Every finding on record at Jkcd Healthcare Consulting, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 7/25/2025. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 7/25/2025. The Agency was not in compliance with the standards for Home Health Agencies, 42 CFR 484, for this survey.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on document review and staff interview, it was determined in 2 of 17 (Pt # 5, Pt #16) patient records reviewed, the Home Health Agency (HHA) failed to ensure the initial assessment visit was conducted by a SN (Skilled Nurse) within 48 hours of the referral date. 1. The following clinical records were reviewed on 7/23/25. The records lacked documentation of an initial assessment by the SN (skilled nurse) within 48 hours of the referral date. Pt # 5 Start of Care: 6/9/25 - referral date: 6/6/25 Diagnosis: Intracranial injury without loss of consciousness. Pt #16 Start of Care: 8/12/24 - referral date: 8/8/24 Diagnosis: Pain Right Hip/ Orthopedic after care. 2. 2. The agency policy titled, “Patient Plan of Care (reviewed 12/24)” , was reviewed on 7/24/25 at approximately 2:00 PM. The policy indicates, “…The initial assessment shall be conducted on the physician ordered start of care date, or within 48 hours of referral, or within 48 hours of a patient’s return home from an inpatient stay of 24 hours or more for any reason other than diagnostic testing. The initial assessment shall be performed at the date the physician requested the start of care, when specified…” 3. 3. During an interview on 7/23/25 at approximately 3:30 PM, Registered Nurse Administrator, E #14, stated, “We do have a couple of patients that didn’t get seen within 48 hours of the referral.”