Texas Life Hospice - Fort Worth

“Based on record reviews and interviews the Hospice Agency failed to develop and implement emergency preparedness policies and procedures, based on an emergency plan that complied with all applicable Federal and State requirements during the 3 (2023, 2024, and 2025) year survey review period in that:The Hospice Agency’s “Emergency Operations Plan and Policies” failed to include involvement of a Disaster Coordinator and Alternate Disaster Coordinator with developing, maintaining and implementing an agency’s emergency preparedness and response plan per State requirements.The Hospice Agency failed to review and update the Agency’s emergency preparedness policies and procedures at least every 2 years per federal requirements. This failure could potentially lead to a delayed emergency response by the Agency’s staff during a disaster or crisis, which could result in evacuation delays and unmet patient needs. Findings:Record review of the Hospice Agency’s undated “Emergency Plan” contained a section labeled “Responsibilities of Staff” with the Administrator listed as the “Incident Commander” and the “Backup” listed as the Director of Patient Care Services. The Emergency Plan contained sections labeled, External Emergency, Patient visits, Plan Activation, Communication Plan, Responsibilities of Staff, Internal Emergencies/Office Evacuation Plan, Equipment/Computer Maintenance, Staff Emergency Plan, and Patient Education Plan. The Emergency Plan read “The Executive Director/Administrator or Designee” will “Act as Incident Commander, as appropriate for the implementation of this plan.” The Emergency Plan did not contain the titles of Disaster Coordinator or Alternate Disaster Coordinator. Further review of the Agency’s Emergency Plan did not contain evidence of who was responsible for developing and maintaining the Hospice Agency’s Emergency Plan.Record review of the Hospice Agency’s undated “Emergency Management Plan” binder revealed a copy of the Texas Administrative Code (official compilation of state agency rules and regulations) rule for Emergency Preparedness Planning and Implementation, for Licensing Standards for Home and Community Support Agencies with an adopted date of February 1,2002 and amended effective date of January 24, 2023. The rule read in part “Agency personnel that must be involved with developing, maintaining, and implementing an agency’s emergency preparedness and response plan include: The administrator; the supervising nurse, if the agency is required to employ or contract with a supervising nurse…; the agency disaster coordinator; and the alternate disaster coordinator.”Record review of the Hospice Agency’s undated “Emergency Management Plan” binder revealed the Agency’s “Emergency Operations Plan and Policies” with last revised date of “February 2022.” The policy read in part “The Administrator, Director and staff implement emergency operations plan, as appropriate…Procedure. Hospice complies with all applicable federal, state and local emergency preparedness requirements. Hospice has established and maintains an emergency preparedness program that meets all requirements. The emergency preparedness program includes but is not limited to, the following elements: Hospice has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least biennially…Delegation of authority and succession plans will be managed by the Administrator and Governing Body, if required.” The policy contained the responsibilities of the “Administrator, Director and/or Manager of Patient Services” in the Agency’s emergency response procedures and recovery strategies. The policy did not contain the titles of Disaster Coordinator, Alternate Disaster Coordinator or the Agency’s titles of “Incident Commander” and “backup” as listed in the Agency’s Emergency Plan. The Agency’s “Emergency Operations Plan and Policies” also did not contain evidence of who was responsible for developing and maintaining the Hospice Agency’s emergency preparedness policy and plan. Further review of the Agency’s emergency preparedness binder did not contain evidence that the Agency’s policy was reviewed or updated after February 2022.An interview was conducted with the Administrator on 8/13/2026 at 3:54pm. The Adm stated that the Agency’s emergency preparedness information and policies came from Consulting Firm #1. The Adm stated “We (the Agency) get the (federal) updates from them (Consulting Firm #1) and then if there’s a different Texas regulation we’ll (The Agency) implement it into our packet. They (Consulting Firm #1) have agencies in Arizona so there are a few things that are different, but we’ll (the Agency will) change them to Texas.” The Adm stated “That’s why I registered with Health and Human Services so I’m getting those state policies and reviewing that (changes in the TAC) and then forwarding it to” Consulting Firm #1 to update the Agency’s policies.An interview was conducted with the Agency’s Administrator and the Director of Clinical Services (DCS A) for Consulting Firm #1 on 8/14/2026 at 9:48am. DCS A stated that she was responsible for the Hospice Agency’s Medicare compliance. The Surveyor shared the findings of the Agency’s “Emergency Plan” and “Emergency Plan and Policies.” When asked about the agency’s policy and procedure for reviewing and updating the Agency’s emergency preparedness policy. DCS A stated that the Agency’s emergency preparedness policies had not been updated since “2022” and “It was not reviewed in detail.” DCS A stated that the Agency she worked for reviewed the policies “annually.” When asked who the Disaster Coordinator was in 2023, 2024 and 2025, the Adm stated that he was the Administrator since the Agency opened in “April of 2021.” The Adm stated “We (the Agency) didn’t have a designated person for Disaster Coordinator” or Alternate Disaster Coordinator. The Adm stated that the “small” Agency did not have a formal Disaster Coordinator or Alternate Disaster Coordinator assigned and that the Administrator and the Agency’s past Directors of Clinical Services shared the Agency’s responsibilities for the Agency’s emergency preparedness program. DCS A stated that the Administrator was responsible for activation of the Agency’s Emergency Plan. DCS A stated, “The Administrator was responsible for testing (conducting exercises to test the Agency’s emergency plan) and updating policies” and reviewing and updating the Agency’s emergency preparedness plan. DCS A stated that the Agency’s Administrator needed “to revise the (emergency) plan where it makes sense” which included the responsibilities of the Disaster Coordinator and Alternate Disaster Coordinator with developing, maintaining and implementing the agency’s emergency preparedness and response plan per State requirements. The Administrator did not provide additional information on why the Agency’s emergency preparedness policies were not reviewed or updated.”

“Based on record reviews and interviews, the Hospice Agency failed to conduct exercises to test the Agency’s emergency plan annually for 2 (2023 and 2024) of the 3-year survey review period in that:The Agency failed to conduct a full-scale community-based exercise or a facility-based functional exercise every 2 years for years 2023 or 2024.The Agency failed to conduct an additional exercise opposite the year of a full-scale community-based exercise, facility-based functional exercise, or activation of the agency’s emergency plan for an actual natural or man-made emergency for years 2023 or 2024. This failure placed the Agency’s patients at risk of harm in the event of an emergency or disaster if the Agency’s emergency plan was not effective. Findings:Record review of the Hospice Agency’s undated “Emergency Management Plan” binder revealed a tabletop drill (A discussion-based meeting where a team talks through an emergency plan using a fake crisis situation) dated “11.2025” for a discussion-based activation of the Agency’s Emergency Plan for an extreme heat weather event. The tabletop drill did not contain a list of attendees. The “Emergency Operations Plan Evaluation/Analysis” for the tabletop drill was signed by the Administrator and dated 11/20/2025. The evaluation/analysis contained documentation stating that the Administrator declared the emergency exercise or actual implementation of the Agency’s Emergency Plan. Further review of the Agency’s “Emergency Management Plan” binder did not provide evidence that the Agency activated their Emergency Plan for an actual or man-made emergency event or conducted an exercise to test the Agency’s Emergency Plan in 2023 and 2024.An interview was conducted with the Administrator on 8/13/2026 at 3:54pm. The Adm stated that the Agency’s policy on the exercise requirements to test the Agency’s Emergency Plan was “yearly.” When asked about the Agency’s policy on the frequency of full-scale community based or facility-based exercises. The Adm stated “I think it’s yearly.” When asked about the agency’s last activation of the Agency’s emergency preparedness plan for a natural disaster or weather-related event, The Adm stated “I have to look it up. I’m not sure.” The Adm stated that the documentation of the agency’s activation of their Emergency Plan “should be in the (Agency’s Emergency Management Plan) binder.” The surveyor shared the findings in the Agency’s Emergency Management Plan binder. The Adm stated that the reason why an exercise was not conducted in 2023 and 2024 was because “We (the Agency) may have had something else in charge of that role during that time period…It would have probably been our previous DCS (DCS B).” The Adm stated that DCS B was employed by the Agency “from 2023 through July of 2024.” When asked about the potential patient outcome for the Agency’s failure to test their Emergency Plan, the Adm stated, “Anything from being out of medications to losing power. Not having enough oxygen for the patient. A patient would suffocate and run out of air... a delay in care. The most severe ones (patients) not having oxygen, not having meds, or maybe living alone and couldn’t get up (out of bed) would have to utilize other services (EMS, fire department) besides the hospital services to help that patient.” The Adm stated that the purpose of the exercises were “to make sure that everybody (Agency staff) knows their responsibilities during that time period (during the activation of the Agency’s Emergency Plan)… To make sure that everyone (Agency staff) is on the same page and to know what is expected from us (Agency management) and what is expected of them (the agency’s staff) and to have an expectation with what’s going on (during an emergency).” The Adm stated that after the exercise the Agency “can also see where there’s places (in the Emergency Plan) that need improvement.”An interview was conducted with the Agency’s Administrator and the Director of Clinical Services (DCS A) for Consulting Firm #1 on 8/14/2026 at 9:48am. DCS A stated that she was responsible for the Hospice Agency’s Medicare compliance. When asked who the Disaster Coordinator was in 2023, 2024 and 2025, the Adm stated that he was the Administrator since the Agency opened in “April of 2021.” The Adm stated “We (the Agency) didn’t have a designated person for Disaster Coordinator” or Alternate Disaster Coordinator. The Adm stated that the “small” Agency did not have a formal Disaster Coordinator or Alternate Disaster Coordinator assigned. The Adm stated that the Administrator and the Agency’s past Directors of Clinical Services shared the Agency’s responsibilities for the Agency’s emergency preparedness program. DCS A stated that the Administrator was responsible for activation of the Agency’s Emergency Plan. DCS A stated, “The Administrator was responsible for testing (conducting exercises to test the Agency’s emergency plan).” When asked why the Agency failed to conduct exercises to test the Agency’s Emergency Plan in 2023 and 2024, the Adm stated it was an “Oversite.”Review of the Agency’s policy “Testing Program for Emergency Operations Plan” with last revised date of February 2022, read in part “Hospice will conduct Exercises to test the EOP at least biennially. Hospice will do the following: participate in a full-scale exercise (if available) that is community- based. When a community- based exercise is not accessible, testing includes participation in an individual facility- based functional exercise every two(2)years. Hospice is exempt from its next required full-scale community-based exercise or individual, facility- based exercise following the onset of an actual man-made or natural emergency that requires activation of the emergency plan. An additional exercise (full scale, functional exercise or tabletop) is conducted every two years, opposite the year that a full-scale exercise or functional exercise is conducted. Hospice is encouraged to seek out local state emergency agencies and healthcare coalitions to participate in a full scale, community-based exercise. If the plan is activated twice in one year, Hospice is exempt from both types of exercises for one year following the actual event.””

“Based on record reviews and interviews the Hospice Agency failed to ensure that Volunteers provided day-to-day administrative and/or direct patient care services at a minimum of 5 percent of the total patient care hours of all paid hospice employees and contract staff during the 3-year (fourth quarter 2023 , 2024, 2025, and first quarter 2026) of the survey review period.The failure to provide volunteers could potentially place patients at risk for unmet socialization and companionship needs. Findings:Record review of the Agency’s undated Quality Assurance and Performance Improvement (QAPI) binder revealed a fourth quarter 2023 ongoing Performance Improvement Project (PIP) with a project begin date of February 1, 2022, for “Development of Volunteer Program.” The PIP read in part, “Q4 audits and data show 0% volunteer hours…5% goal not met…Measurable goal: Agency will meet 5% goal by end of Q4 2023…The data shows the current recruitment and retention efforts to acquire volunteers to provide administrative support and direct patient care was unsuccessful.” The PIP interventions included the Volunteer Coordinator’s responsibility of recruitment and education of volunteers, and monthly reports provided to the agency’s “leadership.”Record review of the Hospice Agency’s undated fourth quarter 2023 “Volunteer Cost Savings” report revealed a cost savings of 0% for the months of October, November, and December of 2023. The report read “PIP will remain in place.”Record review of the Hospice Agency’s undated first quarter 2024 “Volunteer Cost Savings” report revealed a cost savings of 0% for the months of January, February, and March of 2024. The report read “PIP will remain in place.”Review of the Agency’s QAPI binder and Volunteer Cost Savings reports on 8/13/2026 revealed no reports for the second quarter of 2024.Record review of the Hospice Agency’s undated third quarter 2024 “Volunteer Cost Savings” report revealed a cost savings of 0% for the months of July, August, and September of 2024. The report read “PIP will remain in place. Annualized % of Cost Savings = 0.08%.”Record review of the Hospice Agency’s undated fourth quarter 2024 “Volunteer Cost Savings” report revealed a cost savings of 0% for the months of October, November, and December of 2024. The report contained documentation that the Agency’s “interim” created a flier to give to church staff and that the Agency was using social media to recruit volunteers. The report goals read “1 volunteer signed up as of 2/10/2025…Community liaison to encourage/find events for volunteers to get involved. RNs to continue to identify families that would benefit from volunteer services.” The report also contained documentation that the Administrator was the acting volunteer coordinator and “would seek out opportunities within the community to obtain volunteers.”Record review of the Hospice Agency’s undated first quarter 2025 “Volunteer Cost Savings” report revealed a cost savings of 0% for the months of January, February, and March of 2025.Record review of the Hospice Agency’s undated second quarter 2025 “Volunteer Cost Savings” report revealed a cost savings of 0% for the months of April, May and June of 2025.Record review of the Hospice Agency’s undated third quarter 2025 “Volunteer Cost Savings” report revealed a cost savings of 0.7% for July, 0.7% for August, and 1.7% for September of 2025. The report read in part “ This past quarter we (the Agency) received three inquires from potential volunteers. Attempts were made to connect and provide additional information; however, we (the Agency) were unsuccessful in establishing contact.”Record review of the Hospice Agency’s undated fourth quarter 2025 “Volunteer Cost Savings” report revealed a cost savings of 0.5% for October, 0.4% November, and 2.7% in December of 2025. The report read in part “Goals to reach 5%; VC, utilizing word of mouth and social media platforms to recruit additional volunteers.”Record review of the Hospice Agency’s undated first quarter 2026 “Volunteer Cost Savings” report revealed a cost savings of 2.1% for January, 5% in February, and 2.0% in March of 2026. The report read in part “Goals to reach 5%: Continue with Volunteer outreach via website, events, and fliers.”A phone interview was conducted with the Volunteer Coordinator on 8/14/2026 at 11:26am The VC stated that she had been the Agency’s volunteer coordinator for approximately “a year.” When asked about the Agency’s recruitment of volunteers, the VC stated that she used social media, provided Flyers during the Agency’s liaison’s community events, set out posters, and went to retirement communities to educate and recruit potential volunteers. The VC stated that the Agency currently had one patient care volunteer and one non patient care volunteer. The VC stated that the one patient care volunteer was assigned “four patients but she only sees people (patients) every other week.” The VC stated that the Agency’s one non-patient volunteer helped with “events” only due to personal reasons. The VC stated that the Agency had 3 volunteers in the past that quit volunteering due to personal issues that consumed their time. The Surveyor shared the findings of the volunteer cost saving hours from the fourth quarter of 2023 through the first quarter of 2026. When asked about the Agency’s Volunteer cost savings in the last 12 months, the VC stated, “I’m pretty sure that it probably is below 5% because we (the Agency) struggled getting the volunteers.” The VC stated that the Agency’s policy on the yearly Volunteer Cost Saving hour requirement was “5%.” When asked about the potential patients’ outcomes for not having volunteers available to meet the 5% goal, the VC stated, “If you (the Agency) don’t have the volunteers that they (the patients) require there might be a lack of not having the socialization or companionship that the volunteers offer.”An Interview was conducted with the Administrator on 8/14/2026 at 11:48am. The Adm stated that the Agency did not have an assigned Volunteer Coordinator until the present Volunteer Coordinator was assigned approximately “a year” ago. The Adm stated that prior to the assignment of the current Volunteer Coordinator the Administrator took on the role of the Volunteer Coordinator. The Surveyor shared the findings of the volunteer cost saving hours from the fourth quarter of 2023 through the first quarter of 2026, and the interview with the Volunteer Coordinator. When asked about the Agency’s policy on the Volunteer Cost Saving hour percentage that was required yearly, the Adm stated “We are a small agency.” The Adm stated that the Agency became aware of the volunteer hour requirements of 5% “after our last survey.” The Adm stated that during the time he took on the duties of volunteer coordinator he tried to recruit volunteers through “Social Media” and “Church events.” The Adm stated that the agency had difficulties with recruiting volunteers. The Adm stated “We (the Agency) did have one volunteer many years ago (could not recall dates)” that provided volunteer hours but “she left to attend medical school.” The Adm stated that one of the Agency’s current volunteers “works only a few hours and will fill goodie bags for events.” The Adm stated “We (the Agency) are trying our best” to recruit volunteers and “no one is biting (responding).” When asked about the potential patient outcomes for not having the volunteers available to meet the 5% requirement. The Adm stated “ Family (caregiver) burnout…The family may place the patient in a nursing home due to exhaustion.”Review of the Agency’s policy “Volunteer Services” with revised date “February 2021” read in part “Hospice will document and maintain a volunteer staff sufficient to provide administrative and/or direct patient care in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff.””