Every finding on record at Jhonsdtc Inc.

Census: L&CHHS – 1 LHHS – 0 PAS – 187 The Agency was in compliance with 42 CFR Part 484.102, Emergency Preparedness requirements for Home Health Agencies. Abbreviations: Adm – Administrator Alt Adm – Alternate Administrator L&CHHS- License and Certified Home Health Services PAS – Personal Assistance Services DON-Director Of Nurses RN – Registered Nurse LVN -Licensed Vocational Nurse OASIS- Outcome and Assessment Information Set IQIES - Internet Quality Improvement and Evaluation System CMS- Center For Medicare and Medicaid Services

Purpose of Survey – To conduct a recertification. On 03/27/25 the surveyor conducted an unannounced visit and an entrance conference. Census: L&CHHS –1 LHHS – 0 Abbreviations: Adm – Administrator Alt Adm – Alternate Administrator L&CHHS- License and Certified Home Health Services LHHS – Licensed Home Health Services PAS – Personal Assistance Services DON-Director Of Nurses RN – Registered Nurse LVN -Licensed Vocational Nurse OSHA- Occupational Safety and Health Administration CFR – Code of Federal Regulations CDC – Centers for Disease Control and Prevention OASIS- Outcome and Assessment Information Set IQIES - Internet Quality Improvement and Evaluation System CMS- Center For Medicare and Medicaid Services

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: Findings included: Record review of an iQIES Error Summary Report dated 03/26/25 t indicated the agency failed to code and electronically transmit 13 out of 83 OASIS assessments data to the CMS system within thirty days of completing the assessment of the beneficiary. During an interview on 4/6/25 at 3:31 p.m., Administrator stated she was responsible for submitting OASIS assessment data after it was completed by the agency staff. Administrator said the OASIS data was required to be submitted within 30 days after the assessment was complete. Administrator stated that she hires contract staff and that they don’t always submit the assessments timely. Administrator/Supervising Nurse she was the person responsible for reviewing the assessment data before it was submitted, and the nurses turn them in. During an interview on 4/6/25 at 11:00 a.m., the Administrator/Supervising Nurse said the agency identified the root cause of late OASIS submissions as: The agency nurses not submitting the OASIS assessment data in a timely manner. The Administrator/ Supervising Nurse said she was aware that there was an issue with the OASIS assessments being submitted within the 30-day window. She stated that she has a low census and is looking to stop taking home health patients. Record review of an agency policy titled “Oasis Collecting, Encoding and Transmitting reviewed 01/01/21, indicated: · The Agency must electronically report all OASIS data Collected and update as required. · Encode and transmit OASIS information from the agency directly to CMS via the National Quality Improvement Evaluation system, assessment submission and processing. · The Agency must Encode and Electronically transmit each completed OASIS assessment to the CMS system, for each Beneficiary with respect to which information is required to be transmitted within 30 days of completing the assessment of the beneficiary. · The Encoded OASIS data must accurately reflect the patient’s status at the time of assessment. · Accurate OASIS data transmitted to CMS is consistent with the current Conditions of the patient. The agency did not dispute the surveyor's findings. The agency was afforded the opportunity to provided additional policy information upon exit on 03/11/25 at 5:19 pm. No additional documents provided by agency.