Centerwell Home Health

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on agency policy, clinical record review, complaint log review, staff interviews, and patient interview the agency failed to document and investigate the existence of a complaint and the resolution for 1 of 3 patients with a clinical record review. (patient #2) Findings included: A policy [agency name] My home health resources booklet, My rights and responsibilities (not dated) was received on 02/26/2024 at 9:35 A.M. from the agency branch director. The policy stated, “As a patient of the agency, you have the right to… Voice grievances about care which is or is not provided…have grievances investigated by the Company.” Patient #2 was admitted on 12/20/2023 with a diagnoses of NONDISP SIMP SUPRCNDL FX W/O INTERCNDL FX R HUMER (fracture of arm) and UNSP FX UPPER END OF TIBIA (leg fracture). The plan of care for 12/20/2023-02/17/2024 included orders for skilled nurse visits 1 time a week for 1 week, 1 every 2 weeks for 2 weeks, and 1 time a week for 1 week, physical therapy (PT) visits 1 time a week, and occupational therapy (OT) visits 1 time a week for 1 week. For the PT visit of 01/04/2024 there was no evidence of patient #2 reporting a complaint. For the OT visit of 01/11/20/24 there was no evidence of patient #2 reporting a complaint. A review of the agency complaint log was conducted on 02/26/2024 at approximately 9:30 A.M. There was no evidence of complaint or investigation for patient #2. An interview was conducted on 02/26/2024 at approximately 9:00 A.M. with patient #2. Patient #2 stated, “I complained to everyone [agency staff] that came to my house [after the admission visit] about the delay in therapy.” An interview was conducted on 02/26/2024 at approximately 2:00 P.M. with PT #3. PT #3 stated, “I do remember her [patient #2] … She might have been expecting us sooner. It wasn’t really a serious complaint, I told her that I understood her concern. No, I didn’t report her concern to the office. If it’s really a serious complaint or they [patient] are irate we report to the manager and have a case conference.” An interview was conducted on 02/26/2024 at approximately 2:08 P.M. with OT #4. OT #4 stated, “Yes [patient #2 voiced a complaint] … her concern was that she felt like she didn’t get what she needed. [COTA name] called me and reported the concern. I made an attempt to call my supervisor but could not get through. I would [normally] contact [clinical manager’s name] and document it.” An interview was conducted on 02/26/2024 at approximately 2:10 P.M. with the branch director. The branch director stated, “We expect them to notify their supervisor [of a complaint/concern] so we can follow up.””

“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 agency policy, clinical record review, patient interview, and staff interviews the agency failed to complete physical therapy (PT) and occupation therapy (OT) comprehensive assessments within 5 days for 1 of 2 patients with orders for PT and OT. (patient #2) Finding included: A policy, Initial and Comprehensive Assessments (revises 04/2023) was received on 02/26/2024 at approximately 2:30 P.M. from the clinical supervisor. The policy stated, “The initial 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…” Patient #2 was admitted on 12/20/2023 with a diagnoses of NONDISP SIMP SUPRCNDL FX W/O INTERCNDL FX R HUMER (fracture of arm) and UNSP FX UPPER END OF TIBIA (leg fracture). The plan of care for 12/20/2023-02/17/2024 included orders for skilled nurse visits 1 time a week for 1 week, 1 every 2 weeks for 2 weeks, and 1 time a week for 1 week, physical therapy (PT) visits 1 time a week effective 12/24/2023, and occupational therapy (OT) visits 1 time a week for 1 week effective 12/31/2023. The PT comprehensive assessment was conducted on 01/04/2024, 15 days after the admission and 12 days after the physician’s order. The OT comprehensive assessment was conducted on 01/11/2024, 22 days after the admission and 11 days after the physician’s order. An interview was conducted on 02/26/2024 at approximately 9:00 A.M. with patient #2. Patient #2 stated, “Someone came to admit me and then no therapist came or called for weeks.” An interview was conducted on 2/26/2024 at approximately 1:50 P.M. with the clinical manager. The clinical manager stated, “Normally we communicate a delay in assessment with the patient, if we are aware that there will be a delay the patient should be notified at admission.””