Deficiency Index

Every finding on record at Comforthome Caregivers, LLC

Conroe, Texas · CCN 748048

2 findings across 1 survey, in the inspector's own words.

The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.

Survey of February 21, 2025

2 findings
G0000

Surveyor attempted an entrance for a re-licensure and recertification on 2/21/25 at 10:30 am. Agency Census: Unknown ABBREVIATIONS: HHSC – Health and Human Services Commission Adm-Administrator

G0948

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview on 2/21/2025 at 10:30am, the Administrator failed to assume appropriate responsibility for all day-to-day operations of the agency in that the administrator did not ensure that: - The administrator failed to ensure that agency posted contact information when office was closed. - The administrator failed to ensure that agency had a message recording on the agency’s phone number of who to contact in the event of patient needs or emergency. -The administrator failed to be available or have the alternate administrator or designee available to allow a surveyor entry. These failed practices could harm agency’s patients due to the administrator’s inability to properly manage the operations of the agency to ensure safe delivery of care. Pre-survey record review on 2/18/25 of web-based licensure system Texas Unified Licensure Information Portal (TULIP) revealed an administrator, alternate administrator, supervising nurse, and alternate supervising nurse. TULIP also listed the agency address, hours, and contact number. On 2/21/2025 at 10:30am surveyor arrived at the facility with the last physical attempt to contact the agency with no success. At 10:36 am another phone call was made with only the success of being able to leave a message on one of the lines. At 11:04 am pictures were taken with state phone device of the front of the agency’s building. The surveyor left the agency at 1:15pm. At 4:00pm an email was sent to the emails provided on TULIP regarding the attempts made to contact the agency.

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Federal survey findings only. State licensure findings for home health agencies are not shown.

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