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: During interview and record review, the agency failed to ensure completed Outcome Assessment Information Set (OASIS) assessment data was submitted within 30 days to the Center for Medicare and Medicaid Services (CMS) system for 13 of 13 (P55, P56, P57, P58, P59, P60, P61, P62, P63, P64, P65, P66, P67) patients reviewed. Findings include: The Internet Quality Improvement and Evaluation System (iQIES) Report titled OASIS Error Detail Report for dates 1/1/25 to 3/21/25 identified thirteen patients (P55, P56, P57, P58, P59, P60, P61, P62, P63, P64, P65, P66, P67) were triggered for “Record Submitted Late”. During interview with Administrator and Branch Director (BD) on 3/26/25 at 8:35 a.m., the BD verified last submission report was accurate and identified following explanation: “P55 data was not merged with parent company in 4/2024 due to the closing of two branch offices which affected report that identified it needed to be submitted. P56, P57, P59, P60, P61, P63, P66, P67 were locked late. P58 was not submitted because physician refused to sign home care orders and visit was written off. P62 was missed because chart was closed. P64, P65 had to be corrected and clinician did not lock the data before sending it electronically.” The administrator and BD stated the home care agency had an organizational process in place to run a report weekly to identify submission reports that need to be electronically sent to CMS but the report did not trigger the facility to address the issue. They stated the process will now be updated to trigger the facility to address upcoming time frames for submission of OASIS and agency will now run the updated report three times a week. Policy requested for OASIS submission timeframes was not received.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure communication between all providers involved in the plan of care (POC) was initiated for 1 of 2 patients (P3) reviewed for urinary tract infection (UTI). Findings include: P3’s POC for certification period 2/4/25-4/5/25, indicated P3 had diagnoses of Parkinson’s Disease, prostate cancer and had a suprapubic catheter placed in bladder through abdomen to remove urine). P3’s orders of discipline and treatments signed 2/24/25, directed skilled nurse to assess/evaluate co-morbid conditions including Parkinsons and other conditions that present themselves during the course of the episode to identify changes and intervene to minimize complications. P3’s nursing note dated 3/7/25, indicated P3 had a new rash on the perimeter of the suprapubic catheter. P3’s primary provider was notified and P3 instructed to notify urologist who was currently managing the suprapubic catheter. P3’s wife was ok with contacting urologist themselves. P3’s electronic medical record (EMR) lacked indication of whose P3’s urologist was or how to contact them for concerns. When interviewed on 3/26/25 at 10:35 a.m., the Branch Director (BD) stated the agency was not managing the catheter. The administrator stated when patients have specialists involved in their care, the ordering provider was notified for permission to have them involved and able to write orders for the patient and listed on in the EMR. The administrator further stated even though P3’s suprapubic catheter was being managed by the urologist, the agency should still ensure P3’s urologist was known and had the abilities to write orders if needed to support care for the suprapubic catheter. An agency policy titled Coordination of Care/Care Conferences revised 1/2024, directed staff to ensure all healthcare providers, 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.”

“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 interview and record review, the agency failed to ensure home health aide (HHA) visits were provided as ordered for 1 of 2 patients (P5) reviewed for HHA services. Findings include: Findings include: P5’s Plan of Care (POC) for certification period 12/26/24-2/23/25, indicated P5 had diagnoses of heart disease and respiratory failure. The POC indicated as of 1/12/25, P5 required an HHA visit weekly for three weeks. P5’s verbal order dated 1/6/25, indicated P5 required HHA services to start the week of 1/12/25. P5’s electronic medical record (EMR) lacked indication P5 had an HHA visit the week of 1/12/25. Furthermore, the EMR lacked documentation of why the visit was missed and if P5’s provider was notified. When interviewed on 3/26/25 at 10:35 a.m., the Administrator and Branch Director (BD) stated when HHA services were added for patients, if a HHA was not available, the cares could be added on to the nursing services to complete. The administrator and BD verified P5 had orders for HHA visits weekly for three weeks the first visit was not completed by an HHA, nurse or therapist. The administrator verified there was no missed visit or provider notification, and staff were expected to ensure provider notification and documentation was completed. A facility policy titled Physician/Allowed Practitioner Orders revised 9/2024, directed staff to notify the physician/allowed practitioner and all missed visits must be documented in the patient’s medical record with the reason for the missed visit and what physician was notified.”

“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 interview and record review the home health agency (HHA) failed to conduct an initial assessment to determine the immediate care and support needs for 2 of 2 patients (P1 & P2) within 48 hours of the patients return to their home. The HHA completed the visits late due to the convenience of the HHA related to lack of staff. Findings include: P1’s admission orders dated 9/18/24 indicated P1 required wound care three times weekly. Email correspondence dated 9/18/24 at 1:31 p.m. between the transitional care unit’s (TCU) social worker (SW)-A and the HHA’s LPN-A indicated P1 was discharging the transitional care unit on 9/20/24. P1’s Home Health Certification and Plan of Care (POC) dated 9/24/24 -11/22/24 indicated P1’s pertinent diagnoses were chronic ulcer of the left heel and midfoot with necrotic bone (death of bone tissue related to lack of blood supply). P1 received daily skilled nursing visits to perform wound care and assessment. Upon interview on 10/15/24 at 11:55 a.m. the providers care coordinator stated on 9/23/24 she received a call from the HHA and was asked if the agency could perform their start of care for P1 on 9/24/24 due to not having staff until that time. She reached out to the provider and the orders were obtained to perform the start of care on 9/24/24. The care coordinator stated she was aware that P1 left the TCU on 9/20/24. Upon interview on 10/15/24 at 12:30 p.m. LPN-B stated she received the orders from the HHA’s marketing team on 9/19/24. She stated she called the providers care coordinator on 9/23/24 to get a delayed start of care for 9/24/24 due to staffing. LPN-B denied awareness that P1 had wound orders. Upon interview on 10/15/24 LPN-A stated she works as a patient care coordinator for the HHA and supports the HHA’s marketing team. She stated she was aware that HHA patient’s need to have the start of care performed within 48 hours of discharge. She stated she was aware P1 left the TCU on 9/20/20 and stated he should have been seen on 9/22/24. She recalled receiving the TCU orders on 9/19/24. Upon interview on 10/15/24 at 1:32 p.m. P1’s family member (FM)-A stated she picked P1 at the TCU on 9/20/24 at 12:30 p.m. She believed the HHA was going to start cares with P1 on 9/21/24. FM-A called an on-call nurse at the HHA on 9/21/24 asking when a nurse was going to visit P1. She was told not until 9/24/24. FM-A stated she told the on-call staff that she was concerned because P1 did not have a wound vacuum (a treatment used to suction and help heal wounds) on his wound, just a dressing and she was concerned about the dressing not being tended to until 9/24/24. FM-A stated she was told by the on-call nurse that if she had concerns P1 should go to urgent care of the emergency department. Upon interview on 10/15/24 at 1:49 p.m. P1 stated he really did not understand the process of what was going to be taking place when he went was discharged. He stated FM-A manages his medical needs. He stated he did recall he went home and went for four days without the dressing being changed and then got an infection and was currently in the hospital awaiting a below the knee amputation on 10/16/24. Upon interview on 10/15/24 at 3:19 p.m. P1’s medical provider stated she did approve P1’s start of care for 9/24/24. She stated she receives multiple requests from HHA’s stating they frequently do not have staff until a certain date. She was not aware that P1 had left the TCU on 9/20/24 without a wound vac and had a dressing in place without anyone to change it for 4 days. She was aware that P1 developed an infection and was currently in the hospital. She was unaware that P1 was scheduled for a below the knee amputation. P2’s signed POC dated 7/23/24 – 9/20/24 indicated P2’s pertinent diagnoses were complications of amputated stump, infection of amputated stump, end stage renal disease and type 2 diabetes. P2 was seen three times a week for skilled nursing for medication management, education, and wound care treatment. P2’s POC dated 9/21/24 – 11/20/24 was not signed by the provider at the time of survey, however no changes had been made. P2’s orders transmitted from TCU dated 9/12/24 indicated P2 was being discharged on 9/14/24 for wound care. P2’s Patient Information Report dated 9/13/24 indicated P2 would be discharging from TCU on 9/14/24 to resume HHA services for disease, medication, and wound management. PT to evaluate and treat. In addition, a verbal order from P2’s provider to approve orders for the resumption of care to start on 9/17/24 was received. The note does indicate the reason for the delayed resumption of care. Upon interview on 10/15/24 at 12:30 p.m. LPN-B stated she did not recall why P2’s resumption of care was delayed. She stated she would assume it was due to staffing because staffing is the reason most resumption and start of cares were delayed. Upon interview on 10/16/24 at 9:16 a.m. registered nurse (RN)- A stated the marketers receive the referrals and let the referring entity know when the HHA has staff availability. She stated the office LPN’s schedule and if needed reach out to the provider to delay the start of care. Upon chart review she verified P1 and P2 were delayed on their care. RN-A stated she believed the facility was in compliance if they notified the provider of their staff shortage. She stated the HHA always notified the provider of delayed starts. Upon interview on 10/16/24 at 12:41 p.m. the Administrator stated she had been following the survey and realized that the start of cares needed to be within 48 hours and not to accommodate the facility. A policy on Initial Care Planning was not obtained.”