Centerwell Home Health

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on interviews and record review: The agency failed to ensure a resumption of care reassessment was done within 48 hours. For 1 of 3 client records reviewed (Client-B) in that: Client-B did not have a reassessment done within 48 hours after returning from the hospital. This failure placed all clients served by the agency at risk of inconsistent care and lack of appropriate clinical oversight. Record review of general corporate policy titled 03-05 Patient Assessments last revised 09.2025, page 4 of 5 under resumption of care (ROC) “…Completed following discharge form an inpatient facility with 48 hours of facility discharge …” Record review of Client-B, Plan of Care with a Certification period: 11.20.25 to 1.18.26 reveal a 66 year old male with diagnosis(Dx) of Pleural Effusion (abnormal buildup of excess fluid in the pleural space, the thin, fluid-filled area between the lungs and the chest wall), Chronic Kidney Disease ((CKD) the long-term, progressive loss of kidney function, where kidneys are damaged and unable to properly filter waste and fluids from the blood), End stage Renal Disease on dialysis ((ESRD) is the final, permanent stage of chronic kidney disease (stage 5), indicates kidney failure that requires regular dialysis or a kidney transplant to survive), Peripheral Vascular Disease ((PVD) a condition involving blood vessel narrowing (usually in the legs) due to plaque buildup (arteriosclerosis), causing pain and reduced circulation). Further review revealed a hospitalization on 12.13.25 due to respiratory distress and new would to right foot with a hospital discharge of 12.20.25 Record review of ROC (due to hospitalization) was not done until 1.12.26, 19 days after Client B was discharged from the hospital on 12.20.25. Record review of Client-B clinical record for episode period: 11.20.25 to 1.18.26 indicated multiple attempts for visits and client being unavailable/non-compliant. Only two case conferences were noted in chart. One on 11.24.25 for an SOC and the other on 1.13.26 for resumption of care. Neither case conference addressed the missed visits or how to proceed with client care when reassessment was not done until 1.12.26 per clinical coordination note During an interview on 2.10.26 at 11:50 a.m., RN Adm/Supervising Nurse was asked if any notes or case conferences that addressed the non-compliance and the lack of being able to reassess the client. She stated “…I said it happens when admitting the case, we do admission case conferences at the beginning, but we don’t have another case conference that documents that. All I have is nurses documented in the chart about him rescheduling visits and that kind of stuff but that’s all I have I don’t have a case conference per se…” During an interview on 2.10.26 at 12:59 p.m., RN Alt. Adm/ Alternate supervising nurse was asked whether if she could to show a case conference where it was brought up that this patient was not getting the care that was part of his plan of care. She stated “…I don’t know you’re not looking in the wrong place there’s not one there.” Record review of general corporate policy titled 03-16 Coordination of care -case conferences last revised 01.20.24. “…Case conferences will consist of a review of patient care and coordination items including but not limited to: Patient progress toward goals related to plan of care…” “…Case conferences will be conducted more frequently at the discretion of the clinical manager if: a review of adverse events and/or incidents report trends indicating particular care issues.””

“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 interviews and record review: The agency failed to complete 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, for 1 of 3 client records reviewed (Client-B) In that: Client-B primary care practitioners or other health care professionals were not provided with any written notification of client discharge. This failure potentially placed clients at risk of insufficient time to plan for continuation of their health care needs. Record review of Client-B, Episode period: 11.20.25 to 1.18.26. Hospitalization on 12.13.25 and discharged from the hospital on 12.20.25 due to respiratory distress, and new wound to right foot. Record review of the entire client records found no evidence that a discharge was completed at all, or that the client or client’s responsible party was provided with a written notice of the agency’s intent to transfer or discharge the client. There was no evidence that a written notice of discharge was provided to Client-B. During a record review and interview on 2.10.26 at 11:50 a.m., RN Adm/Supervising nurse was asked if the agency provided a written notice of discharged and if you’re able to point that out in the chart. She stated “…No.” Did the agency deliver a written notification no later than five days before the date on which the client was to be transferred or discharged is that anywhere in the chart. She stated “…No…” During an interview on 2.10.26 at 12:59 p.m., RN Alt. Adm/ Alternate supervising nurse was asked if there was any documentation in chart regarding providing written notification discharge and that the patient and doctor were notified. “…No…” Record review on 2.10.26 of Texas policy titled TX 03-25 Discharge or Transfer last revised 08.2024, “…1, provide written notification to the client or the clients patent, family, spouse, significant other or legal representative. 2, notify the clients attending physician or practitioner if he is involved in the agency’s care of the client. b, an agency must ensure delivery of the written notification no later than five days before the date on which the client will be transferred or discharged …”, “…f, an agency must keep the following in the clients file: 1, a copy of the written notification provided to the client or the clients patent, family, spouse, significant other or legal representative…””

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on interview and record review the agency failed to ensure the agency’s infection control program identified the wound infection of one of 17 clients patients (#5) whose records were reviewed for infections in that: Patient #5’s wound infection was not identified on their infection control log for 49 days (2/23/2024 to 4/12/2024). This failure could affect all patients in the agency and could result in infections not being identified and a decline in health status for all agency patients. The findings were: Record review of Patient #5’s ROC POC for certification period 02/25/2024 to 04/24/2024 revealed a SOC of 12/27/2023, diagnosis included Dehiscence of Amputation of Stump (onset date 02/23/2024). Record review of Patient #5’s current medication profile revealed Ciprofloxacin (anti-infective medication) 750 mg tablet daily, ordered on 02/25/2024 for wound infection. Record review of the agency’s infection control log (the agency’s log for identifying and tracking infections) for 12/2024 to 4/2024 revealed Patient #5 was not identified on the logs. During an interview on 04/12/2024 at 08:54 a.m., the Administrator (also Alternate Supervising Nurse) revealed clinical managers were responsible for putting patients identified with infections on the infection log as they reviewed the records and conducted quarterly audits of clinical records. Further interview revealed the nurses out in the field, when conducting supervisor visits, should have checked if infections were logged. The Administrator further revealed she thought the nurse overlooked it. During additional interview with the Administrator on 04/12/2024 at 12:13 p.m. revealed the agency couldn’t trend the infections or monitor infections if patients with infections were not identified on the infection log. During an interview on 4/12/24 at 11:43 a.m. RN A, revealed Patient #5 went to hospital for debridement (removal of damaged tissue) for Right Knee Amputation. RN A did ROC assessment on 2/23/24, RN A stated that Patient #5 came back from the hospital with an antibiotic. Further interview with RN A revealed Patient #5’s wound infection was not logged in the infection control log because “I overlooked it and the patient should have been on the March 2024 infection control log.” During an interview on 04/12/2024 at 12:06 p.m. RN B, Clinical Manager, revealed Patient #5 went to the hospital for a wound infection and the nurse who conducted the supervisory visits and resumption of care should have logged Patient #5 in the infection log. Further interview with RN B revealed the clinical managers should check if it was logged as well. Record review of the agency’s policy and procedure titled “Surveillance, Prevention, and Infection Control (04/2022)”, read in part, “..The infection log will be used to document and collect data regarding patient and clinical staff infections...””