Centerwell Home Health

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on document review, record review, and interview, the agency failed to provide a process and contact information for staff to cooperate and collaborate with local, tribal, regional, state, and federal emergency preparedness officials’ efforts to support an integrated response during a disaster or emergency situation. Failure of the agency to develop and implement a process that includes the contact information for local, tribal, regional, state, and federal emergency preparedness officials may cause delays in the collaborative efforts to reach patients in need during a disaster or emergency situation. Findings included: 1. Document review of the agency’s policy titled, “03-18 CWHH Emergency Preparedness Plan [EPP]”, last reviewed in 01/2026, showed that the communication plan will include: a. The names, primary contact information, and alternate contact information for local, state, and federal emergency preparedness officials. b. During an emergency/disaster event, the agency may request the police/fire department for assistance with evacuation transportation. Document review of the agency’s Disaster Plan for both sites, updated February 2026, showed no evidence of contact information for local, tribal, regional, state, or federal emergency officials in the binders. 2. On 06/11/26 at 3:00 PM, Surveyor #2 interviewed the Branch Manager (Staff #210) about the missing information for local, regional, state, and federal emergency officials’ contact information. Staff #210 stated that the information is in the Emergency Preparedness – Disaster Plan binder. However, it could not be located in the binder.”

“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 document review, observation, and interview, the agency’s staff failed to follow infection prevention and control guidelines to use the proper hand hygiene technique and to clean contaminated equipment. Failure of the agency to adhere to infection prevention and control guidelines places the patient at risk of harm due to exposure to infectious organisms. Findings included: 1. Document review of the agency’s policy titled, “Bag Technique, Home Care,” revised 05/19/25, showed that direct care staff are to perform hand hygiene, and clean and disinfect reusable items prior to returning them to the bag. 2. Observation for 3 of 7 patients showed that: a. During a home visit on 06/10/26 at 12:30 PM, Surveyor #2 observed Staff #203 use the electronic blood pressure cuff on the patient and replace it in their bag without disinfecting the equipment first. b. During a home visit on 06/11/26 at 10:00 AM, Surveyor #3 observed Staff #205 perform wound care to Patient #204. The bandage scissors fell on the floor while repositioning Patient #204. Staff #205 failed to clean the scissors prior to using them to cut a clean dressing. c. During a home visit on 06/10/26 at 10:30 AM, Surveyor #3 observed Staff #207 fail to change gloves after assisting Patient #206 with a shower and before applying a bandage to their foot. Staff #207 failed to perform hand hygiene after removing gloves, prior to placing reusable equipment in their bag. Staff #207 also failed to clean reusable equipment prior to returning it to the bag after patient use. 3. On 06/10/26 at 2:00 PM, Surveyor #3 interviewed the Branch Manager (Staff #210) about observations of the staff’s failure to disinfect equipment and perform hand hygiene. Staff #310 stated that staff participate in bag technique and hand hygiene training during orientation and annually. Staff #310 stated that the agency recently completed survey prep visits to focus on proper bag technique and infection control. Staff #310 stated that they made joint visits with staff to observe infection control and saw no issues at that time.”

“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 the document review, record review, and interview, the agency failed to complete the comprehensive assessment within 5 days of the start of care for 4 of 17 patient records reviewed (Patient #304, Patient #305, Patient #208, and Patient #315). Failure of the agency to complete the comprehensive assessment on time causes delays in treatment and/or services, affecting the patient’s progression toward healing and recovery. Based on the document review, record review, and interview, the agency failed to complete the comprehensive assessment within 5 days of the start of care for 4 of 17 patient records reviewed (Patient #304, Patient #305, Patient #208, and Patient #315). Failure of the agency to complete the comprehensive assessment on time causes delays in treatment and/or services, affecting the patient’s progression toward healing and recovery. Findings included: 1. Document review of the agency’s policy titled, “04-02 Medical Record Documentation”, reviewed and revised on 03/2026, showed that notes and required fields are to be completed on the date of service or as soon as practical thereafter. If documentation occurs after the date of service, it must be clearly labeled as “Late Entry” with the actual entry date/time and author, along with the date of the visit of the amended documentation. 2. Record review of 4 patients (Patient #304, Patient #305, Patient #208, and Patient #315) showed: a. Patient #304 started care on 03/23/26. The referral included Skilled Nursing (SN), Physical Therapy (PT), and Occupational Therapy (OT). The record showed no evidence that the patient received a PT or OT evaluation as ordered in the referral. The record showed no evidence of why the PT and OT evaluations were not completed. b. Patient #305 had the comprehensive assessment completed on 02/13/26. The referral included SN, PT, and OT. The records showed that the OT evaluation was completed on 03/10/26. The record showed no evidence of why the OT evaluation was completed more than 5 days after the start of care. c. Patient #208 started care on 05/09/26. Rehabilitation therapy was authorized on 05/12/26. Speech Therapy (ST) completed the initial assessment on 05/19/26. The record showed no evidence of why the Speech Therapy evaluation was completed more than 5 days after the service was authorized. d. Patient #315 started care on 04/29/25. The referral included PT, OT, and ST. The records showed that the ST evaluation was completed on 05/10/25. The record showed no evidence of why the ST evaluation was completed more than 5 days after the start of care. 3. On 06/11/26 at 1:00 PM, Surveyor #3 interviewed the Branch Manager (Staff #310) about the delayed completion of the comprehensive assessment. Staff #310 stated that the staff pushed back on the requirement to complete secondary evaluations ordered on referral within the 5-day window from the start of care. Staff #310 acknowledged that the comprehensive assessment includes the patient’s health, physical, functional, and cognitive status, and therefore, therapy evaluations are needed to accurately complete the comprehensive assessment if it is ordered.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on document review, record review, and interview, the agency staff failed to document and notify the physician of a missed scheduled visit for 4 of 17 patient records reviewed (Patient #305, Patient #306, Patient #211, and Patient #315). Failure of the agency to document and notify the physician of a missed visit may slow the patient’s progression toward healing and recovery. Findings included: 1. Document review of the agency’s policy titled, “03-12 Physician/Allowed Practitioner Orders”, revised in 01/2026, showed that if fewer visits were provided during the week than ordered, the physician or allowed practitioner will be notified. The policy also showed that all missed visits must be documented in the patient’s medical record to include the reason for the missed visit and the physician or allowed practitioner’s notification. 2. Record review of 4 patient records (Patient #305, Patient #306, Patient #211, and Patient #315) showed that: a. Patient #305 started care on 02/13/26. The physician ordered physical therapy (PT) 2 times weekly for 4 weeks, then weekly for another 4 weeks starting on 04/14/26. The record showed that Patient #205 received only 1 PT visit in the week of 04/26/26 and 05/03/26. The record also showed that Patient #205 received no PT visits the week of 05/24/26. The record showed no evidence that the physician was notified of the missed visits. b. Patient #306 started care on 03/26/26. The physician ordered PT and Home Health Aide (HHA) services weekly starting 05/25/26. The record showed that Patient #206 received no PT or HHA services in the week of 05/25/26. The record showed no evidence that the physician was notified of the missed visits. c. Patient #211 started care on 02/26/26. The physician ordered skilled nursing visits once a week for 9 weeks starting 02/26/26. The record showed that Patient #211 did not receive a skilled nursing visit for the week of 03/01/26. The record showed no evidence of why the visit was missed or that the physician received notification of the missed visit. d. Patient #315 started care on 04/29/25. During the episode from 06/28/25 to 08/26/25, the physician ordered PT 2 times weekly for 3 weeks and occupational therapy (OT) weekly starting on 06/29/25. The record showed that Patient #215 received only 1 PT visit the week of 07/20/25 and received no OT visits the week of 08/03/25. The record showed no evidence that the physician was notified of the missed visits. 3. On 06/11/26 at 3:00 PM, Surveyor #2 interviewed the Branch Manager (Staff #210) about the missed visits. Staff #210 stated that there was no apparent reason why the visits were missed, and no note documenting that the physician was notified of the missed visits.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on document review, record review, and interview, the agency failed to ensure adherence to its policies that address state licensing requirements for 3 of 9 staff records reviewed (Staff #204, Staff #206, and Staff #208). Failure of the agency to maintain and implement policies and procedures in compliance with state home health regulations places the patients at risk for physical, psychological, and/or financial harm from improperly vetted staff. Reference: Item #1 WAC 246-335-525 The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (3) References for personnel, contractors and volunteers; Item #2: WAC 246-335-525(6) Criminal history background checks and disclosure statements for personnel, contractors, volunteers, students, and any other individual associated with the licensee having direct contact with children under sixteen years of age, people with developmental disabilities or vulnerable persons, according to RCW 43.43.830 through 43.43.842 and the following: (a) Criminal history background checks must be processed through the Washington state patrol; (b) Disclosure statements must be approved by the department; and (c) All criminal history background checks and disclosure statements required under this chapter must be renewed within two years from the date of the previous check; Findings included: Item #1 – Personnel, contractors, and volunteers references 1. Record review showed that 3 of 9 staff records (Staff #204, Staff #206, and Staff #208) did not have evidence of collecting or contacting references in their records. 2. On 06/11/26 at 3:00 PM, Surveyor #2 interviewed the Branch Manager (Staff #210) about the missing references. Staff #210 stated that Humana maintains these records. Staff #210 verified that the references were not in the staff records. Item #2 – Criminal background check and disclosure statement 1. Document review of the agency’s policy titled, “WA 07-16: Background Investigations”, revised date 04/2021, showed that criminal background checks and disclosure statements must be renewed within two years from the date of the previous check. 2. Record review of 9 agency staff showed that: a. 2 of 9 staff records (Staff #206 and Staff #208) did not show evidence of having completed the disclosure statement within two years from the date of the last disclosure statement. b. 1 of 9 staff records (Staff #204) did not show evidence of having a criminal background check completed within two years from the date of the last criminal background check. 3. On 06/11/26 at 3:00 PM, Surveyor #2 interviewed the Branch Manager (Staff #210) about the missing disclosure statements and criminal background check. Staff #210 stated that Humana maintains these records. Staff #210 verified that the disclosure statements and background check were not completed. This is a repeated non-compliance that was identified in the recertification survey conducted on 06/29/23. The agency was cited under Tag G0860, §484.100(b) Standard Licensing, referencing WAC 246-335-525(6)(a), (b), and (c).”