Centerwell Home Health

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on facility policy review, record reviews, observations, and patient and staff interviews, the agency failed to ensure patients received a completed copy of the consent and could participate in their care by planning visit frequencies for seven (#1, #2, #3, #4, #5, #6, & #7) patients out of seven observed during home care visits. The findings include: 1. A review of the home health policy title 03-05 Patient Assessments with a revised date of 8/2024 revealed under Initial Comprehensive Assessments: “The Home Health Agency Home Care Consent form will be completed by the initial assessing qualified Clinical Associate to include physician/allowed practitioner ordered disciplines and frequency of care. Additional disciplines ordered by the physician/allowed practitioner will complete the Home Care Consent Addendum form to reflect their service and frequency of care as appropriate.” 2. Staff G, an occupational assistant (COTA), conducted a home visit for patient #1 on 8/27/2024 at 9:00 AM. A review of the patient’s home folder revealed the patient’s copy of the consent was blank. The whiteboard calendar in the home had July 2024 on it. During an interview with patient #1 on 8/27/2024 at 9:20 AM, she said that staff call the night before or the day of the scheduled visit. 3. Staff F, a Registered Nurse (RN), conducted a home visit for patient #2 on 8/27/2024 at 10:00 AM. A review of the patient’s home folder revealed that the patient’s copy of the consent was blank, and the whiteboard calendar in the home had nothing on it. During an interview with patient #2 on 8/27/2024 at 10:20 AM, she said that staff text the night before or the day of the visit. 4. Staff H, a Physical Therapist (PT), conducted a home visit for patient #3 on 8/27/2024 at 11:00 AM. A review of the patient’s home folder revealed that the patient’s copy of the consent form was blank, and the whiteboard calendar had July-Aug on it, but nothing was filled out for visit frequencies. During an interview with patient #3 on 8/27/2024 at 11:15 AM, she said the staff called the night before or the day of the visit. 5. Staff I, a Licensed Practical nurse (LPN), conducted a home visit for patient #4 on 8/27/2024 at 12:30 PM. A review of the patient’s home folder revealed that the patient’s copy of the consent was blank, and the whiteboard calendar in the home had nothing on it. During an interview with patient #4 on 8/27/2024 at 12:40 PM, she said that staff texted the night before or when they were on the way. 6. Staff J, a Physical Therapy Assistant (PTA), conducted a home visit for patient #5 on 8/27/2024 at 1:15 PM. A review of the patient’s home folder revealed that the patient’s copy of the consent was blank, and the whiteboard calendar in the home had nothing on it. During an interview with patient #5 on 8/27/2024 at 1:20 PM, he said the staff called him and told him when they were coming. 7. Staff K, an Occupational Therapist (OT), conducted a home visit for patient #6 on 8/27/2024 at 2:00 PM. A review of the patient’s home folder revealed that the patient’s copy of the consent was blank, and there was no whiteboard calendar in the home. During an interview with patient #6 on 8/27/2024 at 1:20 PM, the caregiver said that they call the night before they are to come for a visit. 8. Staff L, Licensed Practical Nurse (LPN), conducted a home visit for patient #7 on 8/27/2024 at 3:00 PM. A review of the patient’s home folder revealed that the patient’s copy of the consent was blank, and the whiteboard calendar in the home had nothing on it. During an interview with patient #7 on 8/27/2024 at 3:10 PM, he said the staff called and let him know when they were coming. 9. During an interview with the administrator on 8/28/2024 at 9:50 AM, she said the consent form in the home folder should be filled out on the first visit. The administrator also confirmed that the visit calendars should be completed. .”

“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 observation, record reviews, and interview, the agency failed to ensure staff reported a change in condition to the physician for one (#2) patient out of seven home visits conducted. The findings include: On 8/27/2024 at 10:00 AM, Staff F, registered nurse (RN), conducted a home visit for patient #2. During the home visit, Patient #2 reported to Staff F that she had some rectal bleeding. The nurse said, “Well, this is new.” Staff F did not examine the patient for rectal bleeding. A review of the nurse visit note by Staff F, dated 8/27/2024 at 09:49 AM, revealed that on page 2 of 8 under Assessment for Gastrointestinal, there was no documentation of the rectal bleeding the patient had reported. There was also no documentation that the nurse called the physician or the supervisor in the office. A review of the Patient’s Rights from the agency Home Health Policy manual #14 shows the patient has the right to expect the Company to coordinate care through regular communication with their physician or other authorized practitioner, clinicians, and other providers. A review of the plan of care (POC) for patient #2 revealed an admission date of 9/11/2023 and a current certification period of 7/07/2024 to 9/04/2024. Nursing frequencies/Duration of visits has SN (skilled nursing) 1 wk. 9 with Orders of Discipline and Treatments: SN will assess/evaluate co-morbid conditions and other conditions that present themselves during the episode to identify changes and to intervene to minimize complications. Page 2 of 5 of the POC revealed orders for the nurse to report significant changes in status to the physician. During an interview with the administrator on 8/28/2024 at 9:00 AM, she said she did not see any documentation that Staff F reported the rectal bleeding to the patient’s physician.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observations, record reviews, and interviews, the agency failed to provide patients with written information regarding their medication regimen with clear instructions for four patients (#3, #4, #5, and #6) out of seven home care visits conducted. The findings include: 1. Staff H, a Physical Therapist (PT), conducted a home visit for patient #3 on 8/27/2024 at 11:00 AM. A review of the patient’s home folder revealed that the patient did not have a medication list completed. During an interview with patient #3 on 8/27/2024 at 11:15 AM, she said, “I take those meds,” pointing to the bottle on the counter. 2. Staff I, a Licensed Practical nurse (LPN), conducted a home visit for patient #4 on 8/27/2024 at 12:30 PM. A review of the patient’s home folder revealed that the patient did not have a medication list completed. During an interview with patient #4 on 8/27/2024 at 12:40 PM, she said that she did not ever have a medication list other than the one from her physician. 3. Staff J, a Physical Therapy Assistant (PTA), conducted a home visit for patient #5 on 8/27/2024 at 1:15 PM. A review of the patient’s home folder revealed that the patient did not have a medication profile. 4. Staff K, an Occupational Therapist (OT), conducted a home visit for patient #6 on 8/27/2024 at 2:00 PM. A review of the patient’s home folder revealed that a copy of the medication profile was missing. 5. During an interview with the administrator on 8/28/2024 at 9:55 AM, she said a copy of the medication regimen should be in the home folder. .”