Every finding on record at Macbon Home Health Inc

A recertification survey entrance conference was conducted on 06/29/2022 at 12:40 PM with the Adm/PAS Supervisor and Alt Adm/DON/Disaster Coordinator. The census was: LCHHS: 27 LHH: 0 PAS: 25 An exit conference was conducted 07/07/2022 with the Adm/PAS Supervisor and Alt Adm/DON/Disaster Coordinator at 5:50 PM. The preliminary findings were discussed. The agency was given an opportunity to provide additional documentation. Written instructions were provided for how to submit an acceptable plan of correction within 10 days of receipt of the Statement of Deficiencies. ABBREVIATIONS: Adm – Administrator Alt – Alternate CFR – Code of Federal Regulations COVID-19 -Novel Coronavirus Disease of 2019 DON - Director of Nurses EP- Emergency Preparedness LCHHS - Licensed and Certified Home Health LHHS - Licensed Home Health Services PAS- Personal Assistance Services PM - Post meridiem

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 record review and interview, the agency failed to develop and maintain an emergency preparedness plan that was reviewed and updated at least every two years for calendar year 2021. The emergency preparedness plan had not been updated since 01/15/2019. This failure placed patients at risk of harm in the event of an emergency or disaster if the agency's emergency plan was not effective. FINDINGS INCLUDE: Review of the emergency preparedness plan binder included a document dated 01/15/2019 and titled, “Emergency Preparedness Plan Review and Checklist.” The binder did not include any records to establish the agency reviewed and updated their emergency preparedness plan for year 2021, two years after the prior review on 01/15/2019. During an interview with the Adm and Alt Adm/DON/Disaster Coordinator on 07/07/2022 at 1:20 PM, the surveyor presented the above findings of why the emergency preparedness plan was not reviewed and updated at least every two years, with the last review documented on 01/15/2019. The Adm stated everyone was crazy during 2020 and 2021 due to the COVID pandemic but it was always fresh in his and the Alt Adm/DON/Disaster Coordinators mind knowing what needed to be done. The Adm stated he and the Alt Adm/DON/Disaster Coordinator knew the information presented by the surveyor, but it might not be documented. The surveyor presented the above findings of how this failure could impact the clients. The Alt Adm/DON/Disaster Coordinator stated the agency had done almost everything that was required but failed to update the emergency preparedness manual. The Alt Adm/DON/Disaster Coordinator stated if the failure had affected the clients, that would not be good. Agency policy titled "EMERGENCY PREPAREDNESS AND RESPONSE PLAN EC.8" with a revision date of 08/01/2011 read in part: " ...POLICY…Agency will utilize an Emergency Preparedness Plan in the event a situation occurs that could potentially affect the needs for its services or its ability to provide those services…The effectiveness of the Emergency Preparedness Plan will be evaluated at least annually and after each actual disaster/emergency response…”

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness plan that was based on and included a documented facility-based and community-based risk assessment utilizing an all-hazards approach that was reviewed and updated at least every two years for three of three years reviewed (2019, 2020 and 2021). This failure meant the agency lacked organized preparation and planning for care and services in the event of a disaster and could potentially affect the agency's ability to provide care and services to patients during and after a disaster. FINDINGS INCLUDE: Review of the emergency preparedness plan binder included a document titled, "Hazard Threat Analysis" that was undated and a document titled, "Hazard Vulnerability Assessment Tool" that was undated. The hazard threat analysis and the hazard vulnerability assessment tool included a risk assessment for emergencies likely to occur in the agency's service area. The binder did not include a documented facility-based and community-based risk assessment utilizing an all-hazards approach for 2019, 2020 and 2021. During an interview with the Adm and Alt Adm/DON/Disaster Coordinator on 07/07/2022 at 1:28 PM, the surveyor presented the findings of why the agency failed to develop and maintain a facility-based and community-based risk assessment utilizing an all-hazards approach at least every two years. The Adm stated the agency had been short-staffed due to the COVID pandemic and the information was always fresh in their [Adm and Alt Adm/Disaster Coordinator] minds knowing what needed to be done. The surveyor presented the above findings of how this failure could have impacted agency patients and employees. The Alt Adm/DON/Disaster Coordinator stated the agency had done almost everything that was required but failed to update the emergency preparedness manual. The Alt Adm/DON/Disaster Coordinator stated if the failure had affected the clients, that was not good. On 07/07/2022 at 3:30 PM, the Adm presented the surveyor with a stack emergency preparedness papers; several of the pages were dated 07/07/2022. The Adm stated he and the Alt Adm/DON/Disaster Coordinator forgot the agency had the papers from 2022 and just found them in the Alt Adm/DON/Disaster Coordinator’s office. The surveyor reviewed the documents with the Adm and stated they appeared to be copies of documents included in the emergency preparedness binder for 01/15/2019, including scribble markings and exact wording. The surveyor held the documents up to a light and compared them to the 2019 documents. Both sets of documents were identical, word for word, except for dates. The documents included a Hazard Vulnerability Assessment Tool that was undated. The surveyor presented the above findings to the Adm of the 2019 and 2022 documents that appeared exactly the same and asked if the agency completed the 2022 documents after the prior interview on 07/07/2022 at 1:28 PM. The Adm stated the documents were completed by the agency previously but the Adm signed and dated them today [07/07/2022]. The surveyor presented the findings and asked how the information could be the same from 2019 to 2022, when the COVID pandemic was declared in March of 2020, and if the agency actually completed the 2022 documents with new information or just copied the 2019 documents without reviewing and updating the information for 2022. The Adm stated the 2022 documents were copies of the 2019 documents. The surveyor again reviewed the similarities of the 2019 and 2022 documents with the Adm and the Adm stated, “Oh, I see what you are saying. They are the same and I made copies of the 2019 for 2022. I didn’t update anything.” Agency policy titled "EMERGENCY PREPAREDNESS AND RESPONSE PLAN EC.8" with a revision date of 08/01/2011 read in part: “…POLICY…Agency will create a hazard threat analysis…to identify the potential disasters from natural and man-made causes most likely to occur in the agency’s service area… Agency will maintain documentation of compliance with the required elements and agency policies in the Emergency Preparedness Response and Plan Manual…”

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and implement emergency preparedness policies and procedures that were reviewed and updated at least every two years for three of three years reviewed (2019, 2020 and 2021). This failure placed all agency patients at an increased risk of harm in the event of a disaster or emergency. FINDINGS INCLUDE: Review of the agency LCHHS policy manual included a policy titled "EMERGENCY PREPAREDNESS AND RESPONSE PLAN EC.8" with a revision date of 08/01/2011. The manual did not include an updated emergency preparedness and response plan policy since 08/01/2011. Review of the emergency preparedness plan binder revealed no evidence the agency reviewed or updated the emergency preparedness policy EC.8 for 2019, 2020 and 2021. During an interview with the Adm and Alt Adm/DON/Disaster Coordinator on 07/07/2022 at 1:05 PM, the surveyor presented the above findings of when the agency policies and procedures, including EC.8, were last updated. The Adm stated the policies were updated in 2019. The agency did not provided documentation of an updated emergency preparedness policy in 2019. The surveyor presented the above findings of what the updates included in 2019. The Adm stated mainly human resources. The surveyor presented the above findings why the agency’s policy, Emergency Preparedness and Response Plan EC.8, had not been updated since 08/01/2011. The Adm stated he thought it had been updated. The surveyor presented the above findings of how this failure could impact the agency and all patients. The Adm stated as the agency goes along each year, they update their policies. The Adm stated the agency does in-services to educate employees on what has changed and thanked the surveyor for telling him policy EC.8 was outdated. The Alt Adm/DON/Disaster Coordinator stated the agency was practically doing all updates/changes but changes just weren’t included in their policies.

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: THIS IS A CONTINUING DEFICIENCY FROM SURVEY DATED 07/23/2019 CITED AT E0039. Based on record review and interview, the agency failed to review the emergency preparedness plan after each actual emergency response to evaluate its effectiveness and to update the plan as needed for two of two years reviewed (2020 and 2021) in that: The plan was not evaluated and updated following the COVID-19 pandemic that began on 03/14/2020 and the winter storm that occurred on 02/13/2021 through 02/17/2021. This failure placed the agency patients at risk of harm in the event of an emergency or disaster if the agency's emergency plan was not effective. FINDINGS INCLUDE: A review of the emergency preparedness plan binder revealed no evidence of any records to establish the agency conducted an internal review after the COVID-19 pandemic that began on 03/14/2020 and the winter storm that occurred from 2/13/2021 through 02/17/2021. During an interview with the Adm and Alt Adm/DON/Disaster Coordinator on 07/07/2022 at 1:25 PM, the surveyor presented the above findings of why the agency failed to review the emergency preparedness plan after each actual emergency response to evaluate its effectiveness and to update the plan as needed following the COVID-19 pandemic that began on 03/14/2020 and the winter storm that occurred on 02/13/2021 through 02/17/2021. The surveyor presented the above findings of how this failure could have impacted the patients. The Alt Adm/DON/Disaster Coordinator stated the agency had done almost everything that was required but failed to update the emergency preparedness manual. The Alt Adm/DON/Disaster Coordinator stated if the failure had affected the clients, that would not be good. During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 5:25 PM, the surveyor presented the findings from the recertification survey dated 07/23/2019 that included the same deficient practice and the agency’s plan of correction submitted to HHSC to correct the deficient practice and asked why it was not corrected almost three years later. The Adm stated, “Unfortunately, in those three years, we’ve had staffing issues with finding employees because of COVID. We’ve been overwhelmed with all of it. The process of hiring people to do the work needs to be better. There is no place to get help.” The Adm stated he promised the issue would be corrected by the next survey. The surveyor presented the above findings of how the continued, uncorrected failure could impact all agency patients. The Adm stated it had a very negative effect with the work-flow and production was compromised. The Adm stated everyone had trouble getting employees and he and the Alt Adm/DON were the only employees in the office allot of times and it was more than they could get done. The Alt Adm/Don stated the agency checked on-line hiring sites all of the time for employees. Agency policy titled "EMERGENCY PREPAREDNESS AND RESPONSE PLAN EC.8" with a revision date of 08/01/2011 read in part: “…POLICY…Agency will utilize an Emergency Preparedness Plan in the event a situation occurs that could potentially affect the needs for its services or its ability to provide those services…The effectiveness of the Emergency Preparedness Plan will be evaluated at least annually and after each disaster/emergency response…Agency will maintain documentation of compliance with the required elements and agency policies in the Emergency Preparedness Response and Plan Manual…”

A recertification survey entrance conference was conducted on 06/29/2022 at 12:40 PM with the Adm/PAS Supervisor and Alt Adm/DON/Disaster Coordinator. The census was: LCHHS: 27 LHH: 0 PAS: 25 An exit conference was conducted 07/07/2022 with the Adm/PAS Supervisor and Alt Adm/DON/Disaster Coordinator at 5:50 PM. The preliminary findings were discussed. The agency was given an opportunity to provide additional documentation. Written instructions were provided for how to submit an acceptable plan of correction within 10 days of receipt of the Statement of Deficiencies. Abbreviations: Adm - Administrator Alt - Alternate AM - Ante meridiem CFR – Code of Federal Regulations COVID-19 -Novel Coronavirus Disease of 2019 DON - Director of Nurses EP- Emergency Preparedness HHA – Home Health Agency i.e. – for example LHHS - Licensed Home Health Services OASIS- Outcome and Assessment Information Set PAS- Personal Assistance Services PIP – Personal Improvement Project PM - Post meridiem QAPI- Quality Assurance Performance Improvement

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: THIS IS A CONTINUING DEFICIENCY FROM SURVEY DATED 07/23/2019 CITED AT G0422. Based on observation, record review and interviews, the agency failed to provide written notice of the agency's transfer and discharge policy within 4 business days of the initial evaluation visit in three of three (Patient 1, 2 and 3) patients the surveyor conducted home visits. This failure did not conform to the patients right to be provided information regarding the criteria used to determine if the patient could be discharged or transferred from agency services. The failure placed Patient 1, 2 and 3 at risk to have their patient rights violated related to their possible discharge or transfer. FINDINGS INCLUDE: Review of the sample LCHHS admission packet revealed the packet did not include the agency’s transfer and discharge policy. On 07/06/2022 at 12:00 PM, the surveyor arrived at the address listed on the plan of care for Patient 1 and 2. The address was located in a residential area and occupied by a residential care home, Care Home ZZ, where Patient 1 and 2 resided. Upon entering the home, the surveyor requested the agency home folder for Patient 1 and 2. An employee caregiver of the care home, Staff Caregiver YY, stated the folders were not kept in the patient rooms. Staff Caregiver YY left the room and returned with the home folder for Patient 1 and 2. During an interview with Staff Caregiver YY at 12:05 PM, the surveyor asked if anything had been removed from either of the home folders. Staff Caregiver YY stated, “No, nothing.” Patient 1: Record review included a plan of care with a primary diagnosis of bilateral osteoarthritis of the knees dated 06/06/2022 to 08/04/2022 with a start of care date of 10/14/2020. During the home visit and interview on 07/06/2022 at 12:15 PM, the surveyor asked Patient 1 if anything had been removed from the home folder. Patient 1 stated, "No." Review of the agency home folder contained no evidence a written notice of the agency's transfer and discharge policy had been provided. Patient 2: Record review included a plan of care with a primary diagnosis of Alzheimer’s Disease dated 04/23/2022 to 06/21/2022 with a start of care date of 04/28/2021. During the home visit and interview on 07/06/2022 at 12:00 PM, the surveyor asked Patient 2 if anything had been removed from the home folder. Patient 2 stated, “No.” Review of the agency home folder contained no evidence a written notice of the agency's transfer and discharge policy had been provided. Patient 3: Record review included a plan of care with a primary diagnosis of bilateral osteoarthritis of the knees dated 06/07/2022 to 08/05/2022 with a start of care date of 06/07/2022. During the home visit and interview on 07/06/2022 at 11:15 AM, Patient 3’s family member, Family Member 1, stated Patient 3 was completely bedridden, awake all night with a fever and was finally sleeping. The surveyor observed Patient 3 sleeping. Family Member 1 stated she was the primary caregiver for Patient 3. The surveyor inquired if anything had been removed from the home folder. Family Member 1 stated, “No.” Review of the agency home folder contained no evidence a written notice of the agency's transfer and discharge policy had been provided. During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 12:47 PM, the surveyor presented the above findings of why the agency failed to provide written notice of the agency's transfer and discharge policy. The Alt Adm/DON stated, “I don’t understand why I don’t have it in there.” The Adm stated, “We weren’t aware it was required.” The surveyor presented the above findings of how this failure could have impacted Patient 1, 2 and 3. The Adm stated, “They could be confused, wouldn’t know who to call or contact.” During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 5:25 PM, the surveyor presented the findings from the recertification survey dated 07/23/2019 that included the same deficient practice and the agency’s plan of correction submitted to HHSC to correct the deficient practice and asked why it was not corrected almost three years later. The Adm stated, “Unfortunately, in those three years, we’ve had staffing issues with finding employees because of COVID. We’ve been overwhelmed with all of it. The process of hiring people to do the work needs to be better. There is no place to get help.” The surveyor presented the above findings of how the continued, uncorrected failure could impact all agency patients. The Adm stated it had a very negative effect with the work-flow and production had become compromised. The Adm stated everyone had trouble getting employees and he and the Alt Adm/DON were the only employees in the office allot of times and it was more than they could get done.

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: THIS IS A CONTINUING DEFICIENCY FROM SURVEY DATED 07/23/2019 CITED AT G0446. Based on record review and interviews, the agency failed to advise three of three (Patient 1, 2 and 3) patients with the names, addresses and telephone numbers of the following Federally-funded and state-funded entities that served the area the three patients resided in: Agency on Aging; Center for Independent Living; Protection and Advocacy Agency; Aging and Disability Resource Center and Quality Improvement Organization. This failure prevented the agency patients from accessing and obtaining community services that were not provided by the agency. FINDINGS INCLUDE: Review of the sample LCHHS admission packet revealed the packet did not include names, addresses and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. On 07/06/2022 at 12:00 PM, the surveyor arrived at the address listed on the plan of care for Patient 1 and 2. The address was located in a residential area and occupied by a residential care home, Care Home ZZ, where Patient 1 and 2 resided. Upon entering the home, the surveyor requested the agency home folder for Patient 1 and 2. An employee caregiver of the care home, Staff Caregiver YY, stated the folders were not kept in the patient rooms. Staff Caregiver YY left the room and returned with the home folder for Patient 1 and 2. During an interview with Staff Caregiver YY at 12:05 PM, the surveyor asked if anything had been removed from either of the home folders. Staff Caregiver YY stated, “No, nothing.” Patient 1: Record review included a plan of care with a primary diagnosis of bilateral osteoarthritis of the knees dated 06/06/2022 to 08/04/2022 with a start of care date of 10/14/2020. During the home visit and interview on 07/06/2022 at 12:15 PM, the surveyor asked Patient 1 if anything had been removed from the home folder. Patient 1 stated, "No." Review of the agency home folder contained no evidence the agency provided the names, addresses and telephone numbers of the five Federally-funded and state-funded entities that served the area the patient resided. Patient 2: Record review included a plan of care with a primary diagnosis of Alzheimer’s Disease dated 04/23/2022 to 06/21/2022 with a start of care date of 04/28/2021. During the home visit and interview on 07/06/2022 at 12:00 PM, the surveyor asked Patient 2 if anything had been removed from the home folder. Patient 2 stated, “No.” Review of the agency home folder contained no evidence the agency provided the names, addresses and telephone numbers of the five Federally-funded and state-funded entities that served the area the patient resided. Patient 3: Record review included a plan of care with a primary diagnosis of bilateral osteoarthritis of the knees dated 06/07/2022 to 08/05/2022 with a start of care date of 06/07/2022. During the home visit and interview on 07/06/2022 at 11:15 AM, Patient 3’s family member, Family Member 1, stated Patient 3 was completely bedridden, awake all night with a fever and was finally sleeping. The surveyor observed Patient 3 sleeping. Family Member 1 stated she was the primary caregiver for Patient 3. The surveyor inquired if anything had been removed from the home folder. Family Member 1 stated, “No.” Review of the agency home folder contained no evidence a written notice of the agency's transfer and discharge policy had been provided. During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 12:50 PM, the surveyor presented the above findings of why the agency failed to provide Patient 1, 2 and 3 with information on Federally-funded and state-funded entities. The Adm stated, “We didn’t know about them. Where do we find the list?” The surveyor provided the CFR to the Adm and Alt Adm/DON. The surveyor presented the above findings of how this failure could have impacted Patient 1, 2 and 3. The Adm stated, “They could be confused, wouldn’t know who to call or contact.” During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 5:25 PM, the surveyor presented the findings from the recertification survey dated 07/23/2019 that included the same deficient practice and the agency’s plan of correction submitted to HHSC to correct the deficient practice and asked why it was not corrected almost three years later. The Adm stated, “Unfortunately, in those three years, we’ve had staffing issues with finding employees because of COVID. We’ve been overwhelmed with all of it. The process of hiring people to do the work needs to be better. There is no place to get help.” The surveyor presented the above findings of how the continued, uncorrected failure could impact all agency patients. The Adm stated it had a very negative effect with the work-flow and production had become compromised. The Adm stated everyone had trouble getting employees and he and the Alt Adm/DON were the only employees in the office allot of times and it was more than they could get done. The Alt Adm/Don stated the agency checked on-line hiring sites all of time for employees.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: THIS IS A CONTINUING DEFICIENCY FROM SURVEY DATED 07/23/2019 CITED AT G0614 Based on record review and interviews, the agency failed to provide a written visit schedule including the frequency of visits by personnel acting on behalf of the agency to two of three (Patient 1 and 2) patients the surveyor conducted home visits. This failure did not allow the patients the ability to anticipate care and service visits on a regular and consistent basis and placed the patients at risk of missed visits by staff when visits were not scheduled and conflicted with other appointments and the availability of the patients. FINDINGS INCLUDE: On 07/06/2022 at 12:00 PM, the surveyor arrived at the address listed on the plan of care for Patient 1 and 2. The address was located in a residential area and occupied by a residential care home, Care Home ZZ, where Patient 1 and 2 resided. Upon entering the home, the surveyor requested the agency home folder for Patient 1 and 2. An employee caregiver of the care home, Staff Caregiver YY, stated the folders were not kept in the patient rooms. Staff Caregiver YY left the room and returned with the home folder for Patient 1 and 2. During an interview with Staff Caregiver YY at 12:05 PM, the surveyor asked if anything had been removed from either of the home folders. Staff Caregiver YY stated, “No, nothing.” Patient 1: Record review included a plan of care with a primary diagnosis of bilateral osteoarthritis of the knees dated 06/06/2022 to 08/04/2022 with a start of care date of 10/14/2020. The orders included skilled nursing visits one time a week for nine weeks effective week of 05/29/2022 (sic). During the home visit and interview on 07/06/2022 at 12:15 PM, the surveyor asked Patient 1 if anything had been removed from the home folder. Patient 1 stated, "No." Review of the agency home folder contained no evidence a written schedule of visits had been provided. Patient 2: Record review included a plan of care with a primary diagnosis of Alzheimer’s Disease dated 04/23/2022 to 06/21/2022 with a start of care date of 04/28/2021. The orders included skilled nursing visits one time a week for seven weeks effective week of 04/24/2022. During the home visit and interview on 07/06/2022 at 12:00 PM, the surveyor asked Patient 2 if anything had been removed from the home folder. Patient 2 stated, “No.” Review of the agency home folder contained no evidence a written schedule of visits had been provided. During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 12:55 PM, the surveyor presented the above findings of why the the agency did not provide a written schedule of visits. The Alt Adm/DON stated, “I’m surprised they weren’t there. I have one in each of the [office] charts and usually send them to the home.” The surveyor presented the above findings of how this failure could have impacted Patient 1 and 2. The Adm stated, “They could be confused, wouldn’t know who to call or contact.” During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 5:25 PM, the surveyor presented the findings from the recertification survey dated 07/23/2019 that included the same deficient practice and the agency’s plan of correction submitted to HHSC to correct the deficient practice and asked why it was not corrected almost three years later. The Adm stated, “Unfortunately, in those three years, we’ve had staffing issues with finding employees because of COVID. We’ve been overwhelmed with all of it. The process of hiring people to do the work needs to be better. There is no place to get help.” The surveyor presented the above findings of how the continued, uncorrected failure could have impacted Patient 1 and 2. The Adm stated it had a very negative effect with the work-flow and production had become compromised. The Adm stated everyone had trouble getting employees and he and the Alt Adm/DON were the only employees in the office allot of times and it was more than they could get done.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to utilize and monitor patient emergent care services, hospital admissions and re-admissions in the design of a QAPI program in order to monitor the effectiveness and safety of services and quality of care for three of three calendar years (2019, 2020 and 2021). This failure could place the agency patients at risk of negative client care outcomes in the event that substandard care was not identified and corrected by the agency during ongoing QAPI evaluations. FINDINGS INCLUDE: Review of the QAPI binder did not include evidence of performance indicators related to care outcomes on an ongoing basis to ensure the program reflected the complexity of its organization and services including the use of emergent care services, hospital admissions and re-admissions for calendar years 2019, 2020 and 2021. The QAPI binder included 11 unsigned quarterly reports dated from 03/20/2020 to 04/18/2022. The 11 quarterly reports did not include evidence of performance indicators related to care outcomes on an ongoing basis to ensure the program reflected the complexity of its organization and services including the use of emergent care services, hospital admissions and re-admissions for calendar years 2019, 2020 and 2021. During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 1:40 PM, the surveyor presented the findings of why the agency failed to utilize and monitor patient emergent care services, hospital admissions and re-admissions in the design of a QAPI program in order to monitor the effectiveness and safety of services and quality of care for three of three calendar years (2019, 2020 and 2021). The Adm stated the agency hired a consultant to review patient records and the consultant gave the results to the agency. The Adm stated he thought the reports included everything required. The surveyor presented the above findings of how these failures could impact all patients and the agency. The Adm stated it was important for agencies to follow procedures but it was not affecting agency patients. The Alt Adm/DON stated if procedures are not followed, it could impact the quality of care for clients. Agency policy titled "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN QAPI.1” with a revision date of 03/27/2010 read in part: “…POLICY…Agency leaders will develop a plan that sets priorities for data collection and is reviewed and updated at least once within the calendar year…by the QAPI…committee…Agency will strive to improve operational and patient health outcomes by implementing a performance improvement plan that incorporates the following essential processes: designing processes; monitoring performance through data collection; analyzing current performance; and improving and sustaining performance over time…Performance improvement activities identified by leaders will be identified through the collection of data for analysis of agency services with a system that measures significant outcomes. The measures must include the following…negative patient care outcomes…effectiveness and safety of all services provided…the promptness of service delivery…a determination that services have been performed as outlined in the individualized service plan, care plan or plan of care…Agency leaders will ensure the needed resources and mechanisms identified in the planning are available to evaluate and improve any and all work processes as needs are identified…PROCEDURE…A. When planning for performance improvement, agency leaders will consider the following…3. Identifying the reporting path for all performance improvement activities…4. Identifying the major functions and processes carried out by agency: scope, functions…problems…5. Identifying the performance measures for each function and processes within the function; 6. Identifying the data collection methodology (i.e., how and by whom data will be collected and what process will be used to analyze data; 7. Identifying the performance improvement problem-solving method to be used; and 8. Analyzing accumulated data in a way that current performance levels patterns or trends can be identified…C. Agency leaders/QAPI Committee will prioritize performance improvement activities. Criteria in setting priorities will include: 1. The expected impact on performance; 2. Selecting high-risk, high volume or problem-prone processes to monitor; 3. Data obtained from Adverse Event reports…4. The relationship of the potential improvement to the dimensions of performance and function…D. The agency will immediately correct identified problems that directly or potentially threaten the patient care and safety. E. The Performance Improvement activities will document corrective action to ensure that improvements are sustained over time…”

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 record review and interview, the agency failed to conduct and document PIP’s for three of three calendar year 2019, 2020 and 2021 and failed to have at least one PIP in development or on-going for calendar year 2022 that reflected the scope, complexity and past performance of the agency's services and operations and the measurable progress achieved on the projects. This failure placed the agency at risk to not improve and provide quality care and services to all agency patients. FINDINGS INCLUDE: Record review of the agency's QAPI binder did not include any reports, reviews or documentation that indicated the agency had conducted a PIP for calendar year 2019, 2020 and 2021 or had a PIP in development or on-going for calendar year 2022. During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 4:03 PM, the surveyor presented the above findings of what the agency's PIP had been in 2019, 2020 and 2021 and for the current year, 2022. The Adm stated he thought the agency had done PIP’s. The Adm stated the PIP was the total function of the agency to include complaints. The surveyor reviewed the above findings and asked where documentation of PIP’s for 2019, 2020, 2021 and 2022 were located. The Adm stated it’s in their head [Adm and Alt Adm/DON] and was not documented. The surveyor presented the above findings of how this failure could impact all patients and the agency. The Adm stated it was important for agencies to follow procedures but it was not affecting agency patients. The Alt Adm/DON stated if procedures are not followed, it could impact the quality of care for patients.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the Adm and Alt Adm failed to organize and direct the day-to-day operation of the agency in that: 1. The Adm and Alt Adm failed to develop and maintain an emergency preparedness plan that was reviewed and updated at least every two years for calendar year 2021. 2. The Adm and Alt Adm failed to develop and maintain an emergency preparedness plan that was based on and included a documented facility-based and community-based risk assessment utilizing an all-hazards approach that was reviewed and updated at least every two years for three of three years reviewed (2019, 2020 and 2021). 3. The Adm and Alt Adm failed to develop and implement emergency preparedness policies and procedures that were reviewed and updated at least every two years for three of three years reviewed (2019, 2020 and 2021). 4. The Adm and Alt Adm failed to review the emergency preparedness plan after each actual emergency response to evaluate its effectiveness and to update the plan as needed for two of two years reviewed (2020 and 2021) in that: The plan was not evaluated and updated following the COVID-19 pandemic that began on 03/14/2020 and the winter storm that occurred on 02/13/2021 through 02/17/2021. 5. The Adm and Alt Adm failed to provide written notice of the agency's transfer and discharge policy within 4 business days of the initial evaluation visit in three of three (Patient 1, 2 and 3) patients the surveyor conducted home visits. 6. The Adm and Alt Adm failed to advise three of three (Patient 1, 2 and 3) patients with the names, addresses and telephone numbers of the following Federally-funded and state-funded entities that served the area the three patients resided in: Agency on Aging; Center for Independent Living; Protection and Advocacy Agency; Aging and Disability Resource Center and Quality Improvement Organization. 7. The Adm and Alt Adm failed to provide a written visit schedule including the frequency of visits by personnel acting on behalf of the agency to two of three (Patient 1 and 2) patients the surveyor conducted home visits. 8. The Adm and Alt Adm failed to utilize and monitor patient emergent care services, hospital admissions and re-admissions in the design of a QAPI program in order to monitor the effectiveness and safety of services and quality of care for three of three calendar years reviewed (2019, 2020 and 2021). 9. The Adm and Alt Adm failed to conduct and document PIP’s for three of three calendar year 2019, 2020 and 2021 and failed to have at least one PIP in development or on-going for calendar year 2022 that reflected the scope, complexity and past performance of the agency's services and operations and the measurable progress achieved on the projects. These failures showed lack of overall administrative leadership and agency oversight and placed patients at risk of harm in the event of an emergency or disaster due to the lack of organized preparation and planning for care and services in the event of a disaster; violated patient rights; prevented the agency from monitoring and providing safe, professional, quality health care and placed the patients at risk of poor outcomes. FINDINGS INCLUDE: 1. Review of the emergency preparedness plan binder included a document dated 01/15/2019 and titled, “Emergency Preparedness Plan Review and Checklist.” The binder did not include any records to establish the agency reviewed and updated their emergency preparedness plan for year 2021, two years after the prior review on 01/15/2019. During an interview with the Adm and Alt Adm/DON/Disaster Coordinator on 07/07/2022 at 1:20 PM, the surveyor presented the above findings of why the emergency preparedness plan was not reviewed and updated at least every two years, with the last review documented on 01/15/2019. The Adm stated everyone was crazy during 2020 and 2021 due to the COVID pandemic but it was always fresh in his and the Alt Adm/DON/Disaster Coordinators mind knowing what needed to be done. The Adm stated he and the Alt Adm/DON/Disaster Coordinator knew things, including this information but it might not be documented. The surveyor presented the above findings of how this failure could impact the clients. The Alt Adm/DON/Disaster Coordinator stated the agency had done almost everything that was required but failed to update the emergency preparedness manual. The Alt Adm/DON/Disaster Coordinator stated if the failure had affected the clients, that would not be good. Agency policy titled "EMERGENCY PREPAREDNESS AND RESPONSE PLAN EC.8" with a revision date of 08/01/2011 read in part: " ...POLICY…Agency will utilize an Emergency Preparedness Plan in the event a situation occurs that could potentially affect the needs for its services or its ability to provide those services…The effectiveness of the Emergency Preparedness Plan will be evaluated at least annually and after each actual disaster/emergency response…” 2. Review of the emergency preparedness plan binder included a document titled, "Hazard Threat Analysis" that was undated and a document titled, "Hazard Vulnerability Assessment Tool" that was undated. The hazard threat analysis and the hazard vulnerability assessment tool included a risk assessment for emergencies likely to occur in the agency's service area. The binder did not include a documented facility-based and community-based risk assessment utilizing an all-hazards approach for 2019, 2020 and 2021. During an interview with the Adm and Alt Adm/DON/Disaster Coordinator on 07/07/2022 at 1:28 PM, the surveyor presented the findings of why the agency failed to develop and maintain a facility-based and community-based risk assessment utilizing an all-hazards approach at least every two years. The Adm stated the agency had been short-staffed due to the COVID pandemic and the information was always fresh in their [Adm and Alt Adm/Disaster Coordinator] minds knowing what needed to be done. The surveyor presented the above findings of how this failure could have impacted agency patients and employees. The Alt Adm/DON/Disaster Coordinator stated the agency had done almost everything that was required but failed to update the emergency preparedness manual. The Alt Adm/DON/Disaster Coordinator stated if the failure had affected the clients, that was not good. On 07/07/2022 at 3:30 PM, the Adm presented the surveyor with a stack emergency preparedness papers; several of the pages were dated 07/07/2022. The Adm stated he and the Alt Adm/DON/Disaster Coordinator forgot the agency had the papers from 2022 and just found them in the Alt Adm/DON/Disaster Coordinator’s office. The surveyor reviewed the documents with the Adm and stated they appeared to be copies of documents included in the emergency preparedness binder for 01/15/2019, including scribble markings and exact wording. The surveyor held the documents up to a light and compared them to the 2019 documents. Both sets of documents were identical, word for word, except for dates. The documents included a Hazard Vulnerability Assessment Tool that was undated. The surveyor presented the above findings to the Adm of the 2019 and 2022 documents that appeared exactly the same and asked if the agency completed the 2022 documents after the prior interview on 07/07/2022 at 1:28 PM. The Adm stated the documents were completed by the agency previously but the Adm signed and dated them today [07/07/2022]. The surveyor presented the findings and asked how the information could be the same from 2019 to 2022, considering a pandemic was declared in March 2020, and if the agency actually completed the 2022 documents with new information or just copied the 2019 documents without reviewing and updating the information for 2022. The Adm stated the 2022 documents were copies of the 2019 documents. The surveyor again reviewed the similarities of the 2019 and 2022 documents with the Adm and the Adm stated, “Oh, I see what you are saying. They are the same and I made copies of the 2019 for 2022. I didn’t update anything.” Agency policy titled "EMERGENCY PREPAREDNESS AND RESPONSE PLAN EC.8" with a revision date of 08/01/2011 read in part: “…POLICY…Agency will create a hazard threat analysis…to identify the potential disasters from natural and man-made causes most likely to occur in the agency’s service area… Agency will maintain documentation of compliance with the required elements and agency policies in the Emergency Preparedness Response and Plan Manual…” 3. Review of the agency LCHHS policy manual included a policy titled "EMERGENCY PREPAREDNESS AND RESPONSE PLAN EC.8" with a revision date of 08/01/2011. The manual did not include an updated emergency preparedness and response plan since 08/01/2011. Review of the emergency preparedness plan binder revealed no evidence the agency reviewed or updated the emergency preparedness policy EC.8 for 2019, 2020 and 2021. During an interview with the Adm and Alt Adm/DON/Disaster Coordinator on 07/07/2022 at 1:05 PM, the surveyor presented the above findings of when the agency policies and procedures, including EC.8, were last updated. The Adm stated the policies were updated in 2019. The agency did not provided documentation of an updated emergency preparedness policy in 2019. The surveyor presented the above findings of what the updates included in 2019. The Adm stated mainly human resources. The surveyor presented the above findings why the agency’s policy, Emergency Preparedness and Response Plan EC.8, had not been updated since 08/01/2011. The Adm stated he thought it had been updated. The surveyor presented the above findings of how this failure could impact the agency and all patients. The Adm stated as the agency goes along each year, they update their policies. The Adm stated the agency does in-services to educate employees on what has changed and thanked the surveyor for telling him policy EC.8 was outdated. The Alt Adm/DON/Disaster Coordinator stated the agency was practically doing all updates/changes but changes just weren’t included in their policies. 4. A review of the emergency preparedness plan binder revealed no evidence of any records to establish the agency conducted an internal review after the COVID-19 pandemic that began on 03/14/2020 and the winter storm that occurred from 2/13/2021 through 02/17/2021. During an interview with the Adm and Alt Adm/DON/Disaster Coordinator on 07/07/2022 at 1:25 PM, the surveyor presented the above findings of why the agency failed to review the emergency preparedness plan after each actual emergency response to evaluate its effectiveness and to update the plan as needed following the COVID-19 pandemic that began on 03/14/2020 and the winter storm that occurred on 02/13/2021 through 02/17/2021. The surveyor presented the above findings of how this failure could have impacted the patients. The Alt Adm/DON/Disaster Coordinator stated the agency had done almost everything that was required but failed to update the emergency preparedness manual. The Alt Adm/DON/Disaster Coordinator stated if the failure had affected the clients, that would not be good. During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 5:25 PM, the surveyor presented the findings from the recertification survey dated 07/23/2019 that included the same deficient practice and the agency’s plan of correction submitted to HHSC to correct the deficient practice and asked why it was not corrected almost three years later. The Adm stated, “Unfortunately, in those three years, we’ve had staffing issues with finding employees because of COVID. We’ve been overwhelmed with all of it. The process of hiring people to do the work needs to be better. There is no place to get help.” The Adm stated he promised the issue would be corrected by the next survey. The surveyor presented the above findings of how the continued, uncorrected failure could impact all agency patients. The Adm stated it had a very negative effect with the work-flow and production was compromised. The Adm stated everyone had trouble getting employees and he and the Alt Adm/DON were the only employees in the office allot of times and it was more than they could get done. The Alt Adm/Don stated the agency checked on-line hiring sites all of the time for employees. Agency policy titled "EMERGENCY PREPAREDNESS AND RESPONSE PLAN EC.8" with a revision date of 08/01/2011 read in part: “…POLICY…Agency will utilize an Emergency Preparedness Plan in the event a situation occurs that could potentially affect the needs for its services or its ability to provide those services…The effectiveness of the Emergency Preparedness Plan will be evaluated at least annually and after each disaster/emergency response…Agency will maintain documentation of compliance with the required elements and agency policies in the Emergency Preparedness Response and Plan Manual…” 5. Review of the sample LCHHS admission packet revealed the packet did not include the agency’s transfer and discharge policy. On 07/06/2022 at 12:00 PM, the surveyor arrived at the address listed on the plan of care for Patient 1 and 2. The address was located in a residential area and occupied by a residential care home, Care Home ZZ, where Patient 1 and 2 resided. Upon entering the home, the surveyor requested the agency home folder for Patient 1 and 2. An employee caregiver of the care home, Staff Caregiver YY, stated the folders were not kept in the patient rooms. Staff Caregiver YY left the room and returned with the home folder for Patient 1 and 2. During an interview with Staff Caregiver YY at 12:05 PM, the surveyor asked if anything had been removed from either of the home folders. Staff Caregiver YY stated, “No, nothing.” Patient 1: Record review included a plan of care with a primary diagnosis of bilateral osteoarthritis of the knees dated 06/06/2022 to 08/04/2022 with a start of care date of 10/14/2020. During the home visit and interview on 07/06/2022 at 12:15 PM, the surveyor asked Patient 1 if anything had been removed from the home folder. Patient 1 stated, "No." Review of the agency home folder contained no evidence a written notice of the agency's transfer and discharge policy had been provided. Patient 2: Record review included a plan of care with a primary diagnosis of Alzheimer’s Disease dated 04/23/2022 to 06/21/2022 with a start of care date of 04/28/2021. During the home visit and interview on 07/06/2022 at 12:00 PM, the surveyor asked Patient 2 if anything had been removed from the home folder. Patient 2 stated, “No.” Review of the agency home folder contained no evidence a written notice of the agency's transfer and discharge policy had been provided. Patient 3: Record review included a plan of care with a primary diagnosis of bilateral osteoarthritis of the knees dated 06/07/2022 to 08/05/2022 with a start of care date of 06/07/2022. During the home visit and interview on 07/06/2022 at 11:15 AM, Patient 3’s family member, Family Member 1, stated Patient 3 was completely bedridden, awake all night with a fever and was finally sleeping. The surveyor observed Patient 3 sleeping. Family Member 1 stated she was the primary caregiver for Patient 3. The surveyor inquired if anything had been removed from the home folder. Family Member 1 stated, “No.” Review of the agency home folder contained no evidence a written notice of the agency's transfer and discharge policy had been provided. During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 12:47 PM, the surveyor presented the above findings of why the agency failed to provide written notice of the agency's transfer and discharge policy. The Alt Adm/DON stated, “I don’t understand why I don’t have it in there.” The Adm stated, “We weren’t aware it was required.” The surveyor presented the above findings of how this failure could have impacted Patient 1, 2 and 3. The Adm stated, “They could be confused, wouldn’t know who to call or contact.” During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 5:25 PM, the surveyor presented the findings from the recertification survey dated 07/23/2019 that included the same deficient practice and the agency’s plan of correction submitted to HHSC to correct the deficient practice and asked why it was not corrected almost three years later. The Adm stated, “Unfortunately, in those three years, we’ve had staffing issues with finding employees because of COVID. We’ve been overwhelmed with all of it. The process of hiring people to do the work needs to be better. There is no place to get help.” The surveyor presented the above findings of how the continued, uncorrected failure could impact all agency patients. The Adm stated it had a very negative effect with the work-flow and production had become compromised. The Adm stated everyone had trouble getting employees and he and the Alt Adm/DON were the only employees in the office allot of times and it was more than they could get done. 6. Review of the sample LCHHS admission packet revealed the packet did not include names, addresses and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. On 07/06/2022 at 12:00 PM, the surveyor arrived at the address listed on the plan of care for Patient 1 and 2. The address was located in a residential area and occupied by a residential care home, Care Home ZZ, where Patient 1 and 2 resided. Upon entering the home, the surveyor requested the agency home folder for Patient 1 and 2. An employee caregiver of the care home, Staff Caregiver YY, stated the folders were not kept in the patient rooms. Staff Caregiver YY left the room and returned with the home folder for Patient 1 and 2. During an interview with Staff Caregiver YY at 12:05 PM, the surveyor asked if anything had been removed from either of the home folders. Staff Caregiver YY stated, “No, nothing.” Patient 1: Record review included a plan of care with a primary diagnosis of bilateral osteoarthritis of the knees dated 06/06/2022 to 08/04/2022 with a start of care date of 10/14/2020. During the home visit and interview on 07/06/2022 at 12:15 PM, the surveyor asked Patient 1 if anything had been removed from the home folder. Patient 1 stated, "No." Review of the agency home folder contained no evidence the agency provided the names, addresses and telephone numbers of the five Federally-funded and state-funded entities that served the area the patient resided. Patient 2: Record review included a plan of care with a primary diagnosis of Alzheimer’s Disease dated 04/23/2022 to 06/21/2022 with a start of care date of 04/28/2021. During the home visit and interview on 07/06/2022 at 12:00 PM, the surveyor asked Patient 2 if anything had been removed from the home folder. Patient 2 stated, “No.” Review of the agency home folder contained no evidence the agency provided the names, addresses and telephone numbers of the five Federally-funded and state-funded entities that served the area the patient resided. Patient 3: Record review included a plan of care with a primary diagnosis of bilateral osteoarthritis of the knees dated 06/07/2022 to 08/05/2022 with a start of care date of 06/07/2022. During the home visit and interview on 07/06/2022 at 11:15 AM, Patient 3’s family member, Family Member 1, stated Patient 3 was completely bedridden, awake all night with a fever and was finally sleeping. The surveyor observed Patient 3 sleeping. Family Member 1 stated she was the primary caregiver for Patient 3. The surveyor inquired if anything had been removed from the home folder. Family Member 1 stated, “No.” Review of the agency home folder contained no evidence a written notice of the agency's transfer and discharge policy had been provided. During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 12:50 PM, the surveyor presented the above findings of why the agency failed to provide Patient 1, 2 and 3 with information on Federally-funded and state-funded entities. The Adm stated, “We didn’t know about them. Where do we find the list?” The surveyor provided the CFR to the Adm and Alt Adm/DON. The surveyor presented the above findings of how this failure could have impacted Patient 1, 2 and 3. The Adm stated, “They could be confused, wouldn’t know who to call or contact.” During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 5:25 PM, the surveyor presented the findings from the recertification survey dated 07/23/2019 that included the same deficient practice and the agency’s plan of correction submitted to HHSC to correct the deficient practice and asked why it was not corrected almost three years later. The Adm stated, “Unfortunately, in those three years, we’ve had staffing issues with finding employees because of COVID. We’ve been overwhelmed with all of it. The process of hiring people to do the work needs to be better. There is no place to get help.” The surveyor presented the above findings of how the continued, uncorrected failure could impact all agency patients. The Adm stated it had a very negative effect with the work-flow and production had become compromised. The Adm stated everyone had trouble getting employees and he and the Alt Adm/DON were the only employees in the office allot of times and it was more than they could get done. The Alt Adm/Don stated the agency checked on-line hiring sites all of time for employees. 7. On 07/06/2022 at 12:00 PM, the surveyor arrived at the address listed on the plan of care for Patient 1 and 2. The address was located in a residential area and occupied by a residential care home, Care Home ZZ, where Patient 1 and 2 resided. Upon entering the home, the surveyor requested the agency home folder for Patient 1 and 2. An employee caregiver of the care home, Staff Caregiver YY, stated the folders were not kept in the patient rooms. Staff Caregiver YY left the room and returned with the home folder for Patient 1 and 2. During an interview with Staff Caregiver YY at 12:05 PM, the surveyor asked if anything had been removed from either of the home folders. Staff Caregiver YY stated, “No, nothing.” Patient 1: Record review included a plan of care with a primary diagnosis of bilateral osteoarthritis of the knees dated 06/06/2022 to 08/04/2022 with a start of care date of 10/14/2020. The orders included skilled nursing visits one time a week for nine weeks effective week of 05/29/2022 (sic). During the home visit and interview on 07/06/2022 at 12:15 PM, the surveyor asked Patient 1 if anything had been removed from the home folder. Patient 1 stated, "No." Review of the agency home folder contained no evidence a written schedule of visits had been provided. Patient 2: Record review included a plan of care with a primary diagnosis of Alzheimer’s Disease dated 04/23/2022 to 06/21/2022 with a start of care date of 04/28/2021. The orders included skilled nursing visits one time a week for seven weeks effective week of 04/24/2022. During the home visit and interview on 07/06/2022 at 12:00 PM, the surveyor asked Patient 2 if anything had been removed from the home folder. Patient 2 stated, “No.” Review of the agency home folder contained no evidence a written schedule of visits had been provided. During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 12:55 PM, the surveyor presented the above findings of why the the agency did not provide a written schedule of visits. The Alt Adm/DON stated, “I’m surprised they weren’t there. I have one in each of the [office] charts and usually send them to the home.” The surveyor presented the above findings of how this failure could have impacted Patient 1 and 2. The Adm stated, “They could be confused, wouldn’t know who to call or contact.” During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 5:25 PM, the surveyor presented the findings from the recertification survey dated 07/23/2019 that included the same deficient practice and the agency’s plan of correction submitted to HHSC to correct the deficient practice and asked why it was not corrected almost three years later. The Adm stated, “Unfortunately, in those three years, we’ve had staffing issues with finding employees because of COVID. We’ve been overwhelmed with all of it. The process of hiring people to do the work needs to be better. There is no place to get help.” The surveyor presented the above findings of how the continued, uncorrected failure could have impacted Patient 1 and 2. The Adm stated it had a very negative effect with the work-flow and production had become compromised. The Adm stated everyone had trouble getting employees and he and the Alt Adm/DON were the only employees in the office allot of times and it was more than they could get done. 8. Review of the QAPI binder did not include evidence of performance indicators related to care outcomes on an ongoing basis to ensure the program reflected the complexity of its organization and services including the use of emergent care services, hospital admissions and re-admissions for calendar years 2019, 2020 and 2021. The QAPI binder included 11 unsigned quarterly reports dated from 03/20/2020 to 04/18/2022. The 11 quarterly reports did not include evidence of performance indicators related to care outcomes on an ongoing basis to ensure the program reflected the complexity of its organization and services including the use of emergent care services, hospital admissions and re-admissions for calendar years 2019, 2020 and 2021. During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 1:40 PM, the surveyor presented the findings of why the agency failed to maintain and evaluate a QAPI program to include performance indicators related to care outcomes on an ongoing basis and to ensure the program reflected the complexity of its organization and services including the use of emergent care services, hospital admissions and re-admissions for calendar years 2019, 2020 and 2021. The Adm stated the agency hired a consultant to review patient records and the consultant gave the results to the agency. The Adm stated he thought the reports included everything required. The surveyor presented the above findings of how these failures could impact all patients and the agency. The Adm stated it was important for agencies to follow procedures but it was not affecting agency patients. The Alt Adm/DON stated if procedures are not followed, it could impact the quality of care for clients. Agency policy titled "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN QAPI.1” with a revision date of 03/27/2010 read in part: “…POLICY…Agency leaders will develop a plan that sets priorities for data collection and is reviewed and updated at least once within the calendar year…by the QAPI…committee…Agency will strive to improve operational and patient health outcomes by implementing a performance improvement plan that incorporates the following essential processes: designing processes; monitoring performance through data collection; analyzing current performance; and improving and sustaining performance over time…Performance improvement activities identified by leaders will be identified through the collection of data for analysis of agency services with a system that measures significant outcomes. The measures must include the following…negative patient care outcomes…effectiveness and safety of all services provided…the promptness of service delivery…a determination that services have been performed as outlined in the individualized service plan, care plan or plan of care…Agency leaders will ensure the needed resources and mechanisms identified in the planning are available to evaluate and improve any and all work processes as needs are identified…PROCEDURE…A. When planning for performance improvement, agency leaders will consider the following…3. Identifying the reporting path for all performance improvement activities…4. Identifying the major functions and processes carried out by agency: scope, functions…problems…5. Identifying the performance measures for each function and processes within the function; 6. Identifying the data collection methodology (i.e., how and by whom data will be collected and what process will be used to analyze data; 7. Identifying the performance improvement problem-solving method to be used; and 8. Analyzing accumulated data in a way that current performance levels patterns or trends can be identified…C. Agency leaders/QAPI Committee will prioritize performance improvement activities. Criteria in setting priorities will include: 1. The expected impact on performance; 2. Selecting high-risk, high volume or problem-prone processes to monitor; 3. Data obtained from Adverse Event reports…4. The relationship of the potential improvement to the dimensions of performance and function…D. The agency will immediately correct identified problems that directly or potentially threaten the patient care and safety. E. The Performance Improvement activities will document corrective action to ensure that improvements are sustained over time…” 9. Record review of the agency's QAPI binder did not include any reports, reviews or documentation that indicated the agency had conducted a PIP for calendar year 2019, 2020 and 2021 or had a PIP in development or on-going for calendar year 2022. During an interview with the Adm and Alt Adm/DON on 07/07/2022 at 4:03 PM, the surveyor presented the above findings of what the agency's PIP had been in 2019, 2020 and 2021 and for the current year, 2022. The Adm stated he thought the agency had done PIP’s. The Adm stated the PIP was the total function of the agency to include complaints. The surveyor reviewed the above findings and asked where documentation of PIP’s for 2019, 2020, 2021 and 2022 were located. The Adm stated it’s in their head [Adm and Alt Adm/DON] and was not documented. The surveyor presented the above findings of how this failure could impact all patients and the agency. The Adm stated it was important for agencies to follow procedures but it was not affecting agency patients. The Alt Adm/DON stated if procedures are not followed, it could impact the quality of care for patients. Agency LCHHS policy titled, “L&C RESPONSIBILITIES OF THE ADMINISTRATOR LD.6” with a revision date of 07/02/2012 read in part, “…PURPOSE To define the responsibilities of the Administrator…To ensure agency compliance with federal, state and local laws and regulations as appropriate. POLICY The Administrator is responsible for implementing and supervising the administrative policies and operations of the agency and for administratively supervising the provision of all services to agency patients…A. An Administrator will be responsible but not limited to…1. Manage the daily operations of the agency 2. Organize and direct the agency’s ongoing functions…4. Administratively supervise the provision of quality of care to agency patients 5. Supervise to ensure implementation of agency policy and procedures…”