Extended Family Care

“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.”