United America Home Health 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 failed to have a written emergency preparedness and response plan that was reviewed and updated at least every 2 years, based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach for three of the three years reviewed, 2022, 2023, and 2024. This failure placed the agency’s patients at risk of not being adequately prepared in the event of an emergency as the agency had not evaluated its emergency preparedness and response plan to verify its effectiveness and to improve as needed for three years. Findings Include: Review of the agency’s Emergency Preparedness Plan on 09/18/25, revealed there were no supporting documents to show the agency had performed community-based exercises, reviewed the plan, or had activated the plan for any weather / disasters that occurred in the years 2022 (Icy weather and flash flooding), 2023 (drought conditions) or 2024 (Derecho (Wind/Rain event) in May 2024 and Hurricane Beryl in July 2024). There was no documented Risk assessment for any of the three years reviewed, 2022, 2023, and 2024, within the Emergency Preparedness Plan. An interview with the agency’s Emergency Response coordinator (ERC) on 9/19/2025 at 11:10am revealed that the agency had not conducted community-based exercises for the Emergency Preparedness Plan for three of the three years reviewed for 2022, 2023, or 2024. The ERC was unable to provide documents of any activated disaster responses for the years 2022, 2023, or 2024. When asked how often the emergency preparedness plan was reviewed and updated, she stated every three years. When asked if she, or anyone else, attended a local community-based exercise, she stated she had not attended an exercise within the community and was unclear of what a community-based exercise entailed. After the Surveyor provided examples of what Community Based exercises were, the ERC clarified she did not have knowledge if this had been done and stated that the administrator and alternate administrator would know more about community-based exercises. The ERC also stated that the agency had not activated or documented disaster activations for the three years reviewed, 2022, 2023, and 2024. When asked how often the Emergency Preparedness Plan was review and revised, she stated “maybe every 3 years”. When asked how the agency addressed the icy weather, flash flooding, drought, the Derecho event and Hurricane Beryl between 2022 - 2023, she stated “We review the triage list and contact patients accordingly. Then we contact our staff to make sure they are aware of the plan.” When asked what the plan was, she stated the agency “would determine the severity and if they needed to evacuate, they would evacuate to an alternate location.” When asked what the alternate location was, the address or location was not provided. An interview with the Alternate Administrator on 09/19/2025 at 12:46pm revealed that the agency had not performed community-based risk assessments. The alt Admin stated he was not aware that community-based risk assessments needed to be conducted. After the ALT Admin reviewed the agency’s policy and procedure for emergency preparedness, he clarified that the agency had not performed community-based risk assessments for the 3 years, 2022, 2023, and 2024, although the area had icy weather, flash flooding, drought, and the Derecho event and Hurricane Beryl. Review of the agency’s undated policy titled “Emergency Preparedness Planning Program for Texas Home Health Agencies” read in part: “Policy The agency has a written emergency preparedness program that comprehensively describes its approach to a natural, man-made, facility-based disasters and emerging infectious disease (EIDs) based upon the facility- and community-based risk assessment and communication plan utilizing an all-hazards approach. Purpose To coordinate with federal, state, tribal, regional and local emergency preparedness systems to prepare to meet needs, in a consistent manner, of patients and staff during disasters and emergency situations.” “Emergency Plan I. The HHA must develop and maintain a written emergency preparedness program that is reviewed and updated at least annually.……… V. The plan must comply with all applicable federal state and local emergency preparedness requirements and must include, but not limited to, the following elements: B. Be based on and include a documented, facility based and community-based risk assessment, utilizing an all-hazards approach of all risk or emergencies the agency may reasonably expect to confront…… E. Include a process for cooperation and collaboration with local, tribal, regional, state, and Federal Emergency preparedness official’s efforts to maintain an integrated response during a disaster or emergency situation including documentation of the home health efforts to contact such officials and when applicable of its participation in collaborative and cooperative planning efforts........ Training and Testing I. …B. The agency must conduct and document exercises to test the emergency plan at least annually… i. Participate in a full-scale exercise that is community based every two years which is applicable to the agencies risk assessment; or a. When a community-based exercise is not accessible the agency must document details of its efforts to identify a full-scale community based exercise… i. In lieu of the community-based exercise, conduct an individual facility based functional exercise every two years; or ii. If the agency experiences an actual emergency event or response of sufficient magnitude that requires activation of the emergency plan and meets the required community based full scale exercise or individual, facility-based exercise, the agency 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.” Review of the agency’s policy titled “Emergency Preparedness Planning Program” read in part: “..... Required Elements of Emergency Preparedness Plan Written emergency plan based on facility- and community-based risk assessments.........””

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. 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 included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation for three of the three years reviewed. 2022, 2023, and 2024. This failure placed the agency’s patients at risk of not being appropriately prepared/managed in the event of a disaster or emergency situation, as the agency had not coordinated with or had any preplanned state or local emergency contacts for management during a disaster or emergency. Findings included: Review of the Emergency Preparedness Plan on 09/18/25 revealed there were no supporting documents to show the agency had performed community-based exercises, reviewed the plan, or had activated the plan for any weather / disasters that occurred in the years 2022 (Icy weather and flash flooding), 2023 (drought conditions) or 2024 (Derecho in May and Hurricane Beryl in July 2024). There was no documented Risk assessment for three of the three years reviewed, 2022, 2023, and 2024, within the Emergency Preparedness Plan. An interview with the Emergency Response coordinator on 9/19/2025 at 11:10am revealed that the agency had not conducted community-based exercises for the Emergency Preparedness Plan for three of the three years reviewed for 2022, 2023, or 2024. When asked how often the emergency preparedness plan is reviewed and updated, she stated every three years. When asked if she, or anyone else, attended a local community-based exercise, she stated she had not attended an exercise within the community and was unclear of what a community-based exercise entailed. Explanation of Community Based exercises was given, and she clarified she did not have knowledge if this had been done. The EPC stated that the administrator and alternate administrator would know more about community-based exercises. An interview with the EPC on 9/19/2025 at 11:10am revealed that the agency had not documented disaster activations for three of the three years reviewed, 2022, 2023, and 2024. When asked how the agency addressed emergency disasters, she stated “We review the triage list and contact patients accordingly. Then we contact our staff to make sure they are aware of the plan.” When asked what the plan was, she stated the agency “would determine the severity and if they needed to evacuate, they would evacuate to an alternate location.” When asked what the alternate location was the address or location was not provided. An interview with the Alternate Administrator on 09/19/2025 at 12:46pm revealed that the agency had not performed community-based risk assessments. The alt Admin stated he was not aware that community-based risk assessments needed to be conducted. After review of the agencies policy and procedure for emergency preparedness was referenced for his review, it was clarified that the agency had not performed community-based risk assessments for 3 of the 3 years, 2022, 2023, and 2024. Review of the agency’s undated policy titled “Emergency Preparedness Planning Program for Texas Home Health Agencies” read in part: “Policy The agency has a written emergency preparedness program that comprehensively describes its approach to a natural, man-made, facility-based disasters and emerging infectious disease (EIDs) based upon the facility- and community-based risk assessment and communication plan utilizing an all-hazards approach. Purpose To coordinate with federal, state, tribal, regional and local emergency preparedness systems to prepare to meet needs, in a consistent manner, of patients and staff during disasters and emergency situations.” “Emergency Plan I. The HHA must develop and maintain a written emergency preparedness program that is reviewed and updated at least annually. ……… V. The plan must comply with all applicable federal state and local emergency preparedness requirements and must include, but not limited to, the following elements: E. Include a process for cooperation and collaboration with local, tribal, regional, state, and Federal Emergency preparedness official’s efforts to maintain an integrated response during a disaster or emergency situation including documentation of the home health efforts to contact such officials and when applicable of its participation in collaborative and cooperative planning efforts.” “Training and Testing I. … B. The agency must conduct and document exercises to test the emergency plan at least annually… i. Participate in a full-scale exercise that is community based every two years which is applicable to the agencies risk assessment; or a. When a community-based exercise is not accessible the agency must document details of its efforts to identify a full-scale community based exercise… i. In lieu of the community-based exercise, conduct an individual facility based functional exercise every two years; or ii. If the agency experiences an actual emergency event or response of sufficient magnitude that requires activation of the emergency plan and meets the required community based full scale exercise or individual, facility-based exercise, the agency 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..........””

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to transmit completed OASIS assessments (a group of standard data HHAs integrate into their comprehensive assessment, to collect and report quality data to the CMS) within 30 days of completion date, in 3 of 4 months of transmissions reviewed. This failure prevented the patients’ data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. Findings include: During pre-survey, the surveyor reviewed a report ran on 09/15/2025, titled “HHA ERROR Summary by Agency” for Period 09/15/24 to 09/15/25. The report revealed 3217 assessments were processed with 1876 (58.32%) of assessments with error warning -3330, with error description that read, “Record Submitted late: The submission date was more than 30 days after M0090 (assessment) on this new record.” Record review of OASIS validation reports for date range 06/01/25 to 09/18/25 revealed 1361 assessments were submitted for transmission with 667 (49.01%) of the assessments with error warning -3330. Reports for the OASIS Agency Final Validation report revealed the submission date of 06/05/25 with 89 assessments submitted and showed 9 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 07/29/25 with 372 assessments submitted and showed 203 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 07/29/25 with 372 assessments submitted and showed 194 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed the submission date of 07/31/25 with 9 assessments submitted and showed 2 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed the submission date of 09/09/25 with 426 assessments submitted and showed 248 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed the submission date of 09/16/25 with 93 assessments submitted and showed 11 of the assessments had -3330 warning code. During an interview with Alt Adm conducted on 09/18/25 at 12:23 p.m. the surveyor asked who did the OASIS submissions for the HHA. The Alt Adm said he did the OASIS submissions for the HHA. When the surveyor asked Alt Adm if anyone else at the HHA helped with the OASIS submissions, Alt Adm said no, he was responsible for submitting the OASIS data. The Alt Adm said he knew the data needed to be submitted 30 days after the RN did the initial assessment, and that OASIS submissions was an area the Adm told him had to be done on time. The Alt Adm said he really did not have an excuse for not doing the submissions on time except that he just slacked off on doing the submissions. Alt Adm said he did not think any harm would come to the patients for not doing the submissions on time but said he believed the submissions of OASIS data was tied to the agency’s star rating. Review of HHA’s policy titled “OASIS Compliance” dated 4th Quarter 2021, read in part, “Procedure XI. Within 30 days of completion (M0090), OASIS data elements will be encoded and electronically transmitted to the national OASIS system… XIII. The agency must: B. Transmit OASIS data, for all completed assessments, in a format specified by CMS ....” The Adm was unavailable for interview due to being out of the country and unable to be reached via telephone.”