Every finding on record at Efcc Acquisition Corp

Based on the findings of an onsite unannounced State re-licensure and Medicare recertification survey completed on March 1, 2024, Extended Family Care was found not to be in compliance with the following requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on review of agency policy and procedure and staff (EMP) interview, the agency failed to ensure the Emergency Preparedness communication plan included names and contact information for staff. Findings included: Review of agency Emergency Preparedness Plan on 2/29/24 at approximately 2:00pm revealed: "Emergency Preparedness Plan... Agency Wide Plan for Disaster in Service Area...5. The DPS [Director of Professional Services]/designee will initiate a "call down" using the phone tree to assess availability of all staff..." Review of the Emergency Preparedness documentation in conjunction with policy review determined absence of phone tree. Interview with DPS, Senior Patient Care Advocate, and Referral Specialist on 3/1/24 at approximately 2:00pm revealed inability to produce evidence of phone tree. Exit interview on March 1, 2024, at 2:30pm with the Administrator, and Director of Patient Services, Senior Patient Care Advocate, and Referral Specialist confirmed findings.

Based on the findings of an onsite unannounced State re-licensure and Medicare recertification survey completed on March 1, 2024, 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.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, clinical records (CR), and staff (EMP) interview, the agency failed to ensure the Plan of Care (POC) included updated frequency orders for nine (9) of fourteen (14) CRs reviewed (CR 1-4, 6-9, and 12). Findings included: Review of agency policy on 2/29/24 at approximately 2:00pm revealed: ..."MEDICAL SUPERVISION/MEDICAL ORDERS...PROCEDURE...6. Medical orders must contain the following: ...b. Types amount and duration of services desired; ..." Review of clinical records on 3/1/24 between approximately 9:00am and 1:30pm revealed: CR1, start of care date 6/1/23, dates reviewed 10/29/23-1/1/24. Frequency order on plan of care (POC) for skilled nurse services 5-10 hours/night, 3-7 nights/week for 60 days. Effective date 6/1/23, with an end date of 7/31/23. POC failed to include frequency and duration of services for dates reviewed. CR2, start of care date 4/1/23, dates reviewed 4/1/23-4/30/23. Frequency order on POC for home health aide services 5-10 hours/day, 3-5 days/week for 60 days. Effective date 7/15/21, with an end date of 9/13/21. POC failed to include frequency and duration of services for dates reviewed. CR3, start of care date 12/22/23, dates reviewed 1/21/24-2/29/24. Frequency order on POC for home health aide services 10-40 hours/week, 3-7 days/week flex for 60 days. Effective date 12/22/23, with an end date of 2/20/24. POC failed to include frequency and duration of services for dates reviewed after 2/20/24. CR4, start of care date 11/21/23, dates reviewed 1/20/24-2/29/24. Frequency order on POC for home health aide services 2-5 hours/day Monday-Friday on school days and 4-8 hours/day Monday-Friday on non-school days for 60 days. Effective date 12/15/23, with an end date of 2/13/24. POC failed to include frequency and duration of services for dates reviewed after 2/13/24. CR6, start of care date 5/18/23, dates reviewed 5/18/23-7/22/23. Frequency order on POC for home health aide services in lieu of skilled nurse services: 40-84 hours/week, 3-7 days/week for 60 days. Effective date 5/18/23, with an end date of 7/17/23. POC failed to include frequency and duration of services for dates reviewed. CR7, start of care date 10/2/23, dates reviewed 1/30/24-2-29-24. Frequency order on POC for home health aide services 20-40 hours/day, 3-7 days/week for 60 days. Effective date 10/2/23, with an end date of 12/1/23. POC failed to include frequency and duration of services for dates reviewed. CR8, start of care date 2/11/21, dates reviewed 1/27/24-2/29/24. Frequency order on POC for home health aide services 4-9 hours on school days and 8-11 hours on non-school days for 60 days. Effective date 2/12/21, with an end date of 4/13/21. POC failed to include frequency and duration of services for dates reviewed. CR9, start of care date 1/14/21, dates reviewed 12/30/23-2/27/24. Frequency order on POC for home health aide services 20-40 hours/week, 4-6 days/week for 60 days. Effective date 1/14/21, with an end date of 3/15/21. POC failed to include frequency and duration of services for dates reviewed. CR12, start of care date 12/1/22, dates reviewed 1/20/24-2/28/24. Frequency order on POC for skilled nurse services 60-112 hours/week, 5-7 days/week for 60 days. Effective date 2/1/21, with an end date of 4/2/21. POC failed to include frequency and duration of services for dates reviewed. Exit interview on March 1, 2024, at 2:30pm with the Administrator, and Director of Patient Services, Senior Patient Care Advocate, and Referral Specialist confirmed findings.

Based on the findings of an on site unannounced State relicensure and Medicare recertification survey completed on March 19, 2021, 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 on site unannounced State relicensure and Medicare recertification survey completed on March 19, 2021, 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.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of agency policy, clinical record (CR) reviews, and staff (EMP) interview, the agency failed to ensure staff administered treatments in accordance with the written orders of the physician for two (2) of seven (7) patient clinical records reviewed (CR3, CR7). Findings included: Review of agency policies on 3/19/2021 at approximately 12:15 PM revealed the following: "...Initial Assessment...Policy Number: 308...Procedure...10. The plan of care includes identification of...specific actions planned and the type and frequency of health care service to be provided...13. For patients requiring skilled care, the plan of care will include a problem list...The problem list includes...specific interventions with frequency and duration..." Review of CR3 on 3/17/2021 at approximately 12:40 PM. CR3 start of care 8/30/2019, review of certification period 2/19/2021 to 4/19/2021. Plan of Care (POC) revealed "...Interventions...Vital Signs...SN (skilled nurse) to assess: 1. Patient at the beginning and end of each shift...Assessment to include T-P R (temperature, pulse, respiration)...(b/p-blood pressure-if change in condition)..." Reviewed twenty-six (26) SN visits "Continuous Care Patient Care Flowsheet...Vital Signs..." for CR3 from 2/20/2021 through 3/12/2021. There was no documentation of vital sign assessments at the end of the SN shifts per the POC physician order for the visits reviewed. Review of CR7 on 3/18/2021 at approximately 1:45 PM. CR7 start of care 10/10/2019, review of certification period 2/1/2021 to 4/1/2021. Plan of Care (POC) revealed "...Interventions...Vital Signs...SN (skilled nurse) to provide full assessment q (every) shift...Ventilator checks at the beginning and end of shift and PRN (as needed). Check oxygen levels of all tanks daily and document..." Reviewed twenty-two (22) SN visits" Continuous Care Patient Care Flowsheet...Ventilator...Beginning...End...Narrative Note... " for CR7 from 2/1/2021 to 3/13/2021. There was no documentation of ventilator checks at the end of the SN shifts and no documentation of oxygen tank level checks per the POC physician order for the visits reviewed. Exit conference was conducted on 3/19/2021 at approximately 12:40 PM with Administrator (EMP1) and Director of patient services (EMP2). The above findings were reviewed

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of agency policy, clinical record (CR) reviews, and staff (EMP) interview, the agency failed to ensure patient medication instructions included the medication name with dosage/frequency/route, and indication for as needed medication for three (3) of seven (7) patient clinical records reviewed (CR3, CR4, CR7). Findings included: Review of agency policies on 3/19/2021 at approximately 12:15 PM revealed the following: "...Medication Reconciliation Process...Policy Number: 324...Policy...The RN (Registered Nurse) will monitor each client's medication regimen...and accurately document in the medication profile and the client's clinical record. The type of medication, indication for use, administration route, frequency...and duration of use must be documented and reviewed with each medication reconciliation process..." Review of CR3 on 3/17/2021 at approximately 12:40 PM. CR3 start of care 8/30/2019, review of certification period 2/19/2021 to 4/19/2021. Plan of Care (POC) revealed "...Interventions...SN (Skilled Nursing) Respiratory Interventions:..SN to administer oxygen PRN (as needed) to maintain saturations >93%, if oxygen is required at high levels (3 LPM-Liters Per Minute-or greater), call 911 Start Effective date 12/27/2019..." There was no Oxygen with dosage/route/frequency documented on CR3 POC "Medications" and/or medication profile. Review of CR4 on 3/18/2021 at approximately 10:10 AM. CR4 start of care 12/30/2016, review of certification period 2/19/2021 to 4/19/2021. Plan of Care (POC) revealed "...Interventions...SN (Skilled Nursing) Respiratory Interventions:..SN to maintain pulse OX (oximetry) sic) 90% at all times. Apply 2 liters O2 (oxygen) for SATS (saturations) remaining below 90% and notify [parent] Start Effective date: 12/23/2019..." There was no Oxygen with dosage/route/frequency documented on CR4 POC "Medications" and/or medication profile. Review of CR7 on 3/18/2021 at approximately 1:45 PM. CR7 start of care 10/10/2019, review of certification period 2/1/2021 to 4/1/2021. Plan of Care (POC) revealed "...Interventions...SN (Skilled Nursing) Respiratory Interventions:..May administer oxygen 1 - 4 LPM (Liters Per Minute) to keep oxygen saturations equal to or >89%. Start Effective date 2/5/2020..." There was no Oxygen with dosage/route/frequency documented on CR7 POC "Medications" and/or medication profile. Exit conference was conducted on 3/19/2021 at approximately 12:40 PM with Administrator (EMP1) and Director of patient services (EMP2). The above findings were reviewed.