Love’n Comfort Home Health Care, LLC

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on medical record review, staff interview and policy review, the agency failed to ensure home health aide notes were properly maintained to ensure the required services were provided and accurately documented in the medical record to enhance continuity of care. See G1012”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to complete adequate exercise(s) to test the emergency plan at least annually. This had the potential to affect all patients receiving services. Findings include: On 05/27/25 at 11:54 A.M., and then again on 05/28/25 at 6:54 A.M., requested the emergency preparedness program records by email and also phone call on 05/27/25 at 2:16 P.M., with Nurse/HR Director-Administration. However, the facility failed to provide a record of conducting a full-scale exercise, mock disaster drill or tabletop exercise to test the emergency plan within the previous twelve months.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on staff interview, medical record and policy review, the agency failed to ensure home health aide supervisory visits were completed every 14 days. This affected two (Patients #2 and #5) of three skilled patients reviewed. The census was 10. Findings include: 1. Review of Patient #2’s medical record revealed an admission date of 04/28/21 with diagnoses including systemic sclerosis. Review of the recertification period of 04/07/25 through 06/05/25 revealed the patient was to receive one skilled nursing visit each week and 56 hours of aide services each week for nine weeks. Review of the medical record revealed no supervisory visits were documented for the period 04/07/25 through 05/29/25. 2. Review of Patient #5’s medical record revealed an admission date of 04/28/21 with diagnoses including diabetes. Review of the recertification period of 05/22/25 through 07/20/25 revealed the patient was to receive one skilled nursing visit each week and 43 hours of aide services each week for nine weeks. Review of the medical record revealed no supervisory visits were documented since 03/23/25. During an interview on 05/29/25 at 3:18 PM,the Human Resource Director revealed skilled patients are to received aide supervisory visits every 14 days. The Human Resource Director verified there were no supervisory visits in the medical record or the electronic medical record for Patient #2 since 04/07/25 and for Patient #5 since 03/23/25. She stated the nurse did not complete them.”

“Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, — (A) The registered nurse must make an onsite, in person visit every 60 days to assess the quality of care and services provided by the home health aide and to ensure that services meet the patient’s needs; and (B) The home health aide does not need to be present during this visit. (ii) Semi-annually the registered nurse must make an on-site visit to the location where each patient is receiving care in order to observe and assess each home health aide while he or she is performing non-skilled care This Element is not met as evidenced by: Based on staff interview, medical record and policy review, the agency failed to ensure home health aide supervisory visits were completed every 60 days for unskilled patients. This affected three (Patients #1, #3 and #4) of four unskilled patient records reviewed. The census was 10. Findings include: 1. Review of Patient # 1’s medical record revealed an admission date of 04/28/21 with diagnoses including chronic kidney disease. Review of the recertification period of 04/07/25 through 06/05/25 revealed the patient was to receive 28 hours of aide services each week for nine weeks. Review of the medical record revealed no documentation of any supervisory visits since 02/06/25. 2. Review of Patient #3’s medical record revealed an admission date of 04/01/23 with diagnoses including chronic obstructive pulmonary disease and diabetes. Review of the recertification period of 05/20/25 through 07/18/25 revealed the patient was to receive one skilled nursing visit every 60 days and 23 hours of aide services each week for nine weeks. Review of the medical record revealed no documentation of any supervisory visits since 03/20/25. 3. Review of Patient #4’s medical record revealed an admission date of 04/28/21 with diagnoses including ulcerative colitis. Review of the recertification period of 05/13/25 through 07/11/25 revealed the patient was to receive one skilled nursing visit every 60 days and 20 hours of aide services each week for nine weeks. Review of the medical record revealed no documentation of any supervisory visits since 03/13/25. The recertification was completed by the nurse on 05/12/25. During an interview on 05/29/25 at 3:18 PM, the Human Resource Director revealed unskilled patients are to received aide supervisory visits every 60 days. The Human Resource Director verified there were no recent supervisory visits in the medical record or the electronic medical record for Patient’s #1, #3 and #4. She stated the nurse did not complete them.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on medical record review, staff interview and policy review, the agency failed to ensure home health aide notes were completed in the medical record. This affected five (Patients #1, #2, #3, #4 and #5) of seven medical records reviewed. The census was 10. Findings include: 1. Review of Patient #1’s medical record revealed an admission date of 04/28/21 with diagnoses including chronic kidney disease. Review of the recertification period of 04/07/25 through 06/05/25 revealed the patient was to receive 28 hours of aide services each week for nine weeks. Review of the medical record revealed no documentation of any home health aide notes since 04/18/25. 2. Review of Patient #2’s medical record revealed an admission date of 04/28/21 with diagnoses including systemic sclerosis. Review of the recertification period of 04/07/25 through 06/05/25 revealed the patient was to receive one skilled nursing visit each week and 56 hours of aide services each week for nine weeks. Review of the medical record revealed no documentation of any home health aide notes since 04/07/25. 3. Review of Patient #3’s medical record revealed an admission date of 04/01/23 with diagnoses including chronic obstructive pulmonary disease and diabetes. Review of the recertification period of 05/20/25 through 07/18/25 revealed the patient was to receive one skilled nursing visit every 60 days and 23 hours of aide services each week for nine weeks. Review of the medical record revealed no documentation of any home health aide notes since 03/20/25. 4. Review of Patient #4’s medical record revealed an admission date of 04/28/21 with diagnoses including ulcerative colitis. Review of the recertification period of 05/13/25 through 07/11/25 revealed the patient was to receive one skilled nursing visit every 60 days and 20 hours of aide services each week for nine weeks. Review of the medical record revealed no documentation of any home health aide notes since 03/13/25. 5. Review of Patient #5’s medical record revealed an admission date of 04/28/21 with diagnoses including systemic sclerosis. Review of the recertification period of 05/22/25 through 07/20/25 revealed the patient was to receive one skilled nursing visit each week and 43 hours of aide services each week for nine weeks. Review of the medical record revealed no documentation of any home health aide notes since 03/23/25. During an interview on 05/29/25 at 3:18 PM, the Human Resource Director revealed the home health aide notes were misplaced by the Administrator and she could not find them. She stated the Administrator, who is out of town, has been directing her via phone on where to find the notes but she has been unsuccessful. She stated the notes have not been filed in the paper medical records but they have been received because the agency will not bill unless they have the timesheet in hand. The Human Resource Director stated the home health aide hours were put in the electronic medical record based off of the received time sheets. The Human Resource Director verified that the only the times were in the EMR and not the tasks performed by the aides. Review on of the policy titled “Documentation” revealed a home care record is maintained on each client receiving services in order to document all home care services provided and/or needed and to ensure pertinent and timely documentation is obtained on each client. The medical record should include the ongoing patient assessments and all services or care provided.”