Every finding on record at CMHC, Inc.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted February 2 through February 5, 2026, Comprehensive Medical Home 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 conducted February 2 through February 5, 2026, Comprehensive Medical Home 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.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on the review of agency policies/procedures and clinical records, and based on interview with the Administrator (Employee #12) and the Chief Executive Officer/Director of Clinical Services (CEO/DoCS-Employee #13), the agency failed to ensure wound care orders were consistent with skilled nursing (SN) interventions included on the comprehensive assessment for one (1) of two (2) patients for whom home health services were resumed after hospitalization. (Patient #4) Findings include: On February 5, 2026 at approximately 3:20 PM, review of agency policy 2-018, titled "Care Planning Process" revealed the following under "Procedure": 8. The plan of care will be revised no less than every sixty (60) days or as frequently as deemed necessary by the clinician, based on the ongoing assessment of the patient. On February 5, 2026 at approximately 3:20 PM, review of agency policy 5-006, titled "Entries into the Clinical Record", revealed the following: Policy...Documentation in the clinical record will be...accurate...The clinical record should tell a linear story of the course of the patient's care that is managed and delivered by the organization. Patient #4 (Discharge): Between February 3, 2026 at approximately 10:32 AM and February 5, 2026 at approximately 1:07 PM, review of the clinical record revealed wound care provided by the SN (Employee #1) included the following as documented on the resumption of care (ROC) assessment dated 06/10/2025: -Right Lower Extremity Wounds (Wounds #1, #3, #8, #9): Aquacel Ag (wound treatment which contains silver) applied. Review ROC orders obtained by the SN (Employee #1) on 06/10/2025 revealed wound care orders included the following as documented on the "Post Hospital Order": -RLE ulcer and non-pressure ulcer wound care orders included on page 2 and 3: Apply Aquacel Ag three (3) times a week -RLE ulcer wound care orders included on page 4: Apply Xeroform (wound dressing/treatment) twice a week -RLE non-pressure ulcer wound care orders included on page 4: Apply Xeroform every other day. -RLE non-pressure ulcer wound care orders included on page 5: Apply Xeroform and cover with Allevyn border (foam dressing) three (3) times a week and apply Xeroform three (3) times a week. There was no documentation on the "Post Hospital Order" dated 06/10/2025 which provided evidence wound care orders obtained by the SN for the application of Xeroform to the RLE ulcer and non-pressure ulcer wounds were consistent with the wound care provided by the SN during the resumption of care visit completed on 06/10/2025. During interview conducted on February 5, 2026 at approximately 3:25 PM, the Administrator and the CEO/DoCS confirmed wound care orders included on the "Post Hospital Order" were not consistent with SN wound care interventions completed during ROC visit for patient #4.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on the review of agency policies/procedures and clinical records, and based on interview with the Administrator (Employee #12) and the Chief Executive Officer/Director of Clinical Services (CEO/DoCS-Employee #13), the agency failed to ensure skilled nursing (SN) wound assessment findings were documented in accordance with agency policy/procedure and/or physician orders for three (3) of twelve (12) patients for whom wound care was provided by SN staff. (Patients #1, #2 and #15) Findings include: On February 5, 2026 at approximately 3:20 PM, review of agency policy 5-006, titled "Entries into the Clinical Record", revealed the following: Policy...Documentation in the clinical record will be...accurate and reflect the care or services provided...The clinical record should tell a linear story of the course of the patient's care that is managed and delivered by the organization. Procedure...1. A clinical record will be initiated and maintained for each patient receiving care or services, according to organization policies...and will include at a minimum: G. Current patient status and progress towards goals... On February 5, 2026 at approximately 2:59 PM, review of agency policy 2-014, titled "Wound Care Assessment", revealed the following under "Procedure": 2. Documentation of Assessment includes: a. Location and type... b. Length x width x depth... d. Tissue type/color e. Exudate (drainage)-Measurable amount... g. Periwound (tissue surrounding wound) condition... 6. Wound evaluation every visit... Patient #1 (Discharge): Between February 2, 2026 at approximately 12:39 PM and February 5, 2026 at approximately 1:00 PM, review of the clinical record revealed SN was to provide wound care to the left heel wound and that SN interventions included the following as documented on the "Home Health Certification and Plan of Care" for the recertification period of 11/25/2025 through 01/23/2026: SN to assess wound noting condition of wound bed, drainage and periwound and for SN to measure wound weekly. Review of SN visit note documentation dated 12/01/2025 revealed the SN (Employee #8) provided wound care to the left foot wound and that the SN documented that were no signs/symptoms of infection. There was no documentation on the SN visit noted dated 12/01/2025 which provided evidence the SN assessed the condition of the wound bed, wound drainage nor the periwound. Review of the verbal order dated 12/10/2025 revealed an order was received for SN to provide care to the right heel wound (new wound). Review of SN visit note documentation dated 12//10/2025 revealed the SN (Employee #1) provided wound care to the right heel wound. There was no documentation on the SN visit noted dated 12/10/2025 which provided evidence the SN assessed the right heel wound size nor the condition of the wound bed, wound drainage nor the periwound. Patient #2 (Discharge): Between February 2, 2026 at approximately 1:56 PM and February 5, 2026 at approximately 1:03 PM, review of the clinical record revealed SN was to provide wound care to the left lateral foot wound and that SN goals included the following as documented on the "Home Health Certification and Plan of Care" for the recertification period of 11/14/2025 through 01/12/2026: Wound will decrease in size and heal without complications. Review of SN visit note documentation dated 12/11/2025 revealed the SN (Employee #8) provided wound care to the left foot wound and that the SN documented that were no signs/symptoms of infection. There was no documentation on the SN visit noted dated 12/11/2025 which provided evidence the SN assessed the condition of the wound bed, wound drainage nor the periwound. Patient #15: On February 5, 2026 at approximately 7:40 AM, review of the clinical record revealed an additional SN visit was ordered to assess right lower leg and for ace wrap application as ordered on the physician order dated 01/23/2026. Review of the start of care assessment dated 01/17/2026 revealed there were no surgical, stasis ulcer nor pressure wounds present during the initial SN assessment. Review of SN visit note documentation dated 01/24/2026 revealed the SN (Employee #13) documented the knee was assessed and was without signs or symptoms of infection, that wound care was provided and that discharge planning included for "when knee is healed". The SN documented an ace wrap was applied to the left leg. Review of SN visit note documentation dated 01/29/2026 revealed a right knee Incision present, that the incision was clean, dry, intact and closed with surgical glue, and that no signs/symptoms of infection were noted. There was no documentation on the SN visit noted dated 01/24/2026 which provided evidence the SN documented the location and type of knee wound which was assessed nor was documentation present which provided evidence the SN had assessed the length/width/depth of wound to which wound care was provided nor the status of wound drainage. During interview conducted on February 5, 2026 at approximately 3:25 PM, the Administrator and the CEO/DoCS confirmed wound assessment documentation was no completed in accordance with agency policies/procedures or physician orders on the aforementioned dates for the above identified patients.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted January 17 through January 20, 2023, Comprehensive Medical Home 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 conducted January 17 through January 20, 2023, Comprehensive Medical Home 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.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the administrator and the agency President/Chief Executive Officer (CEO), the agency failed to ensure the contact information (address and telephone number) for the Center for Independent Living, Protection and Advocacy Agency and the Aging and Disability Resource Center was provided to seven (7) of seven (7) patients for whom a home visit was conducted. (Patients #1, #3, #4, #5, #6, #7 and #8) Finding include: On January 20, 2023 at approximately 2:39 PM, review of the agency policy titled "Right/Responsibilities" revealed the following: Procedure...1. The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care to the patient, of the following... W. The names, addresses and telephone numbers of the following... 2. Center for Independent Living 3. Protection and Advocacy 4. Aging and Disability Resource Center... On January 17, 2023 at approximately 11:22 AM, review of the patient admission folder/"Patient Handbook" failed to reveal that the contact information for the Center for Independent Living, Protection and Advocacy Agency and the Aging and Disability Resource Center had been included on the patient rights notification forms. Patient #1: A home visit was conducted with a home health aide on 01/18/2023 at approximately 9:25 AM. Patient #3: A home visit was conducted with a registered nurse on 01/18/2023 at approximately 11:40 AM. Patient #4: A home visit was conducted with an occupational therapist on 01/18/2023 at approximately 12:45 PM. Patient #5: A home visit was conducted with a physical therapist on 01/18/2023 at approximately 10:45 AM. Patient #6: A home visit was conducted with a licensed practical nurse (LPN) on 01/19/2023 at approximately 9:00 AM. Patient #7: A home visit was conducted with an LPN on 01/19/2023 at approximately 10:00 AM. Patient #8: A home visit was conducted with an LPN on 01/19/2023 at approximately 11:10 AM. Review of the admission folder/"Patient Handbook" during the above referenced home visits failed to reveal that the contact information for the Center for Independent Living, Protection and Advocacy Agency and the Aging and Disability Resource Center had been included on the patient rights notification forms which were provided to the above referenced patients. During interview on January 20, 2023 at approximately 3:30 PM, the administrator and the agency CEO confirmed that there was no documentation which provided evidence that the contact information for the Center for Independent Living, Protection and Advocacy Agency and the Aging and Disability Resource Center had been included on the patient rights notification forms.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on the review of agency policies/procedures and clinical records, and based on interview with the administrator and the agency President/Chief Executive Officer (CEO), the agency failed to ensure the licensed independent practitioner (LIP-primary care provider) was notified of a variance (change) in the external length of a peripherally-inserted central catheter (PICC-intravenous) for two (2) of two (2) patients for whom PICC line maintenance/care orders were included on the "Home Health Certification and Plan of Care". (Patients #10 and #18) Findings include: On January 20, 2023 at approximately 2:59 PM, review of the agency policy titled "Central Vascular Access Device (CVAD) Malposition" revealed the following: Policy...1. The clinician employs preventative interventions...and promptly intervenes by notifying the licensed independent practitioner (LIP) when catheter malposition is suspected. Key Points...1. There may be no obvious signs and symptoms of catheter migration...8. Primary malposition with peripherally inserted central catheters (PICCs) is more common than other CVAD's... Assessment...2. Measure the external CVAD length and compare to the external CVAD documented at insertion. Dislodgement could indicate that the tip location is suboptimal (less than the highest quality standard) increasing the risk for catheter-related thrombosis (blood clot)... Documentation...1. Document in the patient's health record... g. LIP notification... Patient #10: On January 20, 2023 at approximately 10:03 AM, review of the clinical record revealed skilled nursing (SN) was to perform/provide the following as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 11/09/2022 through 01/07/2023: -SN to measure/document external catheter length each visit. Review of the start of care SN assessment dated 11/09/2022 revealed the registered nurse (RN-Employee #12) documented that the external PICC line length was three centimeters (3 cm). "Skilled Nurse Visit" documentation dated 11/10/2023 revealed the RN (Employee #12) documented that the PICC line was inserted in the left upper extremity (LUE-arm) and that the external PICC line length was zero (0) centimeters which was 3 cm's shorter than the measurement obtained on 11/09/2022. Review of external PICC line measurements documented by the RN (Employee #12) on the "Skilled Nursing Visit" notes revealed the external PICC line lengths obtained between 11/14/2022 and 12/12/2022 included the following: Zero/0 cm, 2.5 cm and 3.0 cm. There was no documentation in the clinical record which provided evidence that the RN (Employee #12) notified the LIP of the above referenced external PICC line length variances. Patient #18: On January 20, 2023 at approximately 1:55 PM, review of the clinical record revealed SN was to perform/provide the following as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 12/08/2022 through 02/05/2023: -SN to measure/document external catheter length each visit. Review of "Skilled Nurse Visit" documentation dated 12/12/2022 revealed the external PICC line length was zero/0 cm as documented by the RN (Employee #11). Review of "Skilled Nurse Visit" documentation dated 12/29/2022 revealed the external PICC line length was one/1 cm as documented by the RN (Employee #11). There was no documentation in the clinical record which provided evidence that the RN (Employee #11) notified the LIP of the above referenced external PICC line length variance. During interview conducted on January 20, 2023 at approximately 3:30 PM, the agency administrator and CEO confirmed the LIP was not notified of the above referenced external PICC line length variances for the above referenced patients.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based review of agency policies/procedures, personnel files, internet-based professional resume details and the Pennsylvania Department of State (PA DOS) professional license verification website, and based on interview with the administrator and the agency President/Chief Executive Officer (CEO), the agency failed to ensure COVID-19 vaccine exemption requests were completed per agency policy/procedure for one (1) of one (1) staff members who requested a medical exemption to the COVID-19 vaccination requirement. (Employee #2) Findings include: On January 17, 2023 at approximately 12:53 PM, review of agency COVID-19 vaccination policies/procedures revealed the following: Policy 9-019 COVID-19 Vaccination...Procedure... 5. A request for Medical Exemption may be submitted...The request is to be completed by the employee's treating physician... Between January 17, 2023 at approximately 12:52 PM and January 20, 2023 at approximately 1:43 PM, review of personnel file documentation revealed the following: Employee #2: The date of hire of the occupational therapist (OT) was 04/07/2022. Review of "Reports View Clinician Schedule" forms revealed the OT provided patient care in August 2022. Review of the OT's Medical Certification for COVID-19 Vaccine Exemption request form revealed the professional title of "Dr." was entered prior to the practitioner signature under the area titled "Medical Provider Name/Title". The signer of the exemption request form included an entry which indicated that the signer was the director of a wellness center. On January 17, 2023 at approximately 1:45 PM, review of internet-based professional resume documentation revealed the signer of the OT's Medical Certification for COVID-19 Vaccine Exemption request form was a Doctor of Pharmacy (Pharmacist). On January 18, 2023 at approximately 8:15 AM, review of PA DOS license verification website revealed the signer of the OT's Medical Certification for COVID-19 Vaccine Exemption request form was not licensed as a medical provider in Pennsylvania. During interview conducted on 01/20/2023 at approximately 3:30 PM, the administrator and CEO confirmed that a PA licensed physician/medical practitioner failed to complete the OT's Medical Certification for COVID-19 Vaccine Exemption request.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on the review of agency policies/procedures and clinical records, and based on interview with a registered nurse (RN-Employee #11), the administrator and the agency President/Chief Executive Officer (CEO), the agency failed to ensure skilled nursing (SN) procedures (treatments) and assessment findings were documented as per agency policy for two (2) of two (2) patients for whom peripherally-inserted central catheter (PICC-intravenous) line maintenance/care orders were included on the "Home Health Certification and Plan of Care". (Patients #10 and #18) Findings include: On January 20, 2023 at approximately 3:11 PM, review of agency policy 5-005, titled "Contents of the Clinical Record", revealed the following: Procedure...1. The following information will be available in the clinical record, as applicable to care and services provided: M. Record and findings of initial and ongoing assessments... CC. Documentation of the assessment data collected, actions and interventions performed, and patient response to care provided... On January 20, 2023 at approximately 3:00 PM, review of the agency policy titled "Vascular Access Devices (VADs): Ongoing Assessment, Site Care, and Dressing Change" (Intravenous) revealed the following: Assessment... 2. Assess the VAD catheter-skin junction site and surrounding areas for redness, tenderness, swelling and drainage... 6. Measure upper arm circumference, each visit of VAD to upper extremity (arm)... Documentation... 1. Document in the patient's record: a. Performance of the procedure... b. Measurement of the external length of the catheter... On January 20, 2023 at approximately 3:06 PM, review of the agency policy titled "Vascular Access Device (VAD) Removal" revealed the following: Documentation... 1. Document in the patient's health record... -Length of the catheter and integrity of the catheter tip at time of removal... Patient #10: On January 20, 2023 at approximately 10:03 AM, review of the clinical record revealed skilled nursing (SN) was to perform/provide the following as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 11/09/2022 through 01/07/2023: -SN to measure/document arm circumference every visit; and -SN to remove midline catheter (CVAD-PICC) and to inspect PICC to ensure catheter is intact, not jagged and length is appropriate. Document findings. Review of "Skilled Nurse Visit" documentation dated 11/10/2023 revealed the PICC line was inserted in the left upper extremity (LUE-arm). There was no documentation in the clinical record which provided evidence that the RN (Employee #12) measured the LUE circumference on 11/25/2023. There was no documentation in the clinical record which provided evidence that the RN (Employee #12) inspected the PICC catheter appearance and length when the RN discontinued (removed) the PICC line on 12/16/2022. Patient #18: On January 20, 2023 at approximately 1:55 PM, review of the clinical record revealed SN was to perform/provide the following as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 12/08/2022 through 02/05/2023: -Change PICC line dressing every 5-7 days; -SN to assess right upper arm PICC site every visit every visit for redness, leakage, drainage, bleeding, edema (swelling) and document findings; -SN to measure/document external catheter length each visit; -SN to measure/document arm circumference every visit; and -SN to remove midline catheter (CVAD-PICC) and to inspect PICC to ensure catheter is intact, not jagged and length is appropriate. Document findings. Review of "Skilled Nurse Visit" documentation revealed two (2) RN's (Employees #5 and #11) provided PICC line maintenance/care between 12/08/2022 and 01/12/2023. There was no documentation in the clinical record which provided evidence that the PICC line dressing was changed on 12/15/2022, 12/21/2022 nor 01/04/2023. There was no documentation in the clinical record which provided evidence that the RUE circumference was measured on 12/12/2022, 12/15/2022, 12/21/2022 nor 01/04/2023. There was no documentation in the clinical record which provided evidence that the external PICC line length was measured on 12/08/2022, 12/09/2022, 12/10/2022, 12/15/2022, 12/21/2022 nor 01/04/2023. There was no documentation in the clinical record which provided evidence that the RN (Employee #11) inspected the PICC catheter appearance and length when the RN discontinued the PICC line on 01/12/2023. During telephone interview conducted on January 20, 2023 at approximately 3:14 PM, the RN (Employee #11) reported that the PICC line dressing was changed and that the RUE circumference, external PICC line length and PICC line appearance upon discontinuation was assessed for patient #18 on the aforementioned dates. The RN reported that all SN procedures/assessment findings are documented in the clinical record but the RN was unable to provide an explanation as to why the PICC line procedures/assessment findings for patient #18 were not documented on the "Skilled Nurse Visit" notes for the above referenced dates. During interview conducted on January 20, 2023 at approximately 3:30 PM, the agency administrator and CEO confirmed PICC line procedures/assessment findings were not documented as per agency policy procedure for the above referenced patients.