Every finding on record at Comfort Care Home Health Agency Inc

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 04/09/2025. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 04/09/2025. The provider had 70 current patients.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to maintain an accurate, updated medication profile in three of three home visit observations conducted (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider's undated, untitled policy, regarding medication reconciliation showed, in part, every time a skilled nurse visit is made the client shall be asked about any change in his/her medication regimen and if any new over the counter medications are found, these will be reported to the doctor and added to the medication administration record (MAR)/checked for major interactions and reported. When a clinician finds a new prescription bottle in the home, the label on the bottle serves as a physician’s order. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 06/25/2022 with a primary diagnosis of neuromuscular disfunction (a condition that disrupts the normal function of the nerves and muscles, or the junction where they connect) and other health conditions. Observation and interview on 04/08/2025 at 11:30 AM, showed the following discrepancy between the patient's home medications and the provider's medication profile: - The medication profile showed the patient took Nystatin (an antifungal) cream, apply to buttocks as needed; and - The patient and the patient's caregiver (CG) stated that this medicine had not been used "for a long time". Per an interview conducted during observation, the registered nurse (RN) - A stated that the Nystatin was on the provider's medication profile and confirmed it was no longer in use. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 12/11/2024 with a primary diagnosis of encounter for change or removal of surgical wound dressing. The patient lived at home with a family caregiver (CG). Observation and interview on 04/07/2025 at 1:00 PM, showed the following discrepancies between the patient's home medications and the provider's medication profile: - The provider's profile showed the patient took escitalopram oxalate (used to treat depression and anxiety) 20 milligrams (mg) by mouth once daily. The patient CG stated that the patient no longer took this medication; - The provider's profile showed the patient took hydralazine (used to treat high blood pressure) 50 mg by mouth twice daily. The patient CG stated that the patient took 50 mg once daily; - The provider's profile showed the patient took magnesium oxide (a mineral supplement) 400 mg by mouth once daily. The patient CG stated that the patient no longer took this medication; and - The provider's profile showed the patient took potassium chloride (used to treat low potassium levels) 20 milliequivalents (mEq) by mouth once daily. The patient CG stated that the patient no longer took this medication. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/05/2025 with a primary diagnosis of type 2 diabetes mellitus (a chronic disease that affects how the body uses sugar for energy), high blood pressure and other diseases. Observation and interview on 04/08/2025 at 8:00 AM, showed the following discrepancies between the patient's home medications and the provider's medication profile: - The provider's profile showed the patient took metoprolol tartrate (an immediate release medicine used to treat high blood pressure)25 mg by mouth twice daily. The CG stated that the patient took metoprolol succinate (an extended release high blood pressure medicine) 25 mg once daily at bedtime; - The provider's profile showed the patient took naproxen 500 mg, one tablet twice daily as needed for pain/swelling. The CG stated that the patient no longer took this medication; - The patient took docusate sodium 100 mg (used to prevent constipation). The provider's profile failed to include this medication; - The patient took simethicone chewable 80 mg four times a day for gas. The provider's profile failed to include this medication; and - The the CG stated that patient used Calmoseptine ointment (used to protect the skin) "at times" and the provider's profile failed to include this medication. During a home visit observation on 04/08/2025 starting at 8:00 AM, the patient’s medications were reviewed with the patient’s cg. Review of the patient’s home medications and the provider’s medication profile, dated 04/07/2025, showed the following discrepancies: -Metoprolol tartrate (used to treat high blood pressure) 25 mg by mouth twice daily. The cg stated that the patient no longer took this medication, the cg stated that the patient took metoprolol succinate (also used to treat high blood pressure) 25 mg at bedtime; and -Naproxen 500 mg, one tablet twice daily as needed for pain and or swelling, the cg stated that the patient no longer took this medication. The provider medication list failed to contain: -Docusate sodium 100 mg. The patient cg stated that the patient used this medication for constipation; -Simethicone 80 mg chew and swallow four times a day for gas, the cg stated that the patient had this medication when needed; and -Calmoseptine ointment (used to protect the skin), that the patient used “at times”. During an interview on 04/09/2025 at 12:00 PM, the home health administrator stated that he/she would expect the medications to be reconciled per policy and should match what the patient is taking.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure all documented entries included appropriate authentication that included an accurate signature date of clinician visits in three of six records reviewed (Records/Patients #2, #3, and #5). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated, undated policy, regarding documentation expectations provided by the alternate administrator showed, in part, all visit notes must be completed with 24-28 hours unless it is the start of care Outcome and Assessment Information Set (OASIS - a standardized data collection tool) and "they can be up to 5 (five) days". RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 12/11/2024 with a primary diagnosis of encounter for change or removal of surgical wound dressing. The patient lived at home with a family caregiver. Review of the clinician visit notes showed the following: - A skilled nurse (SN) visit was made on 02/08/2025 and signed/completed by the clinician on 02/15/2025 (seven days later); - A SN visit was made on 02/24/2025 and signed/completed by the clinician on 03/03/2025 (seven days later); - A SN visit was made on 03/03/2025 and signed/completed by the clinician on 03/11/2025 (eight days later); - An occupational therapy (OT) visit was made on 03/11/2025 and signed/completed by the clinician on 03/16/2025 (five days later); - A physical therapy (PT) visit was made on 03/25/2025 and signed/completed by the clinician on 03/29/2025 (four days later); and - A PT visit was made on 03/29/2025 and signed/completed by the clinician on 04/06/2025 (eight days later). RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/05/2025 with a primary diagnosis of type 2 diabetes mellitus (a chronic disease that affects how the body uses sugar for energy), high blood pressure, and other diseases. Review of the clinician visit notes showed the following: - A SN visit was made on 02/17/2025 and signed/completed on 02/21/2025 (four days later); and - A resumption of care visit was made on dated 03/13/2025 and signed/completed by the clinician on 04/08/2025 (26 days later). RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 01/15/2025 with a primary diagnosis of type 2 diabetes mellitus. The patient lived at home with a family caregiver. Review of the clinician visit notes showed the following: - A SN visit was made on 01/15/2025 and signed/completed by the clinician 02/14/2025 (30 days later); - A PT visit was made on 01/15/2025 and signed/completed by the clinician on 02/02/2025 (18 days later); - A SN visit was made on 01/17/2025 and signed/completed by the clinician on 03/10/2025 (52 days later); - A SN visit was made on 01/29/2025 and signed/completed by the clinician on 02/20/2025 (22 days later); and - An OT visit was made on 02/06/2025 and signed/completed by the clinician on 02/09/2025 (three days later). During an interview on 04/08/2025 at 3:00 PM, the home health alternate administrator stated that he/she would expect clinicians to document visits per the provider policy.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 04/20/2022. During the survey it was determined Comfort Care Home Health Agency, Inc. is in compliance with the requirements of 42 CFR 484.102. Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Comfort Care Home Health Agency, Inc. was completed on 04/20/2022. The agency had 89 current patients.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on home visit observation and interview, the agency failed to provide, in writing, the name and contact information of the administrator in one (Record/Patient #1) of three home visits conducted. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1: During a home visit observation, conducted on 04/18/2022 at 10:35 AM, the agency-provided admission packet contained the name and contact information of the agency’s previous administrator to lodge complaints. During an interview on 04/19/2022 at 3:00 PM, the administrator and alternate administrator both stated that they began working in their positions on 02/01/2022 and changed the contact information in their new admission packets but were not aware that they needed to update the information in the packets of patients who began services prior to their hire date.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on review of the agency’s current patient rights information, home visit observation, and interview, the agency failed to ensure patients were advised, orally and in writing, of the extent to which payment for services may be expected from Medicare, Medicaid, or any other Federally-funded or Federal aid program known to the home health agency (HHA) in, but not limited to, one (Record/Patient #1) of one home visit observation. This deficient practice has the potential to affect all patients served by the agency. Findings included: On 04/18/2022, the clinical manager provided an admission packet for review that included the agency’s current patient rights information. Review of the patient rights information showed the agency failed to ensure that the agency must advise the patient, orally and in writing, of: - The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA; - The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA; - The charges the individual may have to pay before care is initiated; and - Any changes in the information provided in accordance with paragraph (c) (7) of this section when they occur. Observations conducted on 04/18/2022, at 10:35 AM, during patient #1’s home visit, showed the patient rights information failed to include the right that the agency must advise the patient, orally and in writing, of the information noted above. During an interview on 04/18/2022 at 10:20 AM, the administrator and alternate administrator stated that they were not aware of the change in the regulatory language.

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 the agency’s current patient rights information, home visit observation, and interview, the agency failed to ensure the patient was advised of the name, address, and telephone number of the Federally-funded and state-funded entities that serve the area where the patient resides. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s admission packet, which included the patient’s rights information given to patient’s at the start of care, failed to show the name, address, and telephone number of the current quality improvement organization. During an interview on 04/18/2022 at 10:20 AM, the administrator and alternate administrator stated that they were not aware of the change in the quality improvement organization.

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 policy review, clinical record review, and interview, the agency failed to ensure compliance with the elements of an individualized plan of care in two (Records/Patients #3 and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Plan of Treatment (Care),” amended 06/10/2008, showed the plan of treatment is developed in consultation with the agency staff and covers all pertinent diagnoses, including: - Types of services, supplies, and equipment required; - Medications and treatments; - Any safety measures to protect against injury; - Patient/caregiver teaching/training; - Patient specific interventions and education; - Measurable outcomes and goals identified by the agency and the patient; - Any other appropriate items (laboratory procedures, any contraindications or precautions to be observed); and - Strengths, goals, and care preferences. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services, on 03/23/2022, with a primary diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe, COPD) and with a secondary diagnosis of pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). The patient lives in his/her own home with his/her spouse. Review of the skilled nurse notes showed the following: - On 03/28/2022: * The patient’s oxygen saturations (the percentage of oxygen in someone’s blood, normal levels are usually 95% to 100%) were 89%; * The patient’s insurance will not pay for oxygen therapy; * The skilled nurse educated the patient on using an incentive spirometer (a handheld medical device used to help patients improve the function of their lungs by training patients to take slow deep breaths); - On 03/31/2022 and 04/05/2022 the patient: * Used his/her spouse’s oxygen at 3 liters/minute; * Was educated by the nurse on using the incentive spirometer; * Used a cane to assist with walking; * Was smoking cigarettes; and - On 4/12/2022 the patient used his/her spouse’s oxygen at 3 liters/minute. Review of the plan of care (POC), dated 03/23/2022, showed the POC failed to: - Include the cane on the list of durable medical equipment (DME); - Contain information that the patient used his/her spouse’s oxygen; - Include instructions for the nurse to educate on using incentive spirometer; and - Provide education on safety precautions related to smoking while using oxygen in the home. During an interview on 04/18/2022 at 3:00 PM, the clinical manager stated he/she would expect the cane to be added to the DME and the incentive spirometer, oxygen use and smoking to be addressed on the plan of care. Findings included: RECORD/PATIENT #3: Clinical record review showed the patient was admitted to home care on 03/22/2022 with diagnoses of, but not limited to, chronic obstructive pulmonary disease (disease of the lungs, making it hard to get adequate air when breathing) and hypertensive heart disease (CHF included in this heart disease). Review of the patient's POC dated 03/22/2022 to 05/20/2022 showed the following order for the skilled nurse (SN) to assess for signs and symptoms of CHF. POC directed the nurse to monitor daily weights and report weight gain greater than three pounds in 24 hours. CHF exacerbation complications related to insomnia, essential tremor, etc. Review of the SN visit note on 04/11/2022 showed no weight recorded. Clinical record review findings were reviewed with the clinical manager on 04/19/2022 at 3:30 PM. the clinical manager concurred with the findings and no additional information was provided.

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 policy review, home visit observation, and interview, the agency failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases in two (Records/Patients #1 and #2) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #2: The patient was admitted to home health services on 03/30/2022 with a primary diagnosis of hypertensive heart (heart problems after blood pressure being high over a period of time) disease and chronic kidney disease (kidneys damaged and can no longer filter blood). He/she lives in his/her own home. Observation on 04/18/2022 at 1:45 PM, during the patient's home visit, showed: - The physical therapy assistant (PTA) cleaned the equipment that he/she used assessing the patient's vital signs wearing gloves; - The PTA placed his/her equipment back in his/her supply bag; and - The PTA removed his/her gloves and failed to perform hand hygiene after glove removal. During an interview conducted immediately following the home visit observation, the PTA concurred that he/she should have performed hand hygiene after glove removal. Findings were discussed with the clinical manager on 04/18/2022 at approximately 4:30 PM, the clinical manager stated that hand hygiene should have been performed after glove removal. Findings included: Review of the agency’s undated policy titled, “Infection Control Policy,” showed thorough hand washing must be carried out before putting on gloves and after glove removal. Review of the agency’s undated policy titled, “Infection Control Program,” showed: - Hand hygiene should be performed, at a minimum: * Before contact with a patient; * After contact with the patient or objects in the immediate vicinity of the patient; and * After removal of personal protective equipment (PPE); - Examples of PPE include gloves, gowns, face masks; and - Disinfecting wipes and disinfecting spray will be utilized to disinfect the reusable equipment after each patient use. RECORD/PATIENT #1: The patient was admitted to home health services on 01/07/2022 with a primary diagnosis of necrotizing fasciitis (a serious bacterial infection that destroys tissue under the skin, also called flesh-eating disease) and recently underwent a reversal of a colostomy (a surgically created opening in the abdominal wall for passing stool that bypasses a damaged part of the colon). He/she lives in his/her own home with his/her adult child. Observation on 04/18/2022 at 10:20 AM, during the patient’s home visit, showed: - The registered nurse (RN) donned gloves to obtain the patient’s vital signs; - The RN cleaned the blood pressure cuff while wearing the soiled gloves and placed the cuff back into his/her clean equipment bag; - The RN failed to remove soiled gloves and perform hand hygiene before he/she picked up and placed the cleaned cuff back into his/her bag; - The RN donned gloves to remove the soiled dressing from the patient’s abdomen; - The RN picked up his/her phone and took photographs of the wound; - The RN failed to remove the soiled gloves and perform hand hygiene after removing the dressing, before picking up the phone; - The RN failed to disinfect the phone after touching it with the soiled gloves. Per an interview conducted on 04/18/2022 at 11:20 AM, during the home visit, the RN stated that he/she didn’t think about the soiled gloves contaminating the equipment and phone but he/she could see how it could transmit infectious material onto the items. Findings were discussed on 04/19/2022 with the administrator, alternate administrator, clinical manager, and RN nurse consultant. The nurse consultant, clinical manager and administrator stated that hand hygiene should have been performed after patient contact and after the removal of the soiled dressing before any clean equipment or personal items were touched.