Centerwell Home Health

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record reviews, staff interview, and patient family interview the agency Registered Nurse (RN) failed to promptly alert the physician of a change in patient condition (a witnessed fall) for 1 of 3 sampled patients, Patient #1. The findings are: Interview on 04/22/2026 at 9:10 AM with the daughter of Patient #1 revealed the patient experienced a fall in her home during a visit by agency Staff A, a RN, on 09/10/2025. The patient was taken via Emergency Medical Services (EMS) to a local hospital where she was treated and released. The daughter stated Staff A called her after the patient fell and reported that he caught her and eased her to the floor. Staff A insisted the patient did not hit her head during the fall. The daughter stated her mother began experiencing increased confusion later the same night and was taken by ambulance to another hospital, where it was determined she had a brain bleed. She was then transported via EMS back to another local hospital and was admitted. She subsequently passed away at the hospital on 09/17/2025. Review of the clinical record for Patient #1 revealed a skilled nurse clinical note dated 09/10/2025 written by Staff A. The section titled “Clinical Summary” notes “Patient recently recovered from a right hip fracture. She did unfortunately fall on me while I was in the home. She said she had been having issues with her vertigo, I needed to get a urine culture from her. She stood up and I asked her to get her head level, she said she felt good. Started to walk toward the bathroom, I turned around to grab some gloves out of my bag and she yelled my name and started to fall backwards. I jumped over her rocker and was only able to catch her head. She did hit the left side of her body on the floor - 911 was then called and she was brought to the hospital.” The section titled “Care Coordination Physician/Provider contacted” is marked “Pending”. The section titled “Document details related to contacting physician/provider” is marked “Will contact physician”. Further review of the clinical record revealed no documentation that the physician was ever contacted to notify of the patient’s fall. Review of hospital records from both hospitals confirmed the patient was treated for a ground level fall on 09/10/2025 and 09/11/2025 with subsequent admission to FWBMC on 09/11/2025 where she expired on 09/17/2025. Interview with the Branch Director of the agency office in Crestview on 04/22/2026 revealed her statements that she had not been aware of Patient #1’s fall until 11/11/2025 when the patient’s daughter called to request licensure information for Staff A. She stated that at that time, Staff A was no longer working at the agency and was not available for interview, but she performed a record review for Patient #1 at that time and confirmed a fall occurred on 09/10/2025. She also confirmed there is no documentation or evidence to indicate Staff A reported the fall to either the Case Manager, Clinical Manager, or the patient’s physician.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on record reviews and staff interview the agency failed to provide services in accordance with current clinical practice guidelines and accepted professional standards of practice by failing to report a patient fall in accordance with agency policies and procedures for 1 of 3 sampled patients, Patient #1. The findings are: Review of the clinical record for Patient #1 revealed a skilled nurse clinical note dated 09/10/2025 written by Staff A. The section titled “Clinical Summary” notes “Patient recently recovered from a right hip fracture. She did unfortunately fall on me while I was in the home. She said she had been having issues with her vertigo, I needed to get a urine culture from her. She stood up and I asked her to get her head level, she said she felt good. Started to walk toward the bathroom, I turned around to grab some gloves out of my bag and she yelled my name and started to fall backwards. I jumped over her rocker and was only able to catch her head. She did hit the left side of her body on the floor. 911 was then called and she was brought to the hospital.” Review of hospital records from both hospitals confirmed the patient was treated for a ground level fall on 09/10/2025 and 09/11/2025 with subsequent admission to hospital on 09/11/2025 where she expired on 09/17/2025. Review of agency Occurrence Reports (the method used for staff to report unusual occurrences and incidents) for the past 9 months revealed no evidence of a report documenting Patient #1’s fall on 09/10/2025. Interview with the Branch Director of the agency office in Crestview on 04/22/2026 revealed her statements that she had not been aware of Patient #1’s fall until 11/11/2025 when the patient’s daughter called to request licensure information for Staff A. She stated that at that time, Staff A was no longer working at the agency and was not available for interview, but she performed a record review for Patient #1 at that time and confirmed a fall occurred on 09/10/2025. She also confirmed there is no documentation or evidence to indicate Staff A ever completed an Occurrence Report nor is there any evidence to indicate Staff A reported the fall to the Case Manager, Clinical Manager, or the patient’s physician. Review of the agency policy “05-18 Patient Occurrence Reporting and Adverse Events” revealed: Purpose is to ensure timely identification, documentation, investigation, and resolution of all incidents and occurrences that deviate from routine operations and may impact patient safety, associate welfare, or home health agency compliance. Supports regulatory compliance with CMS, state health departments, and accrediting bodies. Definition of Occurrence: Any event that is not consistent with the routine care of a patient or to standard Company procedures/operations. Also referred to as an incident; may include adverse events and near misses; Occurrences/incidents must be documented and investigated. Defines investigation/root cause analysis. Policy ranks occurrences by severity: Critical Incident: An event that poses an immediate threat to health, safety, or welfare and may require external reporting. Level 1 Incident: No deviation from the standard of care. Example: Patient fall incident as a result of not using their assistive device. Level 2 Incident: Confirmed quality issue without the potential for significant adverse effects on a patient. Example: Failure of an associate to follow established policy, procedure, protocol. Level 3 Incident: Confirmed quality issue with the potential for significant adverse effects on a patient. Level 4 Incident: Confirmed quality issue with confirmed significant adverse effects on a patient. Level 5 Incident: Death, not related to the primary diagnosis. Sentinel Event: Any unexpected occurrence or incident involving death or serious physical psychological injury, or any risk of death or serious injury Associates must report incidents/occurrences immediately to Branch Director/Administrator Clinical Manager, or on-call clinician if an incident occurs after hours. An Incident Report Form must be completed within 24 hours of discovery. Administrator or designee must review all reports within 24 hours. Incidents meeting state or CMS reporting thresholds must be submitted to the appropriate authority. When an incident may involve potential (Level 3) or actual major injury or death of a patient (Level 4, Level 5), the agency’s Branch Director/Administrator will immediately notify the Regional Clinical and Operational Team and Escalation Team. Examples of reportable Events: (Includes) Patient falls (witnessed or unwitnessed) Notification: Notify patient’s physician and family (if applicable). Notify regulatory bodies as required. Documentation: All reports and investigations are logged in the Occurrence Report in the EMR. Include in QAPI reviews for trend analysis and performance improvement. Failure of Staff A to report the witnessed fall of Patient #1 led to failure of the agency to appropriately implement an adequate investigation of the incident, and inability of the Quality Improvement Program to address potential issues and possible prevent future falls.”