Every finding on record at Comfortcare Home Health

*EMERGENCY PREPAREDNESS* Survey conducted on 04/14-04/17/2025 revealed the above facility meets all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.

*LAUREL * The Medicare Recertification survey conducted 04/14-04/17/2025 revealed the above facility has met all Medicare Conditions of Participation for Home Health Agencies (HHA). However, Standard-level deficiencies were cited. ___________________

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on staff interview, policy and procedure review, and review of the facility report “HHA error summary by agency”, the facility failed to encode and electronically transmit each completed Outcome and Assessment Information Set (OASIS) assessment within 30 days of completing the assessment of the beneficiary for 48 patients in the past 12 months; 04/01/2024 to 04/01/2025. Findings Include: An interview with the Director on 04/14/2025 at 11:35 a.m. confirmed the agency is supposed to submit OASIS data within 30 days of completing Oasis Data Sets. Review of the facility Internet Quality Improvement and Evaluation System (IQIES) report, “The HHA Error summary report by Agency”, dated 04/11/2024-04/11/2025 for the past 12 months revealed, Error -3330 for 48 patient assessments submitted late within 30 days of completing the assessment of the beneficiary. Review of facility’s policy, “Oasis Data Submission” dated 11/01/2000 revised date 09/21/2011, confirmed “Purpose: To outline the proper procedure for OASIS Data Submission…2. End of the Month…6. Assessments are sent to the state NO LATER than the 30 days after the day of completion…”. During the exit conference on 04/17/2025 at 12:30 p.m. with the Administrator, Director of Nursing, and Special projects coordinator, survey findings were discussed, and no further documentation was submitted for review.