Centerwell Home Health

“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, reviews of agency policies and interviews with agency personnel, for two of thirteen patients (Patient’s #5 & #6) requiring medication pre-pouring and/or administration, the agency nurses failed to follow agency policies. The findings include: a. Patient #5 had a start of care date of 4/15/21 and diagnoses that included paranoid schizophrenia, anxiety and type II diabetes mellitus. The physician’s orders for the certification period of 5/24/25 to 7/22/25 included nursing services once weekly for assessments and pre-pouring of medications. During a joint home visit on 7/01/25 at 9:30 AM with Registered Nurse/RN #1, the surveyor observed the pre-pouring of the patient’s medications, including the removal of medications from a lockbox, including removal of one (1) packet (from a storage bag of 7 individual packets) of MiraLAX powder 17 grams. Review of the clinical record identified that the patient was admitted to the hospital on 5/13/25 with a small bowel obstruction and discharged on 5/16/25 with instructions to take MiraLAX 17 grams (1 packet) daily as needed for constipation, although, review of the medication profile lacked documentation of the MiraLAX 17 grams on the physician’s orders dated 5/24/25. Interview and review of the hospital discharge summary dated 5/16/25 and the current medication profile with the Administrator on 7/01/25 at 12:30 PM failed to identify the MiraLAX order was included on the medication profile and failed to identify RN #1 followed agency policies. b. Patient #6 had a start of care date of 2/22/24 and diagnoses that included bipolar and anxiety disorder. The physician’s orders for the certification period of 5/16/25 to 7/14/25 included nursing services once weekly for assessments and pre-pouring of medications. During a joint home visit on 7/01/25 at 10:15 AM with RN #2, the surveyor observed the pre-pouring of the patient’s medications and the nurses attempted to administer Ozempic 2 milligrams/mg subcutaneously/SQ, although, the medication was not available onsite. A refill was needed and reordered during the visit. RN #2 indicated that she administers the Ozempic weekly for the patient. Review of the physician’s orders dated 5/16/25, lacked documentation in the medication profile of the weekly Ozempic 2 mg injection and the administration of the medication by the nurse. Review of the weekly nursing notes from 5/21/25 to 6/24/25 (six visits) identified the administration by the nurse of the Ozempic 2 mg in the narrative note, but lacked documentation of the Ozempic injection on the electronic medication administration section in accordance with agency policies. i. Interview and review of the weekly nursing notes and the current medication profile with the Administrator on 7/01/25 at 12:40 PM failed to identify the administration of Ozempic 2 mg SQ, with the site of the injection, was included in the electronic medication administered section in accordance with agency policies. Review of agency policies for Medication Review and Documentation directed that during each visit, the Home Health agency clinical associate will review all medications the patient is currently taking, including the routes of administration to ensure medications are current, accurate and documented on the medication profile. Review of agency policy for Administered Medications directed that the written orders must include documentation of the medication name, strength, dose, route of administration, site of administration, date and time of administration. ii. Interview and review of the weekly nursing notes with the Administrator on 7/01/25 at 12:45 PM identified the weekly pre-pouring of medications in the electronic medications administered section identified the number of tablets pre-poured for the week, but failed to include the dates that the medications were pre-poured, in accordance with agency expectations. Review of agency Pre-Poured Medication expectations directed documenting the medications pre-poured for (time frame to be administered) per the medication list of (provide specific date).”

“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 reviews and interviews with agency personnel, for two of thirteen patients (Patient’s #5 & #6) requiring medication pre-pouring and/or administration, the agency nurses failed to ensure a comprehensive care plan. The findings include: a. Patient #5 had a start of care date of 4/15/21 and diagnoses that included paranoid schizophrenia, anxiety and type II diabetes mellitus. The physician’s orders for the certification period of 5/24/25 to 7/22/25 included nursing services once weekly for assessments and pre-pouring of medications. During a joint home visit on 7/01/25 at 9:30 AM with Registered Nurse/RN #1, the surveyor observed the pre-pouring of the patient’s medications including removal of one (1) packet (from a storage bag of 7 individual packets) of MiraLAX powder 17 grams. Review of the clinical record identified that the patient was admitted to the hospital on 5/13/25 with a small bowel obstruction and discharged on 5/16/25 with instructions to take MiraLAX 17 grams (1 packet) daily as needed for constipation, although, review of the medication profile lacked documentation of the MiraLAX 17 grams on the physician’s orders dated 5/24/25. Interview and review of the hospital discharge summary dated 5/16/25 and the current medication profile with the Administrator on 7/01/25 at 12:30 PM failed to identify the MiraLAX order was included in the physician’s orders and failed to identify RN #1 completed a comprehensive care plan. b. Patient #6 had a start of care date of 2/22/24 and diagnoses that included bipolar and anxiety disorder. The physician’s orders for the certification period of 5/16/25 to 7/14/25 included nursing services once weekly for assessments and pre-pouring of medications. During a joint home visit on 7/01/25 at 10:15 AM with RN #2, the surveyor observed the pre-pouring of the patient’s medications and the nurses attempt to administer Ozempic 2 milligrams/mg subcutaneously/SQ, although, the medication was not available onsite. A refill was needed and reordered during the visit. RN #2 indicated that she administers the Ozempic weekly for the patient. Review of the physician’s orders dated 5/16/25, lacked documentation in the medication profile of the weekly Ozempic 2 mg injection and the administration of the medication by the nurse. Review of the weekly nursing notes from 5/21/25 to 6/24/25 identified the administration by the nurse of the Ozempic 2 mg in the narrative note. Interview and review of the physician’s orders and the current medication profile with the Administrator on 7/01/25 at 12:40 PM failed to identify the Ozempic order was included in the physician’s orders and failed to identify RN #2 completed a comprehensive care plan.”

“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 review and interview with agency personnel, for one of thirteen patients (Patient #2) in the survey sample, the agency nurses failed to provide the necessary assessments. The findings include: Patient #2 had a start of care date of 3/06/25 and diagnoses that included major depressive disorder and epilepsy. The physician’s orders for the certification period of 5/05/25 to 7/03/25 included nursing services twice daily for medication administration and assessments. Review of the clinical record from 5/05/25 to 6/16/25 identified assessment of the patient’s vital signs on 5/07/25, 5/08/25, 5/21/25, 6/02/25 and 6/16/25. Interview and review of the nursing notes from 5/05/25 to 6/21/25 (six weeks) with the Administrator on 7/01/25 at 11:30 AM identified it is the agency expectation that vital sign assessments are completed weekly during a clinical visit, but failed to identify the weekly assessment of vital signs for this patient were completed, according to agency expectations.”