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 record review and interview, the agency failed to ensure the plan of care was followed as ordered by the physician for 4 of 17 patients (Patient #305, #306, #310, and #314). Failure to follow the plan of care, as ordered by the physician, puts the patient at risk of worsening symptoms of existing diagnoses. Findings included: 1. Record review of 4 patient records showed the following: a. Patient #305 was admitted on 12/07/23 with diagnoses of unspecified open wound to left lower leg and essential hypertension–not a complete list. On 12/11/23, the physician ordered Skilled Nursing (SN) services 2 time a week for 8 weeks. On 12/26/23, the agency received a verbal order to increase the SN visit frequency to 3 times per week. The week of 12/26/23 and 12/31/23 the patient received 2 of the 3 SN ordered visits. There was no documentation to explain the missed visits, and no evidence the agency notified the patient’s physician. b. Patient #306 was admitted on 12/20/23 with diagnoses of complete intestinal obstruction and pressure ulcer sacral region stage 2 -not a complete list. On 12/30/23 at 11:58 AM, the agency received a verbal order for Skilled Nursing (SN) services 2 times per week. The week of 12/31/23 the patient received no SN visits. There was no documentation to explain the missed visits, and no evidence the agency notified the patient’s physician. c. Patient #310 was admitted on 12/14/23 with diagnoses of poly osteoarthritis, mild cognitive impairment, and essential hypertension-not a complete list. On 12/19/23 at 4:49 PM, the agency received a verbal order for Skilled Nursing (SN) services weekly for 5 weeks, Home Health Aide (HHA) services weekly for 2 weeks then 2 visits per week for 6 weeks starting 12/21/23, and Physical Therapy (PT) services weekly for 3 weeks then 2 visits per week for 5 weeks starting 12/22/23. The week of 12/24/23 and 12/31/23 the patient did not receive HHA services. The weeks of 01/07/24, 01/14/24 and 01/21/24 the patient received 1 of 2 HHA visits. The week of 01/14/24 the patient received no PT visits and the week of 01/21/24 the patient received 1 of 2 PT visits. The record showed documentation of the reason for the missed visits, however it failed to show that the physician was notified of the missed visits. d. Patient #314 was admitted on 08/12/22 with diagnoses of displaced femur fracture, pressure ulcer sacral region and hypertension-not a complete list. The plan of care (485) showed that the physician ordered Skilled Nursing (SN) services 2 visits per week for 1 week then 3 visits per week for 3 weeks then 2 visits per week for 4 weeks. The week of 09/04/22 the patient received 2 of 3 ordered SN visits. The week of 09/11/22 the patient received 1 of 2 ordered SN visits. There was no documentation to explain the missed visits, and no evidence the agency notified the patient’s physician. 3. On 02/01/24 at 1:00 PM, the Surveyor interviewed the agency’s Clinical Manager (Staff #311) of the lack of documentation on the missed visits. Staff #311 stated that Home Care Home Base allows clinicians to complete a missed visit report and document notification of the physical by phone. If the physician is not notified by phone, clinicians mark the field “Office to fax notification to provider (if unable to notify by phone).” The office staff will then fax the missed visit note to the physician’s office. Home Care Home Base (an online data sharing and documentation application for home health and hospice) does not allow the agency to easily document and track the faxing of missed visit notes within the system. Staff #311 acknowledged the findings and stated that they were unable to find any additional documentation on the missed visits or evidence that the notes were sent to the physician.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to timely provide secondary services as ordered by the physician for 5 of 17 patients (Patient #308, #309, #310, and #311). Failure to provide timely services, as ordered by the physician, could place the patient at risk of worsening symptoms of existing diagnoses. Findings included: 1. Record review for 5 of 17 patient records showed: a. Patient #308 had a start of care of 12/12/23. The patient was admitted for primary diagnoses of strain muscle, fascia, tendon of lower back and hypertensive chronic kidney disease—not a complete list. The referral orders dated 11/21/23 and 12/09/23 Physical Therapy (PT) evaluation and Occupational Therapy (OT) evaluation and Home Health Aides (HHA). The plan of care (485) showed that effective 12/31/23 Occupational Therapy would visit the patient 1 time that week. The OT evaluation did not occur. Patient #308 was transferred to the hospital on 12/04/23. The start of care case conference showed documentation that Patient #308 declined the OT evaluation. The record showed no documentation that the physician was notified of patient refusing the OT evaluation. b. Patient #309 had a start of care of 09/14/23. The patient was admitted for primary diagnoses of laceration without foreign body and essential hypertension—not a complete list. The referral orders dated 09/13/23 included skilled nursing (SN), a Physical Therapy (PT) evaluation, an Occupational Therapy (OT) evaluation and Home Health Aides (HHA). The plan of care (485) showed that effective 10/01/23 Occupational Therapy would visit the patient 1 time that week. The Occupational Therapy eval did not occur the week of 10/01/23. A new order for an Occupational Therapy evaluation was received on 10/20/23. The OT evaluation did not occur until 10/24/23. There was no documentation as to why the OT evaluation did not occur timely, and no documentation that the physician was notified of the delayed OT evaluation. c. Patient #310 had a start of care of 12/14/23. The patient was admitted for primary diagnoses of poly osteoarthritis and mild cognitive impairment—not a complete list. The referral orders dated 11/28/23 for skilled nursing (SN), Physical Therapy (PT) evaluation and Occupational Therapy (OT) evaluation and Home Health Aides (HHA). The plan of care (485) showed that effective 01/07/24 Occupational Therapy would visit the patient 1 time that week. The OT evaluation did not occur. A PT visit note dated 01/08/24 showed documentation that Patient #308 declined the OT evaluation. The record showed no documentation that the physician was notified of patient refusing the OT evaluation. d. Patient #311 had a start of care of 08/11/23. The patient was admitted for primary diagnoses of hemiplegia following cerebral vascular accident right side, aphasia, and apraxia—not a complete list. The referral orders dated 08/09/23 included a Physical Therapy (PT) evaluation, an Occupational Therapy (OT) evaluation and a Speech Language Pathology (ST) evaluation. The plan of care (485) showed that effective 08/13/23 Occupational Therapy would visit the patient 1 time that week. Patient #310 did not receive an Occupational Therapy evaluation. There was no documentation as to why the OT evaluation did not occur and no documentation that the physician was notified. e. Patient #314 had a start of care of 08/12/22. The patient was admitted for primary diagnoses of displaced femur fracture and pressure ulcer sacral region—not a complete list. The referral orders dated 08/11/22 included Skilled Nursing (SN), Social Worker (MSW) evaluation, Physical Therapy (PT) evaluation, and Occupational Therapy (OT) evaluation. The record showed no evidence that Patient #314 received an MSW evaluation as ordered on the referral. The plan of care (485) showed that effective 08/21/22 Occupational Therapy would visit the patient 1 time that week. The Occupational Therapy evaluation did not occur the week of 08/21/22. The OT evaluation did not occur until 08/29/22. There was no documentation as to why the OT evaluation did not occur timely, and no documentation that the physician was notified of the delayed OT evaluation and missed MSW evaluation. 3. On 02/01/24 at 1:15 PM, the Surveyor interviewed the agency’s Branch Director (Staff #301) about the failure to complete OT evaluations timely and notify the physician if unable to complete the evaluations. Staff #301 stated that the agency currently only has 1 part time Occupational Therapist. Due to the scheduling, it is difficult for the agency to complete the OT evaluations on time. Staff #301 also stated that the agency’s marketing staff notifies the referral sources of the delay in OT services. However, the marketing staff is unable to document this communication in the patient records. Staff #301 also acknowledged that the agency is not documenting notification to the physician of the delayed or missed evaluations.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to provide documentation of adequate competency training to Home Health Aides that addresses the required subject areas before providing care. Failure to provide adequate competency training to Home Health Aides puts the patients at risk of harm from untrained and unqualified caregivers. Cross Reference: G0764 1. On 01/29/24 the Surveyor reviewed the personnel record of the agency’s only Home Health Aide (Staff #309). The record showed that Staff #309 was hired on 03/01/23. The records showed no evidence that the agency completed the Home Health Aide competency training before providing patient care that addresses the required subject areas as listed on CFR 484.80(b)(3)(i-xv). Cross Reference: G0764 2. On 02/01/24 at 2:00 PM, the Surveyor interviewed the agency’s Branch Director (Staff #301) about the missing documentation of Home Health Aide competency training with the required subject areas before providing patient care. Staff #301 stated that Staff #309 completed the competency training before providing care but acknowledged that the agency was unable to locate the documentation. Staff #301 also stated that the agency’s Clinical Manager (Staff #312) was currently on a joint visit with Staff #309 to complete the competency training. Prior to survey exit, Staff #301 provided the Surveyor with documentation that Staff #309 completed the HHA competency evaluation on 02/01/24.”

“Supervision of home health aides CFR(s): 484.80(h) Standard: Supervision of home health aides. This Standard is not met as evidenced by: Based on record review and interview the agency failed to document Home Health Aide (HHA) supervisory visits no less frequently than every 14 days for 3 of 4 patients receiving HHA services (Patient #308, #309, and #315). Failure to supervise the Home Health Aide at least every 14 days places the patients at risk of receiving services that are not reviewed for continued effectiveness and are not reflective of the patient’s changing needs. Findings included: 1. Record review of the agency’s policy titled, “03-17 Patient Care Supervision” revised 10/2022, showed that supervision of home health aide services will be performed when the patient is receiving skilled nursing services. A RN will make on-site supervisory visits to each patient receiving home health aide services at least every 14 days. When the patient is receiving only therapy and aide services, the licensed therapist will make supervisory visits in lieu of the RN when allowed by state regulations. 2. Record review of 3 patient records showed the following: a. Patient #308 was admitted on 12/12/23 with diagnoses of strain muscle, fascia, tendon of lower back, hypertensive chronic kidney disease-not a complete list. The record showed that Patient #308 was to receive HHA services weekly for 8 weeks. The patient received HHA services on 12/22/23, 12/29/23 and 01/26/24 (35 days duration). There was no documentation of HHA supervisory visits every 14 days during the episode. b. Patient #309 was admitted on 09/14/23 with diagnoses of laceration without foreign body, essential hypertension, sciatica-not a complete list. The record showed that Patient #309 received HHA services 2 times per week for 8 weeks starting 09/17/23 through 11/12/23. The record showed documentation of HHA supervisory visits on 09/28/23 and 10/26/23. There was no documentation of HHA supervisory visits every 14 days as required. c. Patient #315 received home health services from 03/29/23 to 04/24/23 for essential hypertension and surgical aftercare-not a complete list. The record showed that Patient #315 received HHA services 2 times per week from 04/07/23 to 04/24/23 (17 days duration). There was no documentation of HHA supervisory visits every 14 days as required. 3. On 02/01/24 at 2:00 PM, the Surveyor interviewed the agency’s Branch Director (Staff #301) and the agency’s Clinical Manager (Staff #311) regarding the lack of evidence in the patient record that HHA supervisory visits were completed as required by federal law and consistent with the agency’s policy. Staff #301 and #311 acknowledged the findings and stated that they were unable to provide documentation that HHA supervisory visits were conducted on the patients noted above.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to conduct the initial assessment visit within 48 hours of completing the referral for 2 of 17 patients (Patients #308 and #310). Failure to meet this requirement places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Record review of 2 patient records showed the following: a. Patient #308 was admitted on 12/12/23 for primary diagnoses of strain muscle, fascia, tendon of lower back and hypertensive chronic kidney disease-not a complete list. The agency completed the referral on 11/24/23 for physical therapy and occupational therapy, however the start of care (SOC) for physical therapy did not occur until 12/12/23. The record also showed that the agency received an additional referral on 12/09/23. The plan of care (485) showed a verbal SOC as 12/04/23 and the start of care OASIS showed a M102 (Physician Ordered Start of Care) date of 12/12/23. There was no documentation of why the start of care did not occur within 48 hours of the referral or supporting documentation for the M102 date. b. Patient #310 was admitted on 12/14/23 for primary diagnoses of poly osteoarthritis and mild cognitive impairment-not a complete list. The agency received a referral on 11/28/23 for skilled nursing, physical therapy, occupational therapy, and home health aide services, however the SOC did not occur until 1214/23. The record also showed that the clinician documented the M102 (Physician Ordered Start of Care) date as 11/28/23. There was no documentation of why the start of care did not occur within 48 hours of the referral. 3. On 02/01/24 at 1:30 PM, the Surveyor interviewed the agency’s Branch Director (Staff #301) and Clinical Manager (Staff #311) about the delays in the start of care for Patient #308 and #310. Staff #311 acknowledged the findings and stated that they were unable to locate additional documentation that explains why the services did not occur within 48 hours of the referral. Staff #311 also stated that the agency uses the date the referral was received as the verbal SOC date on the plan of care (485). The agency utilizes a central intake department that will enter a care coordination note when the referral has been received, entered, and sent to the agency for review. The agency will review the referral and request any additional documents to complete the referral. Once the agency has completed the referral, staff will enter a care coordination note to indicate that the referral is complete and ready to schedule. Staff #311 also stated that the Clinical Managers will adjust the M102 and M104 dates as appropriate prior to the OASIS being locked.”

“Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This Element is not met as evidenced by: Based on record review and interview, the agency failed to document supervision of Physical Therapy Assistants by a Physical Therapist as required for 4 of 12 sampled patients who received Physical Therapy services (Patient #301, #304, #307 and #308). Failure to supervise Physical Therapy Assistants as required places patients at risk of receiving services that are not reviewed for continued effectiveness and are not reflective of the patient’s changing needs. Reference: RCW 18.74.180 Professional and legal responsibilities - Supervision of assistive personnel. Physical therapist is professionally and legally responsible for patient care given by assistive personnel under his or her supervision. If a physical therapist fails to adequately supervise patient care given by assistive personnel, the board may take disciplinary action against the physical therapist. (2) If patient care is given by a physical therapist assistant, or other assistive personnel, supervision by the physical therapist requires that the patient reevaluation is performed: (a) The later of every fifth visit or every thirty days if a physical therapist has not treated the patient for any of the five visits or within the thirty days; (b) When there is any change in the patient’s condition not consistent with planned progress or treatment goals. Findings included: 1. Record review of the agency’s policy titled, “03-17 Patient Care Supervision” revised 10/2022, showed that unless otherwise specified by state regulations, the minimum frequency of patient care supervisory visits for Therapy Assistants is every 60 days. 2. Record review of 3 patient records showed the following: a. Patient #301 was admitted on 12/27/23 with diagnoses of bilateral primary osteoarthritis of knee, pain in right ankle, lumbago with sciatica and chronic pain. Patient #301 received Physical Therapy (PT) services 2 times weekly for 4 weeks then weekly for 4 weeks. PT services were provided by both a Physical Therapist and Physical Therapy Assistant. The records showed no documentation of supervision of the Physical Therapy Assistant the later of every fifth visit or 30 days as required in Washington state law. b. Patient #304 was admitted on 11/16/23 with diagnoses of pneumonitis, chronic respiratory failure, malignant neoplasm of the right breast and malignant pleural effusion. Patient #304 received Physical Therapy (PT) services 2 times weekly for 9 weeks. PT services were provided by both a Physical Therapist and Physical Therapy Assistant (PTA). In the episode from 11/16/23 to 01/14/24, the patient received PTA services on 12/05/23, 12/07/23, 12/27/23, 01/03/24, and 01/09/24. For the current episode starting on 01/15/24, the patient received PTA services on 01/22/24,01/26/24, and 01/31/24. The records showed a PTA supervisory visit completed on 12/13/23. The record showed no documentation of supervision of the Physical Therapy Assistant the later of every fifth visit or 30 days as required in Washington state law. c. Patient #308 was admitted on 12/12/23 with diagnoses of strain muscle, fascia, tendon of lower back, hypertensive chronic kidney disease-not a complete list. Patient #308 received Physical Therapy (PT) services 2 times weekly for 9 weeks. PT services were provided by both a Physical Therapist and Physical Therapy Assistant. The patient received PTA services on 12/15/23, 12/21/23. 12/22/23, 12/26/23, and 12/29/23. The records showed no documentation of supervision of the Physical Therapy Assistant the later of every fifth visit or 30 days as required in Washington state law. 3. On 02/01/24 at 2:00 PM, the Surveyor interviewed the agency’s Branch Director (Staff #301) and the agency’s Clinical Manager (Staff #311) regarding the lack of PTA supervisory visits. Staff #301 and #311 acknowledged the findings and stated that they were unable to provide documentation that PTA supervisory visits were conducted on the patients noted above.”