Every finding on record at Arms of Comfort Home Health Inc

Purpose: A recertification/ re-licensure survey was conducted on 9/18/2025. Census: Home Health L&C 19 The Agency was in compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Services

Purpose: A recertification/ re-licensure survey was conducted on 9/18/2025. Census: Home Health L&C 19 The Agency was in compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Services Abbreviations: ADM—Administrator AADM—Alternate Administrator CMS—Centers for Medicare & Medicaid Services DON—Director of Nurses HHC—Home Health Coordinator HHSC—Health and Human Services Commission IQies—Internet Quality Improvement and Evaluation System L&C—Licensed and Certified OASIS—Outcome and Assessment Information Set TULIP—Texas Unified Licensure Information Portal

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 agency failed to transmit OASIS data for each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the beneficiary for 7 of 7 OASIS assessments submitted from 10/01/24 to 09/18/25. Failure of the agency to transmit OASIS data within the required time frame prevented the agency’s patient data from being made available to CMS for analysis to evaluate the agency performance levels in the provision of patient care Findings The surveyor reviewed the OASIS Error Detail Report for the agency in the IQIES portal on 09/22/2025, as part of the survey. The report documented 7 late assessments transmitted from 10/01/2024 to 09/18/2025 were submitted more than 30 days after the M0090 (the date of completion of the assessment.) During the entrance conference on 9/18/2025 at 10:55 AM with the Administrator (via phone), DON, and Home Health Coordinator, the surveyor asked for OASIS final validation reports from 10/01/2024 to 9/18/25. The surveyor received the OASIS Agency Final Validation report dated 9/18/2025 from 1/1/2025 to 9/18/2025. The surveyor reviewed the OASIS Agency Final Validation (01/01/25 to 09/18/25) report provided by the agency which documented three late OASIS submissions with the comment “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record” during this time. An interview was conducted with the Administrator (ADM), Home Health Coordinator (HHC), the Alternate Administrative (AADM), and the Director of Nurses (DON) on 9/22/2025 at 1:30 pm. The surveyor reviewed the late transmissions of OASIS assessments with the ADM, HHC, AADM, and the DON. The surveyor asked how long the agency had to submit an OASIS? The DON and HHC stated, “30 days.” The surveyor asked what the process was for OASIS submission. The DON stated, “the nurse does the OASIS and sends it to me to review. I send it back to the nurse once I review it. The nurse makes corrections as needed and either returns it to me for review or turn it in for to be submitted.” Who is responsible for transmitting the assessments? The HHC stated, “I do it.” The surveyor asked what may be the reason an OASIS was not submitted in time? The DON stated, “depending on how many times it needs correcting may cause a late submission.” The HHC stated, “if it [OASIS] falls on a weekend it [OASIS] may be late.” The surveyor asked how it could affect the patient if the OASIS is not submitted on time. The DON stated, “it can cause delays for therapies or wound care.” The Administrator and the Alternate Administrator did not respond to any of the questions asked during this interview. The agency had a policy titled: “8.10 Timelines” revised dated 01/29/2020. The policy read in part: POLICY -Agency will ensure timely provision of service and services to meet the client's needs in compliance with all federal and state laws and regulations. Agency will also establish timely parameters for all client record information. All Agency staff, and physician/physician office staff as appropriate, will be oriented to the following parameters: … Encoding and locking OASIS data for the state within seven (7) days of the completion of the Comprehensive Assessment. Completed, encoded and locked OASIS data will be transmitted with thirty (30) days of the M0090 date…”

An Entrance Conference was conducted on 9/12/2022 at 1:00 p.m. The agency representatives were informed that the purpose of the visit was to conduct a recertification survey. The agency census was: Garland (Parent): L&CHHS-26, LHHS-0, PAS-0 No deficiencies cited.

An Entrance Conference was conducted on 9/12/2022 at 1:00 p.m. with the Administrator and Patient Coordinator. The agency representatives were informed that the purpose of the visit was to conduct a recertification survey. The agency census was: Garland: L&CHHS-26, LHHS-0, PAS-0 An Exit conference was conducted on 9/15/2022 at 10:15 a.m. with the Administrator, Supervising Nurse, Supervisor and Patient Coordinator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of receiving the Statement of Deficiencies. Abbreviations: PT- Physical Therapy PTA- Physical Therapy Assistant OT- Occupational Therapy SN- Supervising Nurse L&CHHS- Licensed and Certified Home Health Services LHHS- Licensed Home Health Services PAS- Personal Assistance Services COVID 19- Coronavirus

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate patient services with other health care providers in 3 of 4 patients receiving therapy services (Patient #1, Patient #5 and Patient #9) in that: 1. The agency failed to notify the physician that Physical Therapy was not provided as ordered for Patients #1, #5 and #9. 2 The agency failed to notify the physician of a 4 week delay in Occupational Therapy evaluation for Patient #9. This failure has the potential that the prescribing physician may not be aware that therapy services were not provided as ordered in the Plan of Care and could affect the health status of patients. Findings: 1. Review of the clinical record of Patient #1 revealed a Plan of Care (POC) dated 7/17/2022 to 9/14/2022 which read in part: “Primary Diagnosis- Hemiplegia following cerebral (infarction) affecting right dominant side; Other Diagnosis- Contracture of muscle, right hand…Orders and Treatments: PT: 1w1 (one time a week for one week), Evaluate and treat, effective week of 7/17/2022.” The clinical record did not contain documentation that a physical therapy evaluation had been completed or that the physician had been notified that the physical therapy evaluation had not been completed. The clinical record contained a document entitled “Patient Communication” which read in part “Date of Contact 7/18/2022, Contacted patient regarding PT order. Patient’s (family member) told patient did not want PT due to fear of Covid 19 spread.” The document was signed by Patient Coordinator and dated 9/14/2022. During an interview with the SN on 9/15/2022 at 9:18 a.m., this surveyor questioned if the physician had been notified that the PT evaluation was not completed. The SN stated the physician had not been notified that the PT evaluation had not been completed as ordered. 2. Review of the clinical record for Patient #5 revealed a POC dated 7/22/2022 to 9/19/2022. The POC read in part: “Other Diagnosis: Venous insufficiency, Bilateral Primary Osteoarthritis. Orders and Treatments: PT eval and treat.” The clinical record contained a document entitled “PT Evaluation” dated 7/26/2022. The document read in part: “Effective 7/26/2022, (PT) 1w1, 2w3, 1w4 (PT once a week for the first week, twice a week for three weeks, once a week for 4 weeks).” Further review of the clinical record revealed Patient #5 received PT visits once a week for the week of 7/24/2022, twice a week for the weeks of 7/31/2022, 8/7/2022 and 8/14/2022, no visits for the week of 8/21/2022, one visit for the week of 8/28/2022 and no visits for the week of 9/4/2022. The clinical record did not contain documentation of missed visits, or that the physician had been notified of missed visits by therapy. The clinical record contained a document entitled “Patient Communication” which read in part: “Date of Contact 8/22/2022, PT was on vacation. Office called patient to notify if patient is willing to wait or would like another PT for re-eval. Patient requested same PT and willing to wait. PT will be on hold until PT is back for re-eval. PTA visit (8/30/2022) due to office forgot to delete his visit.” The document was signed by Office Staff and dated 8/30/2022. During an interview with the SN on 9/15/2022 at 9:30 a.m. this surveyor questioned if the physician had been notified of the missed PT visit. The SN stated the physician had not been notified of the missed visits for Patient #5, or of the delay in the re-evaluation due to therapist not available. 3. Review of the clinical record of Patient #9 revealed a POC dated 7/27/2022 to 9/24/2022 which read in part: “Other Diagnosis: Age related Osteoporosis, Weakness. PT to eval and treat. OT to eval and treat.” The clinical record contained a document entitled “PT Evaluation” dated 8/4/2022 which read in part: “Effective Date 8/4/2022, (PT) 1w1, 3w3, 2w2, 1w1 (once a week for the first week, three times weekly for three weeks, twice weekly for 2 weeks and once weekly for one week). Further review of the clinical record revealed no additional PT visits after the initial evaluation on 8/4/2022, and an OT evaluation on 9/1/2022 (5 weeks after admission). The clinical record did not contain documentation that the physician had been notified of the PT missed visits, or the delay in OT. The clinical record contained documents entitled “Patient Communication” which read in part: “Date of Contact 8/9/2022, Patient wants a Vietnamese PT/ PTA and willing to wait. Agency will update patient progress of Vietnamese therapist.” The document was signed by Patient Coordinator and dated 9/13/2022. “Date of Contact 9/13/2022, 8/12/2022 per (Administrator) patient did not want therapy because of pain related. No PT visits done.” The document was signed by Patient Coordinator and dated 9/14/2022. During an interview with the SN on 9/15/2022 at 9:25 a.m. this surveyor questioned if the physician had been notified of the missed PT visits or the delay in the OT assessment. The SN stated that the physician was not notified that therapy was not provided as ordered, or that PT was not done due to patient having pain with therapy. SN stated patient was initially to be discharged on 9/2/2022 per patient request. SN stated when reviewing patient record for discharge she noticed that the OT evaluation had not been completed, and SN set up OT evaluation prior to discharge. Patient was discharged on 9/9/2022 following 9/1/2022 OT evaluation. 4. Review of the agency policy and procedure manual revealed a policy entitled 4.2 Patient Assessment Guidelines” revised 1/29/2020. The policy read in part: “An assessment performed due to an intra-agency referral will be completed as follows: Occupational Therapy- 4 days…Plan of Care: 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…The HHA must promptly alert the relevant physician to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/ or that the plan of care should be altered…Any revision to the plan of care due to a change in patient health status must be communicated to all physicians issuing orders for the HHA plan of care.” The policy and procedure manual also included a policy entitled “5.8 Implementing Care and Treatment” revised 1/29/2020 which read in part: “When provision of care/ treatment cannot be implemented as established on the care planning documents, the patient’s physician will be notified. The appropriate documentation will be completed and submitted by discipline/ Patient Care Manager.” 5. During an interview with the SN on 9/15/2022 at 9:30 a.m., the SN stated the agency’s failure to notify the physician when therapy cannot be provided according to the POC affects patient care by patient’s not possibly getting the care they deserve.