Every finding on record at Centerwell Certified Healthcare Corp

No deficiencies were cited during the Medicare Recertification survey for CFR 484 Part 484, in which Appendix Z for Emergency Preparedness was also surveyed. The Medicare Recertification survey occurred October 07, 2024 to October 10, 2024. CMS Recertification is approved for this Home Health Facility.

The following deficiencies were cited during the 42 CFR Part 484, Subpart A, B, and C during the survey which occurred October 07, 2024 to October 10, 2024. Four (4) Home visits were conducted and eleven (11) patient files were reviewed. This facility is approved for Medicare Recertification.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on record review, and interview the facility failed to ensure that the patient and representative (if any) contained discharge documentation for patient medical files for Patient #1, Patient #2, Patient #3, Patient #5, and Patient #8. Findings include: Review of facility Policy 03-26 states, "The patient (or patient authorized representative), physician/allowed practitioner and case manager as applicable will be verbally notified of the expected discharge date and reasons for discharge. This notification will be documented in the patient's medical record." Review of patients medical records for Patient #1, Patient #2, Patient #3, Patient #5, and Patient # 8 revealed that no there was no documentation of discharge. Interview with Administrator confirmed that all patient files should contain discharge documentation.

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: Administrator is responsible for ensuring that the Home Health Agency employs qualified personnel. This requirement was NOT MET as evidenced by: Employee records for Employee #3, Employee #4, and Employee #7 did not contain the required background check for all clinical personnel. Findings include: Personnel record review revealed that the required background check for clinical personnel was not contained in the files for Employee #3, Employee #4, and Employee #7. Facility policies and procedures, listed in Chapter 06, entitled, Screening Requirements states , "all clinicians will have a background check before beginning patient care." Interview with Administrator confirmed that background checks are required for all clinical personnel.