Centerwell Home Health

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on review of agency re-licensure documentation and staff interviews, the Governing body failed to ensure the required professional members were appointed to a committee. The findings include: Review of the agency’s state re-licensure requirements identified meeting minutes and attendees for the Professional Advisory Committee (PAC) for years 2024, 2025, and 2026, but failed to identify the required members including a physician, public health nurse, pharmacist, therapist and/or social worker were appointed by the agency governing body. Interview with the Administrator and review of agency documentation on 7/15/26 at 1:10 PM indicated the agency conducted two PAC meetings biannually in 2024, 2025 and one in 2026, however, the attendees consisted of employees of the agency, the Administrator, Clinical Managers and a Physical Therapist, (with no voting power) and did not ensure the appoint of the required physician, public health nurse, pharmacist, therapist and/or social worker as required by state regulation. The Administrator indicated the agency was not able to find a physician to participate on the committee, and felt the remaining members were acceptable.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on clinical record review, review of agency documentation and staff interviews, for one of one patient reviewed (Patient #13) who resided in an Assisted Living Facility/ALF, the agency failed to ensure coordination of care in the management of the patient’s needs. The findings include: Patient #13 had a start of care date of 1/05/26 and diagnoses that included cardiac arrhythmias, hypertensive heart disease with heart failure and dementia. The physician’s orders dated 1/05/26 included nursing services once weekly for assessments and weight monitoring and PT services to improve safety and increase independence. Patient #13 resided in an Assisted Living Facility (ALF). Review of the clinical record and Memorandum of Understanding/MOU between the agency and ALF dated 1/05/26 identified that nursing and PT services were to be provided but failed to identify the frequency of visits and the specific care to be provided by nursing and the physical therapist. Interview and review of the clinical record and MOU document with the Administrator on 7/15/26 at 12 PM identified the MOU included standard information including, the development and revision of the care plan based on assessment/s of the patient’s condition, and case management conferences, communication of changes in the patient’s condition and any updates to the medical orders. The Administrator indicated the MOU did not include the frequency of the clinician visits, the duration (length of time) of service provision, and the specific care to be provided by nursing and physical therapist clinicians at each visit, to ensure a comprehensive care coordination plan for the patient. The agency had no specific policy to review.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on clinical record reviews, review of an agency policy and interview with agency personnel, for three of three patients (Patient #4, #5 and #11) in the survey sample, the agency’s Registered Nurses (RN) failed to reconcile a patient’s medications and failed to measure patients’ wounds in accordance with the agency’s policies. The findings include: Patient #5 had a start of care date of 7/13/22 and diagnoses that included major depressive disorder, anxiety and post-traumatic stress disorder. The physician’s orders for the certification period of 11/05/23 through 1/03/24 included nursing services seven times a week for daily medication administration and the pre-poring of the evening medications and assessments. Patient #5’s medications included Ferrous Fumarate 324 milligrams/mg every morning. During a joint home visit with RN #1 on 12/12/23 at 9:30 AM, the surveyor observed RN #1 pour Ferrous Gluconate 324 mg for administration. Interview and review of the home visit and physician’s orders with the Administrator on 12/13/23 at 11:25 AM identified that the physician had discontinued the Ferrous Gluconate in May 2023 and then restarted it in July, RN #1 accidentally entered Ferrous Fumarate into the electronic record, although the patient received the correct medication and failed to reconcile medications in accordance with agency policy. Review of agency policy for Medication Review and Documentation directed the medication assessment will be performed each clinical visit to ensure medications are current, accurate and documented on the medication profile within the patient’s electronic record. 2. Patient #11 had a start of care date of 8/23/23 and diagnoses that included stage III pressure ulcer of the right buttock, fracture of the left tibia and fibula and type II diabetes mellitus. The physician’s orders for the certification period of 10/22/23 through 12/20/23 included nursing services two times a week for assessments and wound care to the right buttock. Interview and review of the clinical record with the Administrator on 12/14/23 at 11 AM identified twice weekly nursing services provided to Patient #11 for wound care but failed to identify documentation of wound measurements by LPN #2 for the week of 11/05/23 (LPN # 2 visited on 11/07/23 and 11/09/23). Review of the agency’s Wound Care Assessment policy directed wound assessments would be performed every visit and include general observations, drainage amount and type, wound bed appearance and surrounding skin condition. At least once weekly, the assessment of the wound would include measurements. Patient #4 had a start of care date of 11/15/2023 with diagnosis that included chronic respiratory failure, peripheral vascular disease, venous insufficiency, and stage three pressure ulcers. The physician’s orders for the certification period of 11/15/2023 to 01/13/2023 included nursing services twice per week for one week and once per week every two weeks to assess the stage three pressure ulcer to the right heel and wound to the right lower extremity. Interview and review of Patient #4’s clinical nurses’ notes dated 11/16/2023, 11/27/2023, 11/28/2023 and 12/07/2023 with the Administrator on 12/14/2023 at 12:30 PM, identified the Patient’s responsible caregiver performed wound care prior to the nurses’ visits on 11/16/2023, 11/27/2023, 11/28/2023 and 12/07/2023, therefore, the wounds were not assessed or measured by a nurse since the start of care on 11/15/2023.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on clinical record review and interview with agency personnel, for three of seventeen patients (Patient’s #7, #16 and #17) in the survey sample, the agency Registered Nurse/RN failed to ensure the plan of care addressed the patient’s individual needs. The findings include: . Patient #7 had a start of care date of 2/09/23 and diagnoses that included unstageable pressure ulcer of the right heel, arteriosclerotic heart disease and congestive heart failure. The physician’s orders for the certification periods of 2/09/23 through 4/09/23 and 10/07/23 through 12/05/23 included nursing services three times a week to assess and provide wound care to the right heel, physical therapy and occupational therapy services. Interview and review of the initial nursing assessment dated 2/09/23 and subsequent OT/Occupational Therapy evaluation dated 2/14/23 with the Administrator on 12/14/23 at 9:20 AM identified the need for assistance of another person for bathing, dressing and transferring, but failed to identify nursing communication with the physician about the patient’s need for home health aide services. 2. Patient #17 had a start of care date of 10/27/23 and diagnoses that included laceration of the right lower leg, dementia and atrial fibrillation. The physician’s orders dated 10/27/23 included nursing services one time a week for one week, two times a week for two weeks and one time a week for three weeks for wound care and assessments. Patient #17 resided in an Assisted Living Facility. Interview and review of the initial nursing assessment dated 10/27/23 with the Administrator on 12/14/23 at 9:30 AM identified the need for assistance of another person for bathing, dressing and transferring and indicated that the patient has 24-hour care available from facility staff, but failed to identify nursing communication with the physician about the patient’s need for home health aide services. Patient #16 had a start of care date of 05/25/2023 and diagnoses that included chronic kidney disease, congestive heart failure, fractures and falls. The physician’s orders dated 05/25/2023 included nursing services one time a week for three weeks and one time per week every two weeks for nursing assessments. Patient #16 resided in an Assisted Living Facility. Interview and review of the initial nursing assessment dated 05/25/2023 with the Administrator on 12/14/23 at 9:15 AM identified the need for assistance of another person for bathing, dressing, and transferring via a Hoyer lift and indicated the patient had 24-hour care available from facility staff, but failed to identify nursing communication with the physician about the patient’s need for home health aide services.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on clinical record reviews, review of an agency policy and interview with agency personnel, for one of three patients (Patient #4) who required wound care in the survey sample, the agency’s Registered Nurses (RN) failed to assess wounds in accordance with the agency’s policy. The findings include: Patient #4 had a start of care date of 11/15/2023 with diagnosis that included chronic respiratory failure, peripheral vascular disease, venous insufficiency, and stage three pressure ulcers. The physician’s orders for the certification period of 11/15/2023 to 01/13/2023 included nursing services twice per week for one week and once per week every two weeks to assess the stage three pressure ulcer to the right heel and wound to the right lower extremity. Interview and review of Patient #4’s clinical nurses’ notes dated 11/16/2023, 11/27/2023, 11/28/2023 and 12/07/2023 with the Administrator on 12/14/2023 at 12:30 PM, identified the Patient’s responsible caregiver performed wound care prior to the nurses’ visits on 11/16/2023, 11/27/2023, 11/28/2023 and 12/07/2023, therefore, the wounds were not assessed or measured by a nurse since the start of care on 11/15/2023. Review of the agency’s Wound Care Assessment and Clinical Oversight policy identified the RN would perform the initial assessment for open wounds and surgical incisions upon admission and as ordered by the physician/allowed practitioner. The wound dressings would be removed to assess wounds unless a physician/allowed practitioner order was received restricting dressing removal. Wound assessments would be performed every visit and include general observations, drainage amount and type, wound bed appearance and surrounding skin condition. At least once weekly, the assessment of the wound would include measures.”