Centerwell Home Health

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 2 of 5 sampled patients. (Patients #2 and #5) Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient’s health care needs. Findings: According to the agency policy, titled Care Planning, dated 9/2024, the individualized plan of care is developed for the patient 60-day episode of care and must include discipline-specific visits, frequency and duration; and services the agency or physician may include to obtain desired patient outcomes/goals. The agency will notify the physician and patient of any identified changes in the patient’s condition and obtain physician orders to update the patient’s plan of care. According to the agency policy, titled Physician/Allowed Practitioner Orders, dated 9/2024, all missed visits must be documented within the patient’s medical record to include the reason for the missed visit and physician/allowed practitioner notification unless authorized under specific circumstances that are documented on the plan of care. 1. Patient #5 had a start of care date of 5/23/24 and a discharge date of 9/13/24. Clinical record review revealed: a. Plan of Care, dated 7/22/24 to 9/19/24, included orders for skilled nursing visits twice a week for 2 weeks and once a week for 1 week, and order for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. Interim physician order, dated 8/13/24, included skilled nurse visit frequency for twice a week for 5 weeks and once a week for 1 week, with an effective date of 8/11/24. c. Skilled nursing visits, dated 8/1/24 and 8/13/24, identified completed visits. The clinical record lacked documentation of a skilled nurse visit for the week of 8/4/24 through 8/10/24 or documentation of a missed visit. During an interview on 10/23/24 at 10:15 AM, Staff A, Administrator, reported she reviewed the clinical record, a skilled nurse visit was scheduled on the calendar for 8/9/24, was marked as a missed visit, but no missed visit documentation was entered and physician was not notified. d. Skilled nursing visits, dated 7/23/24, 8/1/24, 8/13/24, 8/20/24, 8/30/24 and 9/5/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. 2. Patient #2 had a start of care date of 5/27/21. The clinical record review revealed: a. Plan of Care, dated 9/8/24 to 11/6/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. Skilled nurse visit notes, dated 9/13/24, 9/27/24 and 10/11/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. The above findings were reviewed with the Administrator.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 1 of 2 sampled patients receiving home health aide services (Patient #17). The agency reported patients who received care provided by a home health aide. Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency’s home health aides for each patient increased the risk agency patient’s would receive inappropriate or inconsistent home health aide services. Findings include: According to the agency policy titled Care Planning, dated 9/2022, the RN s responsible for supervising and developing the care plan for the aide or personal care worker when ordered for the patient. The care plan includes tasks with frequency to be performed in addition to other relevant instructions related to the patient assigned. During an interview on 1/23/24 at 9:05 AM the Clinical Manager stated the Registered Nurse creates and reviews the HHA plan of care at least every certification period. Patient #17 had a start of care date of 8/10/23 and discharged from the agency on 8/30/23. a. The Plan of Care (POC), dated 8/10/23 to 10/8/23, included orders for skilled nursing and home care aide services. The POC included aide tasks of assistance with personal care, hygiene and activities of daily living. b. The home care aide (HCA) care plan, dated 8/10/23, included RN assigned tasks to the aide assignment of providing skin care but did not define what type of skin care should be completed by the aide. The HCA care plan failed to included specific instructions for the aide to provide services for the patient. The above findings were reviewed with the Administrator and Clinical Manager. No further information provided prior to the end of the survey.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on clinical record review, agency policy review, patient interview, and agency staff interview, the agency failed to ensure accurate and through completion of pertinent components of the initial comprehensive assessment for 1 of 3 sampled patients with wounds at start of care and received therapy only services. (Patient #9) Failure to accurately and thoroughly complete the comprehensive assessment to address individualized pertinent areas of health to obtain baseline findings placed patients at an increased risk of unidentified condition changes. Findings include: According to the agency’s policy, dated 4/2023, titled Initial and Comprehensive Assessments, each assessment will be performed by a qualified Clinical Associate who has demonstrated verbal/written knowledge of the specific skills needed to perform assessments including specialty assessments (examples: infusion, wound). According to the agency’s policy, dated 11/2022, titled Wound Assessment and Clinical Oversight, The Registered Nurse (RN) performs the initial assessment for open wounds and surgical incisions upon admission and as ordered by the physician/allowed practitioner. Physical Therapists (PTs) may perform the initial assessment in therapy-only cases in accordance with State regulations/practice guidelines and as ordered by the physician/allowed practitioner. Wound assessments will be performed every visit and include general observations, drainage amount and type, wound bed appearance and surrounding skin condition. At least once weekly, the assessment will include wound measurements (length x width x depth in centimeters). A case conference must be conducted for any wound with a variance greater than four points on the Bates-Jensen Wound Assessment Tool (BWAT) and documented on the Wound Conference Coordination. Patient #9 had a start of care date, 12/28/2023. Clinical record review revealed the following. a. The initial comprehensive assessment, dated 12/28/2023, completed by the Physical Therapist, lacked the wound assessment including measurements and staging of a wound on the patient’s sacral area. Documentation included the question; does the patient have at least one unhealed pressure ulcer/injury at a stage 2 or higher, documentation indicated no, noted only post sore redness at sacrum. During a staff interview with Staff I, PT, on January 24th at 11:40 am, PT reported typically a wound identified with comprehensive assessment would be communicated to nursing. Therapist will ask for patients verbal permission to snap a photo to send to the nurses/supervisor in the office for additional guidance and/or obtain orders for nursing in the home. New admissions with assessment of the integumentary system, reads through hospital and referral notes for any indication of wounds or skin issues, will ask the patient if there is any wounds or skin issues and typically tries to assess the sacral area and pressure areas for any issues. With the initial comprehensive assessment, Staff I glanced at the sacral area of Patient #9, recalls only noting redness in the sacrum, no open areas. Recalls reading in patient #9 history prior to admission, pressure sore was present maybe a stage 2. Reports the Spouse indicated they were treating the area and it was healed and spouse had no concerns. b. Occupational therapy (OT) Initial assessment, dated 12/29/2023, patient reported having 3 pressure sores on the buttock sacral area, however refused to let OT look at buttock sacral area. Documentation noted spouse is a retired nurse and reported the pressure sores are healing. During staff interview with Staff G, OT, January 23rd 2024 at 9:50 am, OT reported wounds identified in the home are reported to the Director/Clinical managers in the office, any areas of patient concerns also discussed at weekly plan of care meetings on Wednesdays or sooner if indicated. Attempts are made to gain verbal permission to take a photo and send it to the nursing staff in the office. Reported that some therapy only patients want their physician to address any wounds apart from home services. Recalled Patient #9 reporting pressure sores on his sacral area, but refused to allow therapist to look at those areas. Recalls that Patient #9 spouse is a retired nurse who indicated areas were healing, and treating those areas with zinc cream, spouse was not concerned about the areas at all. During an interview with the patient’s spouse, January 23rd at 8:10 am, spouse indicated patient developed a pressure sore during hospitalization. Patient was discharged from the hospital and admitted to a rehab facility, wound was treated with a zinc cream. Patient’s spouse continued to treat the wound with zinc cream upon return to home, reported it was about an inch long and still had some open areas when discharged to home, much of the area surrounding the wound was reddish with some darker purple. Patient’s spouse reported that the wound was difficult to get air to because of the weight loss, and the buttocks were sticking together, rolled up a micro cloth and placed it between his buttocks to keep moisture out, continued zinc cream and wound healed up. Spouse reported to staff in the home, wound was healing and she was taking care of it with no concerns. During a staff interview with the Administrator, January 22nd at 3:15pm, Administrator reported if wounds are identified in therapy only cases, there is communication with herself or another nursing supervisor and a skilled order will be obtained for a nurse to see the patient when that is indicated. During a staff interview with the Administrator, on January 23rd 2024, at 11:18 am, Administrator reported she could not recall any communication about Patient #9 wound from therapy, verified no documentation in clinical coordination notes communicating a wound with Patient #9 between nursing and therapy. Agency failed to identify a wound on the initial comprehensive assessment. The above findings were reviewed with the agency administrator and clinical managers. Agency staff provided no further information prior to the end of the survey.”

“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 clinical record review, home visit observation, patient and family member interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies and equipment used by the patient to meet their needs and an accurate list of the patient’s current medications for 4 of 17 sampled patients (Patients #3, #5, #6and #7). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: 4. Patient #3 had a start of care date of 11/5/23. Review of the clinical record revealed the following: a. The POC, dated 12/5/23 to 2/2/24 included the following medications: Acetaminophen 300 mg codeine (narcotic analgesic) 15 mg every 6 hours as needed for pain and Dulcolax (bisacodyl) (laxative) 5 mg daily oral for constipation. b. The agency medication list, dated 1/16/24, included the medications Acetaminophen 300 mg codeine 15 mg every 6 hours as needed for pain and Dulcolax 5 mg daily oral for constipation. c. The assisted living medication list, dated 1/17/24, included the medications Acetaminophen 300 mg codeine 30 mg every 6 hours as needed for pain, effective 11/3/23 and Bisacodyl 10 mg suppository daily as needed for constipation, effective 11/3/23. d. The POC included the following DME: adaptive living aids, CPAP, elevated toilet seat, incentive spirometer, rails/grab bars, shower/tub equipment, support surfaces, wheelchair, dressing-alginate/hydrofiber, cotton applicator, foam, gauze, honey, tubular dressing, skin care topical barrier, skin protectant and wound cleanser. e, During an observation home visit on 1/17/23 at 10:00 AM with Staff D, Licensed Practical Nurse (LPN), the surveyor identified the patient had additional DME which included a hospital bed, wheelchair cushion and walker. During an interview during the same home visit, Staff D identified the patient utilized the DME at the start of home health services. The POC failed to include correct medications and all DME the patient required for use. The above findings were shared with the Administrator and Clinical Manager. No further information provided prior to the end of the survey. 1. Patient #5 had a start of care date of 12/29/23. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plan of Care (POC), dated 12/29/23 to 2/26/24, included orders for Metformin (treat high blood sugar) 500 milligram (mg) with instructions for the patient to take two tablets daily, Vitamin C 1000mg with instructions to take 1 tablet daily, Vitamin D3 25 micrograms (mcg) (1,000 unit) tablet with instructions to take 1 tablet daily and Potassium Chloride extended release (ER) 10 milliequivalent (MEQ) Capsule, with instructions to take 1 capsule daily. b. The Client Medication Report printed on 1/16/24 shows Bupropion Hydrochloride (antidepressant) (HCL) Sustained Release (SR) 150 MG tablet, 12 HR SR as an active medication. During a home visit observation on 1/17/24 at 2:30p.m., with Staff E, Physical Therapy Assistant (PTA), an interview with patient’s spouse revealed patient is taking Metformin 500mg, 2 tablets, two times a day per the instructions on the bottle, Vitamin C 500mg chewable tablet 1 time a day, Vitamin D3 50mcg (2000 units) tablets 1 time a day, and Potassium 99mg tablet 1 time a day. Spouse also reported that Bupropion was discontinued in the last 30 days and patient is taking Melatonin, Tumeric, and cranberry supplements. The POC failed to include a complete list of prescribed and over the counter medications with correct doses and frequencies. c. The POC, dated 12/29/23 to 2/26/24, included the following durable medical equipment (DME) used by the patient: tub chair, emergency response system, incontinent supplies, slide board, diabetic supplies, elevated toilet seat, hospital bed, rails/grab bars, shower/tub equipment, walker, walker-rolling, and wheelchair. d. During a home visit observation on 1/17/24 with Staff E, PTA, the surveyor noted the patient was sitting in and utilizing lift chair. The POC failed to identify the DME lift chair. 2. Patient #6 had a start of care date of 1/18/24. a. The POC, dated 1/18/24 to 3/17/24, included the following DME used by the patient: Adaptive living aids, Emergency Response System, grab bars, tub chair, incontinent supplies, cane, elevated toilet seat, rails/grab bars, shower/tub equipment, and walker-rolling. b. During a home visit observation on 1/22/24 at 1:00p.m., with Staff F, Physical Therapist (PT), surveyor noted a heating pad sitting by patient’s chair. Patient reported she used the heating pad for discomfort. The POC failed to identify the DME heating pad. 3. Patient #7 had a start of care date of 12/22/23. a. The POC, dated 12/22/23 to 2/19/24, included the following DME used by the patient: Emergency Response System, Tub chair, shower wand, incontinent supplies, adaptive living aids, elevated toilet seat, rails/grab bars, shower/tub equipment, walker-rolling, wheelchair, wheelchair cushion. b. During a home visit observation on 1/18/22 at 9:00a.m., with Staff G, Occupational Therapist (OT), surveyor observed a urinal with urine in it next to lift chair patient was sitting in. The POC failed to identify the DME urinal and lift chair. Findings include: According to the agency policy, titled Care Planning, dated 1/19/18, the individualized plan of care must include all medications, supplies and equipment required.”