Every finding on record at Efcc Acquisition Corp

Based on the findings of an unannounced on-site federal recertification survey completed on June 11, 2025, Extended Family Care was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced on-site federal recertification survey completed on June 11, 2025, Extended Family Care was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 a review of agency policy, review of clinical records, and an interview with the agency Branch Manager, the agency failed to complete the initial assessment visit within 48 hours of referral, or within 48 hours of the patients return home, or on the physician-ordered start of care (SOC) date, for two (2) of seven (7) clinical records (CR) reviewed (CR#1, CR#7). Agency policy/procedure reviewed on June 11, 2025 at approximately 11:30 a.m. Policy 'Initial Assessment' 'Procedure' (6) "The Plan of Care is developed within 48 hours of referral in ..., Pennsylvania, ..." A review of patient CRs was completed on June 11, 2025 at approximately 1:00 p.m. The patients start of care (SOC) is listed below. CR#1 SOC 05/08/23: Referral from (family) on 05/03/23. No physician ordered start of care date specified. 'Disposition of Intake' "Accepted." Documentation of initial assessment visit by a registered nurse on 05/08/23. (5 days). CR#7 SOC 10/04/23: Referral from (family) on 09/26/23. No physician ordered start of care date specified. 'Disposition of Intake' "Refused." 'If refused, reason:' "No authorization." Documentation of initial assessment visit by a registered nurse on 10/04/23. (8 days). Per the agency Compliance Officer on 06/11/25 at approximately 11:00 a.m., the agency will refuse a referral, wait for payment authorization, and then call the referral source to initiate services. An interview conducted with agency Branch Manager on June 11, 2025 at approximately 1:45 p.m. confirmed the above findings.

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 a review of agency policy, a review of clinical records, and an interview with the agency Branch Manager, agency failed to ensure the patient plan of care included the duration of visits to be made for two (2) of seven (7) clinical records (CR) reviewed (CR#5, CR#6). Agency policy/procedure reviewed on June 11, 2025 at approximately 11:30 a.m. Policy 'Medical Supervision/Medical Orders' 'Procedure' (6) '"Medical Orders must contain the following: (b) Types, amounts, and duration of services desired ..." A review of patient CR was completed on June 11, 2025 at approximately 1:00 p.m. The patients start of care (SOC) is listed below. CR#5 SOC 06/17/22: Recertification period 06/01/25 - 07/30/25 reviewed. 'Home Health Certification and Plan of Care' 'Frequencies' "HHA services 3-9 hours per day x 3-7 days per week total of 40 hours per week ..., RN supervisory visit every 60 days and up to 6 PRN visits for problem solving ..." No duration listed. CR#6 SOC 09/30/20: Recertification period 05/07/25 - 07/05/25 reviewed. 'Home Health Certification and Plan of Care' 'Frequencies' "HHA services 3-9 hours per day x 5-7 days per week up to 44 hours per week ..., RN supervisory visit every 60 days and up to 6 PRN visits for problem solving ..." No duration listed. An interview conducted with agency Branch Manager on June 11, 2025 at approximately 1:45 p.m. confirmed the above findings.

24 consecutive months paid service CFR(s): 484.80(a)(2) A home health aide or nurse aide is not considered to have completed a program, as specified in paragraph (a)(1) of this section, if, since the individual's most recent completion of the program(s), there has been a continuous period of 24 consecutive months during which none of the services furnished by the individual as described in §409.40 of this chapter were for compensation. If there has been a 24-month lapse in furnishing services for compensation, the individual must complete another program, as specified in paragraph (a)(1) of this section, before providing services. This ELEMENT is not met as evidenced by: Based on a review of agency policy, a review of employee files, and an interview with the agency Branch Manager, the agency failed to ensure the employee completed a training program after a 24-month lapse in furnishing home health aide services for compensation, for one (1) out of seven (7) employee files (EF) reviewed (EF#5). Agency policy/procedure reviewed on June 11, 2025 at approximately 11:30 a.m. Policy 'Personnel Records' "Procedure' (1) " ...... Personnel and health records are reviewed for completeness at the time of hire and prior to the employee being placed on a case. ..." (2) "..... Licenses and registrations must be current, ...." A review of EFs was conducted on June 9, 2025 at approximately 11:00 a.m. The employees date of hire (DOH) is listed below. EF#5 DOH 12/10/24: Documentation provided of a Pennsylvania Nurse Aide Registry with an original issue date of 11/24/2010, expiration date of 11/23/2012. Employment history record reviewed. No home health aide employment listed during the (24) consectutive months prior to hire. No documentation provided of the employee completing a training program after a 24-month lapse in furnishing home health aide services for compensation. An interview conducted with agency Branch Manager on June 11, 2025 at approximately 1:45 p.m. confirmed the above findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on a request of agency policy, a review of clinical records, and an interview with the agency Branch Manager, agency failed to send a discharge summary to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the home health agency (HHA) (if any) within five (5) business days for two (2) of two (2) discharged clinical records (CR) reviewed (CR#7, CR#8). Agency policy/procedure requested on June 11, 2025 at approximately 11:30 a.m. No policy provided related to sending the physician and/or receiving facility a discharge summary within the required time frames. A review of patient CRs was completed on June 11, 2025 at approximately 1:00 p.m. The patients start of care (SOC) is listed below. CR#7 SOC 10/04/23: Recertification period 03/27/25 - 05/25/25 reviewed. Patient discharged from agency on 05/14/25. A discharge summary was not sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge. CR#8 SOC 10/09/20: Recertification period 11/17/24 - 01/15/25 reviewed. Patient discharged from agency on 01/12/25. A discharge summary was not sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge. An interview conducted with agency Branch Manager on June 11, 2025 at approximately 1:45 p.m. confirmed the above findings.

Based on the findings of an unannounced onsite Medicare recertification survey completed July 1, 2022, Extended Family Care was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced onsite Medicare recertification survey completed July 1, 2022, Extended Family Care was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on a review of agency policy, review of clinical records, and an interview with the agency Administrator, the agency failed to complete the initial assessment visit within 48 hours of referral, or within 48 hours of the patients return home, or on the physician-ordered start of care date, for six (6) of nine (9) clinical record referrals reviewed (CR#3-CR#7, CR#9). Findings: A review of agency Policy/Procedure was conducted on July 1, 2022 at approximately 10:00 a.m. Policy '306', 'Referral for Services' 'Procedure' section (4) states "Agency nursing staff will be assigned to conduct the in-home patient assessment within 48 hours of agency acceptance of the referral, within 48 hours of the patient returning home, or on the physician ordered start of care date." (Note: This policy is not compliant with regulation.) A review of clinical records conducted on June 29, 2022 at approximately 11:30 a.m. revealed the following: CR#3 SOC 04/14/22: Referral from (insurance company) for skilled nursing services. 'Intake Date' date left blank with no date specified when referral was taken by the agency. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 04/14/22. CR#4 SOC 11/22/20: Referral from (family member) for home health aide services on 10/22/20. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 11/22/20. CR#5 SOC 09/28/20: Referral from (family member) for home health aide services. 'Intake Date' date left blank with no date specified when referral was taken by the agency. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 09/28/20. CR#6 SOC 01/13/22: Referral from (insurance company) for home health aide services. 'Intake Date' date left blank with no date specified when referral was taken by the agency. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 01/13/22. CR#7 SOC 01/12/22: Referral from (insurance company) for home health aide services on 12/29/21. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 01/12/22. CR#9 SOC 04/28/22: Referral from (insurance company) for skilled nursing services and home health aide services. 'Intake Date' date left blank with no date specified when referral was taken by the agency. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 04/28/22. An interview conducted with the agency Administrator on June 29, 2022 at approximately 2:00 p.m. confirmed the above findings.

Classroom and supervised practical training CFR(s): 484.80(b)(1) Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Classroom and supervised practical training must total at least 75 hours. This ELEMENT is not met as evidenced by: Based on a review of agency policy, review of employee files, and an interview with the agency Administrator, agency failed to ensure the home health aide completed a minimum of seventy-five (75) hours of classroom instruction prior to or during the first 3 months of employment for three (3) out of three (3) home health aide employee files (EF) reviewed (EF#5-CR#7). Findings: A review of agency Policy/Procedure was conducted on July 1, 2022 at approximately 10:00 a.m. Policy #213- Personnel Records 'Procedure' section (1) states "..... Each personnel record will contain: (c) ...... In Pennsylvania, must include a minimum of 1 year experience of personal care assistance or satisfactory completion of a home health aide training course." (d) Verified copies of professional licenses, registrations or training certificates for instructors and patient care staff; ......." (Note: This policy is not compliant with regulation.) A review of EFs was conducted on June 28, 2022 at approximately 10:00 a.m. The employees date of hire (DOH) is listed below. EF#5 DOH 11/11/21: Home health aide training documentation was requested on 06/28/22 at approximately 1:00 p.m. No supporting documentation provided of the training content to demonstrate the required classroom and practical training, for a total of seventy-five (75) hours, was conducted per regulatory requirements. EF#6 DOH 01/19/22: Home health aide training documentation was requested on 06/28/22 at approximately 1:00 p.m. No supporting documentation provided of the training content to demonstrate the required classroom and practical training, for a total of seventy-five (75) hours, was conducted per regulatory requirements. EF#67DOH 04/19/21: Home health aide training documentation was requested on 06/28/22 at approximately 1:00 p.m. No supporting documentation provided of the training content to demonstrate the required classroom and practical training, for a total of seventy-five (75) hours, was conducted per regulatory requirements. An interview with the agency Administrator conducted on June 29, 2022 at approximately 2:00 p.m. confirmed the above findings.