Centerwell Home Health

“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 the Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report, review of the Home Health Policy Manual, and staff interview, it was determined that the agency failed to electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the CMS system every 30 days. Findings include: Review of the policy within the Home Health Policy Manuel titled “OASIS Data Collection,” last revised 09/28/2018, revealed the following: OASIS data items will be collected and transmitted within 30 calendar days of the completion of the OASIS assessment. Review of CMS report titled “HHA Error Summary by Agency,” with report period of 02/01/2024 - 02/01/2024 and run date of 2/17/2025, revealed the agency failed to transmit OASIS data to CMS system within 30 days. During an in-office interview on 3/3/2025 at 1:00 p.m., the Administrator revealed that she was aware that the 30-day OASIS submission timeframe requirements were not met during the time frame of 02/01/2024 - 02/01/2024. The Administrator reported that the agency has experienced an interruption of service with the companies OASIS file transfer solution department due to an incident originating at the companies finance department.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on review of the policy titled “03-11 Care Planning, “ record reviews, and staff interviews, it was determined the agency failed to ensure that the individualized plan of care includes all treatments and interventions related to the patient’s diagnoses for four patients (P) (P#2, #7 #9, and P #10) of 17 sampled patients. Findings include: Review of the policy titled “03-11 Care Planning,” last revised 09/2024, reveals the following: Policy Each patient must receive an individualized written Plan of Care (POC) including ongoing updates and/or additions related to patient findings. The Plan of Care • Will be developed in collaboration with the physician/allowed practitioner and Home Health Clinical Associate following the initial /comprehensive assessment and will contain integrated orders from all physicians or allowed practitioners involved in the POC to assure coordination of all services and interventions provided to the patient. • The individualized POC is developed for the patient 60-day episode of care and must include: • Patient -specific interventions and measurable goals. 1.Review of the Plan of Care (POC) for P#9, revealed that P#9 was admitted to the Home Health agency on 1/16/25, with a diagnosis of hypertensive heart disease with heart failure (heart muscle does not pump blood well into the heart) and type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Further review of the POC revealed that the agency failed to address interventions on the POC to monitor fluid retention, weight, or calf measurements with a diagnosis of heart failure and failed to address interventions for diabetic complications and identifying and reporting the signs and symptoms of hypoglycemia and hyperglycemia (refers to blood sugar levels that are too low or too high respectively). 2. Review of the Plan of Care (POC) for P#10, revealed that P#10 was admitted to the Home Health agency on 1/17/25, with a diagnosis of heart failure unspecified (heart muscle does not pump blood well into the heart) and type 2 diabetes with diabetic peripheral angiopathy (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Further review of the POC revealed that the agency failed to address interventions on the POC to monitor fluid retention, weight, or calf measurements with a diagnosis of heart failure and failed to address interventions for diabetic complications and identifying and reporting the signs and symptoms of hypoglycemia and hyperglycemia 3. Review of the Plan of Care (POC) for P#7, revealed that P#7 was admitted to the Home Health agency on 1/27/25, with a diagnosis sarcoidosis (condition that causes tiny collections of cells in any parts of the body), morbid (severe) obesity due to excess calories (overweight), and long-term use of steroids (medicine used for sarcoidosis). Review of medication profile dated 1/27/25 revealed that patient is currently on Prednisone (corticosteroid (cortisone-like medicine or steroid); works on the immune system to help relieve swelling, redness, itching, and allergic reactions) 50 milligrams daily for Sarcoidosis and Victoza 18Mmg/3ml injection daily for weight control. Review of initial assessment visit note dated 1/27/2025, the Physical Therapist (PT) documents the following: patient has steroid -induced hyperglycemia and obesity. Further review of the POC revealed that the agency failed to address interventions to monitor weight loss /gain, or calf measurements for obesity and failed to address interventions for diabetic complications caused by steroids and identifying and reporting signs and symptoms of hypoglycemia and hyperglycemia. 4. Record review reveals P#2 was admitted on 3/14/2024 with the diagnosis of secondary malignant neoplasm of pleura (refers to cancerous tumors affecting the pleura, which is the thin membrane lining the chest cavity and lungs) and co-morbidities that include type 2 diabetes, long term use of insulin and long term (current) use of oral hypoglycemic drugs. Review of “Home Health Certification and Plan of Care,” dated 3/14/2024, reveals P#9 was prescribed Januvia, insulin, and metformin, all anti-diabetic medications. Further review of the clinical record failed to reveal interventions related to diabetes management, including blood sugar monitoring and frequency. On 3/4/25 at approximately 1:30 p.m., an interview was conducted at the agency with the Executive Director (ED) and the Branch Director (BD), who confirmed the plan of care lacked specific interventions for heart failure and diabetic management for above mentioned patients.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on review of policy titled “Service Provided,” record reviews and staff interviews, it was determined that the agency failed to provide services that are ordered by the physician in the plan of care. Specifically, the agency failed to perform blood sugar for two patients (P) (P#9 and P#10) of 17 sampled patients. Findings include: Review of the policy titled “02-18 Services Provided,” Policy Number 02-18, last revised 05/2024, reveals the following: Policy • Home Health services and products are provided directly and /or under arrangement in accordance with physician/allowed practitioner written orders and applicable federal and/or state-specific laws/regulations. 1. Review of the Plan of Care (POC) for P#10 revealed that P#10 was admitted to the Home Health agency on 1/17/25, with a diagnosis of type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) with diabetic peripheral angiopathy (common complication of chronic diabetes). POC revealed an order to report to physician for blood sugar level less than 60 and blood sugar level above 250. Review of visit note dated 2/4/25 failed to reveal blood sugar levels. Review of visit note dated 2/17/25 failed to reveal blood sugar levels. 2. Review of the Plan of Care (POC) for P#9, revealed that P#9 was admitted to the Home Health agency on 1/16/25, with a diagnosis of type 2 diabetes. Review of medication list dated 1/16/25 revealed the following: Accu-Chek Guide me Glucose Meter: Test 4 times daily. Lantus (long-acting insulin that lowers blood sugar) 100 unit/ml (3ml) once daily at bedtime for diabetes. Humalog (fast acting insulin to lower glucose) KWI PEN 100 unit/ml; inject 10 units 3 times daily after meals. POC revealed an order to report to physician for blood sugar level less than 80 and blood sugar level above 300. Review of initial assessment visit note dated 1/16/25 failed to reveal blood sugar levels. Review of visit note dated 1/30/25 failed to reveal blood sugar levels. The agency failed to follow POC by performing, and documenting blood sugar as ordered by physician for P#9 and P#10. On 3/4/2025 at 2:32 p.m., an interview was conducted at the agency with Executive Director (ED) and Branch Director (BD) who confirmed that the agency failed to perform and document blood sugar as ordered by physician for P#9 and P#10.”