Every finding on record at J&K Staffing Solutions, LLC

An Emergency Preparedness Survey was conducted on 11/24/25 pursuant to the Emergency Preparedness Regulations as referenced in the Centers for Medicare and Medicaid State Operations Manual, 42 CFR part 484.102 Appendix Z - Rev. HHA Issued: 04/16/21 with deficiencies cited.

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 review of the facility's Emergency Preparedness Plan (E.P.P.) and interview, it was determined the facility failed ensure their overall E.P.P. policies and procedures were based on/compared with a review of the official community/regional risk assessment to include un-foreseen potential emergency events. Findings include: Review of the facility's Emergency Preparedness Plan (E.P.P.) on 11/24/25 between 10:00 a.m. and 1:15 p.m. with Staff A (Administrator) and Staff B (Operations Manager) revealed the E.P.P. was only developed using information gathered by a facility-based risk assessment and failed to include the official community-based risk assessment which could present un-foreseen/unknown hazards likely to occur within specific geographic areas. An all-hazards approach in the development of the facilities E.P.P. failed to be represented. Interview on 11/24/25 between 1:15 p.m. and 1:30 p.m. with Staff A and Staff B confirmed the above findings and available E.P.P. documentation presented during the Survey process.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan (E.P.P.) and interview, it was determined that the facility failed to ensure the E.P.P. was developed with cooperation, collaboration, or input with/from any emergency management officials familiar with the geographic/regional locations or efforts to maintain an integrated response during an emergency situation. Findings include: Review of the E.P.P. that was presented during the survey on 11/24/25 between 10:00 a.m. and 1:15 p.m. with Staff A (Administrator) and Staff B (Operations Manager) revealed the facility failed to provide any documentation of efforts to contact, cooperate, or collaborate with local, tribal, regional, State, or Federal emergency management officials in E.P.P. planning efforts. Interview on 11/24/25 between 1:15 p.m. and 1:30 p.m. with Staff A and Staff B revealed they were not aware of this requirement or whom to contact.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan (E.P.P.) and interview, it was determined the facility failed to ensure that policies and procedures were developed to inform emergency officials of clients in need of emergency evacuation or assistance. Findings include: Review of the Emergency Preparedness Plan (E.P.P. between 10:00 a.m. and 1:15 p.m. with Staff A (Administrator) and Staff B (Operations Manager) revealed the facility failed to develop policies or procedure to inform emergency officials in the event of an emergency situation in which their client is in need of evacuation assistance due to their current medical issues/needs and capacity during an event. Interview on 11/24/25 between 1:15 p.m. and 1:30 p.m. with Staff A and Staff B confirmed they were not aware of this requirement and had not developed specific policies.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan (E.P.P.) and interview, it was determined that the facility failed to ensure that agreements with other health care providers are arranged to ensure continuity of care for clients in the event the facility has an un-foreseen emergency/disaster event that prevents care being provided. Findings include: Review of the Emergency Preparedness Plan (E.P.P. during survey on 11/24/25 between 10:00 a.m. and 1:15 p.m. with Staff A (Administrator) and Staff B (Operations Manager) revealed the facility failed to have agreements to outline transfers of the client for continuity of care, such as a hospital, nursing home, or like services' provider as well as policies to follow up with clients during an emergency/disaster event beyond the facilities control or when the facility is not able to provide necessary care under their control. Interview on 11/24/25 between 1:15 p.m. and 1:30 p.m. with Staff A and Staff B confirmed the above findings and were unaware of the requirement.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan (E.P.P.) and interview, it was determined that the facility failed to ensure the E.P.P. emergency contact information list included all the required local, Regional, State, and/or Federal emergency management officials. Findings include: Review of the E.P.P. that was presented during the survey on 11/24/25 between 10:00 a.m. and 1:15 p.m. with Staff A (Administrator) and Staff B (Operations Manager) revealed the facility failed to provide complete documented emergency contact information for some of the required agencies, such as New Hampshire DHHS Licensing and Certification Units, Center for Medicare and Medicaid Services (CMS), Federal Emergency Management Agency (FEMA), Homeland Security (HS), and the Hillsborough County Emergency Management (where the main office is located). Additional contact information may be relevant to certain emergency conditions. Interview on 11/24/25 between 1:15 p.m. and 1:30 p.m. with Staff A and Staff B revealed they had included some contact information for the local Police Department (PD), Fire Department (FD), and the town Emergency Management representative but were not aware of the additional contact requirements.

A Health Recertification Survey was conducted on November 24, 2025 through November 25, 2025 pursuant to 42 CFR Part 484 for Home Health Agencies with no deficiencies cited.