Every finding on record at Jackson Medical Center, LLC

A recertification survey was conducted at Jackson Medical Center Home Health from 5/6/26 to 5/8/25. The agency was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted from 5/6/25 to 5/8/25 at Jackson Medical Center Home Health. Standard Level deficiencies were cited and will require a plan of correction.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of CMS (Centers for Medicare and Medicaid Services) HHA (Home Health Agency) Error Summary by Agency Report, CMS OASIS (Outcome and Assessment Information Set) Agency Final Validation Reports, agency policy, and interview with staff, it was determined the agency failed to ensure OASIS data was transmitted to CMS within 30 days after the assessments were completed. This deficient practice affected 504 OASIS assessments and had the potential to affect all OASIS assessments submitted by this agency. Findings include: Agency Policy: OASIS Policy Number: Not Listed Revised/Reviewed: Not Listed 1. Initial Visit Assessment: RN/PT (Registered Nurse/Physical Therapist) to complete OASIS comprehensive assessment on initial visit, but no later than five (5) calendar days after the Start of Care... 4. Quality Staff: Quality Staff must encode, edit, and approve the OASIS information into the computer system within 14 days from the completion by said RN/PT. All information must be transmitted ... no later than 30 days of the assessment date... 1. A pre-survey review of the HHA Error Summary by Agency report for the period from 1/1/24 through 12/31/24 revealed 31.3 % of the OASIS assessments were submitted greater than 30 days after the assessments were completed. A review of the OASIS Agency Final Validation Reports from 1/1/25 through 5/5/25 conducted on 5/8/25 revealed a total number of 381 OASIS assessments were submitted and 170 of those were submitted greater than 30 days after the assessment. Which was a 45 % submitted greater than 30 days after the OASIS assessment. An interview was conducted on 5/8/25 at 1:15 PM with Employee Identifier # 1, Director, who confirmed the agency failed to ensure the OASIS assessments were submitted per agency policy.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on medical record (MR) review, agency policies, and interview with staff, it was determined the agency failed to ensure the Plan of Care (POC) including visit frequencies were followed. This deficient practice did affect one of three MR reviewed of patients receiving Home Health Aide (HHA) services including Home Visit (HV) # 4 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Plan of Care/Physician Orders Policy Number: Not Listed Revised/Reviewed Date: Not Listed Policy... All interventions and treatments provided by the agency are to be consistent with the plan of care... Agency Policy: Scheduling Visits Policy Number: Not Listed Revised/Reviewed Date: Not Listed Visits are scheduled according to physician orders and patient needs...If a visit is missed...we will try to make up the visit if possible... 1. HV # 4 was admitted on 3/7/25 with diagnoses including Urinary Tract Infection, Hypotension, and Pressure Ulcer of Left Ankle. Review of the Home Health Certification (HHC) and POC dated 3/7/25, included physician's orders for Home Health Aide (HHA) two visits per week for nine weeks. Review of the Missed Visit notes dated 3/11/25, 3/14/25, 3/20/25, 3/28/25, 4/1/25, 4/3/25, 4/15/25, 4/18/25, 4/29/25, and 5/1/25 and signed by the HHA revealed the HHA documented the visits were missed. There was no documentation the nurse was notified, no documentation attempts were made to re-schedule the visits, and no documentation the nurse notified the physician. An interview was conducted on 5/8/25 at 1:15 PM with Employee Identifier # 1, Director, who confirmed the agency failed to ensure the visit frequency for HHA was followed.

A recertification survey was conducted at Jackson Medical Center Home Health on June 2,2022. The agency was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted 5/31/22 to 6/2/22 at Jackson Medical Center Home Health with standard level deficiencies cited.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), observations, agency policy and interviews with the staff it was determined the agency failed to ensure the staff updated each patients Medication Profile (MP) per the facility policy. This affected 2 of 4 Home Visits (HV) conducted and did affect HV # 3 and HV # 4 and had the potential to negatively affect all patients served by the agency. Agency Policy: Policy: Medication Management It is the policy of Jackson Home Health to ensure that every patient has an accurate and complete list of the medications they are taking at home recorded in their medical record... When a medication is added, changed, or discontinued, the nurse will document on nurse's note and changes will be made to medication list in the...patient's office chart. It is the policy of Jackson Home Health that the skilled nurse assesses home meds at each skilled nurse visit... 1. HV # 3 was admitted to the agency on 4/22/22 with admitting diagnoses of Hepatic Failure, Unspecified without Coma and Alcohol Cirrhosis of Liver without Ascites. Review of the Home Health Certification and Plan of Care dated 4/22/22 revealed the frequency of visits for the skilled nurse (SN) was 1 time a week for 1 week, 2 times a week for 1 week and 1 time a week for 7 weeks and the Physical Therapy (PT) was 2 times a week for 3 weeks, 1 time a week for 1 week to begin week of 4/24/22. A HV was conducted on 5/31/22 at 2:40 PM with Employee Identifier (EI) # 4, Physical Therapy Assistant (PTA) to observe care provided to the patient. During the HV the patient's medication bottles were observed with the Medication List (ML) provided to the surveyor by the agency and the patient to confirm medications currently taking. The following medications were in the home and not on the ML: Zofran 4 mg (milligrams) by mouth every 6 hours as needed. Start date of 4/22/22. Tessalon Pearls 2 capsules by mouth 3 times a day as needed. Start date 9/15/20. Patient states he takes as needed for his cough. Magnesium Oxide 400 mg by mouth 1 daily. Start date 4/6/22. An interview was conducted on 6/2/22 at 2:20 PM with EI # 1, Administrator, who confirmed the medications should be checked on each visit by the skilled nurse and the the medication list is to be updated at that time. 2. HV # 4 was admitted to the agency on 1/15/22 with a recertification date of 5/15/22 to 7/13/22. The admitting diagnoses was Unspecified Open Wound Left Foot Subsequent Encounter and Atherosclerosis of CABG (Coronary Artery Bypass Graft) without Angina Pectoris. Review of the Home Health Certification and Plan of Care dated 5/15/22 revealed the SN frequency of visits was 1 time a week for 9 weeks. A HV was conducted on 5/31/22 at 1:30 PM with EI # 5, Registered Nurse, to observe wound care provided to the patient. During the HV the patient's medication bottles were observed with the ML provided to the surveyor by the agency and the patient to confirm medications currently taking. The following medications were in the home and not on the ML: Vitamin D3, 1 tablet daily by mouth. Patient stated he/she started in December 2021. Zinc 50 mg, 1 tablet by mouth daily. Patient stated started some time in 2021 after returning home from the hospital. Arthritis Pain Release 650 mg by mouth, 1 tablet at night as needed for pain. Started 4/1/22. Vitamin B 12 500 mcg (micrograms) 1 tablet by mouth daily. Started a week ago. An interview was conducted on 6/2/22 at 1:55 PM with EI # 1 who confirmed the medication list should have been updated with each skilled nurse visit and has currently been updated.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on review of agency policy, infection control documentation and staff interviews, it was determined the agency failed to investigate, analyze and implement an improvement plan for infectious disease prevention. This had the potential to affect all patients admitted to the agency. Findings include: Agency Policy: Infection Control Date: Not documented Purpose: ...4. To define the infection control program, its goals, prioritized objectives, authority, and responsibilities. 5. To define homecare-acquired infections, type of surveillance used, data sources, patient sources and reporting of analysis. Policy: The agency has established a comprehensive infection control program to ensure that there is a functioning, coordinated process in place to reduce the risk of endemic, epidemic and homecare-acquired infections. The infection control program optimizes the use of resources and assesses the safety and quality of patient care provided by establishing a baseline at each agency, monitoring trends within the agency and using the findings to improve care and decrease homecare-acquired infections and other complications. Program Authority and Responsibility: ...The coordination of the infection control activities at the agency level are delegated to the agency Director, who will investigate and follow-up on clinical and employee issues... ...Data Reports for Patient and Employee Infections: Daily, weekly, monthly, quarterly and/or annual summary reports are generated through the Online Event Reporting system for review by agency leadership regarding patient and employee infections... ...Data Analysis: 1. The summary reports are analyzed by the Director and/or designee monthly, quarterly and yearly for problems or undesirable trends. Data is also examined for common factors which may identify agency processes, systems or functions which could have increased risk for infection transmission... On 6/2/22 the surveyor was provided the agency Infection Control Program and documentation. During the Infection Control Program review the surveyor requested the agency documentation for infection tracking, trending, analysis and any actions taken for identified opportunities for improvement and disease prevention. The surveyor was provided the individual patient Infection Log(s), Monthly Patient Infection Log Form(s) and individual Employee Illness Report(s) for 2021 and 2022. Review of the individual patient Infection Log(s) and the Monthly Patient Infection Log Form(s) for 2021 and 2022 revealed no documentation agency infections were reviewed/investigated and no root cause analysis was completed to identify patterns/trends of infections. Further review of the agency Infection Control Program and documentation revealed the Employee Infections Form(s) were kept in the individuals personnel file and there was no documentation the Employee Infections were included in the agency Infection Control Program. An Interview was conducted on 6/2/22 at 12:08 PM with Employee Identifier (EI) # 1, Administrator, who confirmed the agency infection control program failed to include investigation/root cause analysis and no actions for improvement had been implemented for January 2021 to April 2022. EI # 1 also verbalized the Employee Infections Form(s) were given to the hospital and then put in the employees personnel file and were not counted in the agency infection control program.