Every finding on record at Jdm Healthcare Services LLC

Purpose of Visit: Re-certification Survey. Entrance Date: 05/13/2021 An entrance conference was conducted with the administrator, Employee A at 11:35 a.m. via telephone and with the office manager, Employee D in person. Employee A was informed that the purpose of the survey was for a 36-month recertification inspection. L&C Census: 3 Exit Date: 05/18/2021 An exit conference was conducted at 12:45 p.m. with the administrator, Employee A, via telephone and the office manager, Employee D in person. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional information. Additional information was not provided. Written instructions were provided to the agency for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. Met condition of participation. Abbreviation List: L & C- Licensed and Certified EP- Emergency Preparedness

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of the agency's EP material and interview, the agency failed to conduct exercises to test the emergency plan annually, for the years 2018, 2019 and 2020. The failure could place the agency's patients at risk of harm related to lack of organized preparation and planning for patient care and services in the event of a disaster/emergency. FINDINGS INCLUDED: During the entrance conference at 11:35 a.m. on 05/13/2021, the administrator (Employee A) self-identified as the disaster coordinator and identified the alternate administrator, Employee B as the alternate disaster coordinator. Record review of the emergency preparedness plan binder, on 05/13/2021, did not identify any records to establish that the agency had conducted exercises to test the EP plan annually, for the years 2018, 2019 and 2020. The last drill was dated 01/19/2015 and the last actual emergency response was dated 05/19/2015. During an interview on 05/18/2021 at approximately 12:45 p.m. with the administrator, Employee B, the surveyor asked why the agency had not maintained a comprehensive emergency preparedness plan since the last survey dated, 05/07/2018, that included exercises to test the EP plan. The administrator, Employee B replied, "I guess I was just busy with school. But I am going to catch up with it." The surveyor discussed the federal requirements for conducting exercises to test the emergency plan annually. Record review of agency policy titled "EMERGENCY PREPAREDNESS" revised 080111 was not updated to include federal regulatory requirements to conduct exercises to test the emergency plan annually in full-scale drills, tabletop and/or other drills.

Purpose of Visit: Re-certification Survey. Entrance Date: 05/13/2021 An entrance conference was conducted with the administrator, Employee A at 11:35 a.m. via telephone and the office manager, Employee D in person. Employee A was informed that the purpose of the survey was for a 36-month recertification inspection. L&C Census: 3 Exit Date: 05/18/2021 An exit conference was conducted at 12:45 p.m. with the administrator, Employee A, via telephone and the office manager, Employee D in person. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional information. Additional information was not provided. Written instructions were provided to the agency for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. Met conditions of participation. Abbreviation List: L & C- Licensed and Certified NOMNC- Notice of Medicare Non-Coverage POC- Plan of Care SOC- Start of Care PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement SN- Skilled Nursing Registered Nurse (RN) CMS- Center for Medicare and Medicaid Services OASIS -outcome and assessment information set

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 agency failed to ensure proper written notice was provided, in advance of terminating on-going care in two (Patients # 4 and 5 of two inactive patient records reviewed. The agency failed to provide patients # 4 and 5 with the Centers for Medicare and Medicaid form titled Notice of Medicare Non-Coverage. The failure could place the patients at risk of harm due to inadequate or inappropriate continuity of care in the patients' post-discharge needs and could prevent the patients from exercising the right to appeal the discharge decision, if desired. FINDINGS INCLUDED: Clinical Record # 4: Record review of the electronic and hard copy clinical records for Patient # 4 did not contain a POC for the certification period of 07/06/2020 to 08/04/2020. The records contained a SOC OASIS dated 07/07/2020 and signed by Supervising nurse, RN A. The record also contained a SN visit note dated 07/13/2020 conducted by RN A. Patient # 4's record included a discharge OASIS electronically signed by RN A that showed a date of discharge as 07/20/2020. Patient # 4's records did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 07/20/2020. The records did not include a written NOMNC. Clinical Record # 5: Record review of the electronic and hard copy clinical records for Patient # 5 contained a POC for the certification period of 09/02/2020 to 10/31/2020. The POC included a start of care date of 09/02/2020 with a principal diagnosis of encounter for attention to ileostomy. The POC was dated 07/14/2020 and electronically signed by the supervising nurse, RN A. The POC contained an order for skilled nursing visits for two times per week for one week and one time per for eight weeks, "beginning week of 09/02/2020." Patient # 5's record included a discharge OASIS electronically signed by RN A that showed a date of discharge as 09/29/2020. Patient # 5's records did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 09/29/2020. The records did not include a written NOMNC. In an interview on 05/18/2021 at approximately 12:20 p.m. with the administrator/supervising nurse, RN A, the surveyor discussed the above findings and asked why the agency had not provided written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for Patients # 4 and 5. RN A replied, "I will follow-up on that." Agency policy titled "CLIENT DISCHARGE" revised 030110 read in part: " ...POLICY ...Agency will deliver the generic CMS notice NOMNC ... the client (or authorized representative), no less than two days prior to the day of anticipated discharge, or as soon as the provider determines coverage will end ..."

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was updated and revised during the last five days of every 60 days, beginning with the start of care date, in three (Clinical Records # 1, 2 and 3) of three active records reviewed. The failure could place the patients at risk of not having a current comprehensive assessment or not having a current and accurate plan of care. FINDINGS INCLUDED Active Clinical Record #1: Record review of the electronic and hard copy clinical records for Patient # 1 contained a POC for the certification period of 04/21/2021 to 06/19/2021. The POC included a start of care date of 02/26/2020 with a principal diagnosis of essential primary hypertension. The POC was dated 12/21/2020 and electronically signed by the supervising nurse, RN A. The POC contained an order for skilled nursing visits for one time per for nine weeks, "beginning week of 02/15/2021." The POC showed that the comprehensive assessment was not updated and revised during the last five days of every 60 days. The prior 60-day certification period ended on 04/20/2021. Active Clinical Record #2: Record review of the electronic and hard copy clinical records for Patient # 2 contained a POC for the certification period of 02/18/2021 to 04/18/2021. The POC included a start of care date of 02/18/2021 with a principal diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy. The POC was dated 12/21/2020 and electronically signed by the supervising nurse, RN A. The POC contained an order for skilled nursing visits for one time per for nine weeks. Patient # 2's original SOC date was 02/26/2020. The POC showed that the comprehensive assessment was not updated and revised during the last five days of every 60 days. The prior 60-day certification period ended on 02/17/2021. Active Clinical Record #3: Record review of the electronic and hard copy clinical records for Patient # 3 contained a POC for the certification period of 02/15/2021 to 04/15/2021. The POC included a start of care date of 04/21/2020 with a principal diagnosis of type 2 diabetes mellitus with other circulatory complications. The POC was dated 12/14/2020 and electronically signed by the supervising nurse, RN A. The POC contained an order for skilled nursing visits for one time per for nine weeks." The POC showed that the comprehensive assessment was not updated and revised during the last five days of every 60 days. The prior 60-day certification period ended on 02/14/2021. An interview was conducted with the supervising nurse (RN A) on 05/18/2021 at approximately 12:15 p.m., the surveyor asked why the comprehensive assessments/POCs in the clinical records for Patients # 1, 2, and 3 were not updated and revised during the last five days of every 60 days. The supervising nurse, RN A replied, "I guess it's just a confusion of date." Record review of agency policy titled "CLIENT REASSESSMENT/RECERTIFICATION/POST HOSPITAL ASSESSMENT" Revised 042611 read in part: "...The Recertification/...Comprehensive Assessment ... will be revised updated and revised during the last five...days of the episode (day 56-60) ..." Record review of agency policy titled "PLAN OF CARE" revised 040411 read in part: " ...PROCEDURE ...E. The care plan is reviewed and/or revised, with physician participation, at least every 60 days.

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 record review and interview, in one of one agency QAPI program, the agency failed to conduct and document PIP(s) for the calendar years 2018, 2019 and 2020 that reflected the scope, complexity and past performance of the agency's services and operations. The failure could place the agency at risk to not improve and provide quality care and services to the agency's patients. FINDINGS INCLUDED: The surveyor requested all agency QAPI documents/reports/manuals on 05/13/2021. A binder labeled "Agency Profile Manual" was provided by the office manager, Employee D and a binder labeled "QAPI Manual", was provided by the administrator, Employee A. Record review of the binders showed that they contained the following: The agency's written QAPI plan. The last quarterly QAPI report in the binder was for the "1st" quarter of 2012. The last annual agency evaluation was dated "Eval Year 2010." The last client record review was dated 01/19/2015. The last action plan was dated 01/18/2015. A patient perception survey dated 04/20/2021 was included. A patient incident report was included and dated 04/20/2021. The last board of directors meeting was dated 01/30/2015. The binder did not contain any reports, reviews nor documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements, for the years 2018, 2019 and 2020. During an interview on 05/18/2021 at 11:45 a.m., with the administrator, Employee A and the office manager, Employee D, the surveyor asked why the agency had not conducted PIP(s) per federal regulatory requirements for the years 2018, 2019 and 2020. The administrator, Employee A stated that Employee A was not aware of the regulatory requirement to conduct PIP(s). Review of agency policies titled "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN QAPI.1" revised 022710, QAPI.2 revised 12/11/08, QAPI.4 revised 022610 and QAPI.5 revised 022610 were not revised to include the federal regulatory requirement for performance improvement projects.

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: Based on record review and interviews, the agency's governing body failed to ensure that an ongoing program for quality improvement and patient safety was implemented and maintained. In one of one (QAPI Program) the agency failed to address priorities for improved quality of care and patient safety and ensure that: all improvement actions were evaluated for effectiveness; clear expectations for patient safety were established, implemented, and maintained. The agency failed to maintain an agency wide QAPI Program. The QAPI program was not ongoing and focused on Patient outcomes that were measurable, for the years 2018, 2019 and 2020. The failure could place the agency's Patients at risk of negative Patient care outcomes if substandard care was not identified and corrected by the agency during ongoing QAPI evaluations. FINDINGS INCLUDED: The surveyor requested all agency QAPI documents/reports/manuals on 05/13/2021. A binder labeled "Agency Profile Manual" was provided by the office manager, Employee D and a binder labeled "QAPI Manual", was provided by the administrator, Employee A. Record review of the binders showed that they contained the following: The agency's written QAPI plan. The last quarterly QAPI report in the binder was for the "1st" quarter of 2012. The last annual agency evaluation was dated "Eval Year 2010." The client record review was dated 01/19/2015. The last action plan was dated 01/18/2015. A patient perception survey dated 04/20/2021 was included. A patient incident report was included and dated 04/20/2021. The last board of directors meeting was dated 01/30/2015. The binders did not contain any reports, reviews nor documentation that indicated the agency had maintained an agency wide QAPI program that included the federal regulatory requirements, for the years 2018, 2019 and 2020. During an interview on 05/18/2021 at 11:45 a.m., with the administrator, Employee A and the office manager, Employee D, the surveyor discussed the above findings. The surveyor asked why the agency had not ensured that an agency-wide ongoing program for quality improvement and patient safety was implemented and maintained for the years 2018, 2019 and 2020. Employee A replied, "Because I have just been having few patients."