Comfort Care Home Health Agency, Inc.

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure all documented entries included appropriate authentication that included an accurate signature date of clinician visits in three of six records reviewed (Records/Patients #2, #3, and #5). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated, undated policy, regarding documentation expectations provided by the alternate administrator showed, in part, all visit notes must be completed with 24-28 hours unless it is the start of care Outcome and Assessment Information Set (OASIS - a standardized data collection tool) and “they can be up to 5 (five) days”. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 12/11/2024 with a primary diagnosis of encounter for change or removal of surgical wound dressing. The patient lived at home with a family caregiver. Review of the clinician visit notes showed the following: - A skilled nurse (SN) visit was made on 02/08/2025 and signed/completed by the clinician on 02/15/2025 (seven days later); - A SN visit was made on 02/24/2025 and signed/completed by the clinician on 03/03/2025 (seven days later); - A SN visit was made on 03/03/2025 and signed/completed by the clinician on 03/11/2025 (eight days later); - An occupational therapy (OT) visit was made on 03/11/2025 and signed/completed by the clinician on 03/16/2025 (five days later); - A physical therapy (PT) visit was made on 03/25/2025 and signed/completed by the clinician on 03/29/2025 (four days later); and - A PT visit was made on 03/29/2025 and signed/completed by the clinician on 04/06/2025 (eight days later). RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/05/2025 with a primary diagnosis of type 2 diabetes mellitus (a chronic disease that affects how the body uses sugar for energy), high blood pressure, and other diseases. Review of the clinician visit notes showed the following: - A SN visit was made on 02/17/2025 and signed/completed on 02/21/2025 (four days later); and - A resumption of care visit was made on dated 03/13/2025 and signed/completed by the clinician on 04/08/2025 (26 days later). RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 01/15/2025 with a primary diagnosis of type 2 diabetes mellitus. The patient lived at home with a family caregiver. Review of the clinician visit notes showed the following: - A SN visit was made on 01/15/2025 and signed/completed by the clinician 02/14/2025 (30 days later); - A PT visit was made on 01/15/2025 and signed/completed by the clinician on 02/02/2025 (18 days later); - A SN visit was made on 01/17/2025 and signed/completed by the clinician on 03/10/2025 (52 days later); - A SN visit was made on 01/29/2025 and signed/completed by the clinician on 02/20/2025 (22 days later); and - An OT visit was made on 02/06/2025 and signed/completed by the clinician on 02/09/2025 (three days later). During an interview on 04/08/2025 at 3:00 PM, the home health alternate administrator stated that he/she would expect clinicians to document visits per the provider policy.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to maintain an accurate, updated medication profile in three of three home visit observations conducted (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated, untitled policy, regarding medication reconciliation showed, in part, every time a skilled nurse visit is made the client shall be asked about any change in his/her medication regimen and if any new over the counter medications are found, these will be reported to the doctor and added to the medication administration record (MAR)/checked for major interactions and reported. When a clinician finds a new prescription bottle in the home, the label on the bottle serves as a physician’s order. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 06/25/2022 with a primary diagnosis of neuromuscular disfunction (a condition that disrupts the normal function of the nerves and muscles, or the junction where they connect) and other health conditions. Observation and interview on 04/08/2025 at 11:30 AM, showed the following discrepancy between the patient’s home medications and the provider’s medication profile: - The medication profile showed the patient took Nystatin (an antifungal) cream, apply to buttocks as needed; and - The patient and the patient’s caregiver (CG) stated that this medicine had not been used “for a long time”. Per an interview conducted during observation, the registered nurse (RN) - A stated that the Nystatin was on the provider’s medication profile and confirmed it was no longer in use. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 12/11/2024 with a primary diagnosis of encounter for change or removal of surgical wound dressing. The patient lived at home with a family caregiver (CG). Observation and interview on 04/07/2025 at 1:00 PM, showed the following discrepancies between the patient’s home medications and the provider’s medication profile: - The provider’s profile showed the patient took escitalopram oxalate (used to treat depression and anxiety) 20 milligrams (mg) by mouth once daily. The patient CG stated that the patient no longer took this medication; - The provider’s profile showed the patient took hydralazine (used to treat high blood pressure) 50 mg by mouth twice daily. The patient CG stated that the patient took 50 mg once daily; - The provider’s profile showed the patient took magnesium oxide (a mineral supplement) 400 mg by mouth once daily. The patient CG stated that the patient no longer took this medication; and - The provider’s profile showed the patient took potassium chloride (used to treat low potassium levels) 20 milliequivalents (mEq) by mouth once daily. The patient CG stated that the patient no longer took this medication. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/05/2025 with a primary diagnosis of type 2 diabetes mellitus (a chronic disease that affects how the body uses sugar for energy), high blood pressure and other diseases. Observation and interview on 04/08/2025 at 8:00 AM, showed the following discrepancies between the patient’s home medications and the provider’s medication profile: - The provider’s profile showed the patient took metoprolol tartrate (an immediate release medicine used to treat high blood pressure)25 mg by mouth twice daily. The CG stated that the patient took metoprolol succinate (an extended release high blood pressure medicine) 25 mg once daily at bedtime; - The provider’s profile showed the patient took naproxen 500 mg, one tablet twice daily as needed for pain/swelling. The CG stated that the patient no longer took this medication; - The patient took docusate sodium 100 mg (used to prevent constipation). The provider’s profile failed to include this medication; - The patient took simethicone chewable 80 mg four times a day for gas. The provider’s profile failed to include this medication; and - The the CG stated that patient used Calmoseptine ointment (used to protect the skin) “at times” and the provider’s profile failed to include this medication. During a home visit observation on 04/08/2025 starting at 8:00 AM, the patient’s medications were reviewed with the patient’s cg. Review of the patient’s home medications and the provider’s medication profile, dated 04/07/2025, showed the following discrepancies: -Metoprolol tartrate (used to treat high blood pressure) 25 mg by mouth twice daily. The cg stated that the patient no longer took this medication, the cg stated that the patient took metoprolol succinate (also used to treat high blood pressure) 25 mg at bedtime; and -Naproxen 500 mg, one tablet twice daily as needed for pain and or swelling, the cg stated that the patient no longer took this medication. The provider medication list failed to contain: -Docusate sodium 100 mg. The patient cg stated that the patient used this medication for constipation; -Simethicone 80 mg chew and swallow four times a day for gas, the cg stated that the patient had this medication when needed; and -Calmoseptine ointment (used to protect the skin), that the patient used “at times”. During an interview on 04/09/2025 at 12:00 PM, the home health administrator stated that he/she would expect the medications to be reconciled per policy and should match what the patient is taking.”