Every finding on record at Comfort and Passionate Health Services LLP

Substantial Allegation Survey Substantial Allegation 104328 and 105054 No deficiencies were cited related to allegations contained in substantial allegation 104328 or 105054 completed on 03/13/24; however, the facility was found not to be in compliance with all requirements for Home Health Agency participation and the following deficiency was cited. Comfort and Passion Health Services LLC, 369272, is not in compliance with the requirements found at Home Health Agency 424 CFR part 484, Subpart B, C.

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 Medical Record Review (MRR), Complaint Log review, and staff interview, the agency failed to order an appropriate range and frequency for Home Health Aide (HHA) services for 2 (Patients #1 and #3) of 3 patients that were receiving HHA services provided by the agency. This had the potential to affect all patients receiving HHA services from the agency. The census was 96. Findings Include: 1. On 03/12/24 at 11:10 A.M. a review of the Complaint Log revealed there was a concern listed related to a situation when Public Consulting Group (PCG) called the agency concerning an allegation that Patient #1 was not receiving care and services as ordered and concerning Patient #1 giving Staff C money to provide services. A review of the Complaint Log revealed the agency did an investigation, and a review of the investigation revealed an example of the nurse aide services time sheets, and the Staff C's clock-in and clock-out time sheets revealed Staff C provided four hours of Home Health Aide (HHA) services during the week that PCG had requested for review. An interview with the DON and the Administrator during this review confirmed care was provided for four hours that week. On 03/12/24 at 11:45 A.M. a Medical Record Review (MRR) for Patient #1 revealed orders were listed on the 485/Physician order sheet for HHA services “up to” 10 hours each week for the current certification period, and a review of the 485/Physician order sheet for the certification period between 12/17/23-02/14/24 revealed the same “up to” orders were written for HHA services. Further review of the HHA time sheets revealed Staff C was consistently providing four hours of HHA services for Patient #1 each week. On 03/12/24 at 3:00 P.M. an interview with Staff C revealed Staff C provides care and services for Patient #1 between 4-6 hours a week, but he/she has no idea how many hours he/she can provide services or what the specific ordered hours are for HHA services for Patient #1. 2. Review of the medical record for Patient #3 revealed the current 485/physician orders for HHA services were written for "up to" 28 hours a week for the certification period and care was consistently provided 21 hours each week. An interview with the Administrator and the Director of Nursing (DON) at the time of the MRR’s revealed “up to” orders cannot be avoided because it is too hard to adjust for patient needs when they are not always available.