Centerwell Home Health

“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 policy review, record review, and interview, the home health provider failed to provide an initial assessment visit 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 (SOC) date in four of six full records reviewed (Records/Patients #2, #3, and #4). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #1: Review of the clinical record showed the patient admitted to home health services on 07/16/2024 with a diagnosis of hemiplegia (paralysis of one side of the body) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). The patient lived at home with his/her caregiver. Review of the referral documentation showed the patient discharged from a skilled nursing facility on 07/02/2024 with orders for home health services. Review of the admission assessment dated, 07/16/2024, showed the entry for “M0104: Date of Referral” to be 07/15/2024. During an interview on 08/06/2024, the administrator stated that he/she could not provide a physician order for a delayed start of care. RECORD/PATIENT #3: Review of the clinical record showed the patient admitted to home health services on 06/24/2024 with a diagnosis of unilateral primary osteoarthritis of the right hip (chronic condition affecting the joints). The patient lived in an assisted living facility. Review of the admission assessment dated, 06/24/2024. showed the entry for “M0104: Date of Referral” to be 06/20/2024 (four days prior to the admission assessment). During an interview on 08/06/2024, the administrator stated that he/she would expect the admission assessments to be completed within 48 hours of the referral. RECORD/PATIENT #4: Review of the clinical record showed the patient admitted to home health services on 07/02/2024 with a diagnosis of urinary tract infection. The patient lived at home with a caregiver. Review of the referral documentation showed the patient discharge from the hospital on 06/27/2024 with orders for home health services. Review of the admission assessment dated, 07/02/2024. showed the entry for “M0104: Date of Referral” to be 07/01/2024. During an interview on 08/06/2024, the administrator stated that he/she could not provide a physician order for a delayed start of care. Review of the provider’ Start of Care (SOC) Policy revised 09/14/2022, showed in part: - In order for the patient to be “timely” at SOC, the patient must be admitted on the specified ordered date, or within 48 hours of the most updated referral information received by the agency, or within 48 hours of the facility discharge date. RECORD/PATIENT #2: Review of the clinical record showed the patient admitted to home health services on 06/28/2024 with diagnosis which included bladder cancer, pneumonia (an infection in the lungs), and insomnia (a condition of difficulty falling and/ or remaining asleep). The patient lived at home alone. Review of the referral documentation showed the patient discharge from the hospital on 06/25/2024 with orders for home health services. Review of a Coordination Note Report dated 06/27/2024, showed a verbal order dated 06/25/2024 for the patient’s Start Of Care (SOC), During an interview on 08/06/2024, at 9:15 AM, the administrator stated that he/she could not provide a physician order for a delayed start of care. RECORD/PATIENT #5: Review of the clinical record showed the patient admitted to home health services on 06/05/2024 with diagnosis which included dementia ( the loss of cognitive functions which affects thinking, remembering, and reasoning), and hypertension (abnormally elevated blood pressure) .The patient lived at home with a caregiver. Review of the referral documentation showed the patient discharge from the hospital on 06/05/2024, and a physician order dated 6/10/2024 to begin home health services . During an interview on 08/06/2024, at 9:15 AM, the administrator stated that he/she could not provide a physician order for a delayed start of care.”

“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 and updated medication profile was included in the patient record in three of three home visits conducted (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all patients served by the provider. Review of the provider’s Medication Reconciliation and Drug Regimen Review Policy revised 11/05/2019, showed in part: - Medication reconciliation is the process of maintaining an accurate list of all medications the patient is taking including the name, dosage, frequency, indication, and route and comparing the list to the actual bottle /containers, etc. that are in the patient’s home. - The drug regimen review is completed on the Start Of Care (SOC) / Resumption Of Care (ROC). Medication reconciliation is completed by the clinician as often as needed to meet the patient’s needs - Updating of the medication profile is completed on every visit by every licensed clinician. RECORD/PATIENT #2 : Review of the clinical record showed the patient admitted to home health services on 06/28/2024 with diagnosis which included bladder cancer, pneumonia (an infection in the lungs), and insomnia (a condition of difficulty falling and/ or remaining asleep). The patient lived at home alone. Review of the document titled, “Client Medication Report,” dated 08/05/2024, showed the patient was prescribed : -Melatonin (used to treat insomnia) 3 mg tablet. Take two tablets at bedtime; and -Oxycodone (an opioid pain reliever) 5 mg tablet. Take one tablet every 6 hours as needed for pain. Observation on 08/05/2024 at 11:20 AM, during the patient’s home visit, showed the patient no longer took these medications. During an interview on 08/05/2024 at 11:20 AM, the patient stated he/she, “didn’t take the Melatonin since leaving the hospital because it didn’t work”. Additionally, the patient stated he/she, “didn’t take the Oxycodone 5 mg anymore”, but currently took Oxycodone 5 mg with Acetaminophen 325 mg for pain. During an interview on 08/05/2024 at 11:40 AM, Licensed Practical Nurse (LPN) A stated the patient’s medication discrepancies should be identified, and the medication list revised during each visit to show the patient’s current medication. During an interview on 08/06/2024 at 9:15 AM, the administrator stated staff should reconcile and resolve any discrepancies with patient’s medications / medication list during each visit. RECORD/PATIENT #1: Review of the clinical record showed the patient admitted to home health services on 07/16/2024 with a diagnosis of hemiplegia (paralysis of one side of the body) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). The patient lived at home with his/her caregiver. Review of the document titled, “Client Medication Report,” dated 08/05/2024, showed the patient was using: -Lidocaine 4% topical pain relief patch. Place patch on affected area in the morning, remove in the evening; -Melatonin (used to treat insomnia) 5 milligram (mg) tablet. Take one tablet at bedtime; -Phenylephrine-guaifenesin (used to treat runny nose or congestion) 5mg-15mg-100mg/5 milliliter (mL) oral liquid. Take 10 mL four times daily as needed; -Senna plus (used to treat constipation) 8.6 mg-50mg tablet. Take one tablet daily; and -Voltaren arthritis pain 1% topical gel. Apply to affected area every 8 hours as needed for pain. Observation on 08/05/2024 at 11:00 AM, during the patient’s home visit, showed the patient no longer took these medications. RECORD/PATIENT #3: Review of the clinical record showed the patient admitted to home health services on 06/24/2024 with a diagnosis of unilateral primary osteoarthritis of the right hip (chronic condition affecting the joints). The patient lived in an assisted living facility. Review of the document titled, “Client Medication Report,” dated 08/05/2024, showed the patient was taking the following medications: -Cholecalciferol (vitamin D3) 50 micrograms (mcg) capsule. Take one capsule every morning; -Levothyroxine (used to treat an underactive thyroid gland) 137 mcg tablet. Take one tablet daily; -Melatonin 5 mg capsule. Take one capsule at bedtime as needed for insomnia; -Memantine (used to treat dementia) 10 mg tablet. Take one tablet at bedtime; -Ondansetron (used to treat nausea) 4 mg tablet. Take one tablet as needed daily; and -Senna 8.6 mg capsule. Take two capsules as needed every 12 hours. Review of the assisted living facility’s medication list showed the patient was taking the following: -Cholecalciferol 50 mcg tablet. Give 1.5 tablet by mouth in the morning; -Levothyroxine 150 mcg tablet. Give one tablet by mouth in the morning; -Memantine 10 mg oral tablet. Take one in the morning and at bedtime; -Ondansetron 4 mg oral tablet. Take one tablet by mouth every 6 hours as needed for nausea; -Senna 8.6 mg tablet. Give two tablets by mouth every 12 hours as needed for constipation; and -Tylenol oral tablet. Give 1000 mg by mouth every eight hours as needed for pain. This medication was not on the provider’s medication list. The assisted living facility medication profile failed to contain the order for melatonin.”

“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 policy review, record review, and interview, the home health provider failed to ensure all orders were included in the plan of care (POC) in one of six full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient admitted to home health services on 07/16/2024 with a diagnosis of hemiplegia (paralysis of one side of the body) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). The patient lived at home with his/her caregiver. Review of the document titled, “Home Health Certification and Plan of Care,” dated 07/24/2024-09/13/2024, showed a visit frequency order for physical therapy effective 07/16/2024 one time a week for nine weeks. Review of all visit notes showed the following: -The skilled nurse (SN) made a visit on 07/16/2024; -The SN made a visit on 07/23/2024; -The SN made a visit on 08/01/2024; -The occupational therapist (OT) made a visit on 07/22/2024; and -The OT made a visit on 08/05/2024. The POC failed to contain visit frequencies for these disciplines. During an interview on 08/06/2024 at 11:45 am, the clinical manager stated that there was a glitch in the computer system and the frequencies for SN and OT services did not pull over from the calendar. Review of the provider’s Plan Of Care (POC) policy revised 9/2022 showed in part: - The patient or caregiver will be provided a copy of the POC and/or other form of written instructions outlining visit schedule, disciplines and frequency of visits. - Treatments and/or therapy services to be administered by home health agency staff and personnel acting on behalf of the agency. - Updated written information as the POC changes.- The home health agency will notify the physician/allowed practitioner, patient, patient representative (if any) and caregiver if changes are identified in the patient’s condition and obtain physician orders to add or change the current patient POC. The clinician or clinical manager will communicate with all physicians/allowed practitioners involved in the POC as indicated throughout the course of patient care. - Care will be planned to ensure effective utilization of services and resources including the total number of visits/hours appropriate to the care required and ordered.”