Centerwell Home Health

“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 agency failed to ensure clinical documentation was complete and appropriately authenticated and dated in accordance with currently accepted standards of practice for 5 patients (#1, #2, #3, #5, and #6), out of a total sample of 13 patients. Findings include: Review of the agency’s policy titled Patient-Related Documentation Submission, revised March 2026, indicated but was not limited to the following: *Documentation will be submitted/transmitted via a Company-approved secure Electronic Medical Record (EMR) vendor/system via the internet within 24 hours following receipt of documents or completion of a patient visit in order to secure documents in the patient medical record and facilitate coordination of patient care. 1. Patient #1 was admitted to the agency in February 2025 with a diagnosis of type 2 diabetes mellitus with foot ulcer, requiring skilled services. Review of the physician ordered Plan of Care (POC) for certification period 2/11/26 through 4/11/26, indicated the following: *Skilled Nurse (SN) visits two times a week x 1 week, then once a week x 7 weeks Review of the clinical record indicated the following SN visit notes that were signed/dated after the visit: *2/20/26 visit, note completed on 2/23/26 *3/13/26 visit, note completed on 3/19/26 2. Patient #2 was admitted to the agency in February 2026 with a diagnosis of age-related osteoporosis with current pathological fracture, requiring skilled services. Review of the physician ordered POC for certification period 2/22/26 through 4/22/26, indicated the following: *SN visits once a week x 7 weeks, then once every two weeks x 2 weeks *Occupational Therapy (OT) visits once a week x 4 weeks (3/29/26) Review of the clinical record indicated the following SN visit note that was signed/dated after the visit: *4/1/26 Resumption of Care (ROC) visit, note completed on 4/5/26 Review of the clinical record indicated the following OT visit note that was signed/dated after the visit: *4/3/26 visit, note competed on 4/6/26 3. Patient #3 was admitted to the agency in February 2026 with a diagnosis of age-related osteoporosis with current pathological fracture of the left femur, requiring skilled services. Review of the physician ordered POC for certification period 2/13/26 through 4/13/26, indicated the following: *SN visits once a week x 1 week, three times a week x 1 week, then twice a week x 7 weeks Review of the clinical record indicated the following SN visit note that were signed/dated after the visit: *3/20/26 visit, note completed on 3/26/26 4. Patient #5 was admitted to the agency in December 2025 and had a diagnosis of traumatic subdural hemorrhage (life-threatening brain injury involving bleeding between the brain surface and its outer covering) without loss of consciousness, requiring skilled services. Review of the physician ordered POC for certification period 2/12/26 through 4/12/26, indicated the following: *Speech Therapy (ST) visits once a week x 1 week, once every 2 weeks x 2 weeks, once a week x 1 week, once every two weeks x 2 weeks, then once a week x 1 week Review of the clinical record indicated the following ST visit notes that were signed/dated after the visit: *3/20/26 visit, note completed on 3/23/26 *3/28/26 visit, note completed 3/31/26 5. Patient #6 was admitted to the agency in February 2026 with a diagnosis of supraventricular tachycardia (SVT-fast, often sudden heart rate), requiring skilled services. Review of the physician ordered POC for certification period 2/20/26 through 4/20/26, indicated the following: *SN visits once a week x 5 weeks, then once every two weeks x 4 weeks Review of the clinical record indicated the following SN visit notes that were signed/dated after the visit: *3/6/26 visit, note completed on 3/9/26 *3/26/26 visit, note completed on 3/31/26 During an interview on 4/9/26 at 3:24 P.M., the Director, Clinical Manager #1, and Clinical Manager #2, after reviewing the clinical records for patients #1, #2, #3, #5, and #6, said the visit notes had not been completed and submitted within the required timeframe.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was updated the last five days of every 60 days beginning with the start of care date for one patient (#1), out of a total sample of 13 patients. Findings include: Review of the agency’s policy titled Patient Assessments, revised September 2025, indicated but was not limited to the following: *It is the policy of the CenterWell Home Health to ensure that all patients receive timely, comprehensive, and clinically appropriate assessments in accordance with federal regulations, state practice acts, payer requirements, and agency standards. *Follow-up Assessment: Completed within the five-day period prior to the end of each 60-day episode/certification period. All patients must have a comprehensive reassessment during the last five days of each episode when patient care services will continue. Outcome and Assessment Information Set (OASIS-standardized CMS mandated assessment tool for home health patients) data is included for all patients receiving skilled care. Patient #1 was admitted to the agency in February 2025 with a diagnosis of type 2 diabetes mellitus with foot ulcer, requiring skilled services. Review of the clinical record indicated a physician ordered Recertification Plan of Care (POC) for certification period 2/11/26 through 4/11/26. Further review of the clinical record indicated an OASIS Recertification assessment for Patient #1, dated 2/10/26. The assessment was started on 2/10/26 by the skilled nurse but not completed until 2/12/26, after the start of the recertification period. A comprehensive assessment (including OASIS data elements) to reflect the patient’s current health status was not updated or revised in the last 5 days of every 60 days by a skilled nurse until discharged as required. During an interview on 4/9/26 at 12:09 P.M., the Director, Clinical Manager #1, and Clinical Manager #2, after reviewing Patient #1’s clinical record, said an updated comprehensive assessment was not completed within the required timeframe.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded 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 all patient care orders, including verbal orders, were recorded as complete in the plan of care for one patient (#9) out of a total sample of 13 patients. Findings include: Review of the agency policy titled Care Planning, revised March 2026, included but was not limited to the following: *Each patient must receive an individualized written Plan of Care (POC), including updates based on pertinent findings. The POC must specify care and services to meet patient-specific needs and include responsible disciplines, measurable outcomes, and patient/caregiver education. *The Plan of Care: Covers the patient’s 60-day episode of care and includes: -Patient medication schedule with instructions to include: Medication name, dosage, frequency, route of administration and pertinent instructions. Patient #9 was admitted to the agency in February 2026 with a diagnosis of primary osteoarthritis of the left shoulder, requiring skilled services. Review of the physician ordered Plan of Care (POC) for certification period 2/18/26 through 4/18/26 indicated the following medications: -Latanoprost 0.005% eye drops, ophthalmic (eye), 1 “drops” for glaucoma (group of eye diseases that damage the optic nerve, often caused by high fluid pressure inside the eye, leading to irreversible vision loss of blindness) -Prednisolone 1% Moxifloxacin 0.5% eye drops, suspension, ophthalmic, 1 “drops” for glaucoma Further review of the medications did not indicate specific instructions for administration to include the specific eye(s) to be treated (left, right, or both). During an interview on 4/9/26 at 11:38 A.M., the Director, Clinical Manager #1, and Clinical Manager #2, after reviewing the clinical record, said medications are reconciled during the start of care (SOC) skilled nurse visit and the ophthalmic medication orders missed instruction to indicate which eye(s) was/were to be treated. They said the medication orders were incomplete.”

“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 and interview, the agency failed to ensure that a completed discharge summary was 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 Home Health Agency (HHA), if any, within 5 business days of the patient’s discharge for one patient (#13), out of a total sample of 13 patients. Findings include: Review of the agency’s policy titled Patient Assessments, revised September 2025, indicated but was not limited to the following: *It is the policy of the CenterWell Home Health to ensure that all patients receive timely, comprehensive, and clinically appropriate assessments in accordance with federal regulations, state practice acts, payer requirements, and agency standards. *Discharge Assessment: Completed when the patient is discharged from the Home Health agency or within 48 hours of the Home Health agency becoming aware of an unexpected discharge. Patient #13 was admitted to the agency in September 2025 with a diagnosis of hypothyroidism (where an underactive thyroid gland fails to produce enough hormones, slowing the body’s metabolism), requiring skilled services. Review of the clinical record indicated Patient #13 was discharged home from the agency on 11/13/25. Further review of the clinical record indicated a Visit Note Report, dated 1/7/26, indicating discharge data collection. The discharge assessment was not sent to the physician within 5 business days of the patient’s discharge as required. During an interview on 4/9/26 at 3:00 P.M., the Director said the discharge assessment was completed on 1/7/26 and sent to the physician on 1/9/26. She said the assessment was not completed within 5 days of the Patient’s discharge as required.”