Centerwell Home Health

“Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient’s legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This Element is not met as evidenced by: Based on observations, interviews, and record reviews, the agency failed to provide patients with notice of their rights prior to admission for two (#9 and #11) patients out of a sample of seven home visits conducted. The findings include: 1. An interview was conducted with patient #9’s daughter on 7/16/2024 at 4:17 PM while waiting for Staff A, Physical Therapist Assistant (PTA), to arrive for the home visit. Patient #9’s daughter stated the nurse came out on 7/07/2024. “She had me sign an agreement, but we received no information, names, or phone numbers. We did not receive any admission booklet.” Staff A, PTA, conducted patient #9’s home visit on 7/16/2024 at 4:33 PM. Staff A confirmed that the patient did not have an admission pack. “I believe the patient was admitted over the weekend, and the clinician who admitted the patient did not have any extras in his car. I do not know why the home care agreement was the only thing the patient was provided. You will have to ask that clinician.” A review of the Plan of Care (POC) for patient #9 revealed an admission date of 7/07/2024 with a current certification period of 7/07/2024 to 9/04/2024-documentation for Frequency/duration of Visits: SN (skilled nursing) 2wk1, 1wk8, PT (Physical therapy) 1wk1, 2wk4, OT (Occupational therapy) 1wk8. 2. Staff B, Registered Nurse (RN), conducted patient #11’s home visit on 7/17/2024 at approximately 11:30 AM. On 7/17/24 at 11:40 AM, patient #11’s wife said they received no admission booklet when the nurse first came out to start services. “I signed a paper, and that was all I saw. I did not know who to call until the second visit. Staff B, RN, said, “I can get them one now and go over it with them.” Staff B confirmed she had admitted the patient. A review of the Plan of Care (POC) for patient #11 revealed an admission date of 6/30/2024 with a current certification period of 6/30/2024 to 8/28/2024 with documentation for frequency/duration of visits: SN (skilled nursing) 2wk1, 1wk1, 2wk1, 1wk2. 3. During an interview with the administrator on 7/17/2024 at 12:20 PM, she confirmed that the admitting discipline must review the information in the agency admission booklet with the patients before providing care. A review of the agency policy titled 03-09 Patient Rights/Notice of Privacy Practices, which was revised on 4/2022. Policy: Each patient admitted/readmitted will be provided with the Patient Bill of Rights, the Notice of Privacy Practices, and, when applicable, the Outcome and Assessment Information Set (OASIS) Statement of Patient Privacy Rights. .”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on observations, interviews, and record reviews, the agency failed to ensure patients received appropriate notification regarding the agency’s transfer and discharge policy for two (#9 and #11) patients out of seven home care visits conducted. The findings include: 1. An interview was conducted with patient #9’s daughter on 7/16/2024 at 4:17 PM while waiting for Staff A, Physical Therapist Assistant (PTA), to arrive for the home visit. Patient #9’s daughter stated that the therapist came out on 7/07/2024. “He had me sign an agreement, but we received no information. We did not receive any admission booklet.” Staff A, PTA, conducted patient #9’s home visit on 7/16/2024 at 4:33 PM. Staff A confirmed that the patient did not have an admission pack with information about the transfer and discharge policies. 2. Staff B, Registered Nurse (RN), conducted patient #11’s home visit on 7/17/2024 at approximately 11:30 AM. The home health admission pack was requested to be reviewed. At 11:40 AM, patient #11’s wife said they received no admission booklet or information about the transfer and discharge policies. Staff B, RN, said, “I can get them one now and go over it with them.” Staff B confirmed she had admitted the patient. 3. An interview with the administrator was conducted on 7/17/2024 at 1:20 PM. The administrator said the agency is closed on the weekends and that staff should have extra admission packs with them. “All information for patient rights and transfer and discharge information is in the home care admission book. All they have to do is call us, and we will get some to them. Running out of stock is no excuse.” .”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on patient record review, staff interview and facility policy review, the facility failed to ensure the start of care was initiated within 48 hours of the referral for two of 17 patients sampled, Patients #15 and #17. The findings include: 1. A review of patient #17’s medical record revealed the agency received a referral for the patient to receive home health services on 3/11/24. The start of care date was 3/22/24. The review failed to reveal documentation of physician notification of the start of care delay, new orders for an updated start of care date or other documentation of why the admission was delayed. On 7/17/24 at 11:18 AM, an interview was conducted with the Administrator during which she reviewed patient #17’s medical record and verified the agency had received a referral on 3/11/24 and that the start of care was not until 3/22/24. She stated there should be information in the record or a physician’s order for an updated start of care. She confirmed the medical record did not have documentation or other evidence to support that the physician was notified of the delayed start of care or why the admission was not initiated within 48 hours of receipt of the referral. 2. A review of patient #15’s medical record revealed the agency received a referral for the patient to receive home health services on 6/15/24. The start of care date was 6/20/24. The review failed to reveal documentation of physician notification of the delay, new orders for an updated start of care date or other documentation of why the admission was not initiated within 48 hours of receipt of the referral. On 7/17/24 at 12:15 PM, an interview was conducted with the Administrator during which she reviewed the patient’s medical record. She verified that the agency had received a referral for this patient on 6/15/24; however, the start of care was noted to be 6/20/24. She was unable to find evidence to support that the physician was notified of the delayed start of care or documentation as to why the admission was delayed. 3. A review of policy 03-05 “Initial and Comprehensive Assessments” last reviewed on 9/28/18 revealed under the Initial Assessment Visit, “The Home Health agency will conduct an initial assessment visit to the patient: within 48 hours of the referral for services, or within 48 hours of the patient’s discharge from the inpatient facility or on the date the physician/allowed practitioner specifies care is to start. If the Home Health agency receives a referral and cannot make the first visit within 48 hours of the referral or patient discharge from an inpatient facility, the Home Health agency will contact the respective physician/allowed practitioner or referring entity with knowledge of the patient’s current condition. Approval will be obtained for a specific start of care date or referral to another home health agency provider for services.” .”

“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 observations, interviews, and record reviews, the agency failed to notify the physician of a significant change in condition for one (#8) patient out of seven patients sampled during home care visits. The findings include: Patient #8’s spouse was interviewed on 7/16/2024 at 1:15 PM while waiting for Staff C, Occupational therapist (OT), to arrive for the home visit. The spouse said patient #8 had not had a bowel movement (BM) since 7/12/2024 and would let the therapist know about it today. Then, the spouse tried to get the patient to open his eyes. Patient #8 was asleep in a recliner with a Foley catheter bag and tubing strapped to his right thigh. A home care observation with Staff C, OT, was conducted on 7/16/2024 at 1:45 PM for patient #8. The OT conducted her assessment and asked questions. The spouse reported to Staff C that patient #8 had not had a BM since 7/12/2024 when he was in rehab. “I am afraid that is the reason why he is lethargic. I think the last time this happened to him, he acted the same way. He was lethargic, and all he wanted to do was sleep.” Staff C was observed documenting her findings on her tablet. A review of Staff C’s visit note dated 7/16/2024 for patient #8 revealed documentation that the patient’s last BM was on 7/12/2024. There was no documentation that Staff C, OT, notified the clinical manager or called the physician. During an interview with the Director of Nursing (DON) on 7/17/2024 at 2:40 PM, the DON said that she had not heard anything from Staff C about patient #8. Review of the agency policy titled 03-12 Physician/Allowed Practitioner Orders, with a revised date of 4/2023 included the following: Obtaining Orders: Any revision of the patient’s POC (Plan of Care) due to a change in health status must be communicated to ALL physicians/allowed practitioners who are issuing orders related to the patient’s care. .”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on observations, interviews, and record reviews, the agency failed to ensure that all orders for a peripherally inserted central catheter (PICC) were integrated into the plan of care (POC) for one (#11) patient out of 1 sampled with a PICC line from a total of seven home visits. The findings include: A review of the plan of care (POC) for patient #11 revealed an admission date of 6/30/2024, a current certification period of 6/30/2024 to 8/28/2024, and a pertinent diagnosis of Cellulitis of the left upper arm. The frequency and duration ordered for SN (skilled nursing) were: 2 wk 1, 1 wk 1, 2 wk 1, 1 wk 2. Orders for SN and treatments documented SN to administer RUS (right upper extremity) PICC line IV (Intravenous) therapy. Type: Ceftriaxone dose 2 gm, route IV push over 10 minutes every 24 hours. Flush IV with 10ml 0.9% NA (normal saline) before/after administration and every 8 hours when not used. Change dressing using sterile technique: transparent dressing every 7 days and as needed for soiling. Change the cap weekly and after blood draws. The POC did not order who or when the PICC line should be discontinued. The medical record did not reflect any documentation of the type of PICC line inserted or measurements. A home care observation was made on 7/17/2024 at 11:30 AM with Staff B, Registered Nurse (RN), and patient #11, to observe the removal of a PICC line for the patient. Staff B set up her equipment and assessed patient #11. She said she needed to call patient #11’s physician to verify the PICC line was to be removed. Staff B confirmed that the POC did not have orders to remove the PICC line. Staff B, RN, received a call back from patient #11’s physician, who gave a verbal order to remove the PICC Line. During an interview with the Director of Nursing (DON) and the Administrator on 7/17/2024 at approximately 12:30 PM. The DON confirmed that the order for nursing to discontinue the PICC line did not make it to the POC. A review of the home care referral dated 6/20/2024 revealed orders for an End Date of 7/16. “Pull PICC/EOT (end of treatment). The referral did not document the type or size of the PICC line inserted. The Administrator stated that she would ensure that all orders are on the POC in the future. .”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observations, interviews, and record reviews, the agency failed to provide a written visit schedule for each discipline providing services for four (#8, #9, #10, #11) patients out of seven patients sampled during home care visits. The findings include: 1. Patient #8’s spouse was interviewed on 7/162024 at 1:15 PM while waiting for Staff C, the Occupational Therapist (OT), to arrive for her visit. The spouse said, “The staff just call or text us when they are coming. It would be nice to have a say on what works for us. We are not morning people. They gave us a dry-erase board, but there is nothing on it. I have been using it for other things. It would be a blessing if we knew beforehand who and what time they were coming.” A home care observation on 7/16/2024 at 1:45 PM for patient #8 revealed no calendars for the discipline visits. The dry-erase board on the patient’s refrigerator with MD appointments and a “To Do” list on the dry-erase calendar did not include a visit schedule. Staff C confirmed that the dry-erase boards were part of the admission pack and that the disciplines were to document the days and times of their visits. 2. An interview was conducted with patient #9’s daughter on 7/16/2024 at 4:17 PM. The caregiver said that when patient #9 was admitted over the weekend, the agency did not tell her the days they would be coming. “The first two visits, they just showed up. Now, they will give me a call when they come.” A home care observation was conducted on 7/16/2024 at 4:30 PM for patient #9. There were no calendars for the discipline visits. The daughter also stated they had not been informed about who or when someone would be coming when patient #9 was admitted. At that time, during an interview with Staff A, the Physical Therapy Assistant (PTA), he said was unsure why the admitting clinician did not give patient #9 an admission booklet with a dry-erase calendar. He said he could not answer for that clinician, but he could get them one. 3. A home care observation for patient #10 was conducted on 7/17/2024 at 10:30 AM. Patient #10 said, “Oh, I keep my home care book in my file cabinet.” The patient was in her wheelchair, rolled herself into her office area, and, with a magnifying glass, looked for the home health admission booklet. Patient #10 found the booklet. The patient’s home care admission booklet review revealed no calendars or dry-erase boards with a visit schedule. Patient #10 also stated, “No, they do not call me in advance. I get calls or texts when they are coming.” During an interview on 7/17/2024 at 10:58 AM, Staff E, Homemaker/companion, said, “I have never seen a calendar in the home. They call her when they are on their way.” 4. A home care observation on 7/17/2024 at 11:30 AM for patient #11 revealed he did not receive a home care admission booklet on admission. An interview was conducted with patient #11’s spouse at that time. The caregiver said they did not give him any information when they admitted patient #11 over the weekend. During an interview with Staff B, Registered Nurse (RN), on 7/17/2024 at 11:30 AM, she said, “I can get them one now and go over the information with them.” 5. An interview on 7/17/2024 at 1:20 PM with the Director of Nursing, the Administrator and the Director of Clinical Operations confirmed patients should receive information on who and when staff will be coming. 6. A review of the home health policy titled 03-09 Patient’s Rights/Notice of Privacy Practices, with a Revised date of 04/2022, revealed the following: As a patient of the company, patients have the right to...8. Participate in and be informed in advance about treatment, including the completion of assessments to determine care needs; decisions about the care to be provided or revisions to the care plan; the name and title of staff who will perform or supervise their care; the frequency of visits; expected outcomes and goals; and any factors that could impact the effectiveness of their treatment. .”

“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, interviews, and record reviews, the agency failed to provide written information regarding the patient’s correct medication regime for four (#8, #9, #10, and #11) out of seven patients sampled during seven home visits. The findings include: 1. Patient #8’s spouse was interviewed on 7/16/24 at 1:15 PM while waiting for Staff C, the Occupational Therapist (OT), to arrive for her visit. The spouse said they did not give me anything on medications. I have been using what I got from the facility and adding to it.” A home care observation on 7/16/2024 at 1:45 PM for patient #8 revealed there was not a current list of medications from the home health agency in the home. 2. An interview was conducted with patient #9’s daughter on 7/16/2024 at 4:17 PM. The caregiver said that on admission, they did not review her medications and did not provide anything written that she I could follow. Patient #9’s home care observation was conducted on 7/16/2024 at 4:30 PM. The patient’s daughter provided a copy of the discharge medication profile from the rehab facility. “As you can see, I am trying to make sure I give her what she is supposed to have. I am using different colored highlighters to help me know what is what.” During an interview with Staff A, the Physical Therapy Assistant (PTA), on 7/16/2024 at 4:33 PM, he said, “Our standard is to follow the discharge instructions with the medication list.” 3. A home care observation with Staff D, Licensed Practical Nurse (LPN) for patient #10 was conducted on 7/17/2024 at 10:30 AM. Staff D provided a copy of the discharge medication list dated 2023. During an interview on 7/17/2024 at 10:40 AM, patient #10 said, “A couple of weeks ago, I had my neighbor try to type up a list of my medications.” During an interview on 7/17/2024 at 10:58 AM, Staff D confirmed no updated mediation profile was in the home. 4. A home care observation on 7/17/2024 at 11:30 AM for patient # 11 revealed he did not receive a home care admission booklet on admission. An interview was conducted with patient #11’s spouse on 7/17/2024 at 11:30 AM who stated, “No, they have not provided me with a medication profile. They did not review the meds either. I have been trying to follow the discharge instructions, but there are meds on there that he has not been taking since he got home.” During an interview with Staff B, Registered Nurse (RN), on 7/17/2024 at 11:35 AM, she confirmed she had not provided the patient with an updated medication profile. 5. During an interview on 7/17/2024 at 1:20 PM with the Director of Nursing, the Administrator and the Director of Clinical Operations, they confirmed medications need to be reviewed and reconciled with what is in the home. A review of the home health agency policy 03-41 Medication Review and Documentation, revised 10/2022, revealed that the home care agency will assess all medications the patient is taking, prescription and over-the-counter (OTC), to include all routes of administration during each patient visit. .”

“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 observation, interviews, and record reviews, the agency failed to ensure that professional standards of practice were followed during a high-tech procedure for removing a PICC line for one (#11) patient out of a sample of one with a PICC line from seven home visits. The findings include: A review of the Plan of Care (POC) for patient #11 revealed an admission date of 6/30/2024, a current certification period of 6/30/2024 to 8/28/2024, and a pertinent diagnosis of Cellulitis of the left upper arm. Orders for skilled nursing (SN) and treatments documented SN to administer RUS (right upper extremity) PICC line IV (Intravenous) therapy. Type: Ceftriaxone dose 2 gm, route IV push over 10 minutes every 24 hours. Flush IV with 10ml 0.9% NA (normal saline) before/after administration and every 8 hours when not used. Change dressing using sterile technique: transparent dressing every 7 days and as needed for soiling. Change the cap weekly and after blood draws. The medical record did not reflect any documentation of the type of PICC line inserted or measurements. A home care observation was conducted with Staff B, Registered Nurse (RN), for patient #11 on 7/17/2024 at 11:40 AM. Staff B set up her equipment and assessed patient #11. Then, she said she wanted to call patient #11’s physician to verify she was to pull the PICC line today. Staff B, RN, received a call back from patient #11’s physician, who gave a verbal order to remove the PICC Line. Staff B sanitized her hands, gathered gauze and an occlusive dressing, and walked to patient #11, who was sitting on the couch. Staff B then donned non-sterile gloves. Staff B removed the dressing to the PICC insertion site on the right upper arm. Staff B asked the patient to hold his breath and then, with the same gloves on, removed the PICC line. The gauze was applied without a petroleum-based ointment, and the patient held pressure. Staff B removed her gloves with the PICC line wrapped inside them. Staff B walked to the table where the she had set up her equipment. Staff B removed a red biohazard box from her nursing bag and disposed of the PICC line. Staff B did not measure the PICC line or check to ensure the tip of the line was intact. A review of the personnel file for Staff B revealed that a PICC line competency check-off sheet was completed on 5/12/2023. The competency did not have the preceptor or supervisor’s initials or completion date. A request was made for the agency’s policy and procedure for removing a PICC line. A policy was not provided. A review of the agency competency for the removal of PICC line documents: Wash hands, don sterile gloves, explain the procedure to the patient, discontinue all infusates and or clamp extension set, position the patient, remove the dressing from the insertion site, remove stabilization device, inspect the catheter insertion site, slowly remove the catheter, apply pressure to the site with gauze, apply petroleum-based ointment to exit site, and inspect catheter to ensure entire catheter has been removed. An interview was conducted on 7/17/2024 at 12:30 PM with the Director of Nursing (DON) and the administrator. The DON confirmed Staff B should have measured the PICC line after removal. However, the type of PICC line and measurements were not on the referral. The Administrator said, “It will be in the future.” .”