Avatar Healthcare

“Based on record review and interview, the Hospice failed to maintain an emergency plan that was reviewed and updated at least every 2 years. The agency failed to ensure the plan was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach and included 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. The agency did not provide records for the required risk assessment updated at least every 2 years. The emergency preparedness training and testing program documents were not available to be reviewed by the surveyor for 3 (October 2022 – October 2025) of 3 years of the survey review period. This failure meant the agency’s efforts to keep patients and staff safe during emergencies could not be determined. Clients and staff were potentially subjected to unsafe care and services. During the entrance conference 11/18/2025 at 11:45AM the surveyor requested all Emergency preparedness documents for the survey review period October 2022 to October 2025 in writing and verbally to the Administrator / DON. The surveyor requested all Emergency preparedness documents on 11/19/2025 and again on 11/20/2025. No Emergency preparedness documents were provided by the end of the survey.During an interview on 11/20/25 at 11:45 am with the Administrator / DON, the surveyor asked why the agency had not provided access to the Emergency Preparedness documents as requested during the entrance conference. The Administrator stated he had: “no access to them (the records) all that stuff would have been put in a storage locker and not in any order, and I would not be able to provide that information in any timely manner.” The surveyor asked why. The Administrated stated: “It would take an inordinate about of manpower to find it.” The surveyor explained the agency could face citations for not providing the information requested. The Administrator stated they knew that and would write a plan of correction. The surveyor asked what the potential problems and outcomes were for not having/ providing the required documentation. The Administrator stated, “mainly time, there are file cabinets that are not in any order.” The Administrator stated: “The owners tried to sell the agency, and it didn’t work, so now they are trying to figure out where to go, and a new plan for ownership and management.” The surveyor asked when the Administrator /DON was appointed. The Administrator stated: “I became the administrator / DON a month ago. “I was the Administrator / DON 3 years ago- and the new group (the ones trying to buy the agency) let me go, and then I was called a month ago to resume the Administrator / DON roles. The license holders are “going to put it in mothballs and they need a placeholder for the license.” The surveyor asked if the Administrator /DON had done emergency preparedness review of the risk assessment and communication plan, and training and testing of the emergency plan since he was appointed as Administrator/DON. The Administrator stated the agency did not maintain an emergency preparedness plan that was reviewed and updated at least every 2 years The surveyor asked if any work on the emergency preparedness program had been done in the three years before he was appointed Administrator/DON. The Administrator stated he didn’t know as he was sidelined[DH1] . During an interview on 11/20/2025 with the Administrator at 4:45 PM the surveyor asked if the Administrator had any Emergency preparedness program documentation of risk assessment, training, testing and communication plan to provide to the surveyor. The Administrator stated: “Not that I know of. No documents are available.” The surveyor asked who was responsible and how could it affect patient care. The Administrator stated he was responsible and it could cause patient care issues in the event of an emergency. The surveyor asked what the agency Emergency preparedness policies required. The Administrator stated: the documents “should be available and the program should be active at all times and clearly it is not.” The surveyor asked about the effects of not having an active and available program. The Administrator stated the potential effect was “poor compliance, poor patient care, poor marketing, and a very large negative outcome.” The surveyor asked what caused the failure. The Administrator stated they had told the license holder “when they made changes and tried to put all the agencies together all accountability and record keeping went to hell.” The license holder “put me on the sidelines in February of 2024 all the way until Aug 2025. New people took over and during that time, I had no information on the provider and no knowledge of the operations (during that time).Agency policy and procedures: “Emergency Preparedness Response Plan and Procedure Last Reviewed:12/04/24” read in part: Preparing for the potential of a disaster includes, but is not limited to, identification and assessment of risks, integration with community resources, developing plans for mitigation, disaster response and recovery activities, education and training, and conducting exercises… The Hospice will review the All-Hazards Community/Hospice Based Risk Assessment for Potential Disasters to ensure all staff understand each emergency type that poses a risk for the Hospice or the community. The Hospice may have additional risks not listed on the form. In that case, the specific emergency events have been added to the hospice-specific risk assessment…””

“Based on record review and interview, the agency failed to maintain an emergency preparedness training and testing program based on the agency’s emergency plan, a risk assessment, and the communication plan required by the regulations. The agency did not provide records for the required training and testing program that was reviewed and updated at least every 2 years. The emergency preparedness training and testing program was not available to be reviewed by the surveyor for 3 (October 2022 – October 2025) of 3 years of the survey review period. 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 11/18/2025 at 11:45AM the surveyor requested all Emergency preparedness documents for the survey review period October 2022 to October 2025 in writing and verbally to the Administrator / DON. The surveyor requested all Emergency preparedness documents on 11/19/2025 and again on 11/20/2025. No Emergency preparedness documents were provided by the end of the survey.During an interview on 11/20/25 at 11:45 am with the Administrator / DON, the surveyor asked why the agency had not provided access to the Emergency Preparedness documents as requested during the entrance conference. The Administrator stated he had: “no access to them (the records) all that stuff would have been put in a storage locker and not in any order, and I would not be able to provide that information in any timely manner.” The surveyor asked why. The Administrated stated: “It would take an inordinate about of manpower to find it.” The surveyor explained the agency could face citations for not providing the information requested. The Administrator stated they knew that and would write a plan of correction. The surveyor asked what the potential problems and outcomes were for not having/ providing the required documentation. The Administrator stated, “mainly time, there are file cabinets that are not in any order.” The Administrator stated: “The owners tried to sell the agency, and it didn’t work, so now they are trying to figure out where to go, and a new plan for ownership and management.” The surveyor asked when the Administrator /DON was appointed. The Administrator stated: “I became the administrator / DON a month ago. “I was the Administrator / DON 3 years ago- and the new group (the ones trying to buy the agency) let me go, and then I was called a month ago to resume the Administrator / DON roles. The license holders are “going to put it in mothballs and they need a placeholder for the license.” The surveyor asked if the Administrator /DON had done emergency preparedness review of the risk assessment and communication plan, and training and testing of the emergency plan since he was appointed as Administrator/DON. The Administrator stated the agency did not. The surveyor asked if any work on the emergency preparedness program had been done in the three years before he was appointed Administrator/DON. The Administrator stated he didn’t know as he was sidelined. During an interview on 11/20/2025 with the Administrator at 4:45 PM the surveyor asked if the Administrator had any Emergency preparedness program documentation of risk assessment, training, testing and communication plan to provide to the surveyor. The Administrator stated: “Not that I know of. No documents are available.” The surveyor asked who was responsible for maintaining an EP program and how it could affect the patients and staff. The Administrator stated he was responsible and it could affect the patients and staff in an emergency. The surveyor asked what the agency Emergency preparedness policies required. The Administrator stated: the documents “should be available and the program should be active at all times and clearly it is not.” The surveyor asked about the effects of not having an active and available program. The Administrator stated the potential effect was “poor compliance, poor patient care, poor marketing, and a very large negative outcome.” The surveyor asked what caused the failure. The Administrator stated they had told the license holder “when they made changes and tried to put all the agencies together all accountability and record keeping went to hell.” The license holder “put me on the sidelines in February of 2024 all the way until Aug 2025. New people took over and during that time, I had no information on the provider and no knowledge of the operations (during that time).Agency policy and procedures: “Emergency Preparedness Response Plan and Procedure Last Reviewed:12/04/24” read in part: The Hospice will provide initial training and then training at least every two years thereafter on emergency preparedness policies and procedures to all new and existing staff, contract staff, and volunteers. The Hospice will also provide training to all staff when new or updated policies and/or procedures are issued. All training, exercises, and education will be documented on the In-Service Sign In Sheet … The Hospice will conduct exercises to test the emergency plan at least annually. The Hospice will participate in a full-scale exercise that is community-based every two years. If community-based exercise is not accessible, a facility-based functional exercise will be conducted every two years. If the Hospice experiences an actual natural or man-made emergency that requires activation of the emergency plan, the Hospice is exempt from engaging in its next required full scale community-based or facility-based functional exercise for one year following the onset of the emergency event… The Emergency Preparedness Plan, policies, and procedures will be reviewed at least annually, after each actual emergency response to evaluate its effectiveness and is updated as needed. As part of the annual internal review, the Hospice will test the response phase of the emergency preparedness and response plan in a planned drill, if not tested during an actual emergency response. The Hospice will complete the Hospice Emergency Preparedness Plan Evaluation form with input from the staff involved with the drill, exercise, or emergency event…””

“Based on record review and interview, the hospice registered nurse failed to complete an initial assessment within 48 hours after the election of hospice care for 1 (Patient #9) of 14 records reviewed. This failure meant the agency failed to ensure the patient and families’ immediate needs for physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions were not collected to begin the plan of care and provide the immediate necessary care and services. Record review for Patient #9 revealed a Plan of care order dated 07/19/2023 signed by RN A which documented the start of care was 07/02/2023 for the certification period through 08/30/2023. The Plan of care ordered nursing visits once a week for the terminal diagnosis of Alzheimer’s Disease (a progressive brain disorder that impairs memory, thinking and language skills). The record review found no nursing assessment was documented. Nursing visits were documented on 07/03/2023, 07/10/2023, 07/20/2023, 07/24/2023, 07/31/2023 and a discharge due to death was documented on 08/02/2023. The surveyor was unable to interview RN A as the agency failed to provide the personnel file or phone number for RN A. An interview was conducted on 11/20/2025 with the Administrator / DON at 3 pm. The surveyor reviewed the findings from the clinical record review and asked why Patient #9’s record contained no nursing assessment. The Administrator / DON reviewed the electronic medical record and confirmed there was no nursing assessment documented. The surveyor asked why, and the Administrator / DON stated RN A “was a nurse melting down” (not completing her work), and the plan was to get rid of her.” The surveyor asked about the agency’s policy and procedures for nursing assessments. The Administrator / DON stated: “The Policy is to do the assessment within 48 hours of the start of care. “The surveyor asked what the effect to the patient of no initial nursing assessment was done within the 48 hours. The Administrator / DON stated: “Its non- billable to Medicare, and the owner of the care home usually functions as the primary caregiver, and about the patients care, (RN A) was removed.” The surveyor asked how this affected the patient when they had no nursing assessment. The Administrator / DON stated: “You don’t have good interventions without the assessment, and it had the potential to have done great damage. I don’t know anything else.”Review of agency policy, “Patient Assessment PE.5 Last Reviewed:090124” read in part: The Hospice’s registered nurse (RN) will conduct an initial assessment within 48 hours after the election of hospice care is complete (unless the physician, patient, or representative requests that the initial assessment be completed in less than 48 hours). The initial assessment will take place atthe site that hospice services will be delivered and documented in the clinical record. A. The initial assessment includes:1. Evaluating the patient’s immediate physical, psychosocial, and emotional status related to the terminal illness and related conditions;2. Determining the patient’s immediate care and support needs; and 3. Beginning the Plan of Care (POC) in order to provide the necessary care and services. II. The Hospice will conduct and document in writing a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care…”

“Based on record review and interview the hospice failed to document what performance improvement projects were conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects for 3 (October 2022 – October 2025) of 3 years of the survey review period. This failure meant the agency’s efforts to assess, monitor, and improve the care and services provided could not be determined. Patients and staff were potentially subjected to poor quality care and services. During the entrance conference 11/18/2025 at 11:45AM the surveyor requested all QAPI documents including performance improvement projects for the survey review period October 2022 to October 2025 in writing and verbally to the Administrator / DON. The surveyor requested all QAPI documents on 11/19/2025 and again on 11/20/2025. No QAPI documents were provided by the end of the survey.During an interview on 11/20/25 at 11:45 am with the Administrator / DON, the surveyor asked why the surveyor had no access to the complaint logs, QAPI including performance improvement projects, and Emergency Preparedness documents requested during the entrance conference. The Administrator stated he had: “no access to them (the records) all that stuff would have been put in a storage locker and not in any order, and I would not be able to provide that information in any timely manner.” The surveyor asked why. The Administrated stated: “It would take an inordinate about of manpower to find it.” The surveyor explained the agency could face citations for not providing the information requested. The Administrator stated they knew that and would write a plan of correction. What QA project did the agency perform? The Administrator / DON stated he was not aware of any that were performed. The surveyor asked what the potential problems and outcomes were for not having/ providing the required documentation. The Administrator stated, “mainly time, there are file cabinets that are not in any order.” The Administrator stated: “The owners tried to sell the agency, and it didn’t work, so now they are trying to figure out where to go, and a new plan for ownership and management.” The surveyor asked when the Administrator /DON was appointed. The Administrator stated: “I became the administrator / DON a month ago. “I was the Administrator / DON 3 years ago- and the new group (the ones trying to buy the agency) let me go, and then I was called a month ago to resume the Administrator / DON roles. The license holders are “going to put it in mothballs and they need a placeholder for the license.” During an interview on 11/20/2025 with the Administrator at 4:45 PM the surveyor asked if the Administrator had any QAPI documentation to provide to the surveyor. The Administrator stated: “Not that I know of. No documents are available.” The surveyor asked what the agency QAPI policies required. The Administrator stated: QAPI documents “should be available and the program should be active at all times and clearly it is not.” The surveyor asked about the effects of not having an active and available program. The Administrator stated the potential effect was “poor compliance, poor patient care, poor marketing, and a very large negative outcome.” The surveyor asked what caused the failure. The Administrator stated they had told the license holder “when they made changes and tried to put all the agencies together all accountability and record keeping went to hell.” The license holder “put me on the sidelines in February of 2024 all the way until Aug 2025. New people took over and during that time, I had no information on the provider and no knowledge of the operations (during that time).Agency policy and procedures titled: “Performance Improvement Process: Improved Performance QAPI.25 Last Reviewed: 090124”Read in part: “Policy I. Hospice leaders and the Quality Assessment Performance Improvement (QAPI) Committee will beresponsible for setting the priorities for improvement activities based on Hospice functions, the defined measurement factors, the resources required to facilitate the improvement, and the organization’s mission. II. When developing the improvement activities, the Hospice will consider the following: A. The expected impact of the improvement, B. The expectation level for the improvement activity, and C. The measures/data needed to evaluate the effectiveness of the improvement activity. III. Hospice will immediately correct identified problems that directly or potentially threaten the care and safety of patients. IV. The number and scope of distinct performance improvement activities that become projects will be based on the needs of the Hospice’s population and internal organizational needs. These performance improvement projects (PIPs) will reflect the scope, complexity, and past performanceof the Hospice’s services and operations. or problem prone areas, C. Incidence, prevalence, and severity of problems in those areas,D. Impact on palliative outcomes, patient safety, and quality of care, E. The relationship of the potential improvement to the dimensions of performance and function… The Hospice will document what PIPs are being conducted, the reasons for conducting theseprojects, and the measurable progress achieved on these projects…” Quality Assessment Performance Improvement Program QAPI.5 Last Reviewed: 09/01/24” read in part: “Policy I. The Hospice will define develop, implement, and maintain an effective, ongoing, hospice-wide data-driven QAPI plan that is evaluated, reviewed, and updated or revised at least once within the calendar year, or more often if needed, by the QAPI Committee. II. The Governing Body will ensure that the QAPI program: A. Reflects the complexity of the organization and services; B. Involves all Hospice services, and multiple locations, if applicable including those services provided under contract or arrangement; C. Focuses on indicators related to improved palliative outcomes; and D. Takes actions to demonstrate improvement in the Hospice’s performance. III. The Hospice will focus primarily on its processes and/or system performance rather than an individual’s performance yet will recognize the importance of the competence of its staff. IV. The Hospice will maintain confidential documentary evidence of its QAPI program and be able to demonstrate its operation to the Centers for Medicare and Medicaid Services (CMS), the accrediting organization (if any) and the state survey agency … [DH1]Recommend that you add, What QA project did the agency perform? (Since this reg is about QA projects). Try to use some of the wording from the regulation.”

“Based on record review and interview, the governing body (or designated persons so functioning- Administrator) failed to ensure responsibility for the management of the hospice and appointment of a qualified alternate administrator to be responsible for the day-to-day operation of the hospice for 1(Alternate Administrator) of 2 required positions. The governing body and administrator failed to appoint a qualified designated alternate to act in the absence of the administrator effective October 10, 2025. This failure meant agency staff and potential patients had no Alternate Administrator to respond to the Administrative and emergency needs of the agency when the Administrator/DON was not available. Record review of the email provided by AA dated October 10, 2025, confirmed resignation from the agency by AA, notification to HHSC LTC HCSSA licensing, and notice of receipt by HHSC. An interview was conducted on 11/20/2025 at 4:30 PM with the Administrator to review the interview with the former Alternate Administrator / Alternate DON AA resignation. The Administrator stated: “I had no idea.” The license holder / owner told me AA was the alternate administrator / DON when I was hired back as the Administrator / DON in August 2025. The surveyor asked what the agency policy was regarding the appointment of alternates. The Administrator stated the agency had to have alternates “at all times, and there was no allowance for (having) none.” The surveyor asked about the potential effect for the agency and the patients. The Administrator/DON stated: “There would be no one to run it (the agency) if something happens to me.” The surveyor confirmed the agency’s name, license and provider numbers with the Administrator. The surveyor requested to interview the license holder on 11/20/2025 at 4:35 PM. The Administrator stated the license holder was not available for an interview and referred the surveyor to the email sent at 2:59 PM on 11/20/2025 to explain the changes in the agency. Record review of an email from the license holder sent 11/20/2025 at 2:59 PM read in part: “Explanation for Maintaining License While Temporarily Non-Operational To: State Survey Agency / HHSC From: (the agency) Re: Clarification of Temporary Non-Operational Status During Transition Dear Survey Team, thank you for the opportunity to provide clarification regarding the current status of (the agency). (The agency) is maintaining an active hospice license; however, the agency is temporarily non-operational due to a planned administrative transition. This pause in census activity was intentional and taken to ensure full compliance with Medicare, Medicaid, and State of Texas hospice regulations before resuming services. Reason for Temporary Non-Operational Status1. Completion of a Short-Term Administrative Support Arrangement (The Agency) previously utilized a limited-term administrative support arrangement to assist with certain management and operational functions. This arrangement concluded as scheduled. As ownership resumed direct operational oversight, we elected to temporarily pause admissions to ensure a safe and fully compliant transition of governing body responsibilities, administrative processes, and clinical oversight back under the agency’s leadership. This proactive step was taken to avoid any gaps in regulatory compliance or patient care oversight. 2. Ongoing Change of Ownership (CHOW) & Transition Activities The agency is also undergoing an ownership change, with CHOW and Change-of-Information submissions in process. During this transition, the ownership team initiated full administrative and compliance realignment, including Governing body restructuring, Medical Director and clinical oversight updates, QAPI and policy revisions, Administrative and financial controls, Operational readiness planning, Staffing structure and reorientation. To ensure that all regulatory elements were properly aligned, census remained at zero during this transition period.3. Preparing for Safe, Compliant Reactivation Although currently non-operational, the Hospice intends to resume services upon completion of: CHOW acknowledgment and updates, Internal compliance readiness reviews, and Governing body approval. The license is being actively maintained to support seamless reactivation once full compliance is confirmed. Current Operational Summary Census: 0 Admissions: Temporarily paused Patient Care: None provided during this period Billing: No claims submitted Compliance Programs: Maintained and up to date Staffing: Administrative and clinical structure prepared for reactivation Intent: Resume operations once transition activities are complete. Commitment to Compliance We confirm that throughout this temporary pause: No hospice care or clinical services are being performed. No certifications, recertifications, or billing activities are occurring. All policies, manuals, and regulatory programs remain maintained. The pause was strictly for compliance and administrative alignment purposes.Review of the agency’s policy titled, “Administrative Structure – Addendum LD (Leadership).10-TX Last Reviewed: 04/14/23” read in part: Policy I. In addition to the requirements defined in the Administrative Structure policy in the Leadership section of the Administrative Policy Manual, the following requirements will be met: A. The Hospice will prepare and maintain a current description of the Hospice’s organizational structure. The document may be either in the form of a chart or a narrative. The description must include: 1. All services provided by the Hospice;2. The Governing Body, the Administrator, the Supervising Nurse, and the staff, as appropriate, based on services that are provided by the Hospice; and… Procedure I. In addition to the requirements defined in the Administrative Structure policy in the Leadership section of the Administrative Policy Manual, the following requirements will be met: A. The license holder, or the license holder’s designee, will designate, in writing, an Alternate Administrator who meets the qualifications and conditions of an administrator to act in the absence of the Administrator. The Alternate Administrator may be the Clinical Manager…””