Every finding on record at Centerwell Certified Healthcare Corp

An Abbreviated/Partial Extended Survey was initiated on March 31, 2025, and concluded on April 4, 2025, at Centerwell Home Health for complaint #112705. The census was 257. Review of clinical record dated 1/14/25, revealed on admission the admitting nurse documented the following: P#1 complaining of increases frequency and burning when urinating. A urinalysis was collected on 1/15/25, submitted for analysis, but without a signed MD order. The results of the urinalysis were never reviewed or evaluated by an MD. On 1/18/25 P#1 was admitted to hospital with diagnosis of urethral stone and acute kidney injury. The lab results were not reported to the agency until March 31, 2025. On April 1, 2025, an Immediate Jeopardy (IJ) was identified related to CFR 484.60 Care Planning, Coordination, Quality of Care, and 484.105 Organization and Administration. The agency Market Executive of Operations and Market Executive of Clinical were informed of the immediate jeopardy on April 1, 2025, at 5:25 p.m. The noncompliance related to immediate jeopardy was identified to have existed on January 1, 2025. Centerwell Home Health was found not to be in compliance with CFR 484.60 Care Planning, Coordination, Quality of Care, and 484.105 Organization and Administration. On 4/4/25, the Home Health Removal Plan was found acceptable by verifying the implementation fo the following corrective actions: CORRECTIVE ACTIONS: 1.Beginning 4.1.25, 100% of patients currently on service will be audited for any laboratory tests ordered. Documentation of follow up with the laboratory to obtain results to place on the chart, and report to the patient’s practitioner will be reviewed for timeliness and completion. 2. Patient records identified by the 4.1.25 audit as not documented with receipt of and/or follow-up of the ordered laboratory results and/or follow up communication with the practitioner, will be immediately addressed and corrected by getting the physical results and placing on the record and contacting the practitioner. 3. The internal agency process for lab collection and monitoring was reviewed and revised by agency and regional leadership to ensure tracking and follow up of laboratory test orders. The process will be changed to reflect the following process: · The clinical manager who approves an order for lab collection will ensure that the visit modifier #91 is utilized to report the need on the clinicians’ visit that lab work is ordered. This action in the EMR will trigger a reminder to the clinical staff to enter a Lab Clinical Coordination Note. · The Lab Collection Coordination Note is routed to the workflow of the branch coordinator who will forward to the clinical manager for assurance that the lab was collected, resulted, and placed on the record as a check and balance. 4. When a physician signature is required by the lab to complete labs and result them to the agency, signature will be obtained immediately and prior to submission. MONITORING: 1.On 4.1.25, 100% of patients currently on service were audited for any laboratory tests ordered. Documentation of follow up with the laboratory to obtain results to place on the chart, and report to the patient’s practitioner was reviewed for timeliness and completion with the state surveyor on 4.4.25. 2.On 4.1.25, 100% of patients currently on service were audited for any laboratory tests ordered. Documentation of follow up with the laboratory to obtain results to place on the chart, and report to the patient’s practitioner was reviewed for timeliness and completion with the state surveyor on 4.4.25. 3.Beginning 4.7.25, 100% of patients with laboratory testing orders will be audited weekly by the Market Executive of Operations and the Market Executive of Clinical for documentation of completion of ordered labs, ordered lab results, practitioner communication of results, and practitioner acknowledgement, for no less than 90 days. Findings will be reported to the Branch Director. 100% of all records must be compliant to remove 100% review at the end of 90 days. 4. Charts identified in the follow up/monitoring audit as non-compliant in any component of completion; lab completed as ordered, lab retrieval to the chart, and appropriate follow up to the practitioner will receive specific to the findings re-education as evidenced by 1:1 re-instruction to the identified clinician by the Market Executive of Operations and or the Market Executive of Clinical. 5.Beginning 4.4.25 when charts have achieved sufficient compliance, monitoring will drop to 50% of all records of patients with laboratory testing orders will be audited by the Clinical Manager and or the Branch Executive Director. If any records are non-compliant, agency will return to 100% audit until 100% of all records are compliant for 30 days. Clinicians identified as non-compliant will receive 1:1 re-instruction in person by the Clinical Manager. 100% of the patients assigned to the clinician will be audited no less than an additional 60 days or until the threshold of 100% compliance is met. 6.The process for assessment, laboratory testing and follow-up will be added to the agency’s QAPI program as a focus area for monitoring by the Branch Executive Director. The process for assessment, laboratory testing and follow up will be presented by the Branch Director at the next QAPI meeting to be held no later than 5.15.25. 7. Corrective actions; 100% of patients currently on service will be audited for any laboratory tests ordered. Documentation of follow up with the laboratory to obtain results to place on the chart, and report to the patient’s practitioner. Patient records identified by the audit as not documented with receipt of and/or follow-up of the ordered laboratory results and/or follow up communication with the practitioner; will be monitored for completion and timeliness by the Area Vice President of Operations and the Area Vice President of Clinical Operations. Results will be reported to the Branch Director. 8. Corrective actions; 100% of patients currently on service will be audited for any laboratory tests ordered. Documentation of follow up with the laboratory to obtain results to place on the chart, and report to the patient’s practitioner. Patient records identified by the audit as not documented with receipt of and/or follow-up of the ordered laboratory results and/or follow up communication with the practitioner; and monitoring activities will be reported by the Branch Director to the quarterly Quality Assessment and Performance Improvement (QAPI) Committee and regional clinical and operations staff, which will provide further direction and guidance for audit activities as needed based on reported results for the next 4 quarters. The immediate jeopardy was abated on 4/4/25. Conditions remaining out of compliance are CFR 484.60 Care Planning, Coordination, Quality of Care, and 484.105 Organization and Administration and standards 484.60 (c) (1) Notify physician promptly, 484.60 (c) (2) revised plan of care must reflect current information from patient’s updated comprehensive assessment, as evidenced by the following:

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record reviews and staff, family and laboratory interviews, it was determined that the agency's skilled professional staff failed to follow up on services as ordered by the physician in the plan of care for one patient (P) (P#1) of three sampled patients. Specifically, the Registered Nurse (RN) failed to obtain the urinalysis (UA) (a series of tests on your urine to check for signs of common conditions or diseases) results for P#1 that was collected on 1/15/2025 until 3/31/2025. Findings included: Review of urinalysis report from the laboratory revealed the sample was collected for P#1 on 1/15/25, at 10:00 a.m., received at the laboratory on 1/16/25 at 12:35 p.m., and reported on Mar 31, 2025, at 5:39 p.m. Review of clinical record of P#1 failed to reveal the urinalysis result that was collected on 1/15/25. A telephone interview was conducted on 3/31/25 at 3:15 p.m., with the family of P#1 who reported the agency failed to provide the results of the UA obtained for P#1. An interview was conducted on 3/31/25, with the Market Executive of Operations (MEO) on 3/31/25 at 4:30 p.m., and confirmed the UA lab result for P#1’s on 1/15/25, failed to be found in the clinical chart of P#1. A telephone Interview with the Clinical Service Manager (CSM) with the laboratory was conducted on 4/1/25 at 3:00 p.m., confirmed the urinalysis was received on 1/16/25, but the verbal order was missing the physician signature. The CSM reported she faxed a request for the missing physician signature on 1/16/25, without a response from the agency. CSM further reported she also called and spoke to someone at the home health agency on 1/17/25 or 1/18/25 for the missing physician signature. CSM reported it took a month and a half to receive the physician signature for the verbal order submitted on 1/16/25. CSM reported on 3/31/25 at approximately 4:00 p.m., she received a call from the home health agency inquiring about the lab results submitted on 1/16/25. She stated she got another call on 3/31/25, at 4:50 p.m., to confirm what was needed for the lab results to be provided. CSM reported she received the verbal order with physician signature on 3/31/25 and provided the UA results.

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: Based on record review, patient and staff interviews, it was determined that the agency failed to provide services as ordered by the physician in the plan of care and to communicate and coordinate lab test with physician and other health care practitioners for one patient (P) (P1) of three sampled patients. Findings included: An interview was conducted on 3/31/25, with the Market Executive of Operations (MEO) on 3/31/25 at 4:30 p.m., and confirmed the UA lab result for P#1’s on 1/15/25, failed to be found in the clinical chart of P#1. MEO further reported the “best practices” for nurses with labs ordered would be to follow up with lab results and report those results to the physician. MEO reported the lab should have been called for the UA results. Further review of the clinical records failed to reveal results of UA (a test to determine presence of infectious organisms in urine) lab obtained on 1/15/25 for P#1. Cross reference G0940 as it relates to P1-Organization and administration of services.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, and staff interview, it was determined that the agency failed to revise the care plan; specifically increasing Skill Nurse (SN) visits to continually assess one patient (P) (P#1) of three sampled patients. Findings included: Review of clinical record dated 1/14/25, revealed on admission the Registered Nurse (RN) RN AA documented the following: P#1 complaining of increases frequency and burning when urinating. RN AA further documented she recommended that P#1 go to the emergency department (ER). Additional review of the clinical record revealed a family member of P#1 requested a “rapid nurse visit” (a homecare homebase feature for smart scheduling). Review of document titled "Visit Note Report," dated 1/15/25, a urinalysis (a series of tests on your urine to check for signs of common conditions or diseases) was ordered and obtained by Licensed Practical Nurse (LPN) BB. The current plan of care revealed Skill Nurse (SN) visits two times a week. The clinical record failed to reveal a revision to increase skilled nurse visits to continually assess P#1 for signs and symptoms once the urinalysis was ordered. During an interview on 3/31/25 at 4:30 p.m. the MEO confirmed that the hospice agency failed to revise the care plan to increase visits to assess continually P#1 for signs and symptoms once the urinalysis was ordered by the physician.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on clinical record reviews and interviews, it was determined that the agency failed to maintain the highest practicable functional capacity, including providing optimal care to achieve goals for one patient (P) (P#1) of three patients reviewed. Specifically, the agency failed to obtain the urinalysis (UA) (a test to determine presence of infectious organisms in urine) results of P#1 for a month and a half after the specimen was collected and sent to a laboratory for analysis. Findings included: Review of the “Visit Note Report” dated 1/14/25, revealed the admitting nurse documented the following: P#1 complaining of increases frequency and burning when urinating. RN AA further documented it was recommended by RN AA that P#1 go to the emergency department (ER). Further review of the clinical record revealed a family member of P#1 requested a “rapid nurse visit” (a homecare homebase feature for smart scheduling). Review of clinical record of P#1 on 3/31/25, failed to reveal the urinalysis lab results collected on 1/15/25. A telephone interview was conducted on 3/31/25 at 3:15 p.m., with the family of P#1 who reported the agency failed to provide the results of the UA obtained for P#1. An interview was conducted on 3/31/25, with the Market Executive of Operations (MEO) on 3/31/25 at 4:30 p.m., and confirmed the UA lab result for P#1’s on 1/15/25, failed to be found in the clinical chart of P#1. MEO further reported the “best practices” for nurses with labs ordered would be to follow up with lab results and report those results to the physician. MEO reported the lab should have been called for the UA results.