Every finding on record at Ac & Jw Inc

A recertification survey was conducted on 03/24/26. The census was 38 (L&C) and 0 (LHH). The agency is in compliance with no deficiencies cited. Acronyms used: L&C- Licensed and Certified LHH- Licensed Home Health

A recertification survey was conducted on 03/24/26. The census was 38 (L&C) and 0 (LHH). Acronyms used: DHHS- Director of Home Health Services L&C- Licensed and Certified LHH- Licensed Home Health LVN- Licensed Vocational Nurse RN- Registered Nurse

Administrator CFR(s): 484.115(a) Standard: Administrator, home health agency. (1) For individuals that began employment with the HHA prior to January 13, 2018, a person who: (i) Is a licensed physician; (ii) Is a registered nurse; or (iii) Has training and experience in health service administration and at least 1 year of supervisory administrative experience in home health care or a related health care program. (2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. This STANDARD is not met as evidenced by: Findings included: Record review of the weekly visit schedule dated 3/22/26- 3/28/26 indicated the Administrator was an LVN. Record review of the Agency Organizational Chart indicated the Administrator was an LVN. Record review of the Roster of Professional Personnel indicated the Administrator was an LVN. Record review of the personnel file for the Administrator indicated she had an active LVN license with an expiration date of 5/31/27. The Administrator signed job description dated 1/5/26 indicated Qualifications for Employment: Education & Licensing: Bachelor’s degree in Healthcare Administration, Nursing, or a related field. The personnel file did not indicate the Administrator held a license as a physician, RN or hold an undergraduate degree. During an interview on 3/26/26 at 2:23 pm the Alternate Administrator said the Administrator was an LVN. The Alternate Administrator said she did not think the Administrator had an undergraduate degree. The Alternate Administrator said the agency’s policy on qualifications to be the Administrator were to have 3-5 years of leadership experience. The Alternate Administrator said the Owner thought the Administrator only needed to have one of the qualifications. The Alternate Administrator said LVNs were not able to supervise patient care. The Alternate Administrator said an RN would need to be the one supervising patient care. During a telephone interview on 3/26/26 at 2:50 pm the Administrator said she became the agency Administrator right after the new year around 1/5/26. The Administrator said she was an LVN. The Administrator said she did not have an undergraduate degree in health care. The Administrator said she did not have a bachelor’s or associate degree in healthcare. The Administrator said she was not a physician. The Administrator said the agency’s policy on Administrator qualifications was for an RN or LVN with experience. The Administrator said LVNs were not able to supervise patient care. The Administrator said an RN would need to be the one supervising patient care. The Administrator said the directors would all need to be supervising RNs. During a telephone interview on 3/26/26 at 3:17 pm the Owner said the Administrator qualifications were for 2 years of home health experience or 1 year with a degree. The Owner said he did not know if it was required to be an LVN or RN. The Owner said the Administrator had been in home health for over a decade, maybe up to 20 years, so they did not think it was a concern. The Owner said he did not know the agency policy on administrator qualifications off the top of his head. Record review of a Selection of Agency Staff policy dated 1/4/06 indicated “Purpose To ensure a consistent and equitable process for the selection of Agency staff. … Agency leaders will review federal and state employment laws and regulations. All regulations will be incorporated into the selection process and/or job descriptions. … personnel selection process: … verification of qualifications … verification of education/training/licensure/certification …” Record review of a Responsibilities of The Administrator policy dated 4/1/13 indicated “Purpose To define the responsibilities of the Administrator to ensure Agency compliance with applicable federal, state and local laws and regulations as appropriate. Policy Agency Administrator will assume overall responsibility and authority for administrative and leadership functions, supervision of the established organizational plan … The Administrator will be responsible for implementing and supervising the administrative policies and operations of the agency and for administratively supervising the provision of all services to agency patients on a day-to-day basis. Procedure … Ensuring Agency is in compliance with all applicable federal, state, and local laws and regulatory agencies. … Employs or contracts with qualified personnel. …”

Clinical Manager CFR(s): 484.115(c) Standard: Clinical manager. A person who is a licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker, or a registered nurse. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to have an alternate supervising nurse who met the minimum requirements regarding professional licensure for 1 of 2 (Alternate Supervising Nurse) supervising nurses. The agency Alternate Supervising Nurse did not hold a license as a physician, physical therapist, speech‐language pathologist, occupational therapist, audiologist, social worker, or a registered nurse. This failure had the potential to allow patient care to be supervised by an unqualified individual and could lead to negative patient outcomes. Findings included: Record review of the weekly visit schedule dated 3/22/26- 3/28/26 indicated the Alternate Supervising Nurse was an LVN. Record review of the Agency Organizational Chart indicated the Alternate Supervising Nurse was an LVN. Record review of the Roster of Professional Personnel indicated the Alternate Supervising Nurse was an LVN. Record review of the personnel file for the Alternate Supervising Nurse indicated she had an active LVN license with an expiration date of 6/30/27. The Alternate Supervising Nurse’s personnel file gave no indication she was an RN. The Alternate Supervising Nurse signed job description dated 1/2/26 indicated Qualifications for Employment: Education & Licensing: Active Registered Nurse (RN) license in Texas. During an interview on 3/26/26 at 1:35 pm the Alternate Supervising Nurse said she had been the Alternate Supervising Nurse since 1/2/26. The Alternate Supervising Nurse said she was an LVN. The Alternate Supervising Nurse said in order to be the Alternate Supervising Nurse she had to be at least an LVN with one year of experience in home health. The Alternate Supervising Nurse said the Owner’s attorney looked into it and said the Alternate Supervising Nurse could be an LVN. During a telephone interview on 3/26/26 at 2:06 pm the Supervising Nurse said the agency Owner selected the Alternate Supervising Nurse for her position. The Supervising Nurse said the Alternate Supervising Nurse was an LVN. The Supervising Nurse said the agency policy on qualifications to be the Alternate Supervising Nurse was to have previous nursing experience in an administrative role and several years of experience as an LVN. The Supervising Nurse said she was not sure why an LVN was chosen to be the Alternate Supervising Nurse. The Supervising Nurse said LVNs were not able to supervise patient care. The Supervising Nurse said an RN would need to be the one supervising patient care. During an interview and record review on 3/26/26 at 2:23 pm the Alternate Administrator said the Owner was responsible for selecting the Alternate Supervising Nurse. The Alternate Administrator said the agency policy on qualifications for the Alternate Supervising Nurse was to be an RN or LVN with 1-3 years of experience in a home health leadership role. The Alternate Administrator reviewed the agency policy on Responsibilities of The Director of Home Health Services and said it indicated the position was for the responsible RN. The Alternate Administrator said the Owner’s attorney said an LVN could be in the position. The Alternate Administrator said LVNs were not able to supervise patient care. The Alternate Administrator said an RN would need to be the one supervising patient care. During a telephone interview on 3/26/26 at 2:50 pm the Administrator said the agency qualifications for the Alternate Supervising Nurse was someone who had clear knowledge of home health and was either an RN or LVN home health experience. The Administrator said she was not sure if the agency’s policy on the Alternate Supervising Nurse qualifications was for an RN or LVN with home health and management experience and the ability to supervise staff. The Administrator said LVNs were not able to supervise patient care. The Administrator said an RN would need to be the one supervising patient care. The Administrator said the directors would all need to be supervising RNs. During a telephone interview on 3/26/26 at 3:17 pm the Owner said he was aware of another agency that used an LVN as the alternate supervising nurse. The Owner said he talked to an attorney that specialized in Medicare (federal health insurance program for individuals aged 65 or older and younger people with specific disabilities) that told him the Alternate Supervising Nurse could be an LVN. Record review of a Responsibilities of The Director of Home Health Services policy dated 9/21/04 indicated “… Supervising Nurse is the responsible registered nurse for supervising skilled services provided by the agency and who meets qualifications per regulation. This person may also be known as Director of Nurses, Director of Home Health Services or a similar title. … The Director of Home Health Services is a registered nurse. … The Administrator will designate, in writing, the appropriate qualified person to perform the responsibilities of the position in the absence of the Director of Home Health Services.” Record review of a Selection of Agency Staff policy dated 1/4/06 indicated “Purpose To ensure a consistent and equitable process for the selection of Agency staff. … Agency leaders will review federal and state employment laws and regulations. All regulations will be incorporated into the selection process and/or job descriptions. … personnel selection process: … verification of qualifications … verification of education/training/licensure/certification …” Record review of an Administrative Structure policy dated 10/25/07 indicated “… The Administrator will authorize, in writing, a designated Registered Nurse to carry out delegated responsibilities in the absence of the DHHS/Director or Nurses/Supervising Nurse. …”