United Comfort Care, Inc.

“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 record review and interview, the agency failed to conduct an exercise to test the emergency plan or to activate the plan after an actual natural or man-made emergency annually and maintain documentation, for two (2022 and 2023) of three years reviewed. The failure placed the agency’s patients at risk of harm related to lack of organized preparation and planning for patient care and services in the event of a disaster/emergency. Findings include: Record review of the undated emergency preparedness manual did not identify any records/documentation to establish that the agency had participated in a full-scale exercise that was community based every 2 years and conducted on the opposite year of the full-scale exercise, a second community-based exercise, mock drill, or tabletop exercise. The agency’s emergency preparedness records also failed to contain documentation that the agency experienced an actual or man-made emergency that required an activation of the emergency plan that would have exempted the agency from a full-scale exercise for the years 2022 and 2023. The last documented tabletop drill/activation was on 02/14/2021, with a fire drill/and fire drill evaluation on 02/16/2021. The agency’s records did not include an emergency preparedness and response plan policy. After the surveyor reviewed the emergency preparedness records on 11/25/2024, the Office Mgr./PAS Sup provided the following: an undated “Agency Emergency Preparedness Plan Evaluation;” record of a fire drill dated 01/14/2024; and record of a weather activation event dated 01/14/2024. During an interview on 12/03/2024 at approximately 10:05 a.m. with the Admin/DON (disaster coordinator) the surveyor asked who the agency’s disaster coordinator and alternate disaster coordinator was. The Admin/DON self-identified as the coordinator and identified the Alt Admin/Alt DON as the alternate coordinator. The surveyor reviewed the findings and asked who at the agency was responsible for the agency’s EP program. The Admin/DON stated that she was responsible for the program. The surveyor requested the agency’s EP policy. The Admin/DON stated that the agency had a policy at the inception of the agency, but she no long had access to it (the policy was online) and did not have a paper copy of the policy. The surveyor asked why the agency had not completed drills, exercises, or activated the plan during emergency events to test the plan, analyzed and/or maintained documentation of any drills, exercises, and actual events for 2022 and 2023. The Admin/DON replied, “I don’t know.” The Admin/DON stated that she needed to give more oversight (to the agency staff) and have more staff. The surveyor asked how the failure could adversely affect the agency’s patients. The Admin/DON stated that if the patients and staff did not know what to do (in a disaster event) they “will be lost.””

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to conduct and document PIP(s) annually, for three (2021, 2022 and 2023) of three years reviewed for PIP(s), that reflected the scope, complexity and past performance of the agency’s services and operations. The failure placed the agency’s patients’ health and safety at risk if the agency did not identify and improve quality of care and service related to patient health and safety concerns. Findings include: During an interview on 11/25/2024 at 10:00 a.m., the surveyor requested all agency QAPI documents/reports/manuals. Review of agency’s QAPI records revealed the following: Undated Quality Assessment/Performance Improvement Plans; Quarterly QAPI minutes of meetings for 2022, 2023, and 2024; and Quarterly QAPI utilization review reports for 2022, 2023, and 2024. Continued review of the agency’s QAPI records did not reveal any documentation that indicated the agency had: any quality improvement projects undertaken, the reason for conducting the projects, and the measurable progress on achieving the projects; any performance improvement projects either in development, ongoing or completed for the calendar years of 2021, 2022 and 2023. During an interview with the Admin/DON on 12/02/2024 at 12:30 p.m. the surveyor asked who at the agency was responsible for the agency’s QAPI program. The Admin/DON stated that she was responsible for the program. During an interview with the Admin/DON on 12/03/2024 at 10:40 a.m. the surveyor reviewed the findings and asked what the agency’s process was for its QAPI program. The Admin/DON stated that the agency had meetings every quarter to talk about the quality assurance of the patients; how patient care can be improved; if there is an error how it can be corrected. The surveyor asked why the agency had not conducted PIP(s) per federal regulatory requirements (to conduct and document the projects). The Admin/DON stated that she was not aware of the requirement. The surveyor asked how the failure could adversely affect the agency’s patients. The Admin/DON replied, “It would affect the patients. We would not give the patient quality care. We would not know how to improve, and the health and safety of the patient would be compromised.” Review of agency policy titled, “Quality Assessment Performance Improvement Plan” dated 10/01/10 did not reveal that the policy had been updated to include the regulatory requirement of: Beginning July 13, 2018, HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure proper written notice was provided, in advance of terminating on-going care in two (Patients # 6 and 7) of two inactive patient records reviewed. The agency failed to provide Patients # 6 and 7 with the Centers for Medicare and Medicaid form titled “Notice of Medicare Non-Coverage (NOMNC).” The failure could affect the patient’s health and safety and result in harm due to lack of consistent and continuing care in the patient’s post discharge needs. Findings include: Inactive Clinical Record # 6: Record review of the clinical records for Patient # 6 revealed a POC for the certification period of 07/02/2024 to 08/30/2024. Review of the POC revealed a start of care date of 03/04/2024 with a principal diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy (a condition where nerves through the body become damaged and cause pain, weakness, and numbness.). The POC was dated 07/01/2024 and electronically signed by the Admin/DON. The POC contained an order for skilled nursing visits one time per week for one week, two times per week for two weeks and one time per week for five weeks; and Hha visits two times per week for one week and three times per week for eight weeks. Continued review of the records revealed a discharge summary signed by the Admin/DON and dated 09/13/2024. The discharge summary revealed that Patient # 6 was discharged from the agency due to a change in insurance. Continued review of the record revealed a discharge order dated 07/31/2024 with an effective date of 07/31/2024. Further review of Patient # 6’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 07/31/2024. The record did not include a written NOMNC. Inactive Clinical Record # 7: Record review of the clinical records for Patient # 7 revealed a POC for the certification period of 09/05/2024 to 11/03/2024. Review of the POC revealed a start of care date of 05/08/2024 with a principal diagnosis of Radiculopathy, lumbosacral region (swelling in the lower back that causes pain to radiate down the legs). The POC was dated 09/03/2024 and electronically signed by the Admin/DON. The POC contained an order for skilled nursing visits one time per week for one week, two times per week for three weeks and one time per week for five weeks. Continued review of the records revealed a discharge OASIS signed by the Admin/DON and dated 09/23/2024. Review of the discharge OASIS (a tool used by CMS to collect required patient information) revealed that Patient # 7 was discharge at “physician’s request.” Further review of Patient # 7’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 09/23/2024. The record did not include a written NOMNC. During an interview on 12/03/2024 at 11:05 a.m. with the Admin/DON, the surveyor reviewed the above findings and asked who at the agency was responsible for providing the discharge notice. The Admin/DON replied, “I am.” The surveyor asked what the agency process was ensuring that the notices were completed, provided to the patients, and incorporated into the clinical records. The Admin/DON replied, “I do the documentation.” The admin/DON stated that she “let[s] them know to let us know if they need further help and to follow-up with their doctors.” The surveyor asked why the agency had not provided proper written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for Patients # 6 and 7. The Admin/DON stated that the patients requested to discharge, and she was not aware that the notice was needed. The surveyor asked how the failure could adversely affect the patients. The Admin/DON stated, “They won’t have a chance to appeal the decision if needed.” Review of agency policy titled, “Patient Discharge PE.6” dated 08/01/14 read in part: “ ... Purpose...To provide for continuity of care as well as appropriate and timely post-discharge care and documentation. To allow patients to challenge/appeal their provider’s decision to discharge...Agency will deliver the Notice of Medicare Non-Coverage (an...approved Medicare form) to the patient (or representative), at least 2 calendar days before Medicare covered services end or the second to last day of service if care is not provided daily...””

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: This is a continuing deficiency cited at G 0614 at survey dated 11/19/2021. Based on record review, observations, and interviews the agency failed to provide written information in two (Patients # 1 and 3) of two patients who received a home visit with written information reviewed, in that: The HHA failed to provide the patient and caregiver with a copy of written instructions which outlined a visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. The failure placed the patients at risk of harm due to being uninformed and/or unable to identify the staff scheduled to provide care and services on the behalf of the agency. FINDINGS INCLUDED: Clinical Record #1: Review of the clinical record for Patient # 1 revealed that the record contained a POC with a SOC date of 01/15/2024, with the principal diagnosis of type 2 diabetes without complications. The POC for certification period 11/10/2024 to 01/08/2025 was electronically signed by the Admin/DON on 11/07/2024. The POC included an order for skilled nursing visits for two times per week for three weeks and one time per week for six weeks; and Hha visits for four times per weeks for eight weeks and three times per week for one week. During a home visit conducted on 11/27/2024 at 8:00 a.m., the surveyor observed and reviewed Patient # 1’s home admission folder. Patient # 1’s home folder did not include a written current visit schedule. Patient #1 stated that no records had been removed from the admission folder. Clinical Record # 3: Review of the clinical record for Patient # 3 revealed that the record contained a POC with a SOC date of 10/05/2023, with the principal diagnosis of type 2 diabetes without complications. The POC for certification period 09/29/2024 to 11/27/2024 was electronically signed by the Admin/DON on 09/27/2024. The POC included an order for skilled nursing visits for two times per week for three weeks and one time per week for six weeks, effective 09/30/2024. During a home visit conducted on 11/27/2024 at 11:20 a.m., the surveyor observed and reviewed Patient # 3’s home admission folder. Patient # 3’s home folder did not include a written current visit schedule. During an interview on 12/02/2024 12:30 p.m.., the surveyor asked who at the agency was responsible for providing the patients with the required written information (written visit schedule). The Admin/DON stated that she was responsible. During an interview on 12/03/2024 at 10:50 a.m., the surveyor reviewed the findings with the Admin/DON. and asked why the agency had not provided a current written visit schedule to Patients # 1 and 3. The Admin/DON replied, “I did not know that it was mandated to give to them. We talk to them about it.” The surveyor asked how the failure could adversely affect the patients. The Admin/DON replied, “If they don’t have it (a written visit schedule), they won’t know when the staff is coming. If they are disoriented, they may open the door for the wrong person.””