Every finding on record at J Jireh Healthcare Services LLC

Purpose of visit: Recertification/Re-Licensure Survey A Recertification/Re-Licensure/Complaint Survey entrance conference was conducted on 09/18/2023 with the Administrator at 10:00 AM. Agency Census: Licensed and Certified Home Health Services (L&CHHS) 0 Licensed Home Health Services (LHHS) 0 Personal Assistance Services (PAS) 5 Exit Conference was conducted on 09/20/2023 with the Administrator at 1:57 PM. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations: Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Licensed and Certified Home Health Services (L&CHHS) Emergency Preparedness Plan (EPP) DFW (Dallas Forth Worth) Quality Assessment Performance Improvement Plan (QAPI) Texas Uniform Licensure Portal (TULIP) Director of Nurses (DON) Alternate Director of Nurses (ADON) CNA (Certified Nurse’s Assistant)

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: THIS IS A CONTINUED DEFICIENCY CITED AT E004 ON SURVEY DATED 09/23/2020. The agency failed to review and update the agency's emergency preparedness plan (EPP) at least every 2 years for two (2021 and 2022) of three years reviewed. This failure placed the agency patients and the agencies employees at risk of harm from agency staff implementing an emergency plan with outdated emergency contact information and ineffective implementation processes. Findings included: During the entrance conference on 09/18/2023 at 10:00 AM the Administrator self-identified as the Disaster Coordinator. Record review of the EPP documents provided by the Administrator on 09/18/2023 revealed there were no records to confirm that a review and update of the EPP for the years 2021 and 2022. In an interview on 09/18/2023 at approximately 12:35 PM, the surveyor reviewed the findings and the agency emergency preparedness policy with the Administrator. The surveyor discussed the findings and asked if the agency conducted annual internal reviews and updated the agency's emergency preparedness and response plan, in accordance with the agency's policy for the survey review period of 09/17/2020 to 09/18/2023. The Administrator replied, "I was thinking I did it. Agency policy titled "Emergency Preparedness and Response Plan EC.8" revised 080111 read in part: "...PURPOSE I. To ensure Agency develops, maintains, and implements a written Emergency and Response Plan...Based on the Agency's risk assessment...Policy...11. The agency will complete an internal review of the plan at least annually and after each actual emergency response, to evaluate its effectiveness and to update the plan as needed..."

Purpose of visit: Recertification/Re-Licensure Survey A Recertification/Re-Licensure/Complaint Survey entrance conference was conducted on 09/18/2023 with the Administrator at 10:00 AM. Agency Census: Licensed and Certified Home Health Services (L&CHHS) 0 Licensed Home Health Services (LHHS) 0 Personal Assistance Services (PAS) 5 Exit Conference was conducted on 09/20/2023 with the Administrator at 1:57 PM. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Second exit conference was conducted on 11/22/2023 with the Administrator at 10:21 AM. The Administrator was informed the agency was found to be out of compliance with following CMS (Centers for Medicare and Medicaid Services) Conditions of Participation: §484.65: Quality Assessment and Performance Improvement (QAPI) and §484.105: Organization and Administration of Services. The Administrator was informed that the agency will not be able to train their own aides for 2 years and there will be a follow-up visit by surveyor in approximately 45 days. Abbreviations: Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Licensed and Certified Home Health Services (L&CHHS) Emergency Preparedness Plan (EPP) DFW (Dallas Forth Worth) Quality Assessment Performance Improvement Plan (QAPI) Texas Uniform Licensure Portal (TULIP) Director of Nurses (DON) Alternate Director of Nurses (ADON) CNA (Certified Nurse’s Assistant) The agency J-Jireh Healthcare Services was found to be out of compliance with following CMS (Centers for Medicare and Medicaid Services) Conditions of Participation: §484.65: Quality Assessment and Performance Improvement (QAPI) §484.105: Organization and Administration of Services

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on a review of documentation and interviews, the agency failed to meet the condition for quality assessment and performance improvement as evidenced by: Refer to G0660 The agency's governing body failed to ensure that an ongoing program for quality improvement and patient safety was implemented and maintained. The Administrator failed to implement and maintain the agency's QAPI (Quality Assessment and Performance Improvement) Program for three (2020, 2021 and 2022) three the years. This failure could prevent the agency from monitoring the effectiveness and safety of agency services provided to the agency's patients. The failure could also prevent the agency from identifying problems, implementing corrective actions to ensure the health and safety of the agency's patients, and if necessary, revise policies. Refer to G0658 Based on interview and record review, the agency failed to conduct performance improvement projects for 3 of 3 (2020, 2021 and 2022) years reviewed ant to document the reasons for conducting the projects and the progress achieved. This failure prevented the agency from improving the quality of patient care and the effective performance of the agency’s operations.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: THIS IS A CONTINUED DEFICIENCY CITED AT G0658 ON SURVEY DATED 09/23/2020. Based on interview and record review, the agency failed to develop, implement, and evaluate performance improvement projects for 3 of 3 (2020, 2021 and 2022) years reviewed. This failure in the hospice failing to develop, implement, and evaluate performance improvement projects for the years 2020,2021 and 2022 required and could have resulted in the hospice failing to identify and address areas of the hospice's program for which performance could be improved. The findings included: Review of the documentation regarding the hospice's QAPI Program included no documentation to indicate the hospice had developed, implemented, or evaluated a performance improvement project for the years of 2020, 2021 and 2022. During an interview on 09/18/2023 at 2:05 PM, with the Administrator, the surveyor discussed the above findings. The Administrator said, "Since we don’t have any Medicare patients, I didn’t do the QAPI.” The surveyor reviewed the agency QAPI policy and the QAPI Federal and State regulations with the Administrator and explained QAPI is required whether the agency have a census or not. The Administrator stated, “I thought QAPI was only for Medicare patients. Since we didn’t have any Medicare patients it wasn’t done.” Agency policy titled "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN QAPI. 1" revised 100110 read in part: "...PURPOSE To develop a Quality Assessment Performance Improvement Plan (QAPI)…implemented by the QAPI/PI committee, that captures significant outcomes that are essential to optimal care and are used in the care planning and coordination of services and events. POLICY Agency will develop a plan that is reviewed and updated or revised at least once in a calendar year ...by the QAPI/PI Committee..." The policy did not include the requirement to conduct performance improvement project(s) as required by federal regulations beginning in June 2018.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: THIS IS A CONTINUED DEFICIENCY CITED AT G0660 ON SURVEY DATED 09/23/2020. The agency's governing body failed to ensure that an ongoing program for quality improvement and patient safety was implemented and maintained. The Administrator failed to implement and maintain the agency's QAPI (Quality Assessment and Performance Improvement) Program for three (2020, 2021 and 2022) three the years. This failure could prevent the agency from monitoring the effectiveness and safety of agency services provided to the agency's patients. The failure could also prevent the agency from identifying problems, implementing corrective actions to ensure the health and safety of the agency's patients, and if necessary, revise policies. FINDINGS INCLUDED: QAPI binder review: 1. The binder did not contain an annual evaluation of the QAPI program for 2020, 2021 and 2022. 2. The binder did not contain any reports, reviews nor documentation that indicated the agency had maintained an QAPI program that included the regulatory requirements, for the years 2020, 2021 and 2022. The binder did not indicate that the agency had conducted: 1. An analysis of a representative sample of services furnished to patients contained in both active and closed records; 2. A review of negative patient care outcomes; 3. A review of complaints and incidents of unprofessional conduct by licensed staff and misconduct by unlicensed staff; 4. A review of infection control activities; 5. A review of effectiveness and safety of all services provided, including: (-a-) the competency of the agency's clinical staff; (-b-) the promptness of service delivery; and (-c-) the appropriateness of the agency's responses to patient complaints and incidents; 6. A determination that services had been performed as outlined in the individualized service plan, and 7. An analysis of patient complaint and satisfaction survey data; and 8. An annual evaluation of the total operation, including services provided under contract or arrangement. (-a-) Used the evaluation to correct identified problems and, if necessary, revised policies. (-b-) Documentation of corrective action that ensured improvements were sustained over time. During an interview on 09/18/2023 at 2:05 PM, with the Administrator, the surveyor discussed the above findings. The Administrator said, "Since we don’t have any Medicare patients, I didn’t do the QAPI.” The surveyor reviewed the agency QAPI policy and the QAPI Federal and State regulations with the Administrator and explained QAPI is required whether the agency have a census or not. The Administrator stated, “I thought QAPI was only for Medicare patients. Since we didn’t have any Medicare patients it wasn’t done.” Agency policy titled "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN QAPI. 1" revised 100110 read in part: "...PURPOSE To develop a Quality Assessment Performance Improvement Plan (QAPI)/..implemented by the QAPI/PI committee, that captures significant outcomes that are essential to optimal care and are used in the care planning and coordination of services and events. POLICY Agency will develop a plan that is reviewed and updated or revised at least once in a calendar year ...by the QAPI/PI Committee...Areas for improvement will be identified through the collection of data for analysis pf Agency services. Systems of measures include: A representative sample of services furnished to patients contained in both active and discharged charts, Issues of unprofessional conduct by licensed staff and misconduct by unlicensed staff, Infection control activities...Services have been performed as outlined in the care plan, Patient complaints and satisfaction survey data, including agency response to complaints, Patient incidents including agency response to incidents, Effectiveness and safety of all services provided, including Competency of the agency staff; Promptness of service delivery...PROCEDURE ..8. QAPI documents will be kept confidential and be made available to Texas Department of Aging and Disability Services, [Texas Health and Human Services Commission] staff upon request."

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview the Administrator failed to designate a qualified Alternate Administrator, to assume the same responsibilities and obligations as the Administrator who would be responsible for the agency in the absence of the Administrator. This failure places the agency organization at risk of mismanagement that may affect the agency organization, and patient care services in the event the Administrator was unavailable. Findings: The surveyor reviewed the agency records in the web-based licensure system in the Texas Uniform Licensure Portal (TULIP) on 09/18/2023. TULIP revealed the agency Administrator was the License Holder/Owner, and the Alternate Administrator/Alternate Supervising Nurse was Identifier A. TULIP also revealed the agency was licensed to provide licensed home health services (LHHS), licensed and certified home health services (L&CHHS), and personal assistance services (PAS). During an interview on 09/18/2023 at approximately 11:15 AM, with the Administrator, the surveyor reviewed the list current employees. The list contained five Attendants. The surveyor requested a complete list with the Administrator, Alternate Administrator, Director of Nurses (DON), and Alternate Director of Nurses (ADON). The Administrator wrote on the list identifying the Administrator/ADON, and the DON as Identifier A. The surveyor asked was the Administrator a nurse. The Administrator stated, “No.” The Administrator crossed out Alternate DON from the Administrator’s name on the list. The surveyor asked if the agency had an Alternate DON. The Administrator stated, “No.” The surveyor asked was Identifier A still an active employee with the agency. The Administrator stated, “The agency hasn’t had any Medicare patients since the last part of 2020. We haven’t had a DON since the last part of 2020 because the agency didn’t have any patients and couldn’t pay for the nurses. He (Identifier A) had to get another job. He’s (Identifier A) a consultant for the agency if the agency needs help or questions.” The surveyor requested the Administrator call the Supervising Nurse. The Administrator called and said there was no answer to the call. The surveyor requested a corrected list of current employees. During an interview on 09/18/2023 at approximately 11:28 AM, with the Administrator, the surveyor reviewed the amended list current employees. The list contained five Attendants, Identifier A’s name was crossed out (no DON), and Identifier B was added as the DON/Alternate Administrator. The surveyor asked was Identifier B a nurse. The Administrator stated, “No, but she’s (Identifier B) is almost a nurse. She’s in nursing school and is almost finished. The Administrator stated that Identifier B reviewed the Plan of Cares and Nurses notes when the agency had Medicare patients.” The surveyor asked the Administrator if Identifier B had any previous Administrator experience. The Administrator stated, “Yes.” The surveyor requested Identifier B’s personnel file. Review of Identifier B’s personnel file revealed an application dated 10/02/2011. The application read in part, …” Position Applying For: CNA (Certified Nurse’s Assistant). The application contained a section titled “Educational History”, which did not contain any nursing school history. The application also contained a section titled “Work History” did not contain any previous work experience. The personnel did not contain a job description. During an interview on 09/18/2023 at approximately 11:40 AM, with the Administrator presented a second amended current employee list. Identifier B was identified on the list as the Alternate Administrator. The Administrator removed the title of DON from Identifier B on the amended list. The surveyor asked when Identifier B was appointed as the Alternate Administrator. The ADM stated, “10/04/2011.” The surveyor reviewed Identifier B’s personnel file with the Administrator. The surveyor asked why Identifier B was allowed to review nurse’s notes and plan of cares without any nursing experience. The Administrator stated, “What I meant was she mailed out the plan of cares and made sure the doctors signed the orders in a timely manner. She also made sure the nurses turned in their notes on time.” The surveyor if the agency had a DON or ADON. The Administrator stated, “No.” The surveyor asked the Administrator if Identifier B had any previous Administrator experience. The Administrator stated, “Yes, it’s just not documented on the application.” During a phone call interview on 09/19/2023 at approximately 3:26 PM, with Identifier B, the surveyor asked if Identifier B was the Alternate Administrator for the agency. Identifier B stated, “Yes.” The surveyor asked what previous experience and where Identifier B had experience as an Alternate Administrator. Identifier B stated, “Different agencies. I can’t remember right now.” The surveyor could Identifier B remember at least one. Identifier B stated, “I worked at an agency called [Identifier C].” The surveyor told Identifier B, the surveyor was familiar with Identifier C. The surveyor asked was Identifier B an Alternate Administrator with Identifier C. Identifier B stated, “No. I was a CNA and administration.” The surveyor asked if Identifier was willing to assume the responsibilities of the Administrator for the agency being surveyed in the absence of the Administrator. Identifier B stated, “I no longer work for the agency. Since 2011.” At the exit conference on 09/20/2023 at 1:57 PM, the agency had not appointed an alternate administrator.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on record review and interview, the agency who was licensed to provide licensed home health services and licensed and certified home health services, failed to directly employ or contract with an individual who met the qualifications as a supervising nurse and who provided oversight of all patient care services and personnel This failure placed any patients admitted by the agency at risk of poor care and negative health outcomes when no qualified clinical supervise was available. Findings: The surveyor reviewed the agency records in the web-based licensure system in the Texas Uniform Licensure Portal (TULIP) on 09/18/2023. TULIP revealed the agency Administrator was the License Holder/Owner, and the Alternate Administrator/Alternate Supervising Nurse was Identifier A. TULIP also revealed the agency was licensed to provide licensed home health services (LHHS), licensed and certified home health services (L&CHHS), and personal assistance services (PAS). During an interview on 09/18/2023 at approximately 11:15 AM, with the Administrator, the surveyor reviewed the list current employees. The list contained five Attendants. The surveyor requested a complete list with the Administrator, Alternate Administrator, Director of Nurses (DON), and Alternate Director of Nurses (ADON). The Administrator wrote on the list identifying the Administrator/ADON, and the DON as Identifier A. The surveyor asked was the Administrator a nurse. The Administrator stated, “No.” The Administrator crossed out Alternate DON from the Administrator’s name on the list. The surveyor asked if the agency had an Alternate DON. The Administrator stated, “No.” The surveyor asked was Identifier A still an active employee with the agency. The Administrator stated, “The agency hasn’t had any Medicare patients since the last part of 2020. We haven’t had a DON since the last part of 2020 because the agency didn’t have any patients and couldn’t pay for the nurses. He (Identifier A) had to get another job. He’s (Identifier A) a consultant for the agency if the agency needs help or questions.” The surveyor requested the Administrator call the Supervising Nurse. The Administrator called and said there was no answer to the call. The surveyor requested a corrected list of current employees. During an interview on 09/18/2023 at approximately 11:28 AM, with the Administrator, the surveyor reviewed the amended list current employees. The list contained five Attendants, Identifier A’s name was crossed out, and Identifier B was added as the DON/Alternate Administrator. The surveyor asked was Identifier B a nurse. The Administrator stated, “No, but she’s [Identifier B] is almost a nurse. She’s in nursing school and is almost finished. The Administrator stated that (Identifier B) reviewed the Plans of Cares and Nurses notes when the agency had Medicare patients.” The surveyor asked the Administrator if Identifier B had any previous Administrator experience. The Administrator stated, “Yes.” The surveyor requested Identifier B’s personnel file. Review of Identifier B’s personnel file revealed an application dated 10/02/2011. The application read in part, …” Position Applying For: CNA (Certified Nurse’s Assistant). The application contained a section titled “Educational History”, which did not contain any nursing school history. The application also contained a section titled “Work History” did not contain any previous work experience. The personnel did not contain a job description. During an interview on 09/18/2023 at approximately 11:40 AM, with the Administrator presented a second amended current employee list. Identifier B was identified on the list as the Alternate Administrator. The Administrator removed the title of DON from Identifier B on the amended list. The surveyor asked when Identifier B was appointed as the Alternate Administrator. The ADM stated, “10/04/2011.” The surveyor reviewed Identifier B’s personnel file with the Administrator. The surveyor asked why Identifier was allowed to review nurse’s notes and plan of cares without any nursing experience. The Administrator stated, “What I meant was she mailed out the plan of cares and made sure the doctors signed the orders in a timely manner. She also made sure the nurses turned in their notes on time.” The surveyor if the agency had a DON or ADON. The Administrator stated, “No.” At the exit conference on 09/20/2023 at 1:57 PM, the agency had not appointed a supervising nurse.