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 home health agency failed to ensure the patient’s written individualized POC (Plan Of Care) was followed as evidenced by the SN (Skilled Nurse) failing to make visits as ordered per the POC for 1 (#11) out of 13 (#1-#13) sampled patients. Patient #11. Review of the patient’s electronic clinical record revealed the start of care date was 04/08/2025. The patient’s diagnoses included age related macular degeneration and chronic obstructive pulmonary disease. The certification period reviewed was 04/08/2025 to 06/06/2025. Review of the patient’s POC for certification period 04/08/2025 to 06/06/2025 revealed an order for SN 1wk2, 1every2wk6 (skilled nurse visit one time a week for two weeks, one visit every two weeks for six weeks.). Review of the patient’s SN visit notes revealed no evidence a SN visit was made as ordered for the week of 04/13/2025. Further review of the patient’s clinical records revealed no evidence of a missed visit for the week of 04/13/2025. On 05/19/2025 at 2:30 p.m., an interview was conducted with S1BD (Branch Director). S1BD reviewed the patient’s clinical record and confirmed there was no evidence a SN visit was made for the week of 04/13/2025 as ordered. S1BD confirmed there was no evidence of a missed visit note at the time the interview was conducted.”

“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 home health agency failed to coordinate care delivery to meet the patient’s needs as evidenced by the agency nurse failing to inform the physician that the patient’s blood glucose (sugar) readings were not being performed by the patient/caregiver to ensure results were within parameters for 2 (#1, #4) out of 13 (#1-#13) sampled patients. Patient #1: Review of Patient #1’s electronic clinical records revealed the start of care date was 3/21/2025. The patient’s diagnoses included in part, Type 2 diabetes mellitus with hyperglycemia, long term use of insulin and long term (current) use of oral hypoglycemic drugs. Review of the patient’s POC (Plan of Care) for certification period 3/21/2025 to 5/19/2025 reveled an order for “SN 1wk9 (skilled nurse visit one time a week for nine weeks).” Further review of the plan of care revealed an order for “Skilled nurse to observe/assess diabetes…FBS (fasting blood sugar) daily by patient/caregiver…if testing via glucometer/CGM (capillary glucose monitoring). Skilled nurse to administer 15 grams of carbohydrates for blood analysis between 55-69 mg (milligram)/dl (deciliter) and recheck blood glucose in 15 minutes. When subsequent blood glucose is greater than 70mg/dl instruct patient to follow up with a snack or light meal. May administer insulin per order, otherwise notify provider.” Review of the patient’s Coordination Notes of a SN (Skilled Nurse) visit on 03/26/2025 revealed that Patient #1 reported to the SN that she had a history of 500-600 blood glucose levels and resulted in her being hospitalized. She reported that she had been guessing how much insulin to administer due to her glucometer not working. Her daughter reported accidentally damaging the patient’s glucometer. Further review revealed that Patient #1’s insurance would not provide another glucometer due to the patient had just received a glucometer. A review of Patient #1’s Coordination Notes for SN visits on 04/04/2025, 04/08/2025 and 05/02/2025 revealed that the patient still did not have a glucometer to conduct blood glucose testing. Further review of the notes revealed no documented evidence that the SN notified the physician the patient/caregiver was not checking her blood glucose daily due to not having a glucometer. As of 05/19/2025 at 11:30 a.m., during a home visit, Patient #1’s daughter (caregiver) reported that Patient #1 had just received a new glucometer that morning and had not been checking her blood glucose since she had damaged her first glucometer (7 weeks ago). On 05/20/2025 at 3:37 p.m. and at 3:55 p.m., an interview and record review was conducted with S1BD (Branch Director). S1BD confirmed there was no evidence the patient/caregiver was performing blood sugar checks. S1BD confirmed that the SN documented during the above mentioned SN visits that they were aware that the patient/caregiver did not have a glucometer to check the patient’s blood glucose levels. She stated that there was no evidence the SN had followed up the physician to informed the physician that the patient/caregiver was not checking her blood sugar readings to ensure the results were within the parameters. S1BD confirmed that the SN should have informed the physician. Review of the home health agency’s policy and procedure for Coordination of Care – Case Conferences last revised 01/2024 read in part: All healthcare providers- whether internal or external to the company- associated with direct patient care must maintain close communication to ensure each patient receives coordinated care that meets their needs and supports the objectives identified in the Plan of Care… 1. Patient #4. Review of the patient’s electronic clinical record revealed the start of care date was 04/24/2025. The patient’s diagnoses included surgical aftercare following surgery on circulatory system and type II diabetes mellitus. The certification period reviewed was 04/24/2025 to 05/22/2025. Review of the patient’s POC (Plan of Care) for certification period 04/24/2025 to 05/22/2025 revealed an order for skilled nurse 1wk9 (skilled nurse visits one time a week for nine weeks). Further review of the patient’s POC revealed an order for “…Diabetes management…blood glucose out of parameters … will be reported to the provider. FBS (Fasting Blood Sugar) daily by patient/caregiver and prn (as needed) for signs and symptoms of hypo/hyperglycemia. If testing via glucometer skilled nurse to administer 15 grams of carbohydrates for blood analysis between 55-69 mg/dl (milligrams/deciliter) and recheck blood glucose in 15 minutes. When subsequent blood glucose is greater than 70 mg/dl, instruct patient to follow up with a snack or light meal. May administer insulin per order, otherwise notify provider.” Review of the patient’s SN visit note dated 05/01/2025 revealed the patient did not resume checking blood sugar since returning from hospital. There was no evidence the SN informed the physician the patient/caregiver was not checking her blood sugar. Review of the patient’s SN visit note dated 05/05/2025 revealed the patient/caregiver opt not to monitor blood glucose. There was no evidence the SN informed the physician the patient/caregiver was not checking her blood glucose. On 05/19/2025 at 3:30 p.m., a home visit was made to the patient’s home. During the home visit, the patient stated she had a glucometer to check her blood sugar readings. However, the patient stated she was not checking her blood sugar readings and not keeping a log for the nurse to review. During the home visit, an interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN confirmed the patient’s blood sugar readings were not being monitored because the patient was not performing blood sugar checks. On 05/20/2025 at 3:37 p.m. and at 3:55 p.m., an interview and record review was conducted with S1BD (Branch Director). S1BD confirmed there was no evidence the patient/caregiver was performing blood sugar checks. S1BD confirmed there was no evidence the SN informed the physician that the patient/caregiver was not checking her blood sugar readings to ensure the results were within the parameters and that the SN should have informed the physician.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on observation and interview, the SN (Skilled Nurse) failed to educate the patient (Patient #1) and her caregiver on the use of a glucometer machine to ensure monitoring of the patient’s glucose levels for 1 (#1) out of 13 sampled patients. Review of Patient #1’s electronic clinical records revealed the start of care date was 3/21/2025. The patient’s diagnoses included in part, Type 2 diabetes mellitus with hyperglycemia, long term use of insulin and long term (current) use of oral hypoglycemic drugs. Review of the patient’s POC (Plan of Care) for certification period 3/21/2025 to 5/19/2025 revealed an order for “SN 1wk9 (skilled nurse visit one time a week for nine weeks).” Further review of the plan of care revealed an order “Teach related to diabetes management...FBS (fasting blood sugar) daily by patient/caregiver…” On 05/19/2025 at 11:30 a.m., a home visit was conducted with S2RN (Registered Nurse). During the home visit, Patient #1’s caregiver reported that the patient had received a new glucometer today. She stated that she wasn’t familiar with how to use the new glucometer. She stated she had attempted to test the patient’s glucose level earlier that morning and the reading on the glucometer said “error.” At 12:25 p.m., S2RN performed a glucose test with the patient’s new glucometer but failed to demonstrate to the patient and her caregiver how to properly use the glucometer while she was performing the test or before leaving the patient’s home. On 05/19/2025 at 12:35 p.m. an interview was conducted with S2RN. She confirmed that Patient #1’s daughter had expressed having problems operating the patient’s new glucometer machine. When asked if she should have conducted teaching on how to use the glucometer with the patient and her daughter to ensure that they were able to use the glucometer properly, S2RN stated, “Yes.” On 5/20/25 at 3:45 p.m., an interview was conducted with S1BD (Branch Director). She confirmed that the S2RN should have provided education to the patient and her caregiver along with a return demonstration to ensure that they were able to use the patient’s new glucometer.”