Every finding on record at Joyal Health Care Services Inc

During the recertification survey conducted on March 21-22, 2024, at Joyal Healthcare Services, Inc, a home health agency, Emergency Preparedness was reviewed. Joyal Healthcare Services, Inc is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Conditions of Participation for Home Health Agencies.

A recertification survey was completed on March 21-22, 2024 at Joyal Healthcare Services, Inc. The agency was not in compliance with Code of Federal Regulations (CFR) 42, Part 484.22, Conditions of Participation for Home Health Agencies. .

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 agency documentation review, staff interviews, and agency policy review, it was determined that the agency failed to have at least one performance improvement project either in development, on-going or completed each calendar year for 2023 and for 2024 to date. The findings include: Upon review of the agency's Quality Assurance and Improvement Plan (QAPI) it was revealed that the agency did not have any Performance Improvement Projects (PIPs) in development, on-going, or completed for calendar year 2023, or for calendar year 2024 to date. On 3/22/24 at 1:50 pm, in an interview with the Assistant Director of Nursing, she was asked if the agency has any PIPs in development, completed, or on-going. She stated, "I did not identify anything that needed improvement so there are no PIPs in place." The Director of Nursing then stated, "We are so small, and we are not below national standards so it can be hard to create a plan. We will identify problems and focus on something, because there is always something we could work on." A review of the Agency's Policy titled, "Performance Improvement Plan" (undated) revealed: "Goal: To improve the Agency's performance by designing its processes well and systematically collecting data, monitoring, analyzing, and improving patient and/or caregivers' environment by...developing and implementing effective performance mechanisms such as monitoring and evaluation committees, incident reporting and trending, and patient and/or caregiver and physician questionnaires. .

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on staff interviews, agency record review, and agency policy review, it was determined that the agency failed to provide infection control education to staff at periodic intervals consistent with accepted standards of practice. Such education must be provided at orientation, annually, and as needed. The findings include: In an interview on 3/22/24 at 1:37 pm with the Director of Nursing (DON), she was asked if staff and contractors receive infection control education at orientation, annually, and as needed. She stated, "Yes, but I don't have that in writing. We verbally educate Certified Nurse's Aides (CNAs) and clients during visits and supervisory visits." At the time of the interview, an observation was made of a notice in the staff break room for monthly in-services (photograph obtained). Infection Control was not listed as one of the monthly in-services. The DON stated that the in-services are conducted; however, they do not require staff to sign in or have documentation of what was discussed or what education was provided. She said they are so small that they usually just make sure it gets done. The DON stated that she cannot pay staff to come into the office just for an in-service. When asked about annual infection control education, the DON stated they do annual education, but again stated they do not have documentation of attendance or evidence of annual skills review. A review of the Agency Policy titled, "Infection Control Education/Training' (undated) revealed: "Employee education shall occur at the time of employment and at least annually. Records of such training shall be maintained in accordance with the Agency's policy for retention of records."