Every finding on record at Comfort Home Health LLC

An Emergency Preparedness survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 for a Home Health Provider and Supplier. Survey Dates: August 20, 21, 22, and 23, 2024 Census: 30 At this Emergency Preparedness survey, Comfort Home Health was found to be in compliance with Conditions of Participation 42 CFR 484.102 Emergency Preparedness requirements for Medicare Participating Providers and Suppliers.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey dates: August 20, 21, 22, and 23, 2024. 12 Month Unduplicated Skilled Admissions: 5. Partially Extended Survey Announced on 08/21/2024 at 3:05 PM. This deficiency report reflects State findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR 9/4/2024 A2

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, observation, and interview, the agency failed to ensure the plan of care (POC) included all medical equipment, correct quantity of medications, current medications, all safety measures, and patient-specific measurable goals for 4 of 5 active records reviewed (Patient 1,2,3,5). Findings include: 1. Review of an agency policy titled “Practitioners Plan of Treatment” indicated the plan of care must include medications, safety measures, medical equipment, and measurable goals. 2. Review of an agency policy titled “Development of Care Plan” indicated the plan of care should be revised to reflect the changing care needs of the patient. 3. Review of an agency policy titled “Vital Sign Parameters” indicated the physician can establish specific parameters for individual patients and will be written as an order. 4. Review of the clinical record of Patient #1 included plans of care for certification periods 06/11/2024 – 08/09/2024 and 08/10/2024 -10/08/2024 that indicated the following goals: Bowel status will be within normal limits (WNL) for patient and Urinary elimination will be WNL for patient. POC documentation failed to evidence the goals were measurable. During an interview on 09/21/2024 at 2:50 PM the clinical supervisor indicated the goals with WNL depended on the patient and were not measurable. 5. Review of the clinical record of Patient #2 included plans of care for certification periods 06/20/2024 – 08/18/2024 and 08/19/2024 – 10/17/2024 that indicated the following goals: Bowel status will be WNL for patient and Urinary elimination will be WNL for patient. POC documentation failed to evidence the goals were measurable. During an interview on 08/21/2024 at 2:37 PM, when asked how someone reading the WNL goals would know how they are measurable, registered nurse (RN) 2 indicated they wouldn’t. 6. Review of the clinical record of Patient #3 included plans of care for certification periods 06/03/2024 – 08/01/2024 and 08/02/2024 – 09/30/2024 that indicated the following goals: Blood pressure (BP) range will be within physician established parameters and bowel status will be WNL for patient. Certification period 08/02/2024 – 09/30/2024 included a goal: urinary elimination will be WNL for patient. The following medications with start date, 04/10/2023, were listed as on hold: buspirone (used to treat anxiety) and magnesium oxide (used to treat heartburn). POC documentation failed to evidence the goals were measurable, failed to evidence medications on hold status for 2 certification periods were made active or discontinued, and failed to evidence physician established parameters for BP. During a home visit on 08/21/2024 beginning at 9:00 AM, observed Patient #3 step into shower and sit on shower stool while home health aide assisted with the shower. The shower stool failed to be listed on the plan of care. During an interview on 08/21/2024 at 11:44 AM, the alternate clinical supervisor indicated medications of Patient #3 were stored in a lock box due to the people coming in and out of the home. When asked where this information would be found in the POC, the alternate clinical supervisor indicated should be included as a medication safety measure. POC documentation failed to evidence a lock box as a safety measure. When asked where to find the shower stool in the POC, the alternate clinical supervisor indicated it should be in equipment in POC. POC documentation failed to evidence shower stool as equipment. When asked why buspirone and magnesium oxide were on-hold, the alternate clinical supervisor indicated Entity 1 does not want to refill these medications and they should be discontinued. When asked where to find the physician established BP parameters, the alternate clinical supervisor indicated should be in the POC. When asked how to measure the goals bowel status and urinary elimination WNL for patient, the alternate clinical supervisor indicated the goals are not measurable and need more detail. 7. Review of the clinical record of Patient #5 included plans of care for certification periods 06/02/2024 – 07/31/2024 and 08/01/2024 – 09/29/2024 that indicated the goal, urinary elimination will be WNL for patient, and included a medication probiotic (treats bowel problems) cap(s) [sic] daily. POC documentation failed to evidence goal was measurable and failed to evidence the dosage of the probiotic. During an interview on 08/22/2024 at 1:29 PM, when asked how the goal urinary elimination WNL was measurable, licensed practical nurse (LPN) 1 indicated he/she knows the goal would be the number of diapers used each day and indicated the goal does not include that information. When asked how many probiotic capsules are administered daily, LPN 1 indicated one powder packet is given each day, not capsules. 410 IAC 17-13-1(a)(1)(C)(ii)(ix)(x)

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 record review and interview, the home health agency failed to ensure the revised plan of care (POC) was up-to-date and supported by the comprehensive assessment for 1 of 3 active records reviewed of patients receiving skilled nurse only services (Patient #5). Findings include: 1. Review of an agency policy titled “Development of Care Plan” indicated revisions of the POC are done to reflect the changing care needs of patients. 2. Review of the clinical record of Patient #5, start of care date 02/24/2020, included pediatric visit notes completed on 05/28/2024 and 07/27/2024 by licensed practical nurse (LPN) 1 that indicated skin was normal and no wounds were documented. Review of the plans of care for certification periods 06/02/2024 - 07/31/2024 and 08/01/2024 – 09/29/2024, included treatment orders for the following wound dressings: medihoney wound and burn dressing (assists in the removal of dead tissue and aids in wound healing) to external top of spine twice a day and a wet to dry wound dressing (wet gauze applied to wound, allowed to dry, and dead tissue removed with removal of dressing) to the external base of the spine daily, start date 01/31/2024. During an interview on 08/22/204 at 1:29 PM, when asked what wound care is currently being done for Patient #5, LPN 1 indicated Patient #5 has no wounds. When asked when the wound to the top of the spine healed, LPN 1 indicated documentation indicated healed around 02/20/2024. When asked when the wound to the base of the spine healed, LPN 1 indicated documentation indicated healed around 03/08/2024 when Patient #5 was seen by Entity 2. Review of physician orders for Patient #5 entered by the clinical supervisor on 08/21/2024 indicated the wound dressing order to the top of the spine discontinuation date, 02/17/2024, and the wound dressing to the base of the spine discontinuation date, 03/29/2024. During an interview on 08/22/2024 at 2:05 PM when asked why the orders to discontinue wound care for Patient #5 were entered on 08/21/2024, the clinical supervisor indicated when records of Patient #5 were requested, he/she entered the orders to discontinue wound care for the wounds that were healed in March 2024.

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 observation, record review, and interview, the agency failed to ensure infection control practices were upheld for hand hygiene for 2 of 3 active records reviewed with home visits (Patient #2,3). Findings Include: 1. Review of an agency policy titled “Standard Precautions For All Health Care Workers” indicated hands must be washed or antibacterial solution must be used before and after contact with patient and hand hygiene is required when gloves are removed. 2. During a home visit with Patient #2 on 08/21/2024 at 1:00 PM, registered nurse (RN) 2 was observed applying gloves with no hand hygiene, RN 2 prepared medications and nutritional supplement and administered them through Patient #2 GJ (gastrojejunostomy tube inserted through the abdomen into the stomach and the small intestine to provide an alternative way for feeding) tube. RN 2 removed her gloves and failed to perform hand hygiene. RN 2 applied CPT (chest physical therapy vest that uses vibrations to help move mucus out of the lungs) vest to Patient #2. RN 2 applied gloves, without performing hand hygiene, performed oral suctioning, and administered an albuterol nebulizer (turns liquid into an aerosol that can be breathed in through the mouth and nose to loosen mucus in the lungs) treatment. RN 2 removed gloves and failed to perform hand hygiene after removing her gloves. During an interview on 08/21/2024 at 2:37 PM, when asked what should be done before putting on gloves and after removing gloves, RN 2 indicated she should have washed her hands. 3. During a home visit with Patient #3 on 08/21/2024 at 9:00 AM, home health aide (HHA) 1 was observed wearing gloves and attempting to change the light bulb in Patient’s bathroom. HHA 1 removed her gloves and failed to perform hand hygiene after removing her gloves. HHA 1 applied gloves, failed to perform hand hygiene and assisted Patient with showering and shampoo. HHA 1 removed her gloves, failed to perform hand hygiene, and donned new gloves. HHA 1 assisted Patient #3 with putting on pants, transferred Patient from shower stool to toilet stool, and applied deodorant and shirt. HHA 1 removed her gloves failed to perform hand hygiene and placed dirty laundry in the washing machine. During an interview on 08/21/2024 during the home visit, when asked what should be done before putting on gloves and after removing gloves, HHA 1 indicated she should have done hand hygiene. 410 IAC 17-12-1(m)