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 record review and interview, the agency failed to ensure the skilled nurse assessed the patient’s weight for changes per the plan of care for 1 (Patient #3) of 8 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, and Patient #8) sampled patients reviewed for services per the plan of care. Findings: Review of Patient #3’s Home Health Certification and Plan of Care for certification period of 12/01/2023 to 01/29/2024 revealed, in part, the skilled nurse was to assess the cardiovascular system, identify changes, and report a weight gain of 2-3 pounds in a day or a weight gain of 5 pounds in a week. Review of Patient #3’s record revealed no documented evidence and the agency presented no documented evidence the skilled nurse had weighed Patient #3 nor did the agency have documented evidence of the skilled nurse had reviewed a daily weight log for the certification period of 12/01/2023 to 01/29/2024. In an interview on 01/31/2024 at 2:19 p.m., S3Registered Nurse/Clinical Manager stated Patient #3 was unable to stand for a weight; however, the agency had not notified the physician of inability to weigh Patient #3 nor had the agency obtained alternative methods to monitor weight for weight gain.”

“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 agency failed to ensure the patient’s physician was notified of auditory hallucinations, headache, and side effects of medication noncompliance for 1 (Patient #7) of 8 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, and Patient #8) sampled patients reviewed for notification of change. Findings: Review of Patient #7’s Home Health Certification and Plan of Care for certification period of 11/07/2022 to 01/15/2023 revealed, in part, paranoid schizophrenia and generalized anxiety disorder. Review of Patient #7’s Nurse’s Visit Note Report dated 12/19/2022 revealed, in part, Patient #7 had reported something was wrong with his head, reported hearing voices, reported he had a headache. Further review of Patient #7’s Nurse’s Visit Note Report revealed Patient #7’s nurse had assessed Patient #7 with a notable tremor to his bilateral hands and movement of this jaw and tongue. Review of Patient #7’s Nurse’s Visit Note Report revealed Patient #7 was noted to have not been taking his Cogentin (medication used to treat tremors and involuntary movements), Depakote (medication used to treat seizures and/or behaviors), Haldol (medication used to treat psychiatric conditions), Meloxicam (medication used to treat pain/inflammation), and Melatonin (supplement used to improve sleep). Review of Patient #7’s Nurse’s Visit Note Report revealed no documented evidence and the agency presented no documented evidence Patient #7’s physician was notified of the above mentioned findings. In an interview on 01/31/2024 at 1:59 p.m., S4Registered Nurse (RN)/Clinical Manager stated the agency had no documented evidence to present that Patient #7’s physician was notified of the above mentioned findings. S4RN/Clinical Manger acknowledged Patient #7’s physician should have notified of the above mentioned assessment.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the agency failed to coordinate with the patient’s mental health provider to ensure the patient received his injectable medication as ordered for 1 (Patient #7) of 3 (Patient #1, Patient #7, and Patient #8) sampled patients reviewed for behavioral health services. Findings: Review of Patient #7’s Home Health Certification and Plan of Care for certification period of 11/17/2022 to 01/15/2023 revealed, in part, Patient #7 had a diagnosis of Paranoid Schizophrenia. Further review of Patient #7’s Health Certification and Plan of Care revealed the skilled nurse was to administer Patient #7’s Invega Sustenna (medication used to treat psychiatric conditions) 234 milligrams per 1.5 milliliter injection once every four weeks. Review of Patient #7’s record revealed Patient #7 had received his last Invega Sustenna injection on 11/15/2022. Review of Patient #7’s Client Coordination Note Report dated 12/10/2022 revealed, in part, the skilled nurse informed Patient #7’s sister Patient #7 was to be brought to the mental health facility to receive his injection for the month of December 2022. Further review revealed no documented evidence and the agency presented no documented evidence the skilled nurse or the agency coordinated with the mental health facility regarding administering Patient #7’s Invega Sustenna injection for the month of December 2022. Review of Patient #7’s Progress Note dated 12/13/2022 revealed no documented evidence Patient #7’s Invega Sustenna injection had been administered. In an interview on 01/31/2024 at 1:59 p.m., S4Registered Nurse/Clinical Manager stated the agency had no documented evidence of the agency coordinated with Patient #7’s mental health facility to ensure Patient #7 received his Invega Sustenna injection as ordered.”