Every finding on record at Life Comfort Care, Inc.

Observed in Record Review. In 4 of 11 patient records reviewed, it was noted that the RN did not visit at least every 15 days to update the comprehensive assessment. For example in record review #1 and 2 and the record for home visit #1 the RN had not visited since 7/27/22, in record #4 there was no RN visit made between 7/21 and 8/23/22. This was confirmed by the DON.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that the plan of care did not contain measurable or timed outcomes. For example, in record review #4 the stated goals for pain were stated as takes Tylenol as needed, has Roxanol if needed and will remain at a comfortable level during care. In record review #6 the goal for pain was stated as will continue to monitor pain every visit to make patient comfortable, and for weakness the goal was stated as use safety measures to minimize potential for injury. In record review #7 the goal for weakness was stated as will increase strength for optimal functional activities and the goal for incontinence was stated as verbalizes having urinary needs met at an acceptable level. This was discussed with and confirmed by the DON.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted in record review for home visit #3 that medication orders were incomplete or inaccurate. For example, Tylenol was ordered as a 650 mg tab every 4 hours PRN for pain or temperature and also Dexamethasone 1 ml IM as needed without a frequency. This was confirmed by the DON.

Observed in Record Review. In 5 of 11 patient records reviewed, it was noted that the plan of care was not revised to include information from the patient assessments. For example, in record review #3, the patient developed a UTI and had a fall and neither was added to the care plan. In record #6 the patient had a fall and a new wound and neither were added to the plan of care. In record review #5 the patient suffered a fracture of left femur and patella requiring changes in activity and also a UTI and neither were added to the plan of care. In review of record for home visit #1 it was noted that the patient had long term coumadin use and also developed a new wound but neither were added to the care plan and additionally, wound care was no longer being provided but orders for the wound care were not discontinued. In record review for home visit #2 the patient developed a UTI in April and July however the plan of care was not updated to include these issues. This was discussed with and confirmed by the DON.

Observed in Record Review. In 5 of 11 patient records reviewed, it was noted that care was not provided as ordered in the plan of care. For example, in record review #2 the SN frequency was twice weekly but in two different weeks only one visit was made. In record review #3 the SC was to see the patient monthly however there were no visits in July or thus far in August. In record review #4 there was one week when SN visits were not made as ordered. In record review #5 there was no visit made by the MSW for the month of June and visits were ordered monthly and in the same patient the SN frequency was incorrect for two weeks. In record review for home visit #2 there was no monthly visit made in July for the MSW. This was discussed with and confirmed by the DON.

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that cleaning of equipment and bag technique were not followed. For example, in home visit #1 the LVN was observed cleaning equipment both before and after use with an alcohol wipe and immediately placing them back into a large duffle bag without any distinction of a clean or dirty side. In home visits #2 and #3 the RN was observed cleaning equipment using a skin cleansing wipe and applying hand sanitizer prior to cleaning the equipment. This was discussed with the DON. Observed in Tracer Visit. In 1 of 3 home visits conducted, the LVN was observed in home visit #1 not performing hand hygiene following glove removal and prior to donning new gloves. This was discussed with the DON and the staff member.

Observed in Record Review. In 2 of 3 patient records reviewed, where the patient developed an infection during the certification period it was noted that there was no surveillance documentation or completed infection report. This was noted in record review #5 and record review for home visit #2 and discussed with and confirmed by leadership.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that the aide assignment sheet was incomplete. For example, in record review #1 and #8 it was noted that there was no bath type selected by the RN. Additionally, in record review #3 the aide assignment sheet was blank. This was reviewed with and confirmed by the DON.

Observed in Record Review. In 5 of 11 patient records reviewed, it was noted that the supervisory visits for the CHHA were not documented at least every 14 days. In record #1 and 2 there was 27 days between supervisory visits. In record #4 there were no supervisory visits between 7/21 and 8/23/22. In record review #5 and 6 there was more than 50 days between supervisory visits. This was reviewed with and confirmed by the DON.

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that the medication sheet did not reflect what the patient was actually taking. For example, in home visit #2 the hospice medication sheet listed Tylenol as a PRN medication however there was no Tylenol in the patient's medication drawer and the patient denied taking this medication. In home visit #3, the hospice medication sheet stated Tresiba Flex 20 units daily however the patient was taking Lantus 22 units daily since 6/30/22. In addition the hospice medication sheet stated Tylenol in tablet or suppository form however the patient was using the liquid form. In another example the hospice medication sheet listed Dexamethasone IM however this medication was not in the home. The patient was taking Amlodipine 10 mg nightly since 6/30/22 however this medication was not on the hospice medication sheet. In home visit #1 the hospice medication sheet listed Promethazine however this medication was not in the patient's medication drawer. This was confirmed by the DON present on the visits. Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that in record review #1 the MSW assessment was blank, in record review #2 there was no spiritual assessment, in record for home visit #1 and in record review #1 the narrative from the previous IDG meeting were blank. This was confirmed by the DON.

Observed in Document Review. In 1 of 2 contracts reviewed, for DME products it was noted that one of the contracts did not meet the Medicare DMEPOS Supplier Quality and Accreditation Standards at 42 CFR §424.57. For example the DME supplier contract was signed on 5/20/22 as a new provider and they had not yet undergone accreditation however had applied on 8/12/22. Five current patients were served under this contract. This was confirmed with the office manager in charge of contracts.

Observed in HR File Review. In review of the HR file for the Medical Director it was noted that the license had expired on 10/31/20 but the verification was not run until 3/1/21. This was confirmed by the HR staff member.