Centerwell Home Health

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review the agency failed to notify the physician regarding a patient’s missed visit for one of 13 sampled patients (Patient 6). This failure had the physician’s inability to modify the patient’s plan of care. FINDINGS: During a review of Patient 5’s clinical record, Patient 5 was admitted to the agency with a diagnosis of chronic kidney disease, stage four (CKD-4- severe kidney function loss). Patient 5’s episode dates were from 4/14/25 to 6/12/25. Skilled nurse visit frequency was ordered as twice a week for one week then once a week for eight weeks. Patient 5 was not visited by a nurse on the third week of service (4/27/25 to 5/3/25). During an interview on 7/3/25 at 10:15 A.M. with the Market Executive of Clinical Quality (MECQ), the MECQ stated there was no documentation regarding the missed visit for Patient 5. The MECQ stated there was no physician notification regarding the missed visit and the agency should have contacted the physician. During a review of the agency’s policy and procedure (P&P) titled, “Physician/Allowed Practitioner Order,” dated 9/2024, the P&P indicated, “The physician/ allowed practitioner will be contacted for any change order in medications, treatment or Home Health services.””

“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 interview and record review, the agency failed to ensure the clinical record was completed and submitted per the agency’s policy and procedure for one of 13 sampled patients (Patient 7). This failure resulted in ineffective communication regarding patient’s care. Findings: Per the Home Health Certification and Plan of Care (POC), dated 6/10/25 through 8/8/25, Patient 7 was admitted to the agency on 6/10/25 with diagnoses that included acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood). A review of Patient 7’s clinical record was conducted on 6/30/25. There was no documented evidence that Patient 7 was seen by the skilled nurse the week of 6/22/25 through 6/28/25. On 7/3/25 at 10:45 A.M., a joint interview and record review was conducted with the Market Executive of Clinical Quality (MECQ). The MECQ stated the agency’s policy was for the clinicians to submit their notes within 24 hours after the home visit. Skilled Nurse (SN) 1 completed the home visit on 6/24/25, but did not submit the visit note until 7/1/25, therefore it was not in compliance with the agency’s policy. On 7/3/25 at 12:08 P.M., an interview was conducted with SN 1. SN 1 stated she visited Patient 7 on 6/24/25 but did not complete her charting until 7/1/25. SN 1 stated that the agency’s policy was to complete and submit the visit note the next day before nine in the morning. SN 1 further said that it was important to complete and submit the visit note in a timely manner to ensure effective communication among staff. Per the agency’s policy and procedure, revised 9/2024, titled Documentation Submission, “Electronic documentation will be submitted/transmitted via a Company-approved secure Electronic Medical Record [EMR] vendor/system via the internet within 24 hours following receipts of documents or completion of a patient visit...””

“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: Based on interview and record review the facility failed to provide nursing visits as ordered in the plan of care for two of 13 sampled patients (Patient 5 and Patient 6). This failure had the potential to result in patients not being assessed and patient needs not being met. FINDINGS: 1. During a review of Patient 5’s clinical record, Patient 5 was admitted onto the service with a diagnosis of chronic kidney disease, stage four (CKD-4- severe kidney function loss). Patient 5’s episode dates were from 4/14/25 to 6/12/25. Skilled nurse visit frequency was ordered as twice a week for one week then once a week for eight weeks. Patient 5 was not visited by a nurse on the third week of service (4/27/25 to 5/3/25). During an interview on 7/3/25 at 10:15 A.M. with the Market Executive of Clinical Quality (MECQ), the MECQ stated there was no documentation regarding the missed visit for Patient 5. The MECQ further stated there should have been documentation regarding the missed visit. 2. During a review of Patient 6’s clinical record, Patient 6 had a primary diagnosis of left first and second toe wound. Patient 6’s episode dates were from 3/8/25 to 5/6/25. Patient 6 had an order for skilled nurse visits once a week for one week, twice a week for three weeks, then once a week for six weeks. Patient 6 had a missed skilled nurse visit on week five (3/30/25 to 4/5/25). During an interview on 7/3/25, at 11:21 A.M. with the Administrator (Admin), the Admin stated Patient 6 was visited once by a skilled nurse the week of 3/30/25 to 4/5/25 and there should have been two visits. The Admin stated there was no documentation regarding the missed visit on week five (3/30/25 to 4/5/25). The Admin stated it was important to follow the physician’s order for the frequency of visits because if the frequency was not followed there could be a likelihood for more issues. The Admin further stated agency visits determined the patient’s need for home health. During a review of the agency’s policy and procedure (P&P) titled, “Physician/Allowed Practitioner Order,” dated 9/2024, the P&P indicated, “ALL missed visits must be documented within the patient’s medical record to include the reason for the missed visit and physician/ allowed practitioner notification unless authorized under specific circumstances that are documented on the POC.” A review of the agency’s P&P titled, “Care Planning,” dated 9/20/24 was conducted. The P&P indicated, “Professional disciplines – Registered Nurse [RN], Physical Therapist [PT], Speech-Language Pathologist [SLP], Occupational Therapist [OT], Medical Social Worker [MSW] – must assume responsibility for…providing services ordered by the physician/allowed practitioner as indicated in the POC [plan of care]/interim orders.””