Centerwell Home Health

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on nationally recognized standards, procedure review, record review, observation, and interview, the home health provider failed to ensure that staff followed infection control procedures in two of three home visits conducted (Records/Patients #1 and #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the Centers for Disease Control (CDC) document titled, “Clinical Safety: Hand Hygiene for Healthcare Workers,” dated 02/27/2024, showed in part that clinicians must clean their hands: - Immediately before touching a patient; - Before moving from work on a soiled body site to a clean body site on the same patient; - After contact with blood, body fluids, or contaminated surfaces; and - Immediately after glove removal. Review of the provider’s procedure titled, “Standard Precautions,” revised 09/2025, showed that staff perform hand hygiene before and after patient contact, after contact with potentially infectious material, and before performing aseptic tasks; and use alcohol-based hand rubs or soap and water per CDC guidelines. Review of the provider’s procedure titled, “Bag Technique, Home Care,” revised May 19, 2025, showed that the staff would leave disposable, single patient-use items in the home for continued use or have dedicated equipment according to the provider’s guidelines. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/26/2026 with a primary diagnosis of aftercare following joint replacement surgery. The patient lived at home alone. Observation and interview on 06/16/2026 at 10:45 AM, showed the Physical therapist (PT) placed a cloth gait belt on the patient and conducted therapeutic exercises. The PT removed the gait belt from the patient, failed to clean the gait belt, and placed it in his/her supply bag where he/she had just placed his/her clean vital sign equipment. The PT stated that he/she preferred vinyl gait belts, and that he/she cleaned the gait belt weekly in his/her washing machine. During an interview on 06/16/2026 at 1:00 PM, the home health clinical manager for branch office A stated that their practice was for each patient to have their own gait belt. During an interview on 06/17/2026 at 2:50 PM, the home health administrator stated that all equipment was to be cleaned before going in or out of the patient’s home. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/26/2026 with a primary diagnosis of aftercare following joint replacement surgery. The patient lived at home alone. Observation and interview on 06/16/2026 at 10:45 AM, showed the physical therapist (PT) placed a cloth gait belt on the patient and conducted therapeutic exercises. The PT removed the gait belt from the patient, failed to clean the gait belt, and placed it in his/her supply bag where he/she had just placed his/her clean vital sign equipment. The PT stated that he/she preferred vinyl gait belts, and that he/she cleaned the gait belt weekly in his/her washing machine. During an interview on 06/16/2026 at 1:00 PM, the home health clinical manager for branch office A stated that their practice was for each patient to have their own gait belt. During an interview on 06/17/2026 at 2:50 PM, the home health administrator stated that all equipment was to be cleaned before going in or out of the patient’s home. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/28/2025 with a primary diagnosis of a pressure injury to the left and right buttocks (a skin injury caused by unrelieved pressure). The patient resided in a private residence with his/her family member. Observation on 06/17/2026 at 9:45 AM showed registered nurse (RN) A: Performed hand hygiene (PHH) and put on gloves; - Removed the soiled dressings from the right and left buttock; - Performed hand hygiene and put on gloves; - Cleansed the wound on the right buttock; - Failed to remove the soiled gloves, perform hand hygiene, and put on clean gloves; - Cleansed the wound on the left buttock; - Failed to remove the soiled gloves, perform hand hygiene, and put on clean gloves; and - Applied a clean dressing to the right and left buttock; - RN A then removed his/her soiled gloves, performed hand hygiene, and put on clean gloves; - Removed the soiled dressing from the patient’s sacrum (tail bone); - Failed to remove his/her soiled gloves and perform hand hygiene; and - Reached into the clean supply area to retrieve a clean dressing, opened the dressing, and applied it to the patient’s sacrum. During an interview on 06/17/2026 at 11:00 AM, RN B stated that, upon reflection, he/she had failed to perform hand hygiene and put on clean gloves when he/she cleaned the right and left buttock wounds.”

“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 policy review, record review, observation, and interview, the home health provider failed to ensure that staff provided clear and accurate documentation in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Medical Record Documentation,” revised 03/2026, showed that the patient’s medical record was a legal document and all entries would be accurate, complete, legible, and support coordination of care, coverage, coding, and payment. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 01/06/2026 with a primary diagnosis of type 2 (two) diabetes mellitus with foot ulcer (a chronic disease that affects how the body uses sugar for energy). The patient lived at home alone. Review of the clinical record showed: - The plan of care (POC) dated 05/26/2026 included an order for the skilled nurse (SN) to perform/teach diabetic ulcer care to the right foot; - The SN visit notes dated 05/04/2026 through 06/08/2026 contained an anatomical view wound assessment tool that showed the location of the diabetic ulcer was the proximal dorsum right (top of right foot) and included an anatomical figure with an “x” that marked a location on the top of the right foot; - The SN visit notes dated 05/11/2026 through 05/18/2026 and 06/01/2026 through 06/08/2026 included a nursing assessment/plan note that stated the patient’s wound was located on the left plantar foot (bottom/sole of the left foot); and - An interim order dated 06/04/2026 for wound care to the left plantar foot. Observation and interview on 06/17/2026 at 9:45 AM, showed the patient had a wound to the sole of his/her left foot and the SN provided care per the physician order. The SN stated that they had been treating this wound for a while. During an interview on 06/17/2026 at 2:50 PM, the home health administrator stated that the wound is labeled incorrectly and they would fix the record to reflect the correct location.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that staff completed the initial comprehensive assessment within the required time frame for all disciplines ordered at the start of care in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Assessments,” revised 01/2026, showed that the initial comprehensive assessment must be completed no later than five calendar days after the start of care. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/26/2026 with a primary diagnosis of aftercare following joint replacement surgery. The patient lived at home alone. Review of the patient information report showed a coordination note dated 05/21/2026 that showed verbal orders for a start of care on 05/26/2026 for physical therapy (PT) and occupational therapy (OT) to evaluate and treat. Review of a coordination note dated 06/15/2026 showed on 06/02/2026 the OT stated that: - The patient was not available for a visit on 06/03/2026 (eight days after admission) and that was the only day the OT was available to be in the area that the patient lived in; and - Per request of the patient, the OT evaluation visit was rescheduled to the following week on 06/08/2026 and then rescheduled per patient request to 06/09/2026. Review of the OT evaluation note dated 06/09/2026 showed that the assessment visit was conducted 14 days after the patient was admitted. During an interview on 06/17/2026 at 2:40 PM, the home health administrator stated that the OT evaluation should have been completed within the five-day window or on the physician ordered date, and there were no orders in the record for the delay in the OT evaluation.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on policy review, record review, observation, and interview, the home health provider failed to ensure an accurate medication list was maintained for the patient in one of three home visits conducted (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Review and Documentation,” revised 03/2026, showed that during each visit the provider would review all medications the patient was taking for any medication changes, patient adherence to medication orders, and patient knowledge of medications. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 01/06/2026 with a primary diagnosis of type 2 (two) diabetes mellitus with foot ulcer (a chronic disease that affects how the body uses sugar for energy). The patient lived at home alone. Observation and interview on 06/17/2026 at 9:45 AM, showed the RN reviewed all of the patient’s medications and stated that the medications in the home and the provider’s medication profile (PMP) did not match. The following discrepancies were identified: - The PMP showed acetaminophen 325 milligrams (mg) two tablets every six hours as needed for pain. The patient had 500 mg and stated he/she took two tablets twice daily; - The PMP showed allopurinol (lowers uric acid levels) 100 mg daily. The patient had 300 mg tablets one daily; - The PMP showed amiodarone (heart rhythm) 200 mg daily. The patient had 100 mg tablets one daily; - The PMP showed desvenlafaxine succinate (treat depression) ER (extended release) 50 mg daily. The patient had 50 mg and 25 mg tablets and stated that he/she took 75 mg daily; - The PMP showed digoxin (treat heart failure) 0.125 mg every Monday, Wednesday, and Friday. The patient stated that he/she took this every day; - The PMP showed Eliquis (thins the blood) 5 mg twice daily. The patient was out of this medication and stated that he/she took it once daily when he/she had the medication; - The PMP showed fish oil 1000 mg daily. The patient had 2400 mg daily; - The PMP showed furosemide (water pill) 40 mg twice daily. The patient stated that he/she took one daily; - The PMP showed gabapentin (for nerve pain) 100 mg two at bedtime. The patient had 300 mg and took this three times daily; - The PMP showed Klor-Con (water pill) 20 milliequivalents (meq) twice daily. The patient stated that he/she was not taking this medication; - The PMP showed metoprolol (blood pressure) 50 mg daily. The patient had 25 mg daily; - The PMP showed omeprazole (reduce stomach acid) 20 mg daily. The patient stated that he/she was not taking this medication; - The patient had hydroxyzine 25 mg ½ tablet every eight hours as needed for anxiety, glipizide (lower blood sugar) 5 mg daily, and spironolactone (water pill) 50 mg daily in the home and these medications were not on the PMP. During an interview on 06/17/2026 at 2:50 PM, the home health administrator stated that the medication list in the computer should have matched what the patient was taking. If the medications did not match, the physician should have been notified for clarification.”

“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 policy review, record review, observation, and interview, the provider failed to ensure that each patient’s written individualized plan of care (POC) included patient-specific interventions and education, all safety measures regarding high-risk medications, the physical therapy (PT) frequency and duration of visits to be made, and measurable outcomes and goals as identified in the comprehensive assessment, in one of five full records reviewed (Record/Patient: #5). This deficient practice had the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning,” dated 03/2026, showed in part that each patient had to receive an individualized written POC, including updates based on patient findings. The POC had to specify care and services to meet patient-specific needs and include responsible disciplines, measurable outcomes, and patient/caregiver education. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 03/10/2026 with a primary diagnosis of right total knee replacement. The patient resided in his/her own home with the assistance of his/her family. Review of the initial comprehensive assessment, dated 03/10/2026, showed in part that: - The patient reported pain managed with ice, medications, positioning, and rest/sleep; and - The patient had a closed surgical incision with a non-removable dressing. Review of the home health certification and plan of care, with certification dates of 03/10/2026 to 05/08/2026, showed in part that the POC failed to contain: - Orders for the patient to use ice to manage his/her pain; and - Orders for incisional care and/or a removal plan for the non-removable dressing. During an interview on 06/17/2026 at 11:40 AM, the administrator stated that: - They would expect orders for ice therapy, incisional care, and care of the non-removable dressing to be included on the POC; and - They were unable to locate the orders on the patient’s POC.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that drugs, services, and treatments were administered only as ordered by a physician in one of five records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Physician/Allowed Practitioner Orders,” dated 01/2026, showed that all services, treatments, and medications had to be ordered by a physician or allowed practitioner and had to be detailed to include disciplines, visit frequency and duration, and skilled services to be provided. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 01/06/2026 with a primary diagnosis of type 2 (two) diabetes mellitus with foot ulcer (a chronic disease that affects how the body uses sugar for energy). The patient lived at home alone. Review of the skilled nurse visit report notes dated 05/11/2026 and 05/14/2026 showed that the nurse documented he/she applied triamcinolone cream (topical steroid) to the patient’s bilateral lower extremities for treatment of itchy, dry skin. The clinical record failed to include an order. During an interview on 06/17/2026 at 2:55 PM, the home health administrator stated that he/she was unable to find an order for the treatment of itchy, dry skin, but the patient had an order for the use of triamcinolone cream to a rash (no location listed on the order).”

“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 and interview, the home health provider failed to ensure clinicians provided services that were ordered by the physician in one of five records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/28/2025. He/she had a primary diagnosis of a pressure injury to the left and right buttocks (a skin injury caused by unrelieved pressure). The patient had secondary diagnoses of heart failure (a decreased ability of the heart to pump blood) and malnutrition. The patient resided in a private residence with his/her family member. Review of the home health certification and plan of care, with certification dates of 05/23/2026 to 07/21/2026, showed that the nurse was to assess/instruct on daily weight and keeping a log, notify the physician of a weight gain of two to three pounds in 24 hours or five pounds in a week, and, if the patient was unable to weigh, obtain lower extremity circumference at each visit and notify the physician of an increase of 2 centimeters or greater. Review of the skilled nursing visit notes dated 05/29/2026, 06/03/2026, 06/05/2026, 06/08/2026, 06/10/2026, and 06/12/2026, showed the notes failed to contain documentation of the patient’s weight. During an interview on 06/17/2026 at 12:00 PM, the administrator stated that: - They would expect the skilled nurse to document the patient’s weight at each visit; and - They were unable to locate documentation of the patient’s weight in the visit documentation dated 05/29/2026, 06/03/2026, 06/05/2026, 06/08/2026, 06/10/2026, and 06/12/2026.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on review of Missouri statutes, employee file review, and interview, the home health provider failed to ensure that Alzheimer’s (a disease marked by progressive loss of mental capacity) and dementia (a decline in mental capacity) training was provided to non-direct care employees at orientation and annually. This deficient practice had the potential to affect all the patients served by the provider. Findings included: Review of 19 CSR 30-26.010 (1) (B) showed the following requirement: “Licensed home health agencies shall provide dementia-specific training about Alzheimer’s disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients or consumers with Alzheimer’s disease or related dementias. 1.The training for persons providing direct care shall address the following areas, at a minimum: (A) An overview of Alzheimer’s disease and related dementias; (B) Communicating with persons with dementia; (C) Behavior management; (D) Promoting independence in activities of daily living; and (E) Understanding and dealing with family issues. 2.Employees or independent contractors who did not provide direct care for, but may have daily contact with, persons with Alzheimer’s disease or related dementias shall receive dementia-specific training that included, at a minimum: (A) An overview of Alzheimer’s disease and related dementias; and (B) Communicating with persons with dementia. 3.Dementia-specific training about Alzheimer’s disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be presented by an instructor who was qualified by education, experience, and knowledge in the current standards of practice regarding individuals with Alzheimer’s disease and other related dementias. The training shall be provided annually and updated as needed.” Review of non-direct care employee files #1, #2, and #3 showed that the files failed to contain documentation of initial and annual Alzheimer’s and dementia training. During an interview on 06/17/2026 at 9:00 AM, the home health administrator stated that: - Alzheimer’s and dementia training had not been assigned to non-direct care staff members in the past; and - They had already changed the initial and annual training calendar to include Alzheimer’s and dementia training for non-direct care staff.”