Centerwell Home Health

“Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This Standard is not met as evidenced by: Based on clinical record review and staff interview evidence is lacking in four of seventeen records (Patient # 1, 7, 9 and 14) the initial assessment visit was conducted within 48 hours of receiving the referral for services, within 48 hours of the patients return home or the on physician’s ordered start of care. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. Patient # 1 (start of care 10/14/2023) has diagnoses of Chronic Kidney Disease Stage 5 and Type 2 Diabetes Mellitus. The record contains a referral dated 10/04/2023 with no specific physician ordered start of care (SOC) date. The patient discharged home from the hospital on 10/05/2023. The Physical Therapist (PT) conducted the initial assessment on 10/14/2023, nine days after the patient was discharged from the hospital. The record lacks documented evidence the initial assessment was conducted within 48 hours of the patient’s return home. Patient # 7 (start of care 07/10/2023) has diagnoses of Change or Removal of Nonsurgical Wound Dressing and Type 2 Diabetes Mellitus. The record contains a referral dated 07/05/2023 without a specific ordered SOC and documentation the patient discharged home from a skilled nursing facility on 07/07/2023. The initial assessment was completed on 07/10/2023. The record lacks documented evidence the initial assessment was conducted within 48 hours of patients return home. Patient # 9 (start of care 07/26/2023) has diagnoses of Anaplasmosis and Parkinson’s Disease. The record contains a referral dated 07/19/2022 with an ordered start of care date of 07/22/2022. The initial assessment was conducted on 07/26/2023. The record lacks documented evidence the initial assessment was conducted on the physician ordered SOC date of 07/22/2023. Patient # 14 (start of care 12/14/2022) has diagnoses of Laceration without Foreign Body of Right Hand and Laceration without Foreign Body of Left Hand. The record contains a referral dated 12/14/2022 a physician ordered SOC date of 12/23/2023 (the physician was contacted on 12/23/2022 to obtain the SOC date). The record lacks documented evidence the initial assessment was conducted within 48 hours of receiving the referral. The findings were confirmed on 11/15/2023 at 11:00 AM and 11:40 AM, 11/16/2023 at 9:00 AM and 12:00 PM with the Branch Director and Director of Patient Services, no additional evidence was provided.”

“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 clinical record review and staff interview the agency failed to ensure services are provided in accordance with the physician’s Plan of Care (POC) in two of seventeen patient records (Patient # 2, 12). Failure to follow the POC has the potential for patients to receive care that is inconsistent with the physician’s orders resulting in unmet patient needs and possible negative patient outcomes. Patient # 2 (start of care 09/22/2023) has diagnoses of Progressive Supranuclear Ophthalmoplegia and Palmar Fascial Fibromatosis. The record contains an order dated 09/26/2023: Master of Social Work (MSW) effective 09/24/2023 to conduct visits 1 time a week times 2 weeks (1WK2) and 1 time every 4th week times 4 (1Every 4WK4). The record lacks documented evidence of any MSW visits the week of 10/29/2023 through11/04/2023 or that the physician’s was notified of a missed MSW visit that week. Also, the record contains documentation of a MSW visit on 11/13/2023. The record is lacking documented evidence of a physician’s order for this visit. Patient # 12 (start of care 08/08/2023) has diagnoses of Parkinson’s Disease without Dyskinesia and Essential Hypertension. The physician’s POC for certification period 08/08/2023 through 10/06/2023 contains orders for “MSW effective 08/08/2023 two times a week times one-week (2WK1) and one visit every 5th week times 5 (1EVERY5WK5)” and “MSW received verbal order for additional MSW visit to further address community resources and care planning from Stephanie, agent for”...” NP on 08/11/2023 at 10:41 AM”. The record is lacking documented evidence of a MSW visit conducted the week of 08/11/2023 or that the physician was notified of the missed visit. Also, the record contains evidence of a MSW visit conducted on 09/08/2023 that is lacking a physician’s order. The findings were confirmed on 11/15/2023 at 11:30 AM and 11/16/2023 at 9:05 AM with the Branch Director and Director of Patient Services; no additional evidence was provided.”

“Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This Standard is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure in three out of seventeen records (Patient # 8, 9 and 10) professional staff maintain an accurate, current and clearly documented record related to the provision of the patient’s care. Failure to maintain an accurate, current and clearly documented record has the potential for staff to make clinical decisions based on inaccurate and/or missing information with the potential to result in negative patient outcomes. Patient # 8 (start of care 10/17/2023) has diagnoses of Hemiplegia following Cerebral Infarction Affecting Left Non-Dominant Side and Facial Weakness Following Cerebral Infarction. The clinical record contains a Client Coordination Note Report dated 11/08/2023 by the Occupational Therapy Assistant stating the family reports the patient has been taking a medication that is not included on the physician’s orders. The therapy assistant notified the physician and no new orders for the medication were received. The record lacks any further follow up on whether the patient/family were instructed on whether to continue or discontinue taking the medication. Patient # 9 (start of care 07/26/2023) has diagnoses of Anaplasmosis and Parkinson’s Disease. The record contains a referral dated 07/19/2022 with an ordered start of care date of 07/22/2022 and a client coordination note on 07/20/2023 stating “Verbal Order start of care (SOC) 07/19/2023”. The record is lacking documented evidence the physician’s ordered SOC was clarified. Patient # 10 (start of care 08/28/2023) has diagnoses of Obstructive Sleep Apnea and Alzheimer’s Disease. The record contains a referral signed by the physician on 08/24/2023 that lacks a ordered SOC date and a copy of the same referral signed by the physician on 08/24/2023 with an ordered SOC date of 08/28/2023. The patient was discharged from the hospital on 08/24/2023, and the record also contains a Patient Information Report dated 08/25/2023 that states “Verbal Order SOC 08/24/2023”. The record is lacking documented evidence the physician’s ordered SOC was clarified. The findings were confirmed on 11/15/2023 at 11:30 AM and 11:16/2023 at 9:00 AM and 12:05 PM with the Branch Director and Director of Patient Services; no additional evidence was provided.”

“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 clinical record review and staff interview the agency failed to ensure a complete physician’s Plan of Care (POC) was developed to meet the individualized needs of the patient in eight of seventeen patient records reviewed (Patient # 1, 2, 3, 7, 13, 14, 15 and 16). Failure to develop a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Patient # 1 (start of care 10/14/2023) has diagnoses of Chronic Kidney Disease (Stage 5) and Type 2 Diabetes Mellitus. The POC for certification period 10/14/2023 through12/12/2023 contains the following medication orders that are lacking pain scale parameters-direction as to which pain medication to take for what severity of pain level: Lidocaine Pain Relief 4% Topical Patch 1 adhesive patch as needed daily/as needed (PRN). Apply 1 patch to low back for up to a maximum of 8 hours then remove patch before applying a new patch at least 16 hours later; maximum daily dose=1 patch. Tramadol 50 (milligrams) mg tablet 1 tablet as needed every 8 hours/prn. Maximum daily dose = 3 tablets (tabs) and Tylenol 8-hour 650 mg tablet, extended release 2 tablets as needed every 8 hours/prn. Maximum daily dose = 5 tablets (tabs) and or not to exceed 3,000 mg total of acetaminophen from all sources. Patient # 2 (start of care 09/22/2023) has diagnoses of Progressive Supranuclear Ophthalmoplegia and Palmar Fascial Fibromatosis. The Physical Therapist (PT) Admission Assessment conducted on 09/22/2023 documents the patient is using Durable Medical Equipment (DME) of 1/2 bedrail and gait belt. The physician’s POC for certification period 09/22/2023 through11/20/2023 is incomplete as it is lacking orders for DME; specifically, a 1/2 bedrail and gait belt. Patient # 5 (start of care 08/28/2023) has diagnoses of Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia. The physician’s POC for certification period 08/28/2023 through 10/26/2023 contains an order for vital sign (vs) equipment. The order requires clarification as to exactly what specific vs equipment is ordered. Also, the PT Assessment conducted on 08/28/2023 does not identify the patient uses or needs vs equipment. Additionally, the physician’s POC for certification period 10/27/2023 through 12/25/2023 contains orders for DME of a reacher and vs equipment. The PT recertification assessment conducted on 10/23/2023 does not identify the patient has or uses this DME. Patient # 7 (start of care 07/10/2023) has diagnoses of Change or Removal of Nonsurgical Wound Dressing and Type 2 Diabetes Mellitus. The POC’s for certification period 07/10/2023 through 09/07/2023, 09/08/2023 through 11/06/2023 and 11/07/2023 through 01/05/2024 all contain the following medication orders that are lacking pain scale parameters-direction as to which pain medication to take for what severity of pain level: Tramadol 50 mg tablet 1 tablet as needed every 12 hours/prn pain Maximum (Max) daily dose equals two tablets and Tylenol Extra Strength 500 mg tablet 2 tablets as needed every 8 hours/prn pain Max daily dose equals 6 tabs and or not to exceed 3,000 mg from all sources. Patient # 13 (start of care 10/20/2022, discharged 11/30/2022) has diagnoses of Type 2 Diabetes Mellitus with Hyperglycemia and Paroxysmal Atrial Fibrillation. The record contains a Resumption of Care (ROC) order dated 11/03/2022 that is lacking bleeding precautions related to the use of Aspirin and falls precautions related to recent hospitalization due to a fall. Patient # 14 (start of care 12/14/2022, discharged 02/28/2023) has diagnoses of Laceration without Foreign Body of Right Hand and Laceration without Foreign Body of Left Hand. The record contains one order dated 02/01/2023 that contains two different instructions for the frequency of nurse visits: “the nurse to do two times (x2) a week” and “skilled nurse (SN) effective 01/29/2023 one time a week times 3 weeks (1WK3). The order requires clarification as to the frequency the SN should be conducting the visits. Patient # 15 (start of care 10/04/2023, discharged 10/27/2023) has diagnoses of Malignant Neoplasm of Gallbladder and Encounter of Attention to Other Artificial Openings of Urinary Tract. The physician’s POC for certification period 10/04/2023 through12/02/2023 contains the following orders: Eliquis 5 milligrams (mg) tablet oral 2 tablets every 12 hours and Eliquis 5 mg 1 tablet oral every 12 hours. The orders require clarification as to if these doses of medication should be taken together or separately. Patient # 16 (start of care 10/12/2023, discharged 10/24/2023) has diagnoses of Paroxysmal Atrial Fibrillation and Essential Hypertension. The physician’s POC for certification period 10/12/2023 through 12/10/2023 is lacking DME that is identified on the admission assessment dated 10/12/2023 specifically: bed Assist rail, specialty mattress and rolling walker. The findings were confirmed on 11/15/2023 at 11:30 AM and 11/16/2023 at 9:05 AM, 11:45 AM and 12:05 PM with the Branch Director and Director of Patient Services; no additional evidence was provided.”