Every finding on record at Centerwell Certified Healthcare Corp

Unannounced visits were concluded at CenterWell Home Health on 12/14/2023 for the purpose of reviewing the Emergency Preparedness Code of Federal Regulations at §484.102, Condition of Participation for Home Health Agencies (HHA). The agency was in compliance with the requirements at the time of the survey.

Unannounced visits concluded on 12/14/2023 at CenterWell Home Health for the purpose of recertification and re-licensure. Standard-level deficiencies were identified

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and interview with agency personnel, for three of seventeen patients (Patient’s #7, #16 and #17) in the survey sample, the agency Registered Nurse/RN failed to ensure the plan of care addressed the patient’s individual needs. The findings include: . Patient #7 had a start of care date of 2/09/23 and diagnoses that included unstageable pressure ulcer of the right heel, arteriosclerotic heart disease and congestive heart failure. The physician's orders for the certification periods of 2/09/23 through 4/09/23 and 10/07/23 through 12/05/23 included nursing services three times a week to assess and provide wound care to the right heel, physical therapy and occupational therapy services. Interview and review of the initial nursing assessment dated 2/09/23 and subsequent OT/Occupational Therapy evaluation dated 2/14/23 with the Administrator on 12/14/23 at 9:20 AM identified the need for assistance of another person for bathing, dressing and transferring, but failed to identify nursing communication with the physician about the patient's need for home health aide services. 2. Patient #17 had a start of care date of 10/27/23 and diagnoses that included laceration of the right lower leg, dementia and atrial fibrillation. The physician’s orders dated 10/27/23 included nursing services one time a week for one week, two times a week for two weeks and one time a week for three weeks for wound care and assessments. Patient #17 resided in an Assisted Living Facility. Interview and review of the initial nursing assessment dated 10/27/23 with the Administrator on 12/14/23 at 9:30 AM identified the need for assistance of another person for bathing, dressing and transferring and indicated that the patient has 24-hour care available from facility staff, but failed to identify nursing communication with the physician about the patient's need for home health aide services. Patient #16 had a start of care date of 05/25/2023 and diagnoses that included chronic kidney disease, congestive heart failure, fractures and falls. The physician’s orders dated 05/25/2023 included nursing services one time a week for three weeks and one time per week every two weeks for nursing assessments. Patient #16 resided in an Assisted Living Facility. Interview and review of the initial nursing assessment dated 05/25/2023 with the Administrator on 12/14/23 at 9:15 AM identified the need for assistance of another person for bathing, dressing, and transferring via a Hoyer lift and indicated the patient had 24-hour care available from facility staff, but failed to identify nursing communication with the physician about the patient's need for home health aide services.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record reviews, review of an agency policy and interview with agency personnel, for three of three patients (Patient #4, #5 and #11) in the survey sample, the agency’s Registered Nurses (RN) failed to reconcile a patient's medications and failed to measure patients' wounds in accordance with the agency's policies. The findings include: Patient #5 had a start of care date of 7/13/22 and diagnoses that included major depressive disorder, anxiety and post-traumatic stress disorder. The physician's orders for the certification period of 11/05/23 through 1/03/24 included nursing services seven times a week for daily medication administration and the pre-poring of the evening medications and assessments. Patient #5’s medications included Ferrous Fumarate 324 milligrams/mg every morning. During a joint home visit with RN #1 on 12/12/23 at 9:30 AM, the surveyor observed RN #1 pour Ferrous Gluconate 324 mg for administration. Interview and review of the home visit and physician’s orders with the Administrator on 12/13/23 at 11:25 AM identified that the physician had discontinued the Ferrous Gluconate in May 2023 and then restarted it in July, RN #1 accidentally entered Ferrous Fumarate into the electronic record, although the patient received the correct medication and failed to reconcile medications in accordance with agency policy. Review of agency policy for Medication Review and Documentation directed the medication assessment will be performed each clinical visit to ensure medications are current, accurate and documented on the medication profile within the patient’s electronic record. 2. Patient #11 had a start of care date of 8/23/23 and diagnoses that included stage III pressure ulcer of the right buttock, fracture of the left tibia and fibula and type II diabetes mellitus. The physician's orders for the certification period of 10/22/23 through 12/20/23 included nursing services two times a week for assessments and wound care to the right buttock. Interview and review of the clinical record with the Administrator on 12/14/23 at 11 AM identified twice weekly nursing services provided to Patient #11 for wound care but failed to identify documentation of wound measurements by LPN #2 for the week of 11/05/23 (LPN # 2 visited on 11/07/23 and 11/09/23). Review of the agency’s Wound Care Assessment policy directed wound assessments would be performed every visit and include general observations, drainage amount and type, wound bed appearance and surrounding skin condition. At least once weekly, the assessment of the wound would include measurements. Patient #4 had a start of care date of 11/15/2023 with diagnosis that included chronic respiratory failure, peripheral vascular disease, venous insufficiency, and stage three pressure ulcers. The physician's orders for the certification period of 11/15/2023 to 01/13/2023 included nursing services twice per week for one week and once per week every two weeks to assess the stage three pressure ulcer to the right heel and wound to the right lower extremity. Interview and review of Patient #4’s clinical nurses’ notes dated 11/16/2023, 11/27/2023, 11/28/2023 and 12/07/2023 with the Administrator on 12/14/2023 at 12:30 PM, identified the Patient’s responsible caregiver performed wound care prior to the nurses’ visits on 11/16/2023, 11/27/2023, 11/28/2023 and 12/07/2023, therefore, the wounds were not assessed or measured by a nurse since the start of care on 11/15/2023.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record reviews, review of an agency policy and interview with agency personnel, for one of three patients (Patient #4) who required wound care in the survey sample, the agency’s Registered Nurses (RN) failed to assess wounds in accordance with the agency’s policy. The findings include: Patient #4 had a start of care date of 11/15/2023 with diagnosis that included chronic respiratory failure, peripheral vascular disease, venous insufficiency, and stage three pressure ulcers. The physician's orders for the certification period of 11/15/2023 to 01/13/2023 included nursing services twice per week for one week and once per week every two weeks to assess the stage three pressure ulcer to the right heel and wound to the right lower extremity. Interview and review of Patient #4’s clinical nurses’ notes dated 11/16/2023, 11/27/2023, 11/28/2023 and 12/07/2023 with the Administrator on 12/14/2023 at 12:30 PM, identified the Patient’s responsible caregiver performed wound care prior to the nurses’ visits on 11/16/2023, 11/27/2023, 11/28/2023 and 12/07/2023, therefore, the wounds were not assessed or measured by a nurse since the start of care on 11/15/2023. Review of the agency’s Wound Care Assessment and Clinical Oversight policy identified the RN would perform the initial assessment for open wounds and surgical incisions upon admission and as ordered by the physician/allowed practitioner. The wound dressings would be removed to assess wounds unless a physician/allowed practitioner order was received restricting dressing removal. Wound assessments would be performed every visit and include general observations, drainage amount and type, wound bed appearance and surrounding skin condition. At least once weekly, the assessment of the wound would include measures.

Unannounced visits were conducted at Kindred at Home on 8/12/2022 and 8/15/2022 for the purposes of a complaint investigation (CT #71454). The agency failed to ensure that the nurse verified a "new " medication with the physician prior to a medication pre pour, resulting in the patient consuming several days of two medications intended for a family member. The patient became ill and required hospitalization in the intensive care unit. This resulted in a finding of Immediate Jeopardy. The Immediate Jeopardy template was provided to the Administrator on 8/12/22 at 3:15 pm and an action plan was received from the agency on 8/12/22 at 7:10pm. During an onsite visit by the surveyor on 8/15/22, the action plan was verified as implemented, and Immediate Jeopardy was removed as of 8/15/22. The action plan included education to nursing staff on the prepour and medication policy, audits were initiated with the results shared and discussed during Quality Assurance meetings. The facility was out of compliance with the following Conditions of Participation:42 CFR 484.75 Skilled Professional Services, G-700. In addition, standard level deficiencies were identified. Refer to G 702 and G 718.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on clinical record review, interviews, and review of agency policies for 1 of 6 patients (Patient #1) reviewed for medication administration, the agency nurse failed to obtain a physician's order prior to pre pouring medications, which included Methotrexate and Jardiance. As a result, the patient utilized the pill box that contained unauthorized medications and consumed 6 days of two prescription medications intended for a family member. On 8/8/22 the patient had a significant change in condition and subsequently was admitted to the hospital's intensive care unit with Methotrexate Toxicity. This resulted in a finding of Immediate Jeopardy. Refer to G 702 and G 718

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review, interviews, and review of agency policies for 1 of 6 patients (Patient #1) reviewed for medication administration, the agency nurse failed to follow the agencies policy for medication prepour and as a result, included the medications Methotrexate and Jardiance into the patient's pill box for administration absent a physician's order. The patient subsequently consumed 6 days of two prescription medications intended for a family member. On 8/8/22 the patient had a significant change in condition and was admitted to the hospital's intensive care unit with Methotrexate Toxicity. This resulted in a finding of Immediate Jeopardy. The finding includes: Patient #1 had a start of care date to the agency of 7/1/2022 with diagnoses of end stage renal disease, systolic heart failure, type 2 diabetes, anemia, atherosclerotic heart disease, and cardiomyopathy. The physician’s orders for the certification period of 7/1/2022 through 8/29/2022 included nursing services to assess/evaluate co-morbid conditions, review and reconcile medication profile, instruct/reinforce medication management and fill medication planner per current medication orders every week, and as needed. Interview with Person #1 on 8/11/22 at 8:30 am identified Patient #1 lived with a sibling (Sibling #2), with the same last name and resided in separate bedrooms where each of their medication boxes were stored. Person #1 identified that both Patient #1 and Sibling #2 received all prescription medications from the same pharmacy. Person #1 stated that on 8/2/22, the agency RN pre-poured Methotrexate 2.5 mg (a cancer medication, also used to treat psoriatic and rheumatoid arthritis) and Jardiance 25 mg (used to control high blood sugar for Type 2 diabetes), into Patient #1's pill box that was intended for Sibling #2. Patient #1 consumed several days worth of the incorrect medication and was subsequently admitted to the hospital's intensive care unit for Methotrexate Toxicity. Review of the hospital record dated 8/8/22 identified Patient #1 was evaluated in the Emergency Department for difficulty swallowing, resulting in an inpatient hospital admission within the Intensive Care unit for severe Mucositis from an accidental Methotrexate Overdose. Interview with the Pharmacist on 8/11/22 at 1:00 pm identified Patient #1 had never been prescribed Methotrexate or Jardiance from the pharmacy and these medications were not part of his/her current medication profile. It was further identified that the Methotrexate and Jardiance medications were part of Sibling #2’s medication profile and had been recently filled. Interview with RN #1 on 8/12/22 at 11:00 am identified that during the 8/2/22 skilled nursing visit, Patient #1 stated he/she had two (2) new medications prescribed by his/her provider and they had been delivered to his/her residence. RN #1 identified the package was addressed to Patient #1, and that it contained 4 medications, Methotrexate, Levothyroxine, Jardiance, and Hydralazine. RN #1 stated the new medications (Methotrexate and Jardiance) were pre poured into Patient #1 medication pill box with the weekly medications. RN #1 stated she called the physician's office on 8/2/22 to verify and obtain verbal or written orders for the new medications, received a call back from the physician’s nurse who identified she would check the orders with the physician and would get back in touch with RN #1 with the physician's decision on 8/2/22. Although the physician's office did not respond with verification for the new medications, RN #1 did not remove the medications from the patient's pill box and left the patient's home on 8/2/22. RN #1 further stated he/she did not verify the name on the prescription bottles to ensure the medications were for Patient #1, but in fact, the Methotrexate and Jardiance medications were for another person residing in the household with the same last name. RN #1 failed to obtain physician orders prior to pre pouring into the patients pill box, failed to follow the agency policy for Medication Administration and failed to follow-up with the physician's office to verify the medications. On 8/2/22, RN #1 proceeded to enter the new medication orders for Methotrexate 2.5mg, take 6 tablets daily for 7 days and Jardiance 25mg, take ½ tablet daily, into the electronic Medication Record (EMAR), absent a physician's order. RN #1 further identified, on 8/2/22 the new medication order was electronically sent to the Supervisor of Clinical Services (SCS) for approval. On 8/4/22 (two days later) the medication order was electronically transmitted by the SCS to the physician's office for physician approval, per the agency medication administration policy. On 8/8/22 a response was received from the physician's office that directed “patient has renal failure, Methotrexate and Jardiance are not authorized without documentation". As of that date, Patient #1 had taken approximately 6 days of the incorrect medications, approximately 36 tablets of Methotrexate and approximately 3 tablets of Jardiance. As a result, Patient #1 had a change in condition and was admitted to the hospital's intensive care unit for evaluation of difficulty swallowing with subsequent diagnosis of Methotrexate Overdose. Interview with the Clinical Supervisor (RN #2) on 8/16/22 at 1:00pm identified that he/she received the medication order on 8/4/22 (48 hrs. after skilled nursing visit), and identified the delay in completing and sending the approved medication order to the physician was a result of processing through the "workflow documents" as quickly as possible. RN #2 stated that RN #1 should not have filled Patient #1’s pill box with unauthorized medications. Interview with the Administrator on 8/12/22 at 11:00 am identified that RN #1 failed to follow the agency policy for verification of new medication order including a failure to verify the correct patient, the correct medication, the correct dose, the correct frequency and failed to verify and obtain a physician order prior to pre pouring Patient #1's medication for the week. Subsequent to this incident, RN #1 was immediately removed from all patient medication prefill assignments, was re-educated on the focused administration of the "5 rights of medication administration", and 3 on-site supervisory medication visits were scheduled and completed by 8/22/22. The agency Administrator further identified that the agency Medical Director was advised of the medication error incident, including the reeducation process for RN#1 and entire agency staff. Review of the agency Medication Administration policy identified that the nursing staff will follow a specific medication order indicating; patient name, name of medication (brand or generic), route of administration, dosage of medication, strength of medication, frequency of administrations, duration of medication, any special instructions or precautions related to medication, effective date of medication order, and physician/allowed practitioner signature.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, interviews, and review of agency policies for 1 of 6 patients (Patient #1) reviewed for medication administration, the agency nurse filled the patient's pill box with Methotrexate and Jardiance absent a physician's order. The patient consumed 6 days of these two medications and on 8/8/22, experienced a significant change in condition and was subsequently admitted to the hospital's intensive care unit with Methotrexate Toxicity. This resulted in a finding of Immediate Jeopardy. The finding includes: Patient #1 had a start of care date to the agency of 7/1/2022 with diagnoses of end stage renal disease, systolic heart failure, type 2 diabetes, anemia, atherosclerotic heart disease, and cardiomyopathy. The physician’s orders for the certification period of 7/1/2022 through 8/29/2022 included nursing services to assess/evaluate co-morbid conditions, review and reconcile medication profile, instruct/reinforce medication management and fill medication planner per current medication orders every week, and as needed. Interview with Person #1 on 8/11/22 at 8:30 am identified Patient #1 lived with a sibling (Sibling #2), with the same last name and resided in separate bedrooms where each of their medication boxes were stored. Person #1 identified that both Patient #1 and Sibling #2 received all prescription medications from the same pharmacy. Person #1 stated that on 8/2/22, the agency RN pre-poured Methotrexate 2.5 mg (a cancer medication, also used to treat psoriatic and rheumatoid arthritis) and Jardiance 25 mg (used to control high blood sugar for Type 2 diabetes), into Patient #1's pill box that was intended for Sibling #2. Patient #1 consumed several days worth of the incorrect medication and was subsequently admitted to the hospital's intensive care unit for Methotrexate Toxicity. Review of the hospital record dated 8/8/22 identified Patient #1 was evaluated in the Emergency Department for difficulty swallowing, resulting in an inpatient hospital admission within the Intensive Care unit for severe Mucositis from an accidental Methotrexate Overdose. Interview with the Pharmacist on 8/11/22 at 1:00 pm identified Patient #1 had never been prescribed Methotrexate or Jardiance from the pharmacy and these medications were not part of his/her current medication profile. It was further identified that the Methotrexate and Jardiance medications were part of Sibling #2’s medication profile and had been recently filled. Interview with RN #1 on 8/12/22 at 11:00 am identified that during the 8/2/22 skilled nursing visit, Patient #1 stated he/she had two (2) new medications prescribed by his/her provider and they had been delivered to his/her residence. RN #1 identified the package was addressed to Patient #1, and that it contained 4 medications, Methotrexate, Levothyroxine, Jardiance, and Hydralazine. RN #1 stated the new medications (Methotrexate and Jardiance) were pre poured into Patient #1 medication pill box with the weekly medications. RN #1 stated she called the physician's office on 8/2/22 to verify and obtain verbal or written orders for the new medications, received a call back from the physician’s nurse who identified she would check the orders with the physician and would get back in touch with RN #1 with the physician's decision on 8/2/22. Although the physician's office did not respond with verification for the new medications, RN #1 did not remove the medications from the patient's pill box and left the patient's home on 8/2/22. RN #1 further stated he/she did not verify the name on the prescription bottles to ensure the medications were for Patient #1, but in fact, the Methotrexate and Jardiance medications were for another person residing in the household with the same last name. RN #1 failed to obtain physician orders prior to pre pouring into the patients pill box, failed to follow the agency policy for Medication Administration and failed to follow-up with the physician's office to verify the medications. On 8/2/22, RN #1 proceeded to enter the new medication orders for Methotrexate 2.5mg, take 6 tablets daily for 7 days and Jardiance 25mg, take ½ tablet daily, into the electronic Medication Record (EMAR), absent a physician's order. RN #1 further identified, on 8/2/22 the new medication order was electronically sent to the Supervisor of Clinical Services (SCS) for approval. On 8/4/22 (two days later) the medication order was electronically transmitted by the SCS to the physician's office for physician approval, per the agency medication administration policy. On 8/8/22 a response was received from the physician's office that directed “patient has renal failure, Methotrexate and Jardiance are not authorized without documentation". As of that date, Patient #1 had taken approximately 6 days of the incorrect medications, approximately 36 tablets of Methotrexate and approximately 3 tablets of Jardiance. As a result, Patient #1 had a change in condition and was admitted to the hospital's intensive care unit for evaluation of difficulty swallowing with subsequent diagnosis of Methotrexate Overdose. Interview with the Clinical Supervisor (RN #2) on 8/16/22 at 1:00pm identified that he/she received the medication order on 8/4/22 (48 hrs. after skilled nursing visit), and identified the delay in completing and sending the approved medication order to the physician was a result of processing through the "workflow documents" as quickly as possible. RN #2 stated that RN #1 should not have filled Patient #1’s pill box with unauthorized medications. Interview with the Administrator on 8/12/22 at 11:00 am identified that RN #1 failed to follow the agency policy for verification of new medication order including a failure to verify the correct patient, the correct medication, the correct dose, the correct frequency and failed to verify and obtain a physician order prior to pre pouring Patient #1's medication for the week. Subsequent to this incident, RN #1 was immediately removed from all patient medication prefill assignments, was re-educated on the focused administration of the "5 rights of medication administration", and 3 on-site supervisory medication visits were scheduled and completed by 8/22/22. The agency Administrator further identified that the agency Medical Director was advised of the medication error incident, including the reeducation process for RN#1 and entire agency staff. Review of the agency Medication Administration policy identified that the nursing staff will follow a specific medication order indicating; patient name, name of medication (brand or generic), route of administration, dosage of medication, strength of medication, frequency of administrations, duration of medication, any special instructions or precautions related to medication, effective date of medication order, and physician/allowed practitioner signature.