Centerwell Home Health

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. 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 each patient received the home health services that were written in the individualized plan of care (POC), 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: Review of the provider’s policy titled, “Care Planning,” reviewed 03/2026, showed in part the following: - Each patient must receive an individualized written POC, including updates based on patient’s findings; and - The POC covered the patient’s 60-day episode of care and included treatments that were to be provided/administered by home health agency (provider) clinical associates. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/10/2026 with a primary diagnosis of a non-pressure chronic ulcer of left calf with fat layer exposed (a full thickness skin wound where the subcutaneous tissue is visible). The patient resided in his/her home with paid caregivers during waking hours to assist with care. Review of the POC dated 05/10/2026 to 07/08/2026, showed: - Physical therapy (PT) 1wk 1 (once a week for one week), 2 wk 3 (twice a week for three weeks), then 1 wk 5 (once a week for five weeks); and - Skilled nurse (SN) 2 wk 8 (twice a week for eight weeks), then 1 wk 1 (once a week for one week) to perform/teach wound care to the lower left leg. Cleanse with VASHE (a professional-grade, saline-based wound cleanser that effectively removes bacteria, fungi, and spores while helping to reduce wound odor), apply Santyl (chemical agent used to remove dead tissue from a wound), cover was Xeroform (a sterile, non-adhering medical dressing made of fine mesh gauze infused with petroleum (Vaseline) and 3% Bismuth Tribromophenate) and a non-adherent pad, secure with rolled gauze, and tape, then apply Tubigrip (a multi-purpose, elasticated tubular bandage used to provide lasting, even compression and tissue support). Further review of week one of the clinical record showed: - A PT evaluation on 05/15/2026 (week one); - A missed visit note dated 05/29/2026, with reason for missed visit: “Patient was agreeable to one time this week” (week three); and - PT failed to perform a second visit for the week of 05/24/2026 to 05/30/2026 (week three), as ordered in the POC. Observation on 06/16/2026 at 12:44 PM, showed licensed practical nurse (LPN)-A failed to apply Tubigrip after the wound care was performed and the dressing was applied. During an interview on 06/18/2026 beginning at 8:35 AM, the administrator stated that: - The physical therapy assistant (PTA) that documented the missed visit 05/29/2026 was a “newer” employee; - It was discussed with him/her that the physician was to be contacted for orders to update frequency on the POC; and - The POC visit frequency and wound care orders should have been followed.”

“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 that all medications the patient was taking were current in two of three home visit observation records reviewed (Records/Patients #1 and #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 in part the following: - Drug regimen review (DRR)/medication reconciliation is required at start of care (SOC) and whenever the patient’s condition warrants; - The DRR and medication reconciliation include all medications and routes, including over the counter (OTC)/supplements/herbals, and oxygen, and must be documented in the clinical record; - The DRR will include examining medication bottles and prescriptions; and - During each patient visit, the home health provider will review all medications the patient is taking for any medication changes, adverse drug reactions/clinically significant issues, and patient adherence to medication orders. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/11/2026 with a primary diagnosis of orthopedic aftercare (strict adherence to surgeon’s protocols, including pain management, wound care, and physical therapy) and radiculopathy, cervical region (pinched nerve – a nerve root in the neck is compressed or inflamed as it exits the spine), spondylolisthesis, lumbar region (a vertebra in the lower back slips forward out of place over the vertebra below it), chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), polymyalgia rheumatica (inflammatory condition that causes severe muscle pain and stiffness), hypertension (elevated blood pressure), gastroesophageal reflux disease (GERD; chronic upper gastrointestinal disease in which stomach content persistently and regularly flows up into the esophagus), depression, anxiety, and other chronic pain. The patient resided in his/her extended family member’s home. Observation and interview on 06/16/2026 at 11:40 AM, showed the following discrepancies between the provider’s current medication profile (printed on 06/15/2026) and the patient’s home medication bottles: - The provider’s current medication profile showed the patient was to take an aspirin 325 milligrams (mg) daily. The spouse/caregiver stated that he/she did not take it, and it was discontinued after surgery; - The patient’s spouse/caregiver stated he/she takes baclofen (muscle relaxant) 5 mg one by mouth in the AM and at bedtime. The provider’s medication profile failed to include baclofen; and - The patient’s spouse/caregiver stated he/she takes senna (laxative) 8.6 mg one by mouth at bedtime. The provider’s medication profile failed to include senna. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 04/25/2026 with a primary diagnosis of COVID-19 (disease caused by SARS-CoV-2 virus), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), congestive heart failure (CHF; a decrease in the ability of the heart to pump blood), and chronic kidney disease (kidneys are damaged and gradually lose their ability to filter blood and remove waste). The patient resided in his/her own home with spouse/caregiver. Observation and interview on 06/17/2026 at 10:30 AM, showed the following discrepancies between the provider’s current medication profile (printed on 06/16/2026) and the patient’s home medication bottles: - The provider’s current medication profile showed the patient was to take a sacubitril 24 mg-valsartan 26 mg (treats chronic heart failure) 0.5 tablet daily. The spouse/caregiver stated that he/she takes 0.5 tablets twice a day. During an interview on 06/18/2026 beginning at 9:00 AM, the administrator stated that the skilled nurse reconciled medications at the start of care and with any medication changes.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on policy review, record review, observation, and interview, the home health provider failed to ensure clinicians promptly notified the patient’s physician/allowed practitioner of any changes in the patient’s condition or needs that suggested that outcomes were not being achieved and/or that the plan of care should be altered in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning,” reviewed 03/2026, showed in part the following: - Each patient must receive an individualized written plan of care (POC), including updates based on patient’s findings; and - The home health agency (provider) will notify the physician/allowed practitioner and the patient/caregiver/authorized representative of any identified changes in the patient’s condition, and will notify the physician/ allowed practitioner of the change; if a patient for caregiver/ representative refuses care that could negatively impact the patient’s clinical well-being, the clinical associate must attempt to identify the reason for refusal, document in the electronic medical record (EMR), and notify the physician/allowed practitioner ordering the care. Review of the provider’s policy titled, “Physician/Allowed Practitioner Orders,” reviewed 01/2026, showed in part the following: - The physician/allowed practitioner will be contacted for any change in condition that may require a change in medications, treatment, or home health services; - Revisions to the patient’s POC due to a change in the patient’s health status must be communicated to all physicians/allowed practitioners issuing orders related to the patients POC; and - The home health agency provider will notify the physician/allowed practitioner if a patient and/or caregiver/authorized representative refuses any services or treatments ordered and will document that refusal within the patient’s medical record. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/10/2026 with a primary diagnosis of a non-pressure chronic ulcer of left calf with fat layer exposed (a full-thickness skin wound where the subcutaneous tissue is visible). The patient resided in his/her home with paid caregivers during waking hours to assist with care. Review of the POC dated 05/10/2026 to 07/08/2026, showed: - Physical therapy (PT) 1wk 1 (once a week for one week), 2 wk 3 (twice a week for three weeks), then 1 wk 5 (once a week for five weeks); - Skilled nurse (SN) 2 wk 8 (twice a week for eight weeks), then 1 wk 1 (once a week for one week) to perform/teach wound care to the lower left leg. Cleanse with VASHE (a professional-grade, saline-based wound cleanser that effectively removes bacteria, fungi, and spores while helping to reduce wound odor), apply Santyl (chemical agent used to remove dead tissue from a wound), cover was Xeroform (a sterile, non-adhering medical dressing made of fine mesh gauze infused with petroleum (Vaseline) and 3% Bismuth Tribromophenate) and a non-adherent pad, secure with rolled gauze, and tape, then apply Tubigrip (a multi-purpose, elasticated tubular bandage used to provide lasting, even compression and tissue support); and - The POC failed to show a knee brace documented for use to the left knee. Further review of the clinical record showed: - A PT evaluation on 05/15/2026 (week one); - A missed visit note dated 05/29/2026 with reason for missed visit: “Patient was agreeable to one time this week” (week three); and - PT failed to perform a second visit for the week of 05/24/2026 to 05/30/2026 (week three), as ordered in the POC, or request a decrease in visit frequency to update the POC. Observation on 06/16/2026 at 12:44 PM, showed: - Licensed practical nurse (LPN)-A failed to apply Tubigrip after the wound care was performed and the dressing was applied; and - A brace was present to the patient’s left knee (this failed to be documented on the POC). During an interview on 06/18/2026 beginning at 8:35 AM, the administrator stated that: - The physical therapy assistant (PTA) that documented the missed visit 05/29/2026 was a “newer” employee; - It was discussed with him/her that the physician was to be contacted for orders to update frequency on the POC; - Both the SN that routinely saw the patient and the LPN reported that the patient had been refusing the Tubigrip; - The nurse was instructed to notify the physician of the Tubigrip refusal and there was now an updated order without the Tubigrip; - The nurse was instructed to contact the physician about the knee brace which the patient had been using since admission. The physician was notified and the POC was updated.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the clinicians integrated services to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect the coordination of all patients served by the provider. Findings included: Review of the provider’s policy titled, “Coordination of Care - Case Conferences,” reviewed 03/2026, showed the following: - All healthcare providers, whether internal or external to the company, 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 (POC); - Communication between team members may be face to face, via phone, other telecommunication technology and/or secure email, including but not limited to, changes in the patient’s condition resulting in a need to revise/update the POC; and - All communication will be documented in the patient’s medical record. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/10/2026 with a primary diagnosis of a non-pressure chronic ulcer of left calf with fat layer exposed (a full-thickness skin wound where the subcutaneous tissue is visible). The patient resided in his/her home with paid caregivers during waking hours to assist with care. Review of the POC dated 05/10/2026 to 07/08/2026, showed cardiovascular exacerbations (a sudden worsening of heart failure symptoms including, but not limited to breathing difficulties and fluid retention (edema) are identified promptly and interventions initiated to minimize risks. Further review of the clinical record showed: - A physical therapy (PT) evaluation on 05/15/2026 with documented 1+ (A +1 grade (mild) means the skin barely indents (about 2 millimeters (mm) deep) and the skin bounces back and rebounds almost immediately) edema (swelling of the tissues) to right and left lower extremities; - A PT reassessment visit dated 06/09/2026 with documented 2+ (A +2 grade (moderate) means when pressure is applied to the swollen area, it creates an indentation about 4 mm deep that takes up to 15 seconds to disappear) edema (swelling of the tissues) to right and left lower extremities; and - There failed to be any documentation of coordination with nursing regarding the increase in the edema noted on the reassessment visit. During an interview on 06/18/2026 beginning at 8:35 AM the administrator stated that: - The nurse had already contacted the physician on 06/08/2026 about the edema; and - The PT did not document notification to anyone about the increase in the edema.”