Every finding on record at American Best Care Hospice Inc

Based on record review and interview, the agency failed to follow their policy to complete an internal review of its emergency preparedness and response plan at least annually for three (2020, 2021, and 2022) of three years reviewed to evaluate its effectiveness and to update the plan as needed. This failure has the potential to place the agency's patients at risk of harm in the event of an emergency or disaster. --- Findings include: Review of Agency policy dated 070123, read in part, ";Emergency Preparedness and Response Plan - Addendum EC.40-TX.... Policy...A. The Hospice will complete an internal review of the Emergency Preparedness Plan at least annually, and after each actual emergency response, to evaluate its effectiveness and to update the plan as needed... Procedure... B. As part of the annual internal review, the Hospice will test the response phase of its emergency preparedness and response plan in a planned drill if not tested during an actual emergency response..." Review of the contents in the agency's "Emergency Preparedness" binder revealed the Administrator was designated as the emergency preparedness coordinator. The binder contained no evidence the agency conducted an annual review of the emergency preparedness plan for calendar years 2020, 2021, and 2022. In an interview with the Administrator on 12/13/2023 at approximately 1:45 PM, the surveyor reviewed the above findings with the Administrator. The administrator verified that he is the emergency preparedness coordinator. The surveyor asked if there were any other emergency preparedness binders or documents for emergency preparedness. The Administrator stated, " I couldnt find any other documents. I wasnt administrator during those years. The previous administrator possibly didnt know or neglected the duty. I had a drill during the excessive heat warnings 09/23. The plan was evaluated and reviewed after the drill."