Jenmerit Home Health Inc.

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on record review and interview the agency failed to maintain an emergency preparedness plan that was reviewed and updated at least every 2 years for 3 (2023, 2024, and 2025) of three years of the survey review period. The plan failed to be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach (an integrated approach to emergency preparedness planning that focuses on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters, including pandemics and Emerging Infectious Diseases - any newly recognized, mutating, or previously controlled pathogen – such as SARS-COV-2-Coronavirus Disease 19 (the pathogen responsible for the global pandemic of 2019, 2020, and 2021), influenza (respiratory and common infection that is a leading cause of hospitalization in seniors yearly), Ebola (mutated severe viral infection currently spreading in African countries), or Zika (mosquito borne illness that can cause severe brain defects to a fetus). The agency’s risk assessment failed to include specifics to the location of the agency considering the types of hazards most likely to occur in the area (flu), and also failed to include unforeseen widespread communicable diseases (Zika, Ebola, Coronavirus Disease). This failure meant the agency’s emergency preparedness and response plan was not based on an all-hazards risk assessment and patients and staff were potentially at risk for injury during an emergency. Review of the agency’s emergency preparedness program and documents on 06/18/2026 revealed a document titled: “Analysis of Risk Assessment for Potential Disasters dated 04/15/2023” and signed by the Administrator / Disaster Coordinator that documented “None” under section C. Epidemic. The surveyor viewed the entire Emergency preparedness documents provided and found the agency had not documented any assessed risks for contagious diseases in the agency risk assessments and no other more recently dated risk analysis was provided. An interview was conducted with the Administrator / Disaster Coordinator on 06/18/2026 at 11:30 AM. The surveyor asked how the agency conducted its risk analysis. The Administrator stated: “I don’t really have a method. I am just the only one, and my wife used to do it, and now it’s just me.” The surveyor asked why the recent pandemic from COVID-19, Flu, Ebola, or Zika were not identified as potential risks for the agency staff and patients. The Administrator didn’t respond, he just shrugged and looked down. No additional information was provided to explain or correct the findings. Review of agency policy titled: “Emergency Preparedness and Response Plan EC.6 dated 100112” read in part: “…Agency develops, maintains, and implements a written Emergency Preparedness and Response Plan (Plan), based on the Agency’s risk assessment…The written plan will be based on a risk assessment that identifies the disasters from natural and man-made causes that are likely to occur in the Agency’s service area…””

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview the agency failed to ensure the QAPI Program scope could show measurable improvement in indicators for which there was evidence that improvement in those indicators would improve outcomes, patient safety, and quality of care. The HHA failed to measure, analyze, and track quality indicators, and other aspects of performance that would enable the HHA to assess processes of care, HHA services, and operations for 3 (2023, 2024, and 2025) of 3 years of the survey review period. This failure meant agency patients were subjected to potentially poor-quality services as the agency had not reviewed the quality of the agency’s services. The surveyor requested the QAPI program documents for 2023,2024, and 2025 during the entrance conference on 06/16/2026. Review of the documents provided on 06/18/2026 revealed no evidence of any QAPI activities for the PAS clients. There were no indicators that were measured, no analysis of a sample of PAS client active and discharged records, no determination that PAS services had been provided per the service plan, no documentation of any incidents of misconduct by unlicensed staff or lack thereof ; no review of the effectiveness/safety of services provided, and no annual evaluation of the agency’s total operation for 2023, 2024, and 2025. An interview was conducted with the Administrator on 06/18/2026 at 3PM. The surveyor asked who was responsible for the QAPI program in the agency. The Administrator stated: “The DON and myself.” The surveyor asked what the agency did for QAPI. The Administrator responded: “We sit down and talk and if there’s something we need to do, we do it.” The Administrator stated since they didn’t have any Medicare patients there wasn’t anything to review. The surveyor asked why there was no evidence and documentation of a review of the PAS services the agency was providing. The Administrator stated: “Nobody ever told me to include PAS, so we only do skilled, and we have no skilled (patients).” The surveyor asked what the agency policy and procedure was for QAPI. The Administrator stated: “I haven’t read it.” The surveyor asked what the outcome to the agency clients was with the lack of review of the quality of services. The Administrator stated: “I didn’t know I had to do it.” The Administrator stated the agency was not reviewing and completing an analysis of the active and discharged PAS clients, and they had not done an agency annual evaluation for the past three years. The surveyor asked if the DON was available to interview and the Administrator stated they were at their other job and were not available. Agency policy and procedure titled “PAS Policy Manual - Quality Assessment/Performance Improvement Plan QAPI.1” dated “060106” read in part: “Purpose- To develop a Quality Assessment Performance Improvement Plan (QAPI)/ Performance Improvement Plan, implemented by the QAPI/PI committee, that captures significant outcomes that are essential to optimal services and are used in the care planning and coordination of services and events. Policy – Agency will develop a plan that is reviewed and updated or revised at least once within the calendar year, or more often if needed, by the QAPI/PI Committee. … Areas for improvement will be identified through the collection of data for analysis of Agency services. System that measure significant outcomes for optimal care include: A representative sample of services furnished to clients contained in both active and discharged charts, Issues of unprofessional conduct by licensed staff and misconduct by unlicensed staff, Infection control activities, Services have been performed as outlined in the services plan, … Effectiveness and safety of all services provided…Agency leaders will be responsible for setting expectations, developing plans and managing processes to improve the Agency’s performance…” Agency policy and procedures titled “PAS Policy Manual -Agency Evaluation Process QAPI.4” dated “020102” read in part: “Policy Agency leaders (including the Board of Directors, Managers, QAPI Committee) will participate in an annual evaluation of the organization’s performance in relation to its organizational plan for improvement, mission, vision and philosophy. Findings will be utilized to correct identified problems. … The overall program will be reviewed at least annually… A written summarization with recommendations for improvement or change will be presented to the Board of Directors annually and retained at the Agency’s administrative offices…””