Centerwell Home Health

“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: The Home Health Agency (HHA) failed to comply with 484.70(a) for one (1) of three (3) patients observed during a skilled nursing (SN) visit (Patient #4). The HHA failed to prevent the potential transmission of infection by placing a urine soaked adult brief over a new sacral decubitus dressing. Findings include: An observation was conducted at the home of patient #4 on 08/25/25 starting at 3:15 p.m., accompanied by staff #2. The patient was bedbound and lying in bed, alert and oriented. The sitter was present and was with the patient for eight (8) hours a day. The patient was friendly. Staff #2 did vital signs, verified medication, and tried to connect a new wound vac to a decubitus wound on the sacrum, but did not have success. Staff #2 stated the wound vac was different and [he/she] didn’t have knowledge of how to set it up or calibrate it. Staff #2 made a telephone call to the supply company with no answer and left a voice message. Staff #2 assessed and cleaned the wound and applied a clean dressing on the patient’s sacral area. Staff #2 then secured the adult brief back without applying a new one, even though it was visibly soaked with urine. The sitter helped staff #2 turn the patient throughout the dressing change. By the time staff #2 completed the dressing change, the wound vac supply company had not returned the call. A medical record review was conducted for patient #4, SOC date 06/09/25, with a diagnosis that included pressure ulcer of sacral region, stage four (4). Patient #4 received SN and PT services from the home health agency. A review of the Visit Note Report with a visit date of 08/25/25, revealed in part: “...Wound vac arrived but needs set up. Contacted [medical supply company] and notified them via VM [voice mail] that wound vac needs set up by provider before vac can be placed. Previous WC [wound care] orders implemented, CG [caregiver] in home not able to change dressing daily…WC [wound care] performed and documented. Reviewed wound zone tool…” An interview was conducted on 08/26/25 at 3:40 p.m. with staff #1 regarding the wound vac for patient #4. Staff #1 stated: “The [medical equipment company] will send the wound vac and all of the equipment needed. The company trains our staff annually, or more often if the equipment changes. [He/she] had a wound vac previously that was discontinued, but we were putting it back per the family request. The problem that [staff #2] had was that the machine settings were wrong and [he/she] couldn’t get the suction to work. [Patient #4] went to the wound clinic today and they got it applied and working.” Regarding leaving a urine soaked adult brief on the patient following the dressing change, staff #1 stated: “They should never have done that. They know better. It could increase the risk of infection.””

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: The Home Health Agency (HHA) failed to comply with 484.60(c)(1) for one (1) of three (3) patients observed during a skilled nursing (SN) visit (Patient #5). The HHA failed to complete a head to toe assessment following falls experienced by the patient on two (2) consecutive days in order to notify the relevant physician(s) to any changes in the patient’s condition or needs and/or determine that the plan of care should be altered. Findings include: An observation was conducted at the home of patient #5 on 08/26/25 starting at 9:07 a.m., accompanied by staff #3. The patient was in [his/her] bedroom, sitting on the chair by the window, and eating breakfast. Per an adult family member, the patient fell yesterday and today (08/25/25 and 08/26/25) for unknown reasons. The family member called emergency medical services (EMS) for help assisting the patient off the floor; and the patient was put back on the chair both days. When staff #3 asked the non-verbal patient what [he/she] was trying to do when [he/she] fell, the patient pointed to the portable bedside commode. Staff #3 took vital signs, reviewed medication, and discussed with the family member if the patient would benefit from a hospital bed. The adult family member agreed with staff #3’s suggestions. The nurse failed to do a physical head to toe assessment of the patient after it was reported they had fallen for two (2) consecutive days. A medical record review was conducted for patient #5, start of care (SOC) date 07/21/25, with a diagnosis that included ileus. Patient #5 received skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) services from the HHA. A review of the Visit Note Report with a visit date of 08/26/25, revealed in part: “[Primary care physician (PCP)] attempted x 3 [times three]. Office closed with no acceptance of non emergent needs. SN to reattempt with next opening.” And: “Patient/caregiver educated on importance of daily head to toe assessment with reporting any new findings of skin impairment or medical concern to CWHH [CenterWell Home Health]...” An interview was conducted on 08/26/25 at 10:16 a.m. with staff #1 regarding patient #5 falling two (2) consecutive days. Staff #1 stated: “[Staff #3] is a Registered Nurse (RN) and should have completed a head to toe assessment on [patient #5], I don’t know why [he/she] didn’t. We are going to have PT to assess [him/her] tomorrow.” Staff #1 confirmed that the PCP should have been notified and stated: “I believe [he/she] tried to notify the PCP, but the office was closed. [He/She] may be out of the country, [he/she] does that sometimes.””