Every finding on record at Comfort at Home Healthcare Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: 03/25/2025 - 03/28/2025 Active Census: 177 At this Emergency Preparedness survey, Home Helpers Home Health was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR Completed on 04/08/2025 by A4

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 03/25/2025 - 03/28/2025 12-Month Unduplicated Skilled Admissions: 10 Partially Extended on 03/27/2025 at 11:15 AM. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: POC Plan of Care RN Registered Nurse LPN Licensed Practical Nurse EMR Electronic Medical Record HHA Home Health Aide SN Skilled Nurse

Plan of care CFR(s): 484.60(a)(1) 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, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure HHA services were received by patients as ordered on the POC for 3 of 3 home visit patients records reviewed (Patient #1, #2, #3). Findings include: 1. A review of a policy titled "Care Plan", indicated but was not limited to: "Home health services from members of the Agency staff, as well as those under contractual arrangements, shall be provided in accordance with the plan of treatment and the patient care plan…" 2. The clinical record for Patient #1, benefit period 03/07/2025 - 05/05/2025, evidenced orders on the POC for HHA services six (6) hours per day, seven (7) days per week. An interview with RN 1 during the home visit for Patient #1 on 03/26/2025 at 9:00 AM, indicated the patient is receiving HHA services three (3) hours per day, five (5) days per week; the order on the POC is due to the agency's administrative process to request additional time the patient requires from the patient's insurance. 3. The clinical record for Patient #2, benefit period 01/30/2025 - 03/30/2025, evidenced orders on the POC for HHA services six (6) hours per day, five (5) days per week. A review of the patient calendar evidenced on: 02/17/2025, 02/24/2025, 03/03/2025, and 03/10/2025, the patient received three (3) hours of HHA services; on 02/26/2025 and 03/05/2025, the patient received two (2) hours of HHA services; and on 02/19/2025, 03/12/2025, and 03/24/2025, the patient received one (1) hour of HHA services. 4. The clinical record for Patient #3, benefit period 01/31/2025 - 03/31/2025, evidenced orders on the POC for HHA services four (4) hours per day, five (5) days per week. A review of the patient calendar evidenced on: 02/11/2025 and 03/17/2025, the patient received three (3) hours of HHA services; on 02/28/2025, the patient received one (1) hour of HHA services. 5. During an interview on 03/27/2025 at 10:55 AM, the Administrator indicated Patient #1 receives HHA services three (3) hours per day, five (5) days per week. She indicated the patient's HHA orders on the POC are for six (6) hours per day, seven (7) days per week due to Medicaid requirements that a signed and completed POC must be submitted to Anthem in order to request the actual number of hours a patient needs. The Administrator indicated the patient has been denied for the increased hour amount multiple times. She indicated the POC still reflects the higher hour amount due to their process of having the MD sign the POC with the patient's actual hours received then changing the POC in the EMR and having the MD resign the POC with requested hours to send to Anthem. 6. During an interview on 03/27/2025 at 12:53 PM, the Administrator indicated the scheduling department completes monthly audits to ensure that missed visit notes are present in the EMR. Currently the scheduling department has not completed all audits for the timeframe of 02/10/2025 - 03/10/2025. She indicated being unsure why Patient #2 did not receive all ordered HHA hours for the dates: 02/17/2025, 02/19/2025, 02/24/2025, 02/26/2025, 03/03/2025, 03/10/2025, 03/12/2025, and 03/24/2025. 7. During an interview on 03/27/2025 at 1:38 PM, the Administrator indicated the clinical record for Patient #3 did not contain missed visit notes for the dates: 02/11/2025, 02/28/2025, and 03/17/2025. She indicated being unsure why the patient did not receive all ordered HHA hours. 17-13-1(a)

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 record review and interview, the agency failed to ensure POCs included personalized patient and caregiver training and education to promote an efficient discharge for 7 of 7 patients' records reviewed (Patient #1, #2, #3, #4, #5, #6, #7). Findings include: 1. A review of a policy titled "Care Plan", indicated but was not limited to: "Collection of baseline data including … patient/client and family's teaching needs, instructions for timely discharge or referral…" 2. The clinical record for Patient #1, benefit period 03/07/2025 - 05/05/2025, evidenced the POC failed to include education and training for the patient and/or caregiver to ensure a timely discharge or referral of the patient, related to identified measurable goals and interventions. 3. The clinical record for Patient #2, benefit period 01/30/2025 - 03/30/2025, evidenced the POC failed to include education and training for the patient and/or caregiver to ensure a timely discharge or referral of the patient, related to identified measurable goals and interventions. 4. The clinical record for Patient #3, benefit period 01/31/2025 - 03/31/2025, evidenced the POC failed to include education and training for the patient and/or caregiver to ensure a timely discharge or referral of the patient, related to identified measurable goals and interventions. 5. The clinical record for Patient #4, benefit period 02/25/2025 - 04/25/2025, evidenced the POC failed to include education and training for the patient and/or caregiver to ensure a timely discharge or referral of the patient, related to identified measurable goals and interventions. 6. The clinical record for Patient #5, benefit period 03/08/2025 - 05/06/2025, evidenced the POC failed to include education and training for the patient and/or caregiver to ensure a timely discharge or referral of the patient, related to identified measurable goals and interventions. 7. The clinical record for Patient #6, benefit period 07/21/2024 - 09/18/2024, evidenced the POC failed to include education and training for the patient and/or caregiver to ensure a timely discharge or referral of the patient, related to identified measurable goals and interventions. 8. The clinical record for Patient #7, benefit period 12/23/2024 - 02/20/2025, evidenced the POC failed to include education and training for the patient and/or caregiver to ensure a timely discharge or referral of the patient, related to identified measurable goals and interventions. 9. During an interview on 03/27/2025 at 10:55 AM, the Administrator acknowledged the POCs for agency patients do not contain patient/caregiver education and training to meet goals for discharge in relation to identified measurable goals and interventions. 17-13-1(a)(1)(D)(xiii)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on record review, observation, and interview the agency failed to ensure staff followed manufacturer's guidelines for appropriate disinfection of equipment to prevent cross-contamination and ensure safety of staff and patients for 3 of 3 SN home visits (Patient #1, #2, #3). Findings include: 1. A review of a policy titled "HHA Bag Technique Procedure", indicated but was not limited to: "Observe the principles of Standard Precautions at all times…After providing care, clean all equipment with a home health agency-approved disinfectant…" 2. A review of the manufacturer's guidelines and recommendations listed on the container, indicated PDI Sani Cloth Plus Germicidal Disposable Wipes should be used to clean, disinfect hard, nonporous surfaces by unfolding a clean wipe to thoroughly wet surface, allow the surface to remain wet for five (5) minutes, then allow to air dry. If the surface area cleaned is used for food, then potable water rinse is required. When a cloth is used, disposable gloves should be worn to protect the user's skin. There are no directives given for use on porous surfaces. 3. During the home visit with Patient #1 on 03/26/2025 at 9:00 AM, RN 1 cleaned soiled equipment (oxygen sensor, thermometer, stethoscope, and manual blood pressure cuff) with PDI Sani Cloth Plus Germicidal Disposable Wipes. The RN failed to don gloves prior to using the wipes and failed to ensure the surface of the equipment remained wet for three (3) minutes and did not allow equipment to air dry before placing into nursing bag. Interview with RN 1 indicated agency staff was not educated on the guidelines to follow, listed on the PDI Sani Cloth Plus wipes container. Additionally, RN 1 indicated gloves are not usually worn when using the wipes and wet time/air dry time is not met when disinfecting equipment. 4. During the home visit with Patient #2 on 03/26/2025 at 10:15 AM, RN 1 cleaned soiled equipment (oxygen sensor, thermometer, stethoscope, and manual blood pressure cuff) with PDI Sani Cloth Plus Germicidal Disposable Wipes. The RN failed to don gloves prior to using the wipes. 5. During the home visit with Patient #3 on 03/26/2025 at 11:45 AM, RN 1 cleaned soiled equipment (oxygen sensor, thermometer, stethoscope, and manual blood pressure cuff) with PDI Sani Cloth Plus Germicidal Disposable Wipes. The RN failed to don gloves prior to using the wipes. 6. During an interview on 03/26/2025 at 1:30 PM, the Administrator indicated agency staff is expected to don gloves, wipe down soiled equipment, and let the equipment dry for a minute or a few. She acknowledged RN 1 did not follow manufacturer's guidelines for disinfectant usage with the PDI Sani Cloth Plus Germicidal Disposable Wipes during the home visits conducted. The Administrator acknowledged education is needed related to the manufacturer's guidelines as she was also unaware of the three (3) minute surface wet time. 17-12-1(m)

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an RN monitored the care provided to patients by the LPN for 2 of 3 home visit patients records reviewed (Patient #2, #3). Findings include: 1. A review of a policy titled "Patient/Client involvement in Care Planning", indicated but was not limited to: "If the patient/client is receiving care from an LPN/LVN, supervision will occur every 30 days and the patient/client may be visited by both the LPN/LVN and a Registered Nurse or by the Registered Nurse alone…" 2. The clinical record for Patient #2, benefit period 01/30/2025 - 03/30/2025, failed to evidence documentation of RN supervision for LPN care provided to patients. 3. The clinical record for Patient #3, benefit period 01/31/2025 - 03/31/2025, failed to evidence documentation of RN supervision for LPN care provided to patients. 4. During an interview on 03/27/2025 at 12:43 PM, the Administrator indicated LPN supervisory visits should be in the EMR under the supervisory visit tab. She acknowledged the EMR failed to evidence documentation an RN supervised LPN care provided to Patient #2 and #3. 17-14-1(a)(1)(J)

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 record review and interview, the agency failed to ensure discharge summaries were sent to patients' primary care provider within 5 business days of the patient's discharge for 2 of 2 closed records reviewed (Patient #6, #7). Findings include: 1. A review of a policy titled "Discharge/Transfer Policy" indicated but was not limited to: "A written discharge summary, which shall be prepared within 5 days of discharge, will be sent to the physician with a copy maintained in the clinical record…" 2. The clinical record for Patient #6, benefit period 07/21/2024 - 09/18/2024, evidenced a discharge date of 07/27/2024 and a discharge summary sent to the patient's primary physician on 08/15/2024. 3. The clinical record for Patient #7, benefit period 12/23/2024 - 02/20/2025, evidenced a discharge date of 12/24/2024 and a discharge summary sent to the patient's primary physician on 01/08/2025. 4. During an interview on 03/27/2025 at 2:45 PM, the Administrator indicated agency expectation is for the discharge summary to be sent to a patient's primary care provider within 5 days of the patient's discharge from the agency. She acknowledged the discharge summary for Patient #6 and #7 did not meet this requirement.