Centerwell Home Health

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observations, interviews, and record reviews, the agency failed to ensure an accurate reconciliation of medication was completed for 1 (Patient #2) of 4 sampled patients reviewed for medication reconciliation during home visits. Findings: Review of Patient #2’s Client Medication Report, provided to the surveyor on 07/08/2026 as Patient #2’s current medication list, revealed, in part, Patient #2 was prescribed Lasix (medication used to remove excess fluid) 20 milligrams (mg), one tablet by mouth daily. Observation of the label on Patient #2’s Lasix medication bottle on 07/08/2026 at 11:00AM revealed Patient #2’s Lasix was prescribed as 20 mg, 0.5 tablet daily by mouth, with a filled date of 05/20/2026. In an interview on 07/08/2026 at 11:00AM, S2Registered Nurse (RN) confirmed Patient #2 was currently prescribed and taking 0.5 of a tablet of Lasix 20mg daily. In an interview on 07/09/2026 at 5:53PM, S1Administrator/Director of Nursing (DON) indicated the skilled nurse did not reconcile the Lasix discrepancy on Patient #2’s Client Medication Report.”

“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 interview and record reviews, the agency failed to ensure a patient’s physician was alerted to the patient’s change in condition for 1 (Patient #3) of 10 sampled patients reviewed for change in condition requirements. Findings: Review of Patient #3’s Client Coordination Note Report dated 05/26/2026 revealed, in part, Patient #3 was assessed as having adventitious (abnormal) sounds to the bilateral lower lobes (both lower lungs) and bilateral lower extremity pitting edema. Further review revealed Patient #3’s skilled nurse attempted to contact Patient #3’s physician; however, Patient #3’s physician was not contacted and a phone message was left. Further review revealed a fax was sent to Patient #3’s physician’s office. Review of Patient #3’s record revealed no evidence Patient #3’s physician received the message or fax sent to the physician’s office on 05/26/2026. Further review revealed no evidence Patient #3’s physician called the agency back regarding Patient #3’s change in condition. In an interview on 07/09/2026 at 5:57PM, S1Administrator/Director of Nursing (DON) indicated the agency had no evidence the agency or its staff ensured Patient #3’s physician was made aware of Patient #3’s change in condition. S1Administrator/DON further indicated there was no evidence the agency or its staff made any follow-up contact after 05/26/2026 with Patient #3’s physician to ensure the physician had received the message or fax.”

“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 interviews and record reviews, the agency failed to ensure the registered nurse measured the patient’s wound weekly to assess for wound healing status for 3 (Patient #1, Patient #6, Patient #10) of 4 sampled patients reviewed for weekly wound care measurements. Findings: Review of the Wound Ostomy and Continence Nurses Society’s Guidelines revealed, in part, the assessment and documentation of wound status included comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Further review revealed the comprehensive wound assessment included: dimensions and depth, presence, location and depth of any sinus tracts or undermining areas, status and characteristics of the wound bed, volume, color, and odor of exudates, and evidence of infection in surrounding tissues. Further review revealed when recorded over time, this information was used to track the progress of wound healing. Patient #1 Review of Patient #1’s Home Health Certification and Plan of Care for the certification period of 05/16/2026 to 07/14/2026 revealed, in part, the skilled nurse was to assess the integumentary system (skin) and identify changes every skilled nurse visit. Review of Patient #1’s Wound Record Report revealed, in part, Patient #1 had a left mid-calf partial thickness wound. Further review revealed no wound care measurements were obtained from Patient #1’s admit on 05/16/2026 through 05/28/2026. Review of Patient #1’s Visit Note Report dated 05/16/2026 revealed, in part, Patient #1 had moist cobblestone open areas to the left lower extremity. Review of Patient #1’s Visit Note Report dated 05/22/2026 revealed, in part, Patient #1 had a partial thickness open area to the left mid-calf area with moderate serous drainage. In an interview on 07/09/2026 at 5:51PM, S1Administrator/Director of Nursing (DON) indicated the agency had no evidence wound measurements were obtained for Patient #1’s wound from 05/16/2026 through 05/28/2026. S1Administrator/DON further indicated all wounds were to be assessed and measured by a registered nurse weekly to assess for wound healing. Patient #6 Review of Patient #6’s Home Health Certification and Plan of Care for the certification period of 06/12/2026 to 08/10/2026 revealed, in part, the skilled nurse was to assess the integumentary system and identify changes. Review of Patient #6’s Wound Record Report revealed, in part, Patient #6 had an unstageable (a wound which the depth of the wound cannot be measured) deep tissue injury (a wound characterized by a soften area with a bruised appearance indicating deep tissue damage) of the coccyx (area of the buttock). Further review revealed wound assessments dated 06/08/2026, 06/14/2026, 06/22/2026, 06/28/2026, 07/02/2026, and 07/05/2026 did not include wound measurements. In an interview on 07/09/2026 at 6:10PM, S1Administrator/DON indicated the agency had no evidence wound measurements were obtained for Patient #6’s wound from 06/08/2026 through 07/05/2026. Patient #10 Review of Patient #10’s Home Health Certification and Plan of Care for the certification period of 10/28/2025 to 12/26/2025 revealed, in part, the skilled nurse was to assess the integumentary system and identify changes. Review of Patient #10’s Wound Record Report revealed, in part, Patient #10 had a left pretibial (area of the front of the leg just above the ankle) blister. Further review revealed wound assessments dated 11/06/2025 and 11/28/2025 did not include wound measurements. In an interview on 07/09/2026 at 6:24PM, S1Administrator/DON indicated the agency had no evidence wound measurements were obtained for Patient #10’s wound for the week of 11/02/2025 through 11/08/2025 or the week of 11/23/2025 through 11/29/2025, as required.”