Every finding on record at Sfp Acquisition LLC

During the recertification survey conducted on 04/21/2025 to 04/23/2025 at Care Options for Kids, a Home Health Agency, Emergency Preparedness was reviewed. Care Options for Kids is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies.

A recertification survey was conducted on 04/21/2025 to 04/23/2025 at Care Options for Kids. The home health agency was in non-compliance with 42 CFR (Code of Federal Regulations) 484 Subpart A-C, Requirements for Home Health Agencies.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to provide the services as ordered on the Plan of Care by a physician for 2 out of 3 Sampled Patients (SP). SP #3 and SP#4. Findings include: Closed record review conducted on Sample Patient (SP) #2, SP#3 and SP#4 SP #2 orders include nursing services 24 hours/day x7 days per week. Calendar review of visits completed and scheduled show that all of the shifts have been covered or will be covered according to physician orders. SP#3 orders include nursing services 8 hours/day 5 days a week, during school time. Calendar review of visits completed, and schedule showed that 04/11/2025 that the nurse was ill and could not go to child's school, therefore the parent's kept the child home so they could monitor her care. SP#4 orders include nursing services 24 hours/day x7 days. Calendar review of visits completed, and schedule show the following shifts were not covered. 04/10/2025 19:00-0:00, 04/11/2025 19:00-07:00, 04/12/2025 19:00-07:00 and 04/19/2025 19:00-07:00am Survey conducted interview with Director of Nursing, VP, Compliance officers, regional director, Operation Business Director, office staff and Area Director Clinical Services 04/23/2025 11:15am, they all agreed the orders stated 24/7 nursing and they were unable to staff the shifts previously mentioned.

During the recertification survey conducted on 02/07/2022 to 02/10/2022 at South Florida Pediatric Homecare Inc. a Home Health Agency, Emergency Preparedness was reviewed. South Florida Pediatric Homecare Inc. is not in compliance with Emergency Preparedness per Code of Federal (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies. The following is a description of the non-compliance:

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to demonstrate that it has conducted emergency preparedness training at least every 2 years, and has failed to demonstrate it has maintain documentation of all emergency preparedness, including initial and training and staff knowledge of emergency procedures. Findings include: Review of the Comprehensive Emergency Preparedness Plan documentation presented by the Administrator 02/10/22 omitted documentation to demonstrate all active staff have received emergency preparedness initial training and at least every 2 years. Interview conducted with the Administrator on 02/10/22 between 1:25 PM to 1:41 PM acknowledged that provider is not able to demonstrate initial training and ongoing training of the emergency plan to all staff at this time.

A recertification survey was conducted on 02/07/2022 to 02/10/2022 at South Florida Pediatric Homecare Inc. The home health agency was in non-compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to electronically transmit each OASIS (Outcome and Assessment Information Set) data within 30 days of completing the assessment of the beneficiary for 1 out of 10 Sampled Patients (SP). SP#6 Findings include: Clinical record review of SP#6 conducted on 02/09/22 showed a Comprehensive Recertification Assessment completed on 11/07/21. Interview conducted with the Alternate Director of Nursing on 02/10/22 at 12:10 M confirmed that SP#6’s recertification OASIS was not transmitted.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the provider failed to demonstrate the patient received all services outlined in the plan of care for 3 out of 3 active Sampled Patients (SP). SP#1, SP#2 and SP#3 Findings include: Clinical record review of SP#1 revealed a plan of care for certification period of 01/11/22 to 03/11/22 for skilled nursing services 12 -16 hours daily (Monday-Sunday for 12 hours/day; Saturday and Sunday 16 hours/day including all non-school days and Holidays) for 60 days. According to the plan of care the SN (skilled nurse) is to perform complete head to toe and pain assessment every shift and as needed for changes in patient condition. Further review of the clinical record showed no nursing care provided habitually every Sunday, Tuesday, Wednesday, and Thursday. On 02/10/22 at 11:44 AM, interview conducted with Alternate Director of Nursing and Scheduler who stated that SP#1 had 2 nurses on the case but one of the regular nurses had family issue around December and started to call out because she was out of state, then about January 5 or 6 she officially notified agency that she was in [name of country] and didn’t know when she would return. The Scheduler then stated that a new staff was sent to cover the shift, but the SP#1’s caregiver got upset because they live in another family member’s home, and the caregiver didn’t want new staff coming into the home due to COVID-19. The Scheduler confirmed that only the other regular nurse is covering 3-4 days a week only. Telephone interview conducted with SP#1’s caregiver on 02/15/22 at 3:01 pm confirmed that agency does not provide coverage for Sunday, Tuesday, Wednesday and Thursday due to “agency can’t find a nurse”. Clinical record review of SP#2 revealed a plan of care for certification period of 01/01/22 to 03/01/22 for skilled nursing services 24 hours daily for 60 days. According to the plan of care the Skilled Nurse to perform a physical assessment daily and assess vital signs every shift and as needed paying close attention to neurological, respiratory, gastrointestinal, and integumentary systems. Review of the clinical record showed no nursing care provided on 01/02/22, 01/04/22, 01/05/22, 01/07/22, 01/09/22, 01/10/22, 01/15/22, 01/16/22, 01/18/22, 01/19/22, 01/21/22, 01/28/22 and 02/04/22. Further review of service notes revealed that SP#2 habitually receives between 8 hours and 14 hours /day and not the 24 hours /day as ordered on the plan of care. Telephone interview conducted with SP#2’s caregiver on 02/21/22 at 5:51 pm, the caregiver stated the agency has not sent anymore nurses to cover the case since COVID-19 started. The caregiver confirmed that only 2 nurses cover on set schedule (less than 24 hours), but the agency has not offered to send any new nurses to cover more hours. Clinical record review of SP#3 revealed a plan of care for certification period of 01/16/22 to 03/16/22 for skilled nursing services 16 - 24 hours daily (Monday-Sunday for 16 hours/day; Saturday and Sunday 24 hours/day including all non-school days and Holidays) for 60 days. According to the plan of care the SN (skilled nurse) is to perform complete head to toe and pain assessment every shift and as needed for changes in patient condition. Further review of the clinical record showed no nursing care provided on 12/05/21, 12/07/21, 12/12/21, 12/14/21, 12/18/21 to 12/28/21, 01/02/22 to 01/23/22, and 01/25/22 to 02/03/22. A physician order dated 11/28/21 stated that (2) regular nurses have re-located out of service area and “search for staff to cover shift is ongoing”. On 12/18/21 a physician order reads for “services on hold” due to SP#3 on vacation from 12/18/21 to 12/28/21, resuming service as of 12/29/21. Interview conducted with the Alternate Director of Nursing on 02/10/22 at 1:01 PM confirmed that SP#3’s missed visits are due to no staff coverage at this time.

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on record review and interview, the provider is unable to demonstrate documentation of communication with the ordering physician, the patient and representative (if any) before being discharged from the Home Health Agency for 1 out of 10 Sampled Patients (SP). SP#4 Findings include: Closed record review conducted of SP#4 on 02/08/22 revealed patient was admitted to service on 06/18/15 and the Plan of Care for certification period 09/14/21 to 11/12/21 reads for skilled nursing services 12 hours daily (Monday-Sunday and 24 hours/day on sick days) for 60 days. According to the plan of care the Skilled Nurse to assess/evaluate all body systems with emphasis on cardio-respiratory, digestive, and neurological systems as well as nutritional status with strict intake and output charting. Further review of the clinical record for date range of 08/22/21 to 09/20/21 showed no nursing care provided habitually every Sunday, Thursday, Friday, and Saturday. A physician order dated 09/20/21 reads “Due to staff shortage, services on hold until a new staff can cover the case”. On 10/21/21 a physician order reads “Effective 10/21/21 [name] will be discharge from our services due to more than 30 days without services”. Further review of the clinical record omitted documentation on educating the patient and/or representative on the risks and potential adverse outcomes that can result from habitually declining skilled care visits. The provider is unable to demonstrate communication with the physician who is responsible for the patient's home health plan of care, as well as the measures the provider took to investigate the patient's refusal and the interventions the home health agency attempted to obtain patient’s participation with the plan of care. Interview conducted with Alternate Director of Nursing on 02/08/22 from 2:27 pm to 2:34 pm. The Alternate Director of Nursing stated that the patient lived with a different relative and visited with a parent at a different addressed. The patient was non-compliant with skilled nursing visits. The assigned nurse quit the case because SP#4 was not compliant with skilled nursing visits. The agency couldn’t find staff to cover the hours for SP#4. As per Alternate Director of Nursing the provider notified the family of the discharge ahead. The Alternate Director of Nursing states that if clinical record does not contain written documentation of the communications that occur between the family, the patient, and the physician, then it was not documented but the patient and family were involved and aware of the discharge due to no staff availability.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to complete a discharge comprehensive assessment, including the administration of the OASIS (Outcome and Assessment Information Set) items for 1 out of 10 Sampled Patients (SP). SP#4 Findings include: Clinical record review of SP#4 conducted on 02/08/22 contained documentation titled “Summary (Non-OASIS)” and dated 10/21/21. Interview conducted with the Alternate Director of Nursing on 02/08/22 between 2:27 P to 2:34 PM acknowledged that SP#4’s record contains a NON OASIS summary completed for the discharge and agreed the discharge OASIS comprehensive assessment was not completed as required.

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 provider failed to include in the individualized plan of care 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 on 2 out of 3 active Sampled Patients (SP). (SP#1 and SP#3) Findings include: Clinical record review conducted on 02/09/22 of SP#1 and SP#3 contained a Plan of Care that omitted the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. Interview conducted with the Alternate Director of Nursing and Administrator on 02/10/22 between 1:25 PM and 1:41 PM acknowledged findings made by the surveyor.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to demonstrate that 7 out of 7 (Staff A, B, C, D, E, G and H) active staff received annual in-service on infection control. Findings include: The Administrator on 02/10/22 provided documentation that revealed the provider conducted an annual infection control education in-service on 03/27/20. Further review revealed no documentation to show that Staff A, B, C, D, E, G and H participated in an annual in-service infection control. On 02/10/22 at 12:59 PM, the Administrator acknowledged that the provider did not conduct an annual in-service on infection control for the year 2021.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to ensure that the written instructions for the home health aide (HHA) are prepared by the Registered Nurse in 1 out of 10 Sample Patients (SP). SP#6 Findings include: Closed clinical record review of SP#6 revealed the patient was admitted to service on 07/21/2020 and received Skilled Nursing (SN) and Home Health Aide (HHA) services, with a discharge date of 11/30/21. Further review of the clinical record revealed no Aide Care Plan written by the Registered Nurse. The Alternate Director of Nursing on 02/09/22 at 1:44 PM reviewed the clinical record for missing documentation of supervisions and aide care plan. On 02/09/22 at 2:00 PM the Alternate Director of Nursing confirmed that there is no documentation for HHA supervision conducted every 14 days after 10/12/21 and no aide care plan was completed.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to ensure that an onsite visit to the patient's home no less frequently than every 14 days is conducted for supervision of the Home Health Aide (HHA) by a Registered Nurse or other appropriate skilled professional in 1 out of 10 Sampled Patients (SP). SP#6 Findings include: Closed clinical record review of SP#6 revealed the patient was admitted to service on 07/21/2020 and received Skilled Nursing (SN) and Home Health Aide (HHA) services, with a discharge date of 11/30/21. Review of the services rendered from date range 10/03/21 to 11/30/21 revealed no HHA supervision between last supervision dated 10/12/21 and last date of service dated 11/30/21 by the HHA, which was an interval of 49 days. The Alternate Director of Nursing on 02/09/22 at 1:44 PM reviewed the clinical record for missing documentation of supervisions and aide care plan. On 02/09/22 at 2:00 PM the Alternate Director of Nursing confirmed that there is no documentation for HHA supervision conducted every 14 days after 10/12/21 and no aide care plan. Review of the home health agency's policy and procedure titled "Supervision of Personnel" reads “All staff providing NON-skilled care (i.e. from a Home Health Aide or Certified Nursing Assistant) who is either a staff employee or independent contractor of the home health organization will be evaluated at a minimum, every 14 days by a Registered Nurse unless otherwise stipulated by state law. The results of the supervisory visit are documented on the attached form and communicated to the Clinical Care Coordinator and/or Director/Assistant Director of Nursing.”

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 record review and interview, the home health agency is unable to demonstrate 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 Home Health Agency for 4 out 10 Sampled Patients (SP). (SP#4, SP#6, SP#8 and SP#10); and the provider failed to ensure the clinical record included 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 Home Health Agency (HHA) becomes aware of the transfer for 1 out 10 Sample Patients. (SP#5) Findings include: Closed record review of SP#4, SP#6, SP#8 and SP#10 were conducted on 02/08/22 and 02/09/22. The SP#4, SP#6, SP#8 and SP#10 records contained a discharge summary from agency with that omitted details on the summary of care/outcomes in meeting the goals in the plan of care, clinical summary, patient and/or family post discharge instructions. An interview was conducted with the Alternate Director of Nursing on 02/08/22 at 1:43 PM. The Alternate Director of Nursing reviewed the discharge summary for SP#8 and SP#4 and acknowledged that summaries were incomplete; in addition, the Alternate Director of Nursing stated that patients physician were notified of the discharge from agency via a modify order and that the discharge summary were not being sent to the patients’ physicians. Closed record review of SP#5 revealed that on 12/20/21 a transfer to an inpatient facility was completed. The documentation revealed the patient was admitted to hospital [hospital name] due to respiratory distress. Further review of the clinical record revealed no documentation of a transfer summary completed for 12/20/21 was sent to the receiving facility to inform of patient's current course of illness and treatment to ensure the safe and effective transition of care. Interview conducted with the Alternate Director of Nursing on 02/09/22 at 12:02 PM. The Alternate Director of Nursing stated that only the patient’s physician was notified of the transfer to hospital via a modified order and acknowledged that there is no documentation that the transfer summary was sent to the inpatient facility.