Ahealthstar Homecare Agency

“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 develop and maintain an emergency preparedness plan that was reviewed and updated at least every 2 years, and that was based on and included a documented, agency-based and community-based risk assessment, utilizing an all-hazards approach that included strategies for addressing emergency events identified by the risk assessment for 1of 1 emergency preparedness plan. This failure meant the agency’s efforts to keep patients and staff safe during emergencies could not be determined. Clients and staff were subjected to unsafe care and services. During the entrance conference 12/02/2025 at 11:30 AM the surveyor requested all Emergency preparedness documents for the survey review period November 2022 to November 2025 in writing and verbally to the Administrator and DON. The surveyor requested all Emergency preparedness documents again on 12/03/2025. No Emergency preparedness documents plan risk assessments were provided by the end of the survey. During an interview on 12/03/2025 with the Administrator at 1 PM. The surveyor asked about the missing Emergency preparedness program documentation of risk assessments to provide to the surveyor. The Administrator stated: The DON is the Disaster Coordinator, and the surveyor would need to speak with him for that information. During an interview with the DON / Disaster Coordinator on 12/03/2025 at 1:02 PM the surveyor asked about the agency’s risk assessment, the records for the required risk assessment update at least every 2 years for the last three years. The DON / Disaster Coordinator stated: “I didn’t do it.” The surveyor asked about the plan requirements and agency policy and procedures for emergency preparedness risk assessments. The DON / Disaster Coordinator stated the policy, and plan required risk assessment, review, and updates annually. The surveyor asked about the effect on the agency patients. The Disaster Coordinator / DON stated they had a backup agency to take care of the patients if the agency cannot, and funds were available to care for the patients. The surveyor asked why the agency had not documented the risk assessment. The Disaster Coordinator stated he was just returning to work from a serious illness. “That’s not an excuse, and I was gone for 6 months.” The surveyor asked what the biggest risks to the agency patients and the agency were. The Disaster Coordinator / DON stated: “That would be finding attendants. This is becoming a big issue. I can’t find one to go from one place to another because of the pay, and I can’t find anyone to go. It is too low, the pay.” The surveyor asked what the agency’s policy on the risk assessment was. The Disaster Coordinator / DON stated: “Ensure the safety of the patients and have the resources to care for the patients”. The surveyor asked if the policy required the risk assessment to be documented. The Disaster Coordinator / DON stated: “Yes, I haven’t done that since I came back to work.” The surveyor asked how this could affect the patients. The Disaster Coordinator / DON stated: “It is difficult for someone to jump in and implement (the plan). We still need to have it documented. l don’t have an excuse, it needs to be here.” Agency policy and procedures: “Emergency Preparedness and Response Plan Reviewed:”100112” read in part: “Purpose - To ensure Agency develops, maintains, and implements a written Emergency Preparedness and Response Plan, based on the Agency’s risk assessment. To establish a plan of action for providing continuous patient care and continuous business operations, I the event of a disaster. To ensure compliance with “Emergency Preparedness Planning and Implementations”, Licensing Standards for Home and Community Support Services Agencies… Policy-… The written plan will be based on a risk assessment that identifies the disasters from natural and man-made causes that are likely to occur in Agency’s service area…””