Centerwell Home Health

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the patient for 139 assessments processed for the time-period reviewed of 01/08/2024 – 01/08/2025. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare and improve patient care failing to be reported to CMS in the required time frame. Findings included: The HHA Error Summary Report, retrieved from the iQIES website for the time period of 01/08/2024 - 01/08/2025 was reviewed. Review of the HHA Error Summary Report for the time period of 01/08/2024 - 01/08/2025 identified Error #-3330. The description for Error #-3300 read in part, “Record Submitted Late: The submission date is more than 30 days after M0090 (item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with this error was 139 assessments and the percentage of assessments with this error was 2.58% of assessments completed by the Agency. An interview was completed with the Administrator on 1/15/25 at 11:50 AM the surveyor showed Administrator the “Home Health Error Summary” report which indicated that 139 OASIS assessments were late by the agency. Administrator reported that she was aware that this was an issue and that previously they were late due waiting on face-to-face encounters to occur, revisions being made to the plan of care, and a personnel issue where one of the clinical managers was falling behind. Review of the Agency’s policy titled “QAO (Quality Assessment Only) and OASIS Timely Submission”, dated 04/24, revealed that timely OASIS assessment submission was defined as within 30 days of completion.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, record review, and interview, the Agency failed to enforce written policies to address infection control and prevent the spread of infectious and communicable disease for 2 of 7 clients (Client 10 and Client 3). This failure placed clients at risk of acquiring infections and diseases. Findings included: Review of policy titled “10-03 Patient Care: Standard Precautions,” dated 10/2024, revealed that “all clinical associated when performing work-related responsibilities will utilize standard precautions,” and that standard precautions included “clinician bag technique.” Review of document provided by agency titled “Bag technique, home care,” dated 05/20/2024, revealed that placement of the bag was advised to be “on a flat surface that appears to be clean and dry” and that clinicians should use a “fluid-impermeable pad as a barrier beneath the bag as needed if a clean, dry surface isn’t available.” On 1/14/25 at 12:00 PM, the surveyor observed PT A place his equipment bag directly on Client 10’s bed without using a protective barrier between the bag and the Client 10’s bed. PT A did not clean area of the bed with a disinfectant prior to placing his bag on the bed. PT A placed his stethoscope, blood pressure cuff, pulse oximeter, and tape measure directly on Client 10’s bed. After using the items and prior to placing them back into his equipment bag PT A did disinfect the items. PT A did not disinfect his equipment bag after removing it from the surface of Client 10’s bed and leaving the home. On 1/15/25 at 9:00 AM, the surveyor observed RN A place her equipment bag directly on Client 3’s dining table without using a protective barrier between the bag and Client 3’s table. RN A did not clean dining table surface prior to placing bag or equipment on the table. RN A removed her blood pressure cuff and pulse oximeter from the bag. RN A used her pulse oximeter and blood pressure cuff on Client 3. RN A did not clean the blood pressure cuff or pulse oximeter prior to placing them back into the bag. In an interview with PT A on 1/15/25 at 11:31 AM, the Surveyor asked PT A if he was aware if the agency had a policy on using a barrier to separate his equipment from the client’s when placing down his equipment bag. PT A reported that he was not sure what the agency policy was for this. Surveyor informed PT A that on the home visit with Client 10 surveyor observed PT A place his equipment bag directly on Client 10’s bed. Surveyor asked if he thought that he should have used a protective barrier. PT A responded that he used to use a protective barrier during COVID-19, but has not used it since. Surveyor asked if he was concerned about transferring microbes between patient homes. PT A responded that the agency likely has a policy for them to use a barrier and that he just personally has not been doing it. In an interview with the Administrator on 1/15/25 at 11:50 AM, the surveyor asked the Administrator if the agency had a specific policy regarding using a barrier between the clinician’s bag and the surface in the Client’s home. Administrator found that within the infection control policy it stated clinicians should use a clean bag technique. The surveyor asked Administrator to describe what the agency’s expectation is for using a barrier. Administrator responded that clinicians should always be using a barrier between their bag and the surface in the client’s home and that they can place their equipment bag anywhere except on the Client’s floor. The surveyor informed Administrator that on home visits with PT A and RN A, the surveyor observed the clinicians place their bag’s directly on the Client’s bed and dining table without using a barrier. Administrator reported that they both should have used a barrier. Administrator stated that clinicians should always clean their equipment prior to placing it back in the bag and reported that RN A may have taken her smaller equipment bag and cleaned the contents when she returned to her vehicle prior to placing the contents in her larger equipment bag.”