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 review and interview, the home health agency failed to ensure the written plan of care was followed and that the patient’s physician was consulted to approve modifications to the original plan of care (See G572); based on record review and interview, the home health agency failed to ensure the physician was promptly notified of the patient’s change in condition (See G590); and based on record review and interview, the home health agency failed to ensure changes in discharge planning were discussed with the patient and the patient’s physician prior to discharge (See G598). Findings Include: The cumulative effect of these systemic problems had the potential to impact all 246 active patients which resulted in the agency being found out of compliance with the Condition of Participation 42 CFR 484.60 Care Planning, Coordination of Services and Quality of Care.”

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to send a transfer summary to the home health or hospice agency receiving the agency patient for 2 of 2 discharged patients reviewed who were transferred to another agency (Patient #3 and #4). Findings Include: 1. The Complaint and Transfer policy indicated a copy of the transfer summary will be sent to the receiving healthcare provider responsible for the ongoing care of the patient. 2. Patient #3’s clinical record failed to evidence a transfer summary was sent to the patient’s receiving home health agency. On 12/18/2023 at 11:40 AM, Patient #3 relayed the agency had assisted the patient in finding a new home health agency. On 12/19/2023 at 12:11 PM, the Administrator relayed the only place it is documented when the agency sends a discharge or transfer summary is in the fax transmittals. The Administrator indicated the fax transmittal report did not show a transfer summary was sent to Patient #3’s new home health agency. 3. Patient #4’s clinical record failed to evidence a transfer summary was sent to the patient’s receiving hospice agency. On 12/20/2023 at 3:11 PM, the Administrator relayed the agency had not sent a transfer summary to Patient #4’s receiving hospice agency.”

“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 record review and interview, the home health agency failed to ensure the written plan of care was followed and that the patient’s physician was consulted to approve modifications to the original plan of care for 1 of 1 patient reviewed who was discharged for cause (Patient #3). Findings Include: 1. The Care Planning policy indicated the agency will notify the physician if changes to the plan of care (POC) are needed and obtain physician orders to change the current POC. 2. Patient #3’s clinical record included a POC for certification period 09/10/2023 to 11/08/2023 with orders for skilled nursing (SN) services 3 times per week for including but not limited to wound care and monthly urostomy catheter changes. The POC included discharge plans of discharge to family/ self care under the supervision of the medical doctor when goals are met. The SN visit note completed by Registered Nurse (RN) 1 for a visit on 09/13/2023 indicated Patient #3’s goals not met. Unmet goals included but not limited to, patient/caregiver understands basic measures to control generalized depression symptoms; patient/caregiver verbalizes/demonstrates pressure ulcer management, definition of pressure ulcer, treatment application technique, and intended effects; patient tolerates pressure ulcer care without complications; and patient/caregiver verbalizes central line implantable device intravenous therapy purpose and intended benefits. The clinical record included a non-visit discharge assessment completed by RN 1 and dated 09/17/2023. The clinical record failed to evidence the patient’s potential discharge for cause was discussed with the physician and failed to evidence a physician order for discharge. 3. On 12/19/2023 at 11:54 AM, the Clinical Manager relayed Patient #3’s clinical record did not include documentation that the patient’s potential discharge for cause was discussed with Patient #3’s physician and did not include a physician’s order for discharge.”

“Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to follow all the required steps for discharge for cause for 1 of 1 patient record reviewed who was discharged for cause (Patient #3). Findings Include: 1. The Discharge or Transfer policy indicated that prior to discharging a patient for cause the agency must including but not limited to advise the patient/caregiver and the patient’s providers that discharge for specific cause is being considered; make efforts to solve the problems presented by the patient’s behavior or situation; and document any problems, resolution efforts, and contact information for other agencies/providers within the medical record. 2. Patient #3’s clinical record included a plan of care (POC) for certification period 09/10/23 to 11/08/23 with orders for skilled nursing (SN) services 3 times per week to perform wound care and change the patient’s suprapubic catheter. The clinical record failed to evidence Patient #3 or the patient’s ordering physician was notified prior to discharge that the agency was considering discharging the patient for cause. The clinical record failed to evidence the agency made efforts to resolve the alleged problems presented by the patient’s behavior. The clinical record included a SN visit completed by Registered Nurse (RN) 1 on 09/13/2023 which indicated Patient #3 called RN 1 a derogatory name and then apologized about 30 seconds later. The clinical record failed to evidence an incident report related to this alleged incident. 3. On 12/18/2023 at 11:40 AM, Patient #3 relayed he/she received a phone call from the Clinical Manager on the Monday following the 09/13/2023 SN visit. Patient #3 relayed the Clinical Manager stated a staff member had reported the patient calling them a derogatory name to his/her face and that the behavior would not be tolerated and the patient was being discharged effective immediately. Patient #3 indicated the Clinical Manager would not let the patient talk and give his/her side of the story and said it didn’t matter. 4. On 12/19/2023 at 11:42 AM, RN 1 relayed that during the last visit he/she had with Patient #3, he/she called RN 1 a derivative of the “B” word and then apologized. RN 1 relayed he/she did not file an incident report for this alleged incident and had informed the Clinical Manager of the alleged incident the following morning. RN 1 relayed he/she had not felt unsafe. 5. On 12/19/2023 at 11:54 AM, the Clinical Manager indicated he/she would expect a staff member to file an incident report if a patient called him/her a derogatory name during a visit and that the Clinical Manager would investigate the alleged incident by speaking with the patient and the staff member. The Clinical Manager relayed his/her procedure for discharging for cause was to discuss the incident with the patient and bring up the Medicare rights and responsibilities that the patient has a responsibility to provide a safe environment. The Clinical Manager indicated then, that if the patient allowed, and the clinician felt safe, they would do a discharge visit and otherwise would do a non-visit discharge and mail instructions, etc. The Clinical Manager relayed they had spoken with Patient #3 by phone on the day after the alleged incident but that it was not documented in the clinical record. The Clinical Manager indicated Patient #3 at first denied the alleged incident and then indicated it was the clinician’s fault. The Clinical Manager relayed Patient #3 was discharged because the agency was down to only 2 nurses the patient would allow in the home and then he/she made the derogatory statement to RN 1 so “we figured [he/she would] be happier with a different company.” The Clinical Manager indicated they did not believe the health, safety, and/or welfare of the agency’s employees would have been at immediate and significant risk if the agency had continued to provide services to Patient #3. The Clinical Manager relayed Patient #3’s clinical record failed to include the patient’s notification of discharge and failed to include a discussion of the potential discharge with the patient’s physician.”

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure a patient’s complaint was documented for 1 of 2 patient records reviewed who voiced a complaint to the agency (Patient #3). Findings Include: 1. The Complaint Management policy indicated all patient complaints either verbally or in writing would be reviewed, evaluated, and forwarded to the appropriate manager for resolution. The policy relayed the actions and resolution would be documented on the Complaint Log and details of all contacts with the complainant would be documented. 2. The Patient Rights policy indicated patients have the right to have grievances investigated by the agency. 3. The agency’s complaint log failed to evidence documentation of a complaint voiced by Patient #3 to the Clinical Manager on 09/18/2023 related to the circumstances of the allegation the patient had called Registered Nurse (RN) 1 a derogatory name as documented in a nurse visit note by RN 1 on 09/13/2023 and related to the patient’s subsequent discharge for cause. 4. Patient #3’s clinical record failed to evidence Patient #3 voiced a complaint on 09/18/2023 regarding the alleged events during the nurse visit on 09/13/2023 and his/her unexpected discharge from the agency. 5. On 12/18/2023 at 11:40 AM, Patient #3 relayed they received a phone call from the Clinical Manager on 09/18/2023 indicating Patient #3 had reportedly called a clinician a derogatory name to his/her face and was being discharged effective immediately. Patient #3 relayed he/she tried to give their side of the story but that the Clinical Manager told him/her it didn’t matter. 6. On 12/19/2023 at 11:42 AM, RN 1 relayed he/she did not file a grievance or an incident report regarding the alleged events during the skilled nursing visit on 09/13/23. 7. On 12/19/2023 at 11:54 AM, the Clinical Manager relayed that when he/she spoke with Patient #3 regarding the alleged events during the nurse visit on 09/13/2023 Patient #3 at first denied the allegations of calling the clinician a derogatory name and then said it was the clinician’s fault. The Clinical Manager indicated there was no documentation of an investigation of the alleged events.”

“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 and interview, the home health agency failed to ensure the physician was promptly notified of the patient’s change in condition for 1 of 1 patient records reviewed who expressed suicidal ideations (Patient #3). Findings Include: 1. The Coordination of Care - Case Conferences policy indicated communication with the patient’s physician must occur regarding significant changes in the patient’s condition. 2. Patient #3’s clinical record included a skilled nursing (SN) visit note completed by Registered Nurse (RN) 1 for a visit on 09/13/2023 which indicated Patient #3 expressed suicidal ideations to RN 1. The note indicated RN 1 would contact Patient #3’s physician in the morning regarding the suicidal ideations as the patient had not voiced a suicidal plan. The clinical record failed to evidence Patient #3’s physician was contacted regarding the patient’s suicidal ideations. 3. On 12/19/2023 at 11:42 AM, RN 1 relayed his/her usual practice if a patient voiced suicidal ideations was to ask if the patient had a plan and that if the patient had a plan RN 1 would notify the patient’s physician immediately or call the emergency services phone number. RN 1 relayed that if the patient did not have a plan and was with a family member they would still notify the physician but would not call the emergency services phone number unless the patient wanted to go. RN 1 relayed that at his/her last nurse visit with Patient #3, the patient voiced suicidal ideations without a plan. RN 1 indicated physician notification should have been in a visit note or a coordination note and indicated he/she did not complete an incident report regarding the patient voicing suicidal ideations. 4. On 12/19/2023 at 11:54 AM, the Clinical Manager indicated his/her expectation for a clinician if a patient voiced suicidal ideations would be for the clinician to contact emergency services and wait with the patient until emergency services arrived regardless of whether the patient had voiced a plan. The Clinical Manager relayed he/she would also expect the clinician to create an incident report. The Clinical Manager relayed there was no documentation of emergency services or that the patient’s physician were notified of Patient #3’s suicidal ideations.”

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure changes in discharge planning were discussed with the patient and the patient’s physician prior to discharge for 1 of 1 patient records reviewed who were discharged for cause (Patient #3). Findings Include: 1. The Discharge and Transfer policy indicated the patient/caregiver must participate in discharge planning and will receive prior notice of discharge from services. The policy also indicated the physician will be notified of discharge and that notification will be documented in the patient’s medical record. 2. Patient #3’s clinical record failed to evidence the home health agency discussed changes in discharge planning with the patient or the physician. 3. On 12/18/2023 at 11:40 AM, Patient #3 relayed the Clinical Manager informed him/her on 09/18/2023 that the agency was discharging the patient effective immediately and that this came as a surprise to the patient. 4. On 12/19/2023 at 11:54 AM, the Clinical Manager relayed the clinical record did not contain documentation of Patient #3 being informed of the discharge and did not contain documentation that the discharge had been discussed with Patient #3’s physician.”