Centerwell Home Health

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on observations, interviews, and record and policy reviews, the agency failed to ensure a comprehensive assessment was completed for one (#5) patient out of 17 patients sampled. The findings include: A review of the agency policy titled 03-05 Initial and Comprehensive Assessments with a revised date of 4/2023 Initial Assessment Visit: The assessment is the basis for identifying skilled needs and medical necessity for planning patient care and its baseline against which progress toward stated goals and outcomes is measured. Goals and anticipated outcomes will be established due to the assessment process and evaluated ongoing as part of patient care. An observation was conducted on 5/07/2024 at 1:00 PM during a home visit for Patient #5 with Staff K, Licensed Practical Nurse (LPN). Patient #5 was sitting in a recliner with the footrest up. The patient had a hard cast on her right leg from just below the knee to the top of her foot. There was a walker in the room. The patient was dressed in a hospital gown. Patient #5 said, “I have not slept well since coming home from the hospital. I have sat and slept in this recliner for 12 days. I have been waiting for a hospital bed since I got home. I don’t know what to do. I have called everyone I know, and no one gets back to me.” Staff K checked the patient’s vital signs, but did not listen to lung sounds or bowel sounds. Staff K checked the pedal pulse on the right foot only. Staff K did not observe the patient’s skin for potential breakdown due to her limited mobility and sitting and sleeping in her recliner for the past 12 days. Patient #5 also mentioned that she was on Warfarin and that she did not know how she would get to the physician’s office to have it checked. “The last time they checked my blood, it was low, so they changed the dose of my blood thinner. I’m worried that it may get too high.” Staff K continued to review the Zones of care, green, when, and what to report. Staff E, RN, did not call the physician for orders to check the patient’s PT/INR level or assist the patient in contacting the durable medical equipment (DME) company to see what was needed to get Patient #5 a hospital bed. A review of the Plan of Care (POC) for Patient #5 revealed an admission date of 4/29/2024 and a current certification period of 4/29/2024 to 6/28/2024. The primary diagnosis of fracture of the right fibula and a pertinent secondary diagnosis of AFib with cardio conversion. Frequency and duration of visits: SN (skilled nurse) 1 week 3. Orders of Discipline and Treatments: “Skilled Nurse to evaluate and develop a plan of care to be countersigned by the physician. SN will assess and evaluate co-morbid conditions, including other conditions present during this episode, identify changes, and intervene to minimize complications. The LPN will perform a nursing assessment to observe and report changes to the registered nurse (RN).” For DME and supplies: Nothing is listed. A review of the medication profile revealed that the patient is taking Warfarin 2.5 mg, two tablets on Monday and Friday and one tablet on Tuesday, Wednesday, Thursday, Saturday, and Sunday. A review of the admission note dated 4/30/2024 and completed by Staff H, RN, under Narrative: “The patient is unsafe to exit the home without supportive devices such as crutches, canes, wheelchairs, and walker. DME: The patient currently has a hospital bed ordered. The doctor’s office said it should be delivered today or tomorrow. The patient has grab bars in the shower, an anti-skid mat on the floor, and a shower chair. The patient also has a wheelchair, a walker, a cane, and a handle assist device. The patient has a history of falls and several fractures. There was no documentation that the patient was educated on Warfarin signs and symptoms to report. “Mobility- Ability to change and control body position: Very limited, occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Friction and Sher: Potential Problem: Moves freely or requires minimum assistance. During a move, the skin probably slides to some extent against sheets, chair restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.” During an interview conducted on 5/08/2024 at 9:51 AM, Staff C, Registered Nurse (RN), said he completed the admission for Patient #5 on 4/30/2024. “No, I did not assess her skin because she refused. I probably should have documented that. I think she wears briefs. She has a bedside commode; when she needs to use it, her husband will bring it and help her. Patient #5 told me her physician checked her PT/INR once a month. I did not think about her being unable to go to the physician’s office with a cast on. Regarding the hospital bed, I called the physician’s office, and they told me it should be delivered the next day or so.” A review of the visit note dated 5/07/2024 signed by Staff K. LPN documented, “Advised to speak with a physician about PT/INR machine.” Interventions: Provided Instruction on the basic use of assistive devices to ensure the patient is safe until the next visit—documents communication with the RN. An interview was conducted on 5/08/2024 at 9:00 AM with Staff H, the Clinical Manager. Staff H said that evaluating lung sounds, bowel sounds, and pedal pulses and checking for skin issues are part of the observations the LPN should make. “I do not see anything about ordering a PT/INR machine or calling the physician to see if he wants us to check it. I will do that right now.” Staff H said someone should have followed up on the hospital bed. A telephone interview was conducted with Patient #5 on 5/08/2024 at 11:15 AM. Patient #5 said that no one had asked to check her skin. “My husband would tell me if he saw anything when he puts me onto the bedside commode. I wear briefs but use the bedside commode for a bowel movement if I can. I sit in the recliner like you saw me when you came with the nurse. I cannot sit in a different position because of the cast. That is why I need the hospital bed with a bar so I can at least move off my backside. No, no one has asked me about the hospital bed. I have been working with the DME company myself. Something got messed up somewhere.” An interview was conducted with the Regional VP of the Durable Medical Equipment company on 5/08/2024 at 11:40 AM. He said that between the discharge planner and the rehabilitation facility, and the insurance company, there had been a problem with the order for a hospital bed. “Patient #5 called and was transferred to me. I advocated for the patient. I told my boss about the issue and that this patient had been sleeping in her recliner for almost two weeks. I will make sure they deliver her hospital bed tomorrow. No, we did not get a call from the home care agency. I would have thought they would have helped her figure out what the issue was with the referral from the rehab facility since they admitted her after she was discharged.” .”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record reviews, interviews, and review of data reports, the agency failed to ensure that the Outcome and Assessment Information Set (OASIS) assessment was transmitted to the CMS system within 30 days of the M0090 (date assessment completed) in order to allow an outside contractor to complete a review of the OASIS data for two of 16 sampled Medicare/Medicare Advantage patients, #3 and #8. The findings include: Review of the Internet Quality Improvement Evaluation System (IQIES) Home Health Agency (HHA) Error Summary report for the first quarter 01/01/2024-03/31/24, indicated an error rate of 5.74% for the error code 3330, Record Submitted Late (error 3330). A review of the available data for the current quarter to date, 04/01/24-05/06/2024 revealed an error rate of 21.96%, an increase of 16.22%. In total there were 3255 assessments processed with 353 errors, noted as error 3330, record submitted late. Review of the OASIS Agency Final Validation Reports dated 05/06/2024, indicated that 37 of 91 transmitted OASIS had error message 3330. According to the Centers for Medicare and Medicaid Services (CMS) OASIS Error Message User Guide dated January 18, 2023, the OASIS Provider Final Validation report is automatically generated within 24 hours of successful submission of a file. All warning errors should be reviewed and corrected if appropriate, to ensure the data uploaded is accurate and complete. Error 3330 message is “Record submitted late: The submission date is more than 30 days after M0090 on this new record. The potential cause is the assessment was not submitted within CMS timing guidelines. The submission date minus M0090 (date assessment completed) should be no more than 30 days.” CMS suggested actions include to “review the assessment timing schedule in the Current OASIS Guidance Manual and verify that all assessments are submitted in a timely manner.” On 05/06/2024 at 2:15 PM, an interview was conducted with the Administrator regarding the OASIS validation reports. She was asked if she was aware of the agency’s Home Health Agency (HHA) Error Summary rates, as shown above. She stated, “Yes, we were just discussing this. We are aware that we have issues with our submissions being greater than 30 days after our M0090 dates. I just got approval to have four remote clinical managers dedicated to catching up this work, I’ll have all four of them for two weeks each. We have split up their workflow and have a plan with the goal to get the current ones locked and transmitted within the time limit. One of our clinical manager positions in each branch is an open position. I did just hire one, but she is now on leave.” She was asked if the agency has a performance improvement project in place regarding these submission dates. She stated, “No, I don’t think we do. We’ve talked about it verbally, but it’s not on our last Quality Assurance and Performance Improvement (QAPI). We plan to bring it to our next QAPI.” Employee G, Clinical Manager, was present for this interview. She stated, “The issues started really occurring in March when we started taking more Humana patients. We were already short on clinical managers from people moving on.” For Patient #3, the RN OASIS admission assessment was completed on 03/29/2024 (M0090 date). On 05/06/24, the information remained not transmitted. This was 38 days after the completion of the OASIS assessment. For Patient #8, the RN OASIS recertification assessment was completed on 03/14/2024 (M0090 date). An interview with the Administrator on 05/07/2024 at 09:10 AM confirmed the OASIS was locked and transmitted on 04/15/2023. This was 32 days from the M0090 date. .”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observations, interviews, and policy reviews, the agency failed to ensure that staff followed their infection control policy for bag technique for two (#5, #6) patients observed during two of seven home visits conducted. The findings include: A review of the agency policy titled Bag Technique, home care with a revision date of May 22, 2023, Introduction: A bag is commonly used by home health care workers to transport patient care equipment and supplies to and from patients’ homes. When a bag is brought into a home, there is a risk of germs being introduced from the bag into the patient’s environment or of the bag becoming contaminated with microorganisms from the home, which could be transferred to the worker’s vehicle or into the homes of other patients. A home health care worker follows the bag technique to prevent the transmission of microorganisms that may be present on the outside or the inside of the bag. The bag technique involves proper hand hygiene, placement, cleaning maintenance, and management of equipment and supplies. This procedure applies to any device used to carry supplies into a patient’s home, including backpacks, wheeled bags, shoulder bags, hand-carried bags, computer bags, and wraparound-style bags. Implementation: Don’t allow the bag to touch the patient. Perform hand hygiene before entering the bag. Never remove items while wearing gloves. Never place any dirty or soiled items into the bag. Don’t bring the bag into a patient’s home if there are unsanitary or infectious conditions. Instead, transfer equipment and supplies needed for the visit to disposable double bags. Clean and disinfect equipment used during the visit before leaving the home and place it within the inner disposable bag. Discard the outer bag inside the patient’s home. When you shouldn’t bring the bag into a home: There are grossly unsanitary conditions in the patient’s home. Placement of the bag and supplies in the patient’s home: Place a nonwheeled bag on a flat surface that appears clean and dry. Use an impermeable pad as a barrier beneath the bag if a clean surface isn’t available. Clinical alert: Using an impermeable fluid as a barrier between the bag and the patient’s property and health reduces the risk of contamination. A review of the agency policy titled 10-01 Surveillance, Prevention, and Infection Control Policy: The agency will notify and reduce the risk of acquisition and transmission of healthcare-associated infections. Hand Hygiene, Infections, and Symptoms: Hand hygiene is the most effective means of preventing disease transmission in the home. An observation was conducted on 5/07/2024 at 1:00 PM during a home visit for Patient #5 with Staff K, licensed practical nurse (LPN). Staff K walked into the patient’s home with a shoulder bag. Staff K placed the bag on a couch next to the patient. Staff K used hand sanitizer and donned gloves. Then, she reached into her equipment bag and pulled out a thermometer, pulse oximetry, stethoscope, and blood pressure cuff. Then put the cuff on the patient’s right arm. Staff K’s blood pressure cuff would not work. Patient #5 handed the nurse her automated blood pressure cuff. Staff K placed the cuff on Patient #5. Then Staff K picked up the thermometer and took the patient’s temperature. Next, Staff K put the pulse oximeter on the patient’s finger. Once Staff K completed taking the patient’s vital signs with the same pair of gloves, she put all the equipment back into the bag without cleaning or removing her gloves or sanitizing her hands. Staff K continued with her visit and checked the patient’s pedal pulse on the right foot with the hard cast, using the same gloves she had donned at the beginning of the visit. At the end of the visit, Staff K pulled off her gloves, handed them to the patient, and asked her to throw them in the trash can beside her reclining chair. Staff K did not sanitize her hands after removing her gloves. An observation was conducted on 5/07/2024 at 2:15 PM during a home visit for Patient #6 with Staff K, LPN. Upon entrance to the patient’s home, a strong nose-stinging odor ermeated through the house. Dried debris and dead insects on the floors were observed throughout the home. The kitchen counters and sink had dishes piled up and covered with dark, fuzzy debris. The patient’s significant other led us to a room at the end of a hallway where the patient was in a bed with dirty sheets. Dirt and debris were observed throughout the room on the walls and floor. Dirty dishes were on a dresser, windowsill, and top of a window air conditioner. The window air conditioner had black debris on the seal around the window and inside of the air conditioner. Staff K put her equipment bag on top of a dresser inside a closet where the significant other removed the doors. On the same dresser were brown stained clothes and towels. Staff K reached into her equipment bag and pulled out her thermometer, pulse oximeter, and blood pressure cuff without cleaning her hands. Staff K then donned gloves and checked the patient’s vital signs. Then, with her gloves on, she put the dirty equipment back in her bag. Staff K did not clean the equipment after using or removing her gloves. During a phone interview on 5/08/2024 at 11:15 AM., Patient #5 said that a few nurses would put something down to protect her couch before putting their equipment bag on it. “Sometimes they use hand sanitizer and wear gloves. Then sometimes they don’t.” During an interview conducted on 5/08/2024 at 11:30 AM, Staff G, Clinical Manager, the clinical manager confirmed the home for Patient #6 was unsanitary. Staff G said that Staff K, LPN, should not have taken her equipment bag into the patient’s home. “It would have been better if she put the equipment in her pocket. No, she should have taken the equipment home in a disposable bag.” Staff G then added that their policy is for clinicians to sanitize their hands before and after using gloves and before putting clean equipment back in their bags. .”

“Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This Element is not met as evidenced by: Based on interviews, record reviews, and policy reviews, the agency failed to follow its policy to ensure patients’ rights to address their complaints regarding their treatment or care for one (#3) out of 17 sampled patients. The findings include: A review of the agency policy titled 03-23 Complaint Management with a revision date of 05/2023 revealed Policy: All complaints made by patients, and family, or the patient’s responsible party either verbally or in writing will be reviewed, evaluated, and forwarded to the appropriate manager for resolution. Actions and resolutions will be documented on the Complaint Log. All complaints will be logged with ongoing documentation until resolved. Complaint Investigation, Documentation, Resolution: The Home Health agency must investigate complaints made by a patient, patient representative (if any), patient caregivers, and family, including but not limited to the following topics: Treatment or care that is or fails to be furnished, is furnished inconsistently, or is furnished inappropriately. Attempts will be made to resolve complaints at the local level within three business days or within a mutually acceptable timeframe with the complainant. If resolution is not possible through the local home health agency, the upline manager will be contacted. If the complaint cannot be resolved during the first contact, a plan of corrective action, including associated timeframes, will be developed and communicated to the complainant. Details of all contacts with the complainant will be documented. The home health agency Administrator will be responsible for documentation of the investigation and resolution of the complaint in the agency’s complaint log. Within the home health agency, the administrator is accountable for receiving and resolving patient grievances. If not resolved at the local home health agency, complaints are referred through upline managers for resolution. An observation was conducted on 5/07/2024 at 3:00 PM. Staff J, Physical Therapy Assistant (PTA), made a home visit with Patient #3. Patient #3 said, “I told the last person who came to see me that I did not want Staff I, Physical Therapist (PT), back out here, and they sent him back anyway!” A review of the agency Complaint Log revealed no documentation of a complaint from Patient #3. Review of the completed visit report revealed that Staff I, PT, conducted visits to Patient #3 on 4/08/2024, 4/17/2024, and 5/03/2024. A review of the clinical note dated 5/07/2023 and signed by Staff J, PT revealed no documentation of the complaint from Patient #3. During an interview on 5/08/2024 at 8:45 AM, Staff H, Director of Clinical Services (DON), said no one had told her about Patient #3’s complaint. “I will enter a clinical alert into the system to address the complaint.” .”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interviews, and record reviews, the facility failed to complete a comprehensive medication review for one (#7) patient observed during one out of seven home visits conducted. The findings include: A review of the agency policy titled 03-41 Medication Review and Documentation with a revised date of 10/2022. Policy: The Home Health agency will assess all medications the patient is taking -both prescription and over-the-counter (OTC)- to include all routes of administration during each patient visit. A drug regimen review (DRR) and medication reconciliation will include all patient medications. They will be performed during the initial comprehensive assessment, each comprehensive assessment after that, and when a new medication is added to the patient’s plan of care. When conducting medication assessments, Clinical Associates must complete the following actions with the patient/caregiver and/or staff interview regardless of where the patient resides. Examine medication bottles, prescriptions, and current medication lists provided by the patient. Review medication lists from the physician/allowed practitioner and/or inpatient facility within the last 30 days and compare them to home medications found to ensure complete, accurate medication availability to the patient. Clinical Associate follow-up with the physician/allowed practitioner is required for all medication discrepancies. The medication review includes all prescribed OTC medications and supplements/herbals administered by all routes. On page 4 of 5, Medication Instruction: Instruction provided to the patient/caregiver will be documented in the patient’s medical record to include validation, understanding, and demonstrated competency as applicable. A review of the policy 03-05 Initial and Comprehensive Assessments, revised 4/2023, revealed Patient Medications: A Drug Regimen review (DRR) and Medication reconciliation will be performed during the initial assessment, each subsequent assessment, and ongoing thereafter as part of patient care. An observation was conducted on 5/07/2024 at 9:15 AM during a home visit for Patient #7 with Staff L, Registered Nurse (RN). Staff L conducted a discharge visit and reviewed the medications in the patient’s home against the plan of care. Staff L said, “I see no medication profile in the patient’s home folder.” Staff L then asked Patient #7 if she could review all the medications he was taking. The patient opened a cabinet and pulled out two bottles of Atorvastatin 20 mg tablets. Patient #7 said he takes one 20mg tablet of Atorvastatin every morning. Patient #7 said he takes Vitamin B12, Vitamin D, and Tylenol 500 mg as needed for his chronic back pain. Staff L stated that the plan of care (POC) listed the Atorvastatin 40 mg one tablet daily. Staff L said that Vitamin B12, Vitamin D, and Tylenol are not on the POC. Patient #7 said, “I have been taking only one Atorvastatin tablet for a while. Staff L said she would need to contact his physician to verify the correct dose of Atorvastatin. A review of Staff L’s visit note from the home visit on 5/07/2024, a call back was received from the patient’s physician on 5/07/2024 at 4:20 PM confirming the patient was to take Atorvastatin 20 mg tablets, one tablet every day, not 40mg. During an interview on 5/07/2024 at 9:30 AM, Staff L, said the medications Patient #7 took did not match the POC. A review of the POC for Patient #7 revealed an admission date of 4/25/2024 with a current certification period of 4/25/2024 to 6/23/2024, revealing a primary diagnosis of neoplasm of the bladder. On line 21 of the POC for Orders of Disciplines and Treatments: SN (skilled nurse) frequency 1wk1, 2wk1, 1wk1. SN will review the medication profile, reconcile medications, and instruct/reinforce medication management. The medication profile listed Atorvastatin 40 mg, 1 tablet daily. Reviewing the Client Coordination Note Report dated 4/25/2024 documented that “medications were reconciled at the time of the visit and of all medications in the home.” A review of the confirmed visit report documents an SN (skilled nurse) admission visit on 4/25/2024. The visit note does not document communication with the patient’s physician for medication reconciliation. Regular nursing visits were completed on 4/29/2024 and 5/02/2024 with no documentation about medication reconciliation or physician contact. This lack of documentation highlights the importance of accurate medication reconciliation. A review of the discharge visit note dated 5/07/2024 by Staff L, RN, who documented a call to the patient’s physician and verified the dose of Atorvastatin, which was 20 mg tablet once daily. “Wrong dose in tablet for Atorvastatin.” Staff L documented that she called the primary physician, and the medication dose was clarified: Atorvastatin 20 mg, 1 tablet daily. During an interview on 5/08/2024 at 8:40 AM, Staff H, the Clinical Manager, reviewed the patient’s medical record and confirmed that the POC and the patient’s medication profile had Atorvastatin 40 mg, to be taken one tablet daily. Staff H confirmed there was no documentation that the physician was contacted or a physician’s order to clarify the correct dose of the medication. .”

“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 observation, interviews, and record reviews, the facility failed to provide a written patient medication profile and instructions for one patient (#7) observed during one out of seven home visits conducted. The findings include: A review of the agency policy titled 03-11 Care Planning with a revised date of 09/2022 revealed that the patient or caregiver will be provided a copy of the Plan of Care (POC) and another form of written instructions outlining the patient’s medication schedule/instructions to include medication name, dosage, frequency and which medications will be administered by the home health agency clinician or other person acting on behalf of the agency. An observation was conducted on 5/07/2024 at 9:15 AM during a discharge visit for Patient #7. Staff L, a Registered Nurse (RN), reviewed the medications in the patient’s home folder against the plan of care. Staff L said, “I already see something that should be in the home folder. There is not a medication profile or written medication instructions.” Patient #7 said that he had not removed anything from the folder. In an interview on 5/07/2024 at 9:20 AM, Staff L said, “The admitting nurse should have completed a list of medications and instructions, which should have been completed at admission and left for the patient in the home folder.” An interview was conducted on 5/08/2024 at 8:40 AM. Staff H, the Clinical Manager, said, “Yes, the nurse should leave a copy of the medication profile and instructions in the patient’s home folder for the patient and caregiver. The nurse who conducted the admission should have completed a medication profile with instructions for the patient and left it in the home folder.” .”