Centerwell Home Health

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on record review and interview, the agency failed to inform patients and caregivers of the correct state toll free home health hot line phone number, resulting in a lack of information to voice concerns or questions regarding CenterWell Home Health. Findings include: On 2/13/25, the agency’s booklet titled, “My home health resources booklet” was reviewed. Page 4 of the booklet states to report a complaint about CenterWell Home Health to call the State Home Health Hotline Number 800-979-4662. This is not the home health hotline number for the State of Michigan. The correct hotline phone number for Michigan is 1-800-882-6006. The finding was reviewed with and acknowledged by the Administrator (Adm) on 2/13/25 at 8:45 a.m. at the time of discovery.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the Plan of Care failed to include objectively measurable goals to determine the patient’s progress towards attaining the goals in 4 of 13 (P-1, P-2, P-3, P-4, P-5, P-6, P-7, P-8) medical records reviewed, resulting in the inability to determine the patient’s progress towards obtaining the goals. Findings included: P-5: The Start of Care (SOC) was dated 12/19/2024. The Plan of Care (POC) for the certification period 12/29/2024 to 2/16/2025 identified diagnoses of Open Wound of Right Forearm, Hypertension, Myocardial Infarction, Urinary Incontinence, Obesity, Right Artificial Knee and Hip Joint. This patient was receiving Skilled Nursing (SN) services 1xweekx1 week, 2xweekx3 weeks,1xweekx2 weeks, and 1 visit every 2xweekx2.During a review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient’s progress towards attaining the goals. Examples included: “A Plan of Care will be established that meets the patient’s nursing needs and countersigned by Physician; Changes in skin integrity will be identified promptly and interventions initiated to minimize risks, Changes in Pain status/management are identified promptly and reported to physician.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-6: The Start of Care was dated 3/1/2024. The Plan of Care for the certification period 3/1/2024 to 4/29/2024 identified diagnoses of Urinary Tract Infection, Hypertensive Heart Disease with Heart Failure, Paroxysmal Atrial Fibrillation, Anemia, Rheumatoid Arthritis, Spinal Stenosis, Osteoporosis w/o fracture, Systemic Lupus erythematosus, Hydronephrosis, Hyperlipidemia, Dependence on Wheelchair. This patient was receiving (Skilled Nursing (SN) services 1xweekx1 and 2xweekx1; Physical Therapy (PT) services 1xweekx1; and Occupational Therapy (OT) services 1xweekx1week. Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient’s progress towards attaining the goals. Examples included: “A Plan of Care will be established that meets the patient’s nursing needs and countersigned by physician; Genitourinary Exacerbations are identified promptly and interventions initiated to minimize risks; Patient adheres to medication regimen; PRN visits will be performed timely as indicated.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-7: The Start of Care was dated 4/8/2024. The Plan of Care for the certification period 4/8/2024 to 6/6/2024 identified diagnoses of Cutaneous Abscess of Left Axilla, Hypertension, Depression, Anxiety Disorder, Stimulant use, and Alcohol Use. This patient was receiving Skilled Nursing (SN) services 3xweekx2weeks and 2xweekx2weeks. Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient’s progress towards attaining the goals, nor were they specific to the patient’s identified needs. Examples included: “A Plan of Care will be established that meets the patient’s nursing needs and countersigned by physician”; “PRN visits will be performed timely as indicated”; Cardiovascular Exacerbations are identified promptly and interventions initiated to minimize risks. These goals are not objectively measurable nor are they specific to the patient’s identified needs. P-8: The Start of Care was dated 8/8/2024. The Plan of Care for the certification period 8/8/2024 to 10/6/2024 identified diagnoses of “Age-related Osteoporosis of the Left and Right Humorous and Forearm; Hypertensive Chronic Kidney Disease stage 3; Chronic Obstructive Pulmonary Disease (COPD); Hypothyroidism; Abdominal Aortic Aneurysm without Rupture; and Osteoarthritis. The patient was receiving Skilled Nursing services 1xweekx4 weeks; Physical Therapy Services 1xweekx5 weeks; Occupational Therapy services 1xweekx4 weeks; and Home Health Aide services 1xweekx1week and 2xweekx2weeks. Upon review of the record, it was noted the goals on the Plan of Care were not objectively measurable to determine the patient’s progress towards attaining the goals. Examples included: “Cardiovascular exacerbations are identified promptly and interventions initiated to minimize risks; Changes in skin integrity will be identified promptly and interventions initiated to minimize risks; PRN visits will be performed timely as indicated; Patient will receive assistance with personal care and hygiene and other activities of daily living as needed”. These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. These findings were reviewed with and acknowledged by the Administrator (ADM) on 2/14/2025 at 1:45 p.m. P-1: The Start of Care (SOC) was dated 11/7/2024. The Plan of Care (POC) for the certification period 1/6/2024 to 3/6/2025 identified diagnoses of chronic kidney disease (CKD), congestive heart failure (CHF), and Hypertension. This patient was receiving Skilled Nursing (SN), Physical Therapy (PT), and Occupational Therapy (OT) services. During a review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient’s progress towards attaining the goals. Examples included: “Patient/caregiver verbalizes/demonstrates heart failure management as evidenced by improved cardiovascular status and no unplanned hospitalizations by 3/6/2025; Changes in skin integrity will be identified promptly and interventions initiated to minimize risks.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-2: The SOC was dated 1/14/2025. The POC for the certification period 1/14/2025 to 3/14/2025 identified diagnoses of venous insufficiency, diabetes mellitus, and Hypertension. This patient was receiving SN, PT, OT, and home health aide (HHA) services. During a review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient’s progress towards attaining the goals. Examples included: “A Plan of Care will be established that meets the patient’s nursing needs and countersigned by physician; Patient/caregiver verbalizes/demonstrates hypertension management as evidenced by improved blood pressure readings and no unplanned hospitalizations by 3/14/2025.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-3: The SOC was dated 1/22/2025. The POC for the certification period 1/22/2025 to 3/22/2025 identified diagnoses of rib fractures, diabetes mellitus, and atrial fibrillation. This patient was receiving SN, PT, OT, and home HHA services. During a review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient’s progress towards attaining the goals. Examples included: “Patient/caregiver verbalizes/demonstrates atrial fibrillation management as evidenced by improved heart rhythm/rate and no unplanned hospitalizations by 3/22/2025; Patient/caregiver verbalizes/demonstrates hypertension management as evidenced by improved blood pressure readings and no unplanned hospitalizations by 3/22/2025.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-4: The SOC was dated 1/23/2025. The POC for the certification period 1/23/2025 to 3/23/2025 identified diagnoses of rib fractures, diabetes mellitus, and atrial fibrillation. This patient was receiving SN, PT, OT, and home HHA services. During a review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient’s progress towards attaining the goals. Examples included: “Patient/caregiver verbalizes/demonstrates depression management including but not limited to medication adherence as evidenced by decreased symptoms and improvement of mood by 3/23/2025; Patient/caregiver verbalizes/demonstrates hypertension management as evidenced by improved blood pressure readings and no unplanned hospitalizations by 3/23/2025.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. During an interview on 2/4/2025 at 10:30 a.m., the administrator (Adm) and the clinical manager (CM) acknowledged the above findings.”