Jakpa Health Care Inc.

“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, the agency failed to conduct and document performance improvement projects for three of three calendar years (2022, 2023 and 2024) and failed to have at least one performance improvement project in development or ongoing for calendar year 2025 that reflected the scope, complexity and past performance of the agency’s services and operations and the measurable progress achieved on the projects. This failure could prevent the agency from identifying weaknesses and making improvements in patient care. Findings Included: Record review of the agency’s personal assistance services and licensed and certified quality assessment performance improvement binder and the agency’s annual evaluation binder, provided by the Adm/DON on 06/26/2025, did not include any reports, reviews or documentation that indicated the agency conducted performance improvement projects for calendar year 2022, 2023 and 2024 or had a performance improvement project in development or ongoing for calendar year 2025. In an interview with the Administrator on 06/26/2025 at 11:45 AM, the Adm/DON stated she was responsible for the agency’s overall quality assessment performance improvement activities. In an interview with the Adm/DON on 07/02/2025 at 1:35 PM, the Adm/DON stated it was an oversight the agency did not have any performance improvement projects for the years 2022, 2023, 2024 and 2025. The surveyor asked how this failure could affect agency patients. The Adm/DON stated the agency might not know what to improve on and what to do differently for each patient which could affect the agency as a whole. The Adm/DON stated it was very important to have performance improvement projects and she would focus on that and make improvements. The surveyor asked why the agency policy was not followed. The Adm/DON stated the agency usually did performance improvement projects. Agency policy titled, “Quality Assessment Performance Improvement Program QAPI.1” with a revision date of 01/13/2018, read in part, “… To develop, implement, evaluate, and maintain an effective, ongoing, Agency-wide, data-driven Quality Assessment Performance Improvement…Program as defined by its QAPI Plan. Policy… III… The Agency will maintain documentary evidence of its QAPI program… D. Performance improvement projects… 1. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency’s services and operations. 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects…””

“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 provide the proper written Notice of Medicare Non-Coverage no later than two days in advance of terminating on-going care in one of five discharged records reviewed (Patient 1). This failure placed Patient 1 at risk of adverse health outcomes as the agency would not be providing the patient time to arrange for proper continuity of care after discharge from the agency. Findings included: A patient discharge list with discharge reason was provided to the surveyor by the Adm/DON on 06/27/2025. Patient 1: Record review of the medical record included a plan of care dated 04/23/2025 to 06/21/2025 signed by the physician on 05/05/2025 and the Adm/DON on 04/23/2025 for a 66 year old patient with a start of care date of 04/23/2025. The plan of care included a diagnosis of diabetic (high blood sugar) wounds on the left and right foot with bone involvement and orders for an agency nurse to perform wound care two times a week for nine weeks. The discharge list included the discharge date was 06/21/2025 with a discharge reason of the recertification order (process of renewing or verifying a patient’s eligibility for home health care services) was not signed by the doctor who was on vacation. The record included a discharge assessment signed and dated by the ADON on 06/21/2025. The assessment included the patient had seven diabetic foot wounds that required an agency nurse to provide dressing changes two times weekly. The record included a discharge summary/order signed and dated by the ADON on 06/21/2025. The discharge summary/order included the patient was discharged due to the doctor not signing agency recertification orders for the episode beginning 06/22/2025. The discharge summary/order included the wounds were not healed and the patient was discharged unexpectedly. The record did not include the Centers for Medicare and Medicaid Services form titled, “Notice of Medicare Non-Coverage.” During an interview with the Adm/DON on 06/26/2025 at 1:00 PM, the Adm/DON stated: Patient 1 was discharged from the agency because the doctor who ordered home health went on a two week vacation and could not sign the agency’s recertification order; there was not another physician/clinician to sign the recertification order. If the recertification order was not signed, the agency would risk not receiving payment from [Payor Source]. The Adm/DON instructed the patient to go to the doctor’s office for dressing changes on the days the agency nurse would normally visit. The doctor’s office and the patient were notified prior to discharge and the patient agreed to receive wound care changes at the doctor’s office. During an interview with the Adm/DON and the ADON on 07/02/2025 at 1:45 PM, the surveyor asked why Patient 1 was not given the Notice of Medicare Non-Coverage form at least 2-days in advance of agency discharge. The Adm/DON stated: The doctor did not sign the agency’s recertification order. The patient was notified of agency discharge on 06/21/2025, the same day he was discharged from the agency. The patient was instructed to go to the doctor’s office to receive wound care. There was no reason for the agency to provide the Notice of Medicare Non-Coverage notice because the rule to provide the notice did not apply in that situation. The ADON stated the patient was verbally notified on 06/18/2025 the agency was having problems getting the doctor to sign the recertification order. The surveyor asked why the agency policy was not followed. The Adm/DON stated the policy did not apply in that situation. The ADON stated the discharge was not anticipated. The surveyor asked how this failure could affect the patient. The Adm stated the patient had to go to the doctor’s office for the dressing changes. Agency policy titled, “Patient/Client Transfer and Discharge Notices PE.6” with a revised date of 01/132018 read in part, “… Purpose To provide guidance on completion of the required… discharge notices… Policy I. Prior to… discharging a patient/client, the Agency will provide written notification to the patient/client or the patient’s/client’s parent, family, spouse, significant other, or legal representative… III. The Agency will deliver the Notice of Medicare Non-Coverage… to the patient/client (or authorized representative), at least two (2) calendar days before Medicare covered services end or the second to last day of service if care is not provided daily…Procedure II. Notice of Medicare Non-Coverage (NOMNC) A. Agency staff will provide valid delivery notice (involves both delivery and completion) of the NOMNC to the patient/client (or their representative) when the end of all covered care is foreseen, even if the patient/client agrees with the discharge. B. At least two (2) calendar days before Medicare covered services end or the second to last day of service if care is not provided daily, the Agency representative will provide the NOMNC to the patient/client (or their representative) when providing the… notice of discharge… C. If the Agency fails to give valid notice, patient/client coverage continues for at least two (2) days after the notice is received…””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included all pertinent diagnoses and patient specific interventions in two of five discharged records reviewed (Patient 2 and 3) in that: In one of five discharged records reviewed (Patient 2), the plan of care did not include a diagnosis of an allergic reaction and hyperlipidemia (high fat levels in the blood) and vital sign, pain and blood sugar parameters to report to the physician/ordering clinician. In one of five discharged records reviewed (Patient 3), the plan of care did not include vital sign, pain and blood sugar parameters to report to the physician/ordering clinician. These failures placed patients at risk of harm from agency staff who could not address the patient’s risk factors and type of services needed for appropriate care and at risk of a declining health status and complications. Findings included: Patient 2: Record review of the medical record included a plan of care dated 03/15/2024 to 05/13/2024 signed by the ordering Nurse Practitioner on 04/15/2024 and the Adm/DON on 03/15/2024 for a 61 year old patient with a start of care date of 03/15/2024. The plan of care included a diagnosis of arthritis, diabetes (high blood sugar levels), chronic pain, heart failure, hypertension (high blood pressure) and migraines (severe headaches). The plan of care included orders for a nurse to visit two times in 60 days and physical therapy to visit two times a week for eight weeks. The plan of care read in part, “… poorly controlled diabetes… severe shoulder pain… right knee is swollen and painful… reports pain to right and Left knee, left shoulder, left upper and lower extremities and lower back rates at 8 on a scale of 1 to 10… Pt’s blood pressure is 197/105 and 198/100 (a normal blood pressure is considered less than 140/80) SN gave… her ordered clonidine (a prescription medication to lower blood pressure) B/P retaken after 3o minutes was 180/90… instructed… on… keep all doctors appointments which include… pain management doctor…” The record included a progress note signed and dated on 03/12/2024 by Nurse Practitioner. The progress note read in part, “… Reason for Appointment… Allergic reaction… presents with an allergic reaction which has been going on for 2 weeks. Her symptoms include dry mouth, swollen gum, itchy throat and ears… frequent falls which has resulted in left shoulder pain… She also complains of numbness in both feet… progressive worsening of the pain… Hypertension: Her BP is labile (significant changes over short periods). She sees cardiologist (heart doctor) and is on multiple antihypertensives (blood pressure medications). She is not consistent with taking her medications… chronic pain: due to multiple joints pain… hyperlipidemia…” The record included a document titled, “Face to Face Certification” signed and dated by Nurse Practitioner on 03/13/2024 that included a diagnosis of hyperlipidemia. The plan of care did not include a diagnosis of an allergic reaction and hyperlipidemia and vital sign, pain and blood sugar parameters to report to the physician/ordering clinician. During an interview with the Adm/DON on 06/26/2025 at 11:45 PM, the surveyor asked who was responsible for ensuring the plan of cares included all the required elements. The Adm/DON stated the ADON checks the plan of cares first and then the Adm/DON does the second check. During an interview with the Adm/DON on 07/02/2025 at 12:45 PM, the surveyor asked why the plan of care did not include a diagnosis of an allergic reaction and hyperlipidemia and vital sign, pain and blood sugar parameters to report to the physician/ordering clinician. The Adm/DON stated she missed including the information on the plan of care and it was an oversight. The Adm/DON stated the parameters should have been included on the plan of care. Patient 3: Record review of the medical record included a plan of care dated 04/11/2024 to 06/09/2024 signed by the physician on 05/22/2024 and the Adm/DON on 04/11/2024 for a 61 year old patient with a start of care date of 04/11/2024. The plan of care included a diagnosis of aftercare following joint replacement surgery, arthritis, diabetes, radiculopathy (pinched nerve in spine) and hypertension. The plan of care included orders for a nurse to visit two times in 60 days and physical therapy to visit two to three times a week for six weeks. The plan of care read in part, “… reports pain to right knee, left knee, right shoulder and lower extremities and lower back rates at 5 on a scale of 1 to 10…” The plan of care did not include vital sign, pain and blood sugar parameters to report to the physician/ordering clinician. During an interview with the Adm/DON on 07/02/2025 at 1:30 PM, the surveyor asked why the plan of care did not include vital sign, pain and blood sugar parameters to report to the physician/ordering clinician. The Adm/DON stated it was an oversight and the parameters should have been included on the plan of care. During an interview with the Adm/DON on 07/02/2025 at 1:45 PM, the surveyor asked how the patients could have been affected by not including all the required information on the plan of cares. The Adm/DON stated the nurses might not report something that needed to be reported. The Adm/DON stated agency policy was not followed because it was an oversight. Agency policy titled, “Plan of Care TX.6” with a revision date of 01/13/2018 read in part, “… Purpose To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client/s specific needs and problems… Procedure I. The appropriate licensed professional staff member, with physician participation, is responsible for developing the plan of care… III. Each patient/client must receive an individualized written plan of care… A. The individualized plan of care must include the following… all pertinent diagnoses… patient/client-specific interventions…””