Policy Agency will develop a plan that is reviewed and updated or revised at least once within the calendar year, or more often if needed…. Procedure...3. The QAPI committee will consist of, at a minimum, the Administrator, Supervisor, representative from disciplines providing services. The QAPI Committee will meet at least twice a year or more often, if needed…..."

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to adopt a written policy addressing infection control including the prevention of and the spread of infectious and communicable disease. The agency failed to update its infection control policy and program to include the COVID-19 Pandemic. The failure placed the agency's client at risk of contracting and spreading communicable diseases, specifically COVID-19. During the entrance conference on 11/01/2021 at approximately 10:28 a.m., the surveyor requested all agency infection control logs/documents/reports/binders. Review of the infection control binder did not show that the agency had updated its infection control program, policy and procedure, in 2020, to prevent the spread of COVID-19 among its clients and staff. During an interview on 11/2/2021 at 11:58 p.m., with the Adm the surveyor discussed the above findings of why the infection control program and policy had not been updated to include procedure to prevention and control the spread of COVID-19 in 2020. The Administrator stated that updating the infection control policy and program was overlooked. Review of agency policy titled "Infection Control Program IC.1" revised 090109 revealed that it did not include procedures for the prevention and control of spread of COVID-19.