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 a review of agency policy, a review of clinical records, and an interview with the agency Administrator, the agency failed to ensure services ordered by a nurse practitioner/physician assistants collaborating or supervising physician was identified in the patients written plan of treatment for four (4) of four (4) clinical records (CR) reviewed that were signed by a nurse practitioner/physician assistant (CR#6, CR#7, CR#12, CR#13). ‘House Bill No. 2401, Session of 2022’ section (2) “ Home health care services may be ordered by nurse practitioners and physician assistants as provided under section 1814(a) and 1835(a) of the Social Security Act (49, Stat. 620, 42 U.S.C. § 1395 et. seg.), if the nurse practitioners or physician assistants collaborating or supervising physician is identified in the patients written plan of treatment. ... “ Agency policy/procedure was reviewed on December 5, 2025 at approximately 12:15 p.m. Policy 03-11 ‘Care Planning’ ‘Policy’ “... The individualized POC (plan of care) must specify: Care and services to meet patient specific needs identified in the comprehensive assessment and provided in accordance with accepted standards of practice and respective State Practice Acts. ..... “ A review of CRs was completed on December 5, 2025 at approximately 12:00 p.m. The patients start of care (SOC) is listed below. CR#6 SOC 11/05/25: Verbal order from a physician assistant was taken by a registered nurse on 11/05/25 for the certification period 11/05/25 - 01/03/25. The physician assistants countersignature was obtained on 11/14/25. The physician assistants collaborating/supervising physician was not identified in the patients written plan of treatment. CR#7 SOC 12/11/24: Verbal order from a nurse practitioner was taken by a registered nurse on 10/02/25 for the certification period 10/07/25 - 12/05/25. The nurse practitioners countersignature was obtained on 11/03/25. The nurse practitioners collaborating/supervising physician was not identified in the patients written plan of treatment. CR#12 SOC 09/03/25: Verbal order from a nurse practitioner was taken by a registered nurse on 10/31/25 for the certification period 11/02/25 - 12/31/25. The nurse practitioners countersignature was obtained on 11/19/25. The nurse practitioners collaborating/supervising physician was not identified in the patients written plan of treatment. CR#13 SOC 08/22/25: Verbal order from a nurse practitioner was taken by a registered nurse on 08/20/25 for the certification period 08/22/25 - 10/20/25. The nurse practitioners countersignature was obtained on 09/15/25. The nurse practitioners collaborating/supervising physician was not identified in the patients written plan of treatment. An interview conducted with the agency Administrator on December 5, 2025 at approximately 12:30 p.m. confirmed the above findings.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on a review of agency policy, review of clinical records, and an interview with the agency Administrator, the agency failed to ensure a written summary report for each patient was sent to the attending physician at least every 60 days for four (4) of seven (7) recertification clinical records (CR) reviewed (CR#5, CR#7 - CR#9). Agency policy/procedure was reviewed on December 5, 2025 at approximately 12:15 p.m. Policy ‘03-16 Coordination of Care - Case Conferences’ ‘Case Communication’ states “The clinical Manager or designee will send a written summary of the Plan of Care to the physician/allowed practitioner at least every 60 days for all patients.” A review of CRs was completed on December 5, 2025 at approximately 12:00 p.m. The patients start of care (SOC) is listed below. CR#5 SOC 08/20/25: Patients most recent recertification period 10/19/25 - 12/17/25. Patients ‘Home Health Certification and Plan of Care’ for the period of 08/20/25-10/18/25 was reviewed. Documentation provided of a written summary being sent to the physician on 10/20/25. (62 days). CR#7 SOC 12/11/24: Patients most recent recertification period 10/07/25 - 12/05/25. Patients ‘Home Health Certification and Plan of Care’ for the period of 12/11/24 - 02/08/25 was reviewed. Documentation provided of a written summary being sent to the physician on 02/10/25. (62 days). CR#8 SOC 07/01/25: Patients most recent recertification period 10/29/25 - 12/27/25. Patients ‘Home Health Certification and Plan of Care’ for the period of 07/01/25 - 08/29/25 was reviewed. Documentation provided of a written summary being sent to the physician on 09/02/25. (64 days). CR#9 SOC 05/15/25: Patients most recent recertification period 11/11/25 - 01/29/26. Patients ‘Home Health Certification and Plan of Care’ for the period of 05/15/25 - 07/13/25 was reviewed. Documentation provided of a written summary being sent to the physician on 07/14/25. (61 days). An interview conducted with the agency Administrator on December 5, 2025 at approximately 12:30 p.m. confirmed the above findings.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on a review of agency policy, a review of clinical records, and an interview with the agency Administrator, the agency failed to ensure a discharge summary was sent to the primary care practitioner or other health care professional responsible for providing care and services to the patient after discharge from the home health agency within 5 business days of the patient’s discharge for one (1) of five (5) discharged clinical records (CR) reviewed (CR#13). Agency policy/procedure was reviewed on December 5, 2025 at approximately 12:15 p.m. Policy 03-25 ‘Patient Discharge or Transfer’ ‘Discharge/Transfer Summary’ “ .... Patients discharged to their physician/allowed practitioner will be sent within five business days of the Home Health agency discharge date. ....” A review of CRs was completed on December 5, 2025 at approximately 12:00 p.m. The patients start of care (SOC) is listed below. CR#13 SOC 08/22/25: Patient was discharged from the agency on 09/17/25. Patients ‘Home Health Certification and Plan of Care’ for the period of 08/22/25-10/20/25 was reviewed. Documentation provided of a ‘Discharge-Transfer Summary Report’ being sent to the physician late on 10/14/25. (27 days.) An interview conducted with the agency Administrator on December 5, 2025 at approximately 12:30 p.m. confirmed the above findings.”