Centerwell Home Health

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record reviews and staff, family and laboratory interviews, it was determined that the agency’s skilled professional staff failed to follow up on services as ordered by the physician in the plan of care for one patient (P) (P#1) of three sampled patients. Specifically, the Registered Nurse (RN) failed to obtain the urinalysis (UA) (a series of tests on your urine to check for signs of common conditions or diseases) results for P#1 that was collected on 1/15/2025 until 3/31/2025. Findings included: Review of urinalysis report from the laboratory revealed the sample was collected for P#1 on 1/15/25, at 10:00 a.m., received at the laboratory on 1/16/25 at 12:35 p.m., and reported on Mar 31, 2025, at 5:39 p.m. Review of clinical record of P#1 failed to reveal the urinalysis result that was collected on 1/15/25. A telephone interview was conducted on 3/31/25 at 3:15 p.m., with the family of P#1 who reported the agency failed to provide the results of the UA obtained for P#1. An interview was conducted on 3/31/25, with the Market Executive of Operations (MEO) on 3/31/25 at 4:30 p.m., and confirmed the UA lab result for P#1’s on 1/15/25, failed to be found in the clinical chart of P#1. A telephone Interview with the Clinical Service Manager (CSM) with the laboratory was conducted on 4/1/25 at 3:00 p.m., confirmed the urinalysis was received on 1/16/25, but the verbal order was missing the physician signature. The CSM reported she faxed a request for the missing physician signature on 1/16/25, without a response from the agency. CSM further reported she also called and spoke to someone at the home health agency on 1/17/25 or 1/18/25 for the missing physician signature. CSM reported it took a month and a half to receive the physician signature for the verbal order submitted on 1/16/25. CSM reported on 3/31/25 at approximately 4:00 p.m., she received a call from the home health agency inquiring about the lab results submitted on 1/16/25. She stated she got another call on 3/31/25, at 4:50 p.m., to confirm what was needed for the lab results to be provided. CSM reported she received the verbal order with physician signature on 3/31/25 and provided the UA results.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on clinical record reviews and interviews, it was determined that the agency failed to maintain the highest practicable functional capacity, including providing optimal care to achieve goals for one patient (P) (P#1) of three patients reviewed. Specifically, the agency failed to obtain the urinalysis (UA) (a test to determine presence of infectious organisms in urine) results of P#1 for a month and a half after the specimen was collected and sent to a laboratory for analysis. Findings included: Review of the “Visit Note Report” dated 1/14/25, revealed the admitting nurse documented the following: P#1 complaining of increases frequency and burning when urinating. RN AA further documented it was recommended by RN AA that P#1 go to the emergency department (ER). Further review of the clinical record revealed a family member of P#1 requested a “rapid nurse visit” (a homecare homebase feature for smart scheduling). Review of clinical record of P#1 on 3/31/25, failed to reveal the urinalysis lab results collected on 1/15/25. A telephone interview was conducted on 3/31/25 at 3:15 p.m., with the family of P#1 who reported the agency failed to provide the results of the UA obtained for P#1. An interview was conducted on 3/31/25, with the Market Executive of Operations (MEO) on 3/31/25 at 4:30 p.m., and confirmed the UA lab result for P#1’s on 1/15/25, failed to be found in the clinical chart of P#1. MEO further reported the “best practices” for nurses with labs ordered would be to follow up with lab results and report those results to the physician. MEO reported the lab should have been called for the UA results.”

“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 review, patient and staff interviews, it was determined that the agency failed to provide services as ordered by the physician in the plan of care and to communicate and coordinate lab test with physician and other health care practitioners for one patient (P) (P1) of three sampled patients. Findings included: An interview was conducted on 3/31/25, with the Market Executive of Operations (MEO) on 3/31/25 at 4:30 p.m., and confirmed the UA lab result for P#1’s on 1/15/25, failed to be found in the clinical chart of P#1. MEO further reported the “best practices” for nurses with labs ordered would be to follow up with lab results and report those results to the physician. MEO reported the lab should have been called for the UA results. Further review of the clinical records failed to reveal results of UA (a test to determine presence of infectious organisms in urine) lab obtained on 1/15/25 for P#1. Cross reference G0940 as it relates to P1-Organization and administration of services.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on record review, and staff interview, it was determined that the agency failed to revise the care plan; specifically increasing Skill Nurse (SN) visits to continually assess one patient (P) (P#1) of three sampled patients. Findings included: Review of clinical record dated 1/14/25, revealed on admission the Registered Nurse (RN) RN AA documented the following: P#1 complaining of increases frequency and burning when urinating. RN AA further documented she recommended that P#1 go to the emergency department (ER). Additional review of the clinical record revealed a family member of P#1 requested a “rapid nurse visit” (a homecare homebase feature for smart scheduling). Review of document titled “Visit Note Report,” dated 1/15/25, a urinalysis (a series of tests on your urine to check for signs of common conditions or diseases) was ordered and obtained by Licensed Practical Nurse (LPN) BB. The current plan of care revealed Skill Nurse (SN) visits two times a week. The clinical record failed to reveal a revision to increase skilled nurse visits to continually assess P#1 for signs and symptoms once the urinalysis was ordered. During an interview on 3/31/25 at 4:30 p.m. the MEO confirmed that the hospice agency failed to revise the care plan to increase visits to assess continually P#1 for signs and symptoms once the urinalysis was ordered by the physician.”