Centerwell Home Health

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on document review and staff interview, the agency failed to electronically transmit completed Outcome and Assessment Information Set (OASIS-a group of standard data elements developed to enable systemic comparative measurements of home health care patient outcomes) assessments to the Centers for Medicare and Medicaid Services (CMS) system within the required 30 days of completing the assessments of the beneficiary. Findings include: Review of the agency policy entitled, Patient Assessments, revised 9/2025, included the following: *OASIS Data Collection: -The Home Health Agency will collect OASIS data response items and other pertinent information for each agency patient receiving skilled care. -OASIS data items will be collected and transmitted within 30 calendar days of the completion of the OASIS assessment. Review of the Home Health Agency (HHA) Error Summary by Agency Report indicated the agency had 175 late OASIS Assessment submissions between 2/12/25 to 2/12/26, out of a total of 2637, which equaled to a 6.64% error rate. During an interview on 3/3/26 at 8:30 A.M., the Administrator said she oversees the OASIS submissions as there have been staffing issues at the agency. She further said she was not aware of the late submissions.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review, policy review, and interview the facility failed to ensure staff entries were legible, clear, complete, appropriately authenticated, dated, and timed, relative to a.) staff visit notes for 6 patients (#2, #3, #4, #10, #11, #12), and b.) physician ordered Home Health Certifications and Plans of Care (POC) for 2 patients (#2 and #11), out of a total sample of 17 patients. Findings included: Review of the agency policy entitled, Documentation Submission, revised 9/2024, included the following: *Electronic documentation will be submitted/transmitted via a Company-approved secure Electronic Medical Record (EMR) vendor/system within 24 hours following a receipt of documents or completion of a patient visit in order to secure the documents in the patient medical record and facilitate coordination of patient care. Review of the agency policy entitled, Physician/Allowed Practitioner Orders, revised 9/2024, included the following: *All orders will be signed and dated by the certifying physician/allowed practitioner within 30 days from the date verbal orders are received or from the start of care (SOC) date for initial orders unless an earlier date is required under state regulations. All orders are to be tracked for timely return. 1. Patient #2 was admitted to the agency in December 2025 with a diagnosis of fracture of the left femur (bone extending from the hip to the knee). a. Review of the physician ordered Home Health Certification and Plan of Care (POC) for certification period 12/7/25 through 2/4/26 indicated the following: -Physical Therapy (PT) visits: 3 times a week for 1 week, and 1 time every 2 weeks times 4. Review of the clinical record indicated the following: *12/7/25 PT visit: note was signed on 12/14/25. *12/12/25 PT visit: note was signed on 12/17/25. *1/13/26 PT visit: note was signed on 2/9/26. b. Review of the clinical record indicated the Home Health Certification and POC, dated 12/7/25 through 2/5/26, was signed by the physician on 1/11/26, and not within the 30 day required timeframe. 2. Patient #3 was admitted to the agency in January 2026 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD-a condition involving constriction of the airways and difficulty or discomfort in breathing) with Acute Exacerbation (a sudden worsening of symptoms, specifically increased shortness of breath, sputum volume, lasting 24-48 hours often caused by an infection). a. Review of the Home Health Certification and POC, dated 1/20/26 through 3/20/26, indicated the following: -SN visits: 2 times a week for 2 weeks and 1 time a week for 7 weeks. Review of the clinical record indicated the following: *1/20/26 SN visit: note was signed on 1/22/26. 3. Patient #4 was admitted to the agency in January 2026 with a diagnosis of age related osteoporosis with pathological fracture (bone fracture caused by weakness of the bone structure) of the right shoulder. a. Review of the Home Health Certification and POC, dated 1/24/26 through 3/24/26, indicated the following: -PT visits: 1 time a week times 1, 2 every 2 weeks times 2, 1 every week times 3 weeks, and 1 every 2 weeks times 4. Review of the clinical record indicated the following: *1/24/26 PT visit: note was signed on 1/31/26. 4. Patient #10 was admitted to the agency in January 2026 with a diagnosis of pneumonia. a. Review of the Home Health Certification and POC, dated 1/9/26 through 3/9/26, indicated the following: -PT visit: effective 1/18/26, 1 time a week times 1. Review of the clinical record indicated the following: *1/22/26 PT visit: note was signed on 1/24/26. 5. Patient #11 was admitted to the agency in December 2025 with a diagnosis of orthopedic aftercare following surgical amputation (removal of a limb). a. Review of the Home Health Certification and POC, dated 12/11/25 through 2/8/26, indicated the following: -PT visits: 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 4 weeks. Review of the clinical record indicated the following: *12/11/25 PT visit, note was signed on 12/14/25. b. Review of the clinical record indicated the Home Health Certification and POC, dated 12/11/25 through 2/8/26, was signed by the physician on 1/22/26, and not within the 30 day required timeframe. 6. Patient #12 was admitted to the agency in November 2025 with a diagnosis of hypertensive heart disease and chronic kidney failure with heart failure (chronic high blood pressure causes both heart muscle changes and kidney damage). a. Review of a physician order, dated 12/1/25, indicated the following: -PT visits: effective 11/30/25, 1 time a week for 3 weeks, 1 every 2 weeks 2 times, and 1 time a week for 2 weeks. Review of the clinical record indicated the following: *12/1/25 PT visit, note was signed on 12/3/25. *12/31/25 PT visit, note was signed on 1/14/26. During an interview on 3/3/26 at 3:00 P.M., after reviewing the clinical records for patients #2, #3, #4, #10, #11, and #12, the Administrator said the clinical notes were signed late and not within the required 24 hour timeframe. She further said the Home Health Certifications and POCs for patients #2 and #11 were signed by the physicians beyond the required 30 day timeframe.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure the initial assessment visit was held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner ordered start of care date, for 2 patients (#15 and #16), out of a total sample of 17 patients. Findings include: Review of the agency policy entitled, Patient Assessments, revised 9/2025, included the following: *Initial Assessment Visit: *The Home Health agency will conduct an initial assessment visit to the patient: -within 48 hours of the referral for services, or -within 48 hours of the patient’s discharge from an inpatient facility, or -on the date the physician/allowed practitioner specifies care is to start. -If the Home Health agency receives a referral and cannot make the first visit within 48 hours of the referral or patient discharge from an inpatient facility, the Home Health agency will contact the respective physician/allowed practitioner or referring entity with knowledge of the patient’s current condition. Approval will be obtained for a specific start of care date or referral to another home health agency provider for services. 1. Patient #15 was admitted to the agency in December 2025 with a diagnosis of surgical aftercare following surgery on the digestive tract (a long, twisting tube of organs that digests food and removes waste). Review of the clinical record indicated the physician provided a referral to the agency on 12/10/25 for nursing services. Further review of the clinical record indicated an initial skilled nursing visit was made on 12/15/25, 5 days after the referral. 2. Patient #16 was admitted to the agency in September 2025 with a diagnosis of Type 2 Diabetes Mellitus (a chronic disease characterized by high levels of sugar in the blood) without complications. Review of the clinical record indicated the physician provided a referral to the agency on 9/26/25 for nursing services. Further review of the clinical record indicated an initial skilled nursing visit was made on 9/29/25, 3 days after the referral. During an interview on 3/3/26 at 3:30 P.M., after reviewing the clinical records for patients #15 and #16, the Administrator said neither of the initial nursing visits occurred with 48 hours of the referrals, as required.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure that services were provided as ordered by the physician or allowed practitioner, as indicated in the plan of care (POC), for 2 patients (#6 and #7), out of a total sample of 17 patients. Findings include: Review of the agency policy entitled, Care Planning, revised 9/2024, included the following: *The POC: -serves as the patient’s care-planning document, -will be developed in collaboration with the physician/allowed practitioner and Home Health Clinical Associates following the initial/comprehensive assessment and will contain integrated orders from all physicians or allowed practitioners involved in the POC to assure coordination of all services and interventions provided to the patient. 1. Patient #6 was admitted to the agency in February 2026 with a diagnosis of hypertensive heart disease and chronic kidney failure with heart failure (chronic high blood pressure causes both heart muscle changes and kidney damage). Review of the clinical record indicated a physician order, dated 2/10/26, for Occupational Therapy (OT) visits, effective 2/8/26, 2 times a week for 1 week and 1 time a week for 2 weeks. Further review of the clinical record indicated 1 OT visit was provided for the week of 2/8/26, and not 2 visits, as ordered. 2. Patient #7 was admitted to the agency in December 2025 with a diagnosis of laceration to the left lower leg. Review of the Home Health Certification and POC for certification period 12/1/25 through 1/29/26 indicated the following: -Skilled Nurse (SN) visits: 1 time a week for 3 weeks, 2 times a week for 3 weeks, and 1 time a week for 3 weeks. Review of the clinical record indicated 1 SN visit was provided for the week of 12/21/25, and not 2 visits, as ordered. During an interview on 3/3/26 at 11:30 A.M., after reviewing the clinical records, the Administrator said the POC was not followed for patients #6 and #7 when physician ordered visits were missed, and not provided, as ordered.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure staff communicated with the physician involved in the plan of care, related to the current plan of care (POC), for 2 patients (#6 and #7), out of a total sample of 17 patients. Findings include: Review of the agency policy entitled, Management of Missed Visits, revised 7/18/22, included the following: *The agency will make every effort to follow the patient’s plan of care (POC) including the physician ordered visit frequency and duration. When a patient is not available for a visit on the assigned date, the visit will be rescheduled with the goal of meeting the physician ordered frequency in the same clinical week. *At the end of the clinical week, if a visit was not made in accordance with the physician ordered number of visits, then a Missed Visit form will need to be completed and the communication with the physician/allowed practitioner is documented. 1. Patient #6 was admitted to the agency in February 2026 with a diagnosis of hypertensive heart disease and chronic kidney failure with heart failure (chronic high blood pressure causes both heart muscle changes and kidney damage). Review of the clinical record indicated a physician order, dated 2/10/26, for Occupational Therapy (OT) visits, effective 2/8/26, 2 times a week for 1 week and 1 time a week for 2 weeks. Review of the clinical record indicated 1 OT visit was provided for the week of 2/8/26, and not 2 visits, as ordered. Further review of the clinical record did not contain any documentation that the physician had been notified of the missed OT visit for the week of 2/8/26. 2. Patient #7 was admitted to the agency in December 2025 with a diagnosis of laceration to the left lower leg. Review of the Home Health Certification and POC for certification period 12/1/25 through 1/29/26 indicated the following: -Skilled Nurse (SN) visits: 1 time a week for 3 weeks, 2 times a week for 3 weeks, and 1 time a week for 3 weeks. Review of the clinical record indicated 1 SN visit was provided for the week of 12/21/25, and not 2 visits, as ordered. Further review of the clinical record did not contain any documentation that the physician had been notified of the missed SN visit for the week of 12/21/25. During an interview on 3/3/26 at 11:30 A.M., after reviewing the clinical records for patients #6 and #7, the Administrator said the physician had not been notified of the missed physician ordered scheduled visits, as required.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure a completed discharge summary was sent to the primary care practitioner or other health care professional responsible for providing care and services to the patient after discharge from the agency within 5 business days of the patient’s discharge, for 3 patients (#3, #13 and #17), out of a total sample of 17 patients. Findings include: Review of the agency policy entitled, Patient Discharge or Transfer, revised 3/2025, included the following: *Discharge/Transfer Summary: -Patients discharged to their physician/allowed practitioner will be sent within 5 business days of the Home Health agency discharge date. 1. Patient #3 was admitted to the agency in January 2026 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD-a condition involving constriction of the airways and difficulty or discomfort in breathing) with Acute Exacerbation (a sudden worsening of symptoms, specifically increased shortness of breath, sputum volume, lasting 24-48 hours often caused by an infection). Review of the clinical record indicated the patient was discharged from the agency on 2/24/26. Further review of the clinical record did not contain any documentation that the discharge summary was sent to the physician. During an interview on 3/3/26 at 12:00 P.M., the Administrator gave the surveyor a copy of a fax report that indicated the discharge summary was sent to the physician on 3/3/26. The Administrator said the discharge summary was sent late and not within the required timeframe. 2. Patient #13 was admitted to the agency in November 2025 with a diagnosis of aftercare following surgery for neoplasm (abnormal growth of tissue). Review of the clinical record indicated the patient was discharged from the agency on 12/9/25. Further review of the clinical record did not contain any documentation that the discharge summary was sent to the physician. During an interview on 3/3/26 at 2:00 P.M., the Administrator gave the surveyor a copy of a fax report that indicated the discharge summary was sent to the physician on 1/12/26. The Administrator said the discharge summary was sent late and not within the required timeframe. 3. Patient #17 was admitted to the agency in November 2025 with a diagnosis of wedge compression fracture of unspecified thoracic vertebrae (occurs when the front part of the middle spine vertebrae collapses forming a wedge shape). Review of the clinical record indicated the patient was discharged from the agency on 12/17/25. Further review of the clinical record did not contain any documentation that the discharge summary was sent to the physician. During an interview on 3/3/26 at 2:15 P.M., the Administrator gave the surveyor a copy of a fax report that indicated the discharge summary was sent to the physician on 1/12/26. The Administrator said the discharge summary was sent late and not within the required timeframe.”