Every finding on record at Efcc Acquisition Corp

Based on the findings of an unannounced onsite Medicare recertification and state re-licensure survey conducted on April 14 -17, 2024, Extended Family Care agency 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 and state re-licensure survey conducted on April 14 - 17, 2024, Extended Family Care agency 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.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on review of clinical records, agency policies and procedures, and interview with agency administrator, the agency failed to provide the prescribed frequency and duration of skilled nurse home health services documented in the individualized plan of care as prescribed by the physician in one (1) of seven (7) clinical records (CR) reviewed (CR#3).; and failed to notify physician of missed skilled nursing service hours in one (1) of seven (7) clinical records (CR) reviewed (CR#3). Review conducted on April 16, 2024, at approximately 2 PM, of clinical records revealed: CR#3, start of care (soc) 11/6/2013, certification period 3/13/24 to 5/11/24: * Denotes missing SN service hours. -Plan of Care document - physician order for frequency and duration of skilled nursing (SN) care services documented as “SN up to 16 hours per day x 7 days per week. Hours of service not provided may be used for coverage for any shift needs on days, evenings, and/or nights beyond the 16 hour/day, … effective 2/7/2024.” -April 1, 2024, Plan of Care document, updated physician order for frequency and duration of skilled nursing (SN) care services: “SN 18 hours/day, Monday-Friday, x 60 days; 16 hours/day Saturday and Sunday, x 60 days, Start Effective 4/1/24.” Frequency and duration of SN provided hours revealed: * denotes missed SN service hours. -March 13 – 21, 2024, 16 hours of SN services provided each day. -*March 22, 2024, 14 hours of SN services provided. -*March 23, 2024, 2 hours of SN services provided. -*March 24,2024, 11.5 hours of SN services provided. -March 25 – 26, 2024, 16 hours of SN services provided each day. -*March 27, 2024, 9 hours of SN services provided. -March 28 – 29, 2024, 16 hours of SN services provided each day. -*March 30, 2024, 10 hours of SN services provided. Physician notified of missing SN shift coverage, no available SN staff. -*March 31, 2024, 10.5 hours of SN services provided. **New physician orders for frequency and duration effective April 1,2024. -*April 1, 2024, 14 hours of SN services provided. -*April 2 - 4, 2024, 16 hours of SN services provided each day. -April 5, 2024, 18 hours of SN services provided. -*April 6, 2024, 10 hours of SN services provided. Physician notified of missing SN shift coverage, no available SN staff. -*April 7, 2024, 10.5 hours of SN services provided. -*April 8, 2024, 14 of SN services provided. -*April 9 -11, 2024, 16 hours of SN services provided each day. -April 12, 2024, 18 hours of SN services provided. -*April 13, 2024, 10 hours of SN services provided, open SN shift from 8 AM to 4 PM. -*April 14, 2024, 10.5 hours of SN services provided. -*April 15-16, 2024, 14 hours of SN services provided. Review conducted on April 17, 2024, at approximately 1:00 PM, of agency policies revealed: -Policy 310, Staffing Cases, page 2 of 2, Item 7: “In the event that a shift is unable to be staffed or staffed outside of the frequency/duration that was approved by the payor source, the Patient Care Advocate will be responsible to entering a missed shift report and/or communication note documenting the reason for the variance in hours.” -Policy 309, Continuity of Care, page 3 of 3, Item 7: “If agency staff misses visits or services as required by the plan of care, the agency must notify the responsible physician of the missed visit if that is any potential for clinical impact upon the patient. The physician will determine whether the patient visit may be skipped or additional interventions are required by the agency.” -Policy 328, Medical Supervision/Medical Orders: Page 2 of 11, Item 4. “Medical orders are established and documented for the health care services the Organization provides to those patients who: a. Are being actively treated by a medical practitioner for a diagnosed health care problem that is directly related to the home care services being provided.”; page 3 of 11, “item 6. Medical orders must contain the following: b. Types, amounts, and duration of services; c. Frequency of services.”; … page 7 of 11, “2. Organizational Responsibilities a. Communicate information regarding the home care plan, including outcomes, to physician in a reasonable time frame. … c. Carry out physician orders as stated in the plan of treatment, notify the physician of the need for review and/or revision.”; and … page 8 of 11, “e. A missed visit that was scheduled or treatment that could not be given (done by MD request) may not need to notify physician, but notify the office.” Interview conducted on April 17, 2024, at approximately 3:15 PM, with agency administrator revealed: Missing SN service hours on Sundays (3/24/24, 3/31/24, 4/7/24, and 4/14/24) reflected CR#3’s family decision to provide skilled care while at church services; this verbal communication request from the family was never documented in CR#3’s clinical record; notification of physician for missing SN service hours were not always performed; and confirmation of missing SN provided service hours.

Based upon the findings of an unannounced onsite Medicare recertification survey completed April 29, 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 unannounced onsite Medicare recertification survey completed April 29, 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.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on a review of agency policy and an interview with the agency Administrator, the agency failed to maintain a coordinated agency-wide program for the surveillance of communicable disease by failing to ensure all staff are screened and triaged for COVID-19 for one (1) of one (1) interviews (Interview #1). Findings Include: CMS-QSO-20-18-HHA (03/10/2020) 'Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home Health Agencies (HHAs)' 'Guidance' states " ...... . Also, HHAs should be monitoring the health status of everyone (patients/residents/visitors/staff/etc.) in the homecare setting for signs or symptoms of COVID-19". "How should HHAs monitor or restrict home visits for health care staff? Health care providers (HCP) who have signs and symptoms of a respiratory infection should not report to work". Survey Form 'COVID-19 Focused Infection Control Survey: Acute and Continuing Care' section 'Education, Monitoring, and Screening of Staff' asks "Is the facility screening all staff at the beginning of their shift for fever and signs/symptoms of illness? Is the facility actively taking their temperature and documenting absence of illness (or signs/symptoms of COVID-19 as more information becomes available). Agency policy reviewed April 29, 2021 at approximately 11:00 a.m. Policy #610 'Exposure to Coronavirus (2019-nCoV): Disease Response and Management' 'Procedure' (1) states "..... and employees are to self screen prior to shift." (Note: This policy does not address the documentation of COVID-19 screening). Interview #1: On April 27, 2021 at approximately 12:45 p.m. an interview was conducted with the agency Administrator. The Administrator was asked if agency employees in the field, who report directly to the patients home to start their daily work shift, are self screening for COVID-19 symptoms and documenting the results. The Administrator stated "The field staff self screen prior to their shifts but there is no documentation of the self screening process." An interview conducted with agency Administrator on April 29, 2021 at approximately 1:15 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 home health aides have completed a minimum of 75 hours of classroom and supervised practical training for three (3) out of three (3) home health aide employee files (EF) reviewed (EF#8-EF#10) and one (1) of one (1) interviews conducted (Interview #1). Findings Include: Agency policy requested April 29, 2021 at approximately 11:00 a.m. Agency policy requested April 29, 2021 at approximately 11:00 a.m. Policy #314 'Description of Services' 'Home health Aide/Personal Care Aide' section (3) states "...... HHAs shall have successfully completed a basic training program in HHA services or an equivalent exam. They shall also possess written evidence of completion." Section (4) 'Definition of a Personal Care Aide (PCA) states 'In all other states, a PCA shall: (a) "Have previous experience in a home health environment and/or (b) Completed an approved training program in Personal Care Aide services." (Note: Policy provided does not address the requirement of home health aides completing a minimum of 75 hours of classroom and supervised practical training). A review of EFs and agency policy was conducted on April 27, 2021 at approximately 10:00 a.m. The employees date of hire (DOH) is listed below: EF#8 DOH 01/09/20: Home health aide training documentation was requested on 04/27/21 at approximately 11:30 a.m. The agency provided a 'Annual Paraprofessional Performance Evaluation' dated 01/14/20 which included a competency 'Required Skill' checklists with nineteen (19) topics. "The "Competency ' section was marked "S" (Satisfactory), the 'Method' section was marked "I" (Interview), and the date was marked 01/14/20. No documentation provided of the employee completing the required 75 hours of classroom and supervised practical training. EF#9 DOH 12/17/19: Home health aide training documentation was requested on 04/27/21 at approximately 11:30 a.m. The agency provided a 'Annual Paraprofessional Performance Evaluation' dated 01/14/20 which included a competency 'Required Skill' checklists with nineteen (19) topics. "The "Competency ' section was marked "S" (Satisfactory), the 'Method' section was marked "I" (Interview), and the date was marked 01/14/20. No documentation provided of the employee completing the required 75 hours of classroom and supervised practical training. EF#10 DOH 10/30/19: Home health aide training documentation was requested on 04/27/21 at approximately 11:30 a.m. The agency provided a 'Annual Paraprofessional Performance Evaluation' dated 10/30/19 which included a competency 'Required Skill' checklists with nineteen (19) topics. "The "Competency ' section was blank with no entries, the 'Method' section was blank with no entries, and the date was marked 10/30/19. No documentation provided of the employee completing the required 75 hours of classroom and supervised practical training. Interview #1: An interview was conducted with the agency Administrator on 04/28/21 at approximately 10:00 a.m. The Administrator was asked about the agency's procedure for training home health aides. The Administrator stated "We hire people with experience (+ one year) and do competency testing evaluations. An interview conducted with agency Administrator on April 29, 2021 at approximately 1:15 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 review of agency policy, clinical records, and an interview with the agency Administrator, the agency failed to discharge/notify the physician of the agency discharging a patient from home health services for one (1) of five (5) active clinical records (CR) reviewed (CR#5) and the agency failed to send a completed transfer summary to the nursing home/facility within 2 business days for two (2) of two (2) inactive clinical records (CR) reviewed (CR#6, CR#7). Findings include: Agency policy requested on April 29, 2021 at approximately 11:00 a.m. Policy #316 'Interruption of Services' 'Procedure' (2) states "The patient will be considered a new admission if they have been off service for more than sixty (60) days for any reason. A new admission process/abbreviated intake, assessment, and physicians orders will be required. Policy #338 'Transfer and Discharge Policy' 'Procedure' (3) states "When the patients needs and services require a level of care that the agency is not equipped to provide the agency will do the following: (c) Once the patient/representative picks an alternative entity, the agency must contact the entity to facilitate a safe transfer through communication with the entity and providing all transfer information. (d) Will ensure timely transfer of patient information to facilitate continuity of care either prior to patient entry or simultaneously when the new patient services begin." A review of CRs was conducted on April 29, 2021 at approximately 9:00 a.m. The patients start of care (SOC) is listed below: CR#5 (SOC 02/06/20): Physicians Plan of Care (POC) recertification dated 12/02/20-01/30/21 revealed ""HHA (Home Health Aide) "5 hours day Monday-Friday school days, 9 hours a day Monday-Friday non school days." Patients last date of service was 12/04/20 (144 days total to current date of 04/27/21). Per the Administrator, the patient is/ has been in (foreign country). The patient is on "Hold". The patient was never discharged from the agency, per policy ( > sixty days off service). There was no documentation to show that a completed discharge summary was completed/sent to the primary care practitioner or other health care professional. CR#6 (SOC 08/09/16): Physicians Plan of Care (POC) dated 11/16/20-01/14/20 revealed "HHA (Home Health Aide) "2 hours day x3 days week." Patients last date of service was 12/07/20. Per the Administrator, the patient was admitted to the hospital on 12/07/20-12/28/20, followed by an admit to a rehabilitation center on 12/28/20 which then resulted in permanent placement into a nursing home. No documentation provided showing the agency sent a completed transfer summary to the nursing home within 2 business days of becoming aware of the transfer. CR#7 (SOC 09/08/20): Physicians Plan of Care (POC) dated 01/06/21-03/06/21 revealed "HHA (Home Health Aide) "2 hours day Monday-Thursday and as requested by the patient or family." Patients last date of service was 02/26/21. Per the Administrator, the patient was admitted to a nursing home on 03/11/21. No documentation provided showing the agency sent a completed transfer summary to the nursing home within 2 business days of becoming aware of the transfer. An interview conducted with agency Administrator on April 29, 2021 at approximately 1:15 p.m. confirmed the above findings.