D Life Healthcare Services Inc.

“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), §485.542(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’s failed to have a written emergency preparedness and response plan that comprehensively described its approach to a disaster that could affect the need for its services or it ability to provide those services based on a risk assessment that identifies the disasters from natural and man-made causes that are likely to occur in all of the agency’s services area for 3 of 3 years reviewed--2022, 2023, & 2024. This failure places the agency’s clients at risk for harm due to the agency not being properly prepared for the different types of disasters that could occur in Agency’s listed service areas and affect the agency clients in those areas. Pre-Survey review of the TULIP account for D-Life Healthcare Services, Inc. on 10/21/2024 revealed Agency is a Home Health licensed facility with license number 009130 and the following home health service area/geographic area listed: Regions 5, 6, 7, and 8. Continued review of the D-Life Healthcare Services, Inc. TULIP account revealed the “Geographic Areas”, that the agency’s current service area included: “Region 5 Counties Served: Hardin; Jasper; Jefferson; Newton; Orange; Polk; San Jacinto” “Region 6 Counties Served: Austin; Brazoria; Chambers; Colorado; Fort Bend; Galveston; Harris; Liberty; Matagorda; Montgomery; Walker; Waller; Wharton.” “Region 7 Counties Served: Bastrop; Brazos; Caldwell; Fayette; Grimes; Madison; Washington” “Region 8 Counties Served: Bexar; Calhoun; Dewitt; Gonzales; Jackson; Lavaca; Victoria” Record review of Agency’s Emergency Preparedness Plan on 10/24/2024 revealed a document titled: “D-LIFE HEALTHCARE SERVICES, Inc. EMERGENCY PREPAREDNESS AND RESPONSE PLAN” dated: “September 1, 2008”. Document further read in part: “…. The Board of Directors of D-Life Healthcare Services Inc. has appointed the Agency Administrator to serve as the Disaster/Emergency Coordinator.” The document had the name and signature of the Administrator. Record review of Agency’s Emergency Preparedness Plan on 10/24/2024 revealed three documents titled and dated: “D-LIFE HEALTHCARE SERVICES, INC. AGENCY RISK ASSESSMENT AND HAZARD VULNERABILITY TOOL, 3/10/22, 2/18/23, and 3/29/2024”. All three documents mentioned above included the signature of the Administrator / Designated Emergency / Disaster Coordinator. During interview with Administrator on 10/24/2024 at approximately 2:03 PM, he was asked if he was the Agency’s Disaster/Emergency Coordinator. Administrator stated that he was the Agency’s Emergency Disaster Coordinator. When asked if the Emergency Preparedness Risk Assessments dated, “3/10/22, 2/18/23, and 3/29/2024” were completed by him as the Emergency / Disaster Coordinator, he stated: “yes, I completed those assessments.” The Surveyor then asked which, of the four regions (Region 5, 6, 7 and 8), listed under the agency’s service area did the Risk Assessments mentioned above belong to, as the Risk Assessment documents failed to contain any of the four listed service areas (Region 5, 6, 7, or 8). The Administrator / Emergency / Disaster Coordinator stated the Risk Assessments mentioned above and dated, “3/10/22, 2/18/23, and 3/29/2024” were completed for Region 6. When asked if he had completed any Risk Assessments for the other three regions listed under the agency’s geographic area/service area (Region 5, 7, or 8), he stated, “No Risk Assessments were completed for any of the other Agency’s three listed areas (Region 5, 7, or 8)” as he did not know the Risk Assessments needed to be done separately for each of the service areas. Record review of the Agency’s policy titled: “PLANNING AND IMPLEMENTATION PHASES OF EMERGENCY PREPAREDNESS 1. RISK ASSESSMENT AND HAZARD VULNERABILITY ASSESSMENT” and dated: “1/3/2010”. Policy reads in part…… “Our Agency will conduct a risk assessment and evaluation of the likely emergencies in our Agency service area.””