Every finding on record at Pleasure Nwachukwu

A relicensure/recertification survey entrance conference was conducted with the Adm/DON on 10/24/2023. The census was: LCHHS: 0 LHH: 0 PAS: 9 Abbreviations: Adm – Administrator DON – Director of Nurses LCHHS - Licensed and Certified Home Health LHHS - Licensed Home Health Services OM – office manager PAS – personal assistance services PM - post meridiem Sup - supervisor

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on record review and interview, the agency's written emergency preparedness and response plan failed to include a continuity of operations business plan which addressed emergency financial needs, essential functions for client services, critical personnel and how to return to normal operations as quickly as possible in three of three years reviewed (2020, 2021 and 2022). 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: Record review of the agency’s emergency preparedness binder included a 2-page from titled, “BUSINESS CONTINUITY PLAN” [page 23-24] that was blank and not filled out. Record review of the agency’s policy manual included an 8-page form titled, “CONTINUITY OF OPERATIONS BUSINESS PLAN” that was blank and not filled out. During an interview with the Adm/DON and telephone interview with the PAS Sup/OM on 10/26/2023 at 2:40 PM, the surveyor asked why the 2-page form from the emergency preparedness binder titled, “BUSINESS CONTINUITY PLAN” and the 8-page form from the policy manual titled, “Continuity of Operations Business Plan” were both blank and not filled out. The Adm/DON stated they didn’t fill the forms out because they were mainly for skilled patients, not non-skilled patients. The Adm/DON stated the agency only had non-skilled patients, so they didn’t fill the forms out. The surveyor asked why the agency did not use a form tailored to the services the agency provided. The PAS Sup/OM stated it was difficult to find a form to fit the services being provided. The PAS Sup/OM stated the agency did not have the money to hire a consultant to assist the agency. The Adm/DON stated if the state [of Texas] could provide the form to the agency, it would be helpful. Agency policy titled "EMERGENCY PREPAREDNESS AND RESPONSE PLAN" with a revision date of 10/01/2012 read in part, “…POLICY…3. Agency's written Emergency Preparedness and Response Plan will include…3.2. A Continuity of Operations Business Plan to address emergency financial needs, essential functions for client services, critical personnel, and how to return to normal operations as quickly as possible..."

A relicensure/recertification survey entrance conference was conducted with the Adm/DON on 10/24/2023. The census was: LCHHS: 0 LHH: 0 PAS: 9 The agency was found in compliance with the Medicare Conditions of Participation and no deficiencies were cited.