Extended Family Care

“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.”

“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.”