Every finding on record at Jaicstar Home Care Inc

• Purpose of visit: Recertification/Relicensure • Entrance date: 08/14/2024 • Census: L&C-0 LHHS-0 PAS-0 The facility is in compliance with no deficiencies cited. Abbreviations: Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Licensed and Certified Home Health Services (L&CHHS)

• Purpose of visit: Recertification/Relicensure • Entrance date: 08/14/2024 • Census: L&C-0 LHHS-0 PAS-0 Abbreviations: Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Licensed and Certified Home Health Services (L&CHHS) Quality Assurance and Performance Improvement (QAPI) Quality Improvement Organization (QIO) Benefits Improvement and Protection Act (BNI) Centers for Medicare and Medicaid Services (CMS) Plan of Care (POC) Start of Care (SOC) Outcome and Assessment Information Set (OASIS) Office of Management and Budget (OMB)

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to provide proper written notice, when the agency believed that the services may be non-covered care in that: 2 (Patients #1 and #2) 5 of discharged patient records reviewed the agency failed to provide the correct contact phone number of the Quality Improvement Organization (QIO) for the patients to appeal the discharge decision prior to when home health services ended. This failure placed the patients at risk of being unable to exercising their right to appeal the discharge decision. Findings include: Regulation Review: July 1, 2005, the new Medicare regulations Benefits Improvement and Protection Act (BNI) gave beneficiaries access to the new expedited determination process when their home health agency services were ending. There are two notices required by these regulations. The first is a generic notice (called a Notice of Medicare Provider Non-coverage) that the provider will deliver at least two days prior to when a beneficiary's Medicare coverage of services is ending. The phone number for the Quality Improvement Organization (QIO) should be included in this notice. The second is a detailed notice (called a Detailed Explanation of Provider Non-Coverage) that the provider will deliver to the beneficiary and the appropriate QIO only if the beneficiary requests an expedited review by the QIO of the decision that coverage for items and/or services should end. QIO Review: Quality Improvement Organization (QIO) Identifier AA in the Centers for Medicare and Medicaid Services (CMS), Area 6: including Texas, contact phone number XXX-XXX-0636. Review of discharge records: Discharged Patient #1 Review of the discharge record revealed a Plan of Care (POC) for the certification period of 06/04/2024 to 08/02/2024 with a Start of Care (SOC) date of 12/07/2023. The POC included a principal diagnosis of Paraplegia, Unspecified (is an impairment in motor or sensory function of the lower extremities). The POC read in part, “…Discharge plans: Discharge when medical condition is stable, and patient is no longer in need of skilled services.” The discharge record contained a form Outcome and Assessment Information Set (OASIS) (is a group of standard data elements home health agencies (HHAs) integrate into their comprehensive assessment, to collect and report quality data to the Centers for Medicare & Medicaid Services) read in part, “…OASIS-E Discharge… Visit Date 07/20/2024…Episode Goals…All goals met…” The discharge record contained a Center for Medicare/ Medicaid Services (CMS) form titled, "Notice of Medicare Non-Coverage" was signed by Patient #1 and dated 7/10/24. The form did not include the Quality Improvement Organization (QIO) or the phone contact number. Patient #1 discharge record did not include the notice of appeal that included the Quality Improvement Organization (QIO), Identifier AA and the phone contact number XXX-XXX-0636. Discharged Patient #2 Review of the discharge record revealed a POC for the certification period of 05/27/2023 to 07/25/2023 with a SOC date of 01/27/2023. The POC included a principal diagnosis of Malignant neoplasm of esophagus, unspecified (a growth of cells that starts in the esophagus. The esophagus is a long, hollow tube that runs from the throat to the stomach. The esophagus helps move swallowed food from the back of the throat to the stomach to be digested). The POC read in part, “…Discharge plans: Discharge when medical condition is stable, and patient is no longer in need of skilled services. Discharge when goals met”. The discharge record contained a form “Outcome and Assessment Information Set (OASIS) (is a group of standard data elements home health agencies (HHAs) integrate into their comprehensive assessment, to collect and report quality data to the Centers for Medicare & Medicaid Services) read in part, …OASIS-E Discharge… Visit Date 07/25/2023…Episode Goals…All goals met…” The discharge record contained a Center for Medicare/ Medicaid Services (CMS) form titled, "Notice of Medicare Non-Coverage" was signed by Patient #2 and dated 7/14/23. The form did not include the Quality Improvement Organization (QIO) or the phone contact number. Patient # discharge record did not include the notice of appeal that included the Quality Improvement Organization (QIO), Identifier AA and the phone contact number XXX-XXX-0636. In an interview with the Alternate Administrator/Director of Nursing on 08/14/2024 at approximately 10:20 AM, the surveyor reviewed the above findings regarding the discharged Patients #1and #2. The surveyor asked was discharged Patients #1 and #2 given the correct contact phone number of the Quality Improvement Organization (QIO) for the patients to appeal the discharge decision prior to when home health services ended. The Alternate Administrator/Director of Nursing reviewed the agency's Medicare QIO form provided to the discharged patients. Alternate Administrator/Director of Nursing stated, "Office Manager is responsible for updating the forms." The Alternate Administrator/Director of Nursing asked the Office Manager to step into the office. The surveyor asked if the agency's Medicare QIO form provided to the discharged patients had been updated with the proper QIO and phone contact number. The Office Manager stated, “I neglected to edit the form.” Agency policy titled "Patient/Client Transfer, Discharge, and Agency Dissolution PE.25" revised 050224, read in part: "...II. Discharge…G. The Agency will provide notice to eligible patients/clients of the right to expedited determinations using the Notice of Medicare Non-Coverage (an OMB-approved Medicare form) when the period of covered care ends…”

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: Based on interview and record review, the agency failed to conduct performance improvement projects for 3 of 3 (2021, 2022 and 2023) years reviewed. This failure could have resulted in the agency failing to identify and address areas of the agency'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 2021, 2022 and 2023. In an interview with the Alternate Administrator/Director of Nursing on 08/14/2024 at approximately 10:00 AM, the surveyor requested the Quality Assurance and Performance Improvement (QAPI) documents and asked who was responsible for the QAPI program. The Alternate Administrator/Director of Nursing said, “I’m responsible for the QAPI program.” The surveyor discussed the above findings. The Administrator said, "We didn’t do Performance Improvement Projects probably because we did it for our larger agency but not this agency.” Agency policy titled "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT Program QAPI.5" revised 050124 read in part: "...III. The QAPI Plan will be developed based on…E. Performance improvement projects 1. The number and scope of distinct improvement projects conducted annually…2. The Agency will document the quality improvements projects undertaken…”