Comfort Care Medicare Inc

The agency failed to ensure the patient had the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to completion of all assessments, care to be furnished, establishing and revising the plan of care, disciplines…

The agency failed to follow a Plan of Care (POC) established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan of Care (POC) for 3 of 6 sampled patients (Patients #2…

The agency failed to ensure the patient participated in, was informed about, and gave consent or refused care in advance of and during treatment for 6 of 6 sampled patients (Patients #1, #2, #3, #4, #5, and #6).

The agency failed to include the patient's diagnosis on the Plan of care (POC) for 1 of 6 patient reviewed (Patient #5).

The agency failed to provide medications, treatments or services only as ordered by the physician for 3 of 4 sampled patients with therapy services (Patients #1, #2, and #3).

The agency failed to ensure the emergency preparedness plan reviewed every 2 years.

The home health agency failed to complete an individualized emergency plan developed as part of the comprehensive assessment, maintaining documentation of the plan in the patient's chart and in the patient's home setting, for 1 of 3 sampled patients with home visits (Patient #3).

The agency failed to ensure participation an emergency preparedness exercises annually.

The agency failed to comprehensively provide wound assessments for 1 of 3 sampled patients with wounds (Patients #7) and failed to provide a comprehensive patient assessment with recertification assessments 1 of 2 patients with wounds (Patient #7).

The home health agency failed to ensure the drug regimen review identified at a minimum the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and/or patient compliance with medications for 7 of 8 sampled patients (Patients #1, #2, #3…

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 2 of 3 home visit observations (Patients #2 and #3).

The agency failed to provide agency patients with written medication schedule/instructions, including: medication name, dosage and frequency.

The agency failed to provide agency patients with written information on any treatments to be administered by agency personnel acting on behalf of the agency, including therapy services.

The agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 1 of 3 sampled patients receiving home health aide services…

The agency failed to ensure the clinical record included the patient's current documentation and a complete chart for 3 of 8 sampled patients (Patients #1, #5 and #8).

The agency: 1) failed to ensure agency staff followed the plan of care in the delivery of services and alerted the physician to changes in the plan of care (G0572); 2) failed to ensure the Plan of Care accurately reflected recertification dates, care, treatment and services provided to the patient…

The agency: 1) failed to develop a Quality Assessment and Performance Improvement (QAPI) program which included measurable improvements in indicators for which there is evidence that improvement may improve patient health and safety outcomes and increase quality of care.

The agency failed to follow a Plan of Care established and periodically reviewed by a doctor of medicine, osteopathy or podiatry or notify the physician of the need to vary from the physician ordered Plan for Care for 3 of 10 sampled patients (Patients #4, #5 and #6).

The agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program which included measurable improvements in indicators for which there is evidence that improvement may improve patient health and safety outcomes and increase quality of care.

The agency failed to use quality indicator data derived from Outcome and Assessment Information Set (OASIS) and other relevant data when designing it's Quality Assessment and Performance Improvement (QAPI) program.

The agency failed to identify performance improvement activities to track adverse patient events, analyze cause and implement preventative actions.

The agency failed to document reasons for conducting performance improvement projects and the measurable progress achieved on these projects which reflect the scope, complexity and past performance of the home health agency's services and operations.

The agency failed to ensure the governing body oversees an ongoing Quality Assessment and Performance Improvement (QAPI) program that addresses priorities for improved quality of care and patents safety, all improvement actions are evaluated for effectiveness; clear expectations are established…

The agency failed to ensure staff provided care in accordance with agency expectations and accepted infection control standards of practice for staff observed during a home visit for 2 of 6 patients (Patients #1 and #2).

The agency failed to ensure agency staff ensured the patient participated in, informed about and had consent or refused care in advance of and during treatment before the agency initiated care for 1 of 11 sampled patients (Patients 3).

Agency policy review the agency failed to provide an initial assessment visit within 48 hours of receipt of referral and/or return home, for 1 of 11 sampled patients (Patients #3).

The agency failed to complete a drug regimen review, including all required components, with each comprehensive assessment within the allowed timeframe for 5 of 10 sampled patients (Patients #4, #5, #6, #8 and #9).

Agency clinicians failed to complete updates to the comprehensive assessment at recertification in the last 5 days of each certification period for 2 of 7 sampled patients requiring a recertification assessment (Patients #1 and #2).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient and accurate recertification dates for 3 of 10 sampled patients (Patients #1, #5 and #6).

The agency staff failed to provide medications and treatments only as ordered by the physician for 6 of 10 sampled patients (Patients #1, #3, #4, #5, #6 and #7).

The agency failed to focus performance improvement activities on high risk, high volume or problem prone areas.

The agency failed to focus performance improvement activities on high risk, high volume or problem prone areas.

The agency failed to identify a problem that directly or potentially threaten the health and safety of patients.

The agency failed to aim actions at performance improvement and measure the success of implementation of those actions, tracking performance to ensure the improvements are sustained.

The agency failed to ensure 4 of 4 sampled home health aides (Staff M, N, P and Q), assigned to perform tasks requiring extra skills exceeding the level of basic home health skills for 3 of 5 sampled patients (Patients #8, #9 and #10) with home health aide services, had documented evidence of…

The agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed in writing by the skilled professional assigning the home health aide to the patient for 3 of 5 sampled patients receiving home health aide services…

The agency failed to ensure the documentation of annual on-site supervision to the location where the patient is receiving care in order to assess each home health aide while the aide is performing patient care for 2 of 2 sampled home health aides (Staff M and N) requiring annual on-site…

The agency failed to ensure the patient's clinical record included accurate documentation of interventions and maintained pertinent current information in the patient record for 3 of 10 sampled patients (Patients #2, #5 and #6).

The agency: 1) Failed to ensure start of care comprehensive assessments were completed by the fifth day following each patient's start of care.

The agency failed to: 1) determine satisfactory competency with extra skills provided as an extension of nursing prior to assigning an aide to a patient who required the task to be performed (Please refer to G768); 2) assure all aides are assigned specific, individualized tasks for each patient by…

The agency failed to have a written policy and procedure for cooperation and collaboration with tribal, State, and Federal emergency preparedness officials.

The agency.

The agency failed to ensure the development of a procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation.

The agency failed to ensure the development of a written policy and procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency.

The agency failed to have a written policy and procedure for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

The agency's emergency preparedness communication plan failed to include contact information for tribal, state, and federal officials and other sources of assistance.

The agency failed to ensure training in emergency preparedness to all existing staff consistent with their expected roles for directly hired and contracted staff in 2017 and 2018. The agency provided services to 329 patients at the time of the survey.

The agency failed to ensure participation in two emergency preparedness exercises in 2018. The agency reported a current census of 329 patients.

The agency failed to transmit OASIS data within 30 days of the OASIS M0090 date for 7 of 7 sampled patients requiring transmission of OASIS data (Patients #2, #7, #8, #9, #10, #11 and #13).

The agency failed to ensure 4 of 5 sampled home health aides (Home Health Aides K, L, M and N), assigned to perform tasks requiring extra skills exceeding the level of basic home health skills for 3 of 4 sampled patients (Patients #1, #5 and #8) receiving the assigned tasks after 7/1/19, the…

The agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 7 of 9 sampled patients receiving home health aide services after 7/1/19, the agency's projected plan of correction date (Patients #1, #2, #5, #6…

The agency failed to ensure authentication of hand written entries made in each patient's clinical record included the employee's signature, title, date and time of the signature for 7 of 14 sampled patients (Patients #1, #2, #7, #9, #10, #13, and #16).

The agency failed to ensure the completion of all pertinent components of the comprehensive assessment by the fifth day following the start of care for 4 of 13 sampled patients (Patients #1, #8, #11 and #13).

The agency failed to complete a drug regimen review with each comprehensive assessment for 3 of 4 sampled patients requiring a comprehensive assessment after 8/12/19, the agency's previous plan of correction date (Patients #3, #4 and #13 ).

The agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 6 of 9 sampled patients requiring a recertification assessment (Patients #1, #2, #4, #7, #10, and #11).

The agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 2 of 4 sampled patients requiring a resumption of care assessment (Patients #4 and #11).

The agency failed to provide medications, treatments or services only as ordered by the physician for 4 of 14 sampled patients (Patients #3, #6, #12 and #16).

The agency failed to report changes in patient clinical findings or changes in patient needs to the physician for 2 of 14 sampled patients (Patients #3 and #7).

The agency failed to ensure home health aides provided care to agency patients only as ordered by the physician and/or as directed by the skilled professional assigning the home health aide to the patient for 7 of 9 sampled patients receiving home health aide services (Patients #1, #2, #5, #6, #8…

The agency failed to ensure a registered nurse or other appropriate health care professional completed home health aide supervision at least every 14 days for 3 of 8 sampled patients who received hands on personal care services in conjunction with skilled service provision after 7/1/19, the…

The agency failed to document all required components of home health aide supervision every 14 days when a skilled services was provided in conjunction with the aide services and every 60 days when no skilled service was provided for 8 of 8 sampled patients receiving home health aide services for…

The agency failed to complete and send a transfer summary to the physician responsible for providing care to the patient after transfer to an inpatient facility within 2 business days of the patient's transfer for 2 of 6 sampled patients with transfers (Patients #4 and #11).

The agency failed to follow a Plan of Care established and periodically reviewed by a doctor of medicine, osteopathy or podiatry or notify the physician of the need to vary from the physician ordered Plan for 4 of 13 sampled patients (Patients #2, #4, #7 and #9).

The agency failed to ensure agency staff advised the patient of the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the…

The facility failed to accurately complete a drug regimen review, including completion of all required components with the completion of each comprehensive assessment for 12 of 13 records reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #12 and #13).

The agency failed to ensure completion of the update of the comprehensive assessment at discharge within 2 calendar days of identification of the need to discharge a patient for 2 of 3 sampled patients requiring a discharge comprehensive assessment (Patients #11 and #12).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care for 2 of 2 sampled patients with home visits (Patients #1 and #2).

The agency failed to ensure the home health aides successfully completed competencies in all basic home health aide skills which require a registered nurse, or other appropriate skilled professional in consultation with a registered nurse, to evaluate the competency of the aide by direct…

The agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 1 of 9 sampled patients receiving home health aide services (Patient #6).

The agency failed to ensure 1 of 10 sampled home health aides (Staff E), assigned to perform tasks requiring extra skills exceeding the level of basic home health skills for 1 of 9 sampled patients (Patient #7) with home health aide services, had documented evidence of competency by a registered…

The agency failed to ensure home health aides provided services according to the home health aide written care plan for 7 of 9 sampled patients (Patients #1, #4, #6, #7, #8, #9 and #10) receiving aide services.

The agency failed to ensure a registered nurse (RN) or other appropriate health care professional completed home health aide supervision at least every 14 days for 1 of 9 sampled patients who received hands on personal care services in conjunction with skilled service provision (Patient #7).

The agency failed to ensure a registered nurse (RN) completed home health aide supervision at least every 60 days while observing each home health aide present and providing direct patient care for 1 of 1 sampled patients who received hands on personal care services with no skilled service…

The agency failed to ensure registered nurses supervising home health aides maintained documentation of a review of all required supervisory elements including following the patient plan of care, maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks…

Agency clinicians failed to follow a Plan of Care established and periodically reviewed by a doctor of medicine, osteopathy or podiatry for 1 of 3 sampled patients (Patient #3).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care and/ or failed to ensure the Plan of Care contained current, accurate information for 2 of 3 sampled patients (Patients #1 and #2).

The agency failed to update the Plan of Care with all new orders for 2 of 3 sampled patients (Patients #2 and #3).