Every finding on record at Centerwell Certified Healthcare Corp

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 2/1/2024. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 2/1/2024. The Agency was not in compliance with Standards for Home Health Agencies, 42 CFR 484 for Home Health Agencies, for this survey as evidenced by:

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on document review, observation, and interview, it was determined for 1 of 1 (Pt #7) home visit patients living in a Assisted Living Facility, the Agency failed to ensure the patient’s home medication list was current and accurately reflected all medication names, dosages and frequencies. Findings include: 1. Pt #7 Start of Care (SOC): 11/6/2023 Diagnosis: Unilateral Primary Osteoarthritis, Right Knee During the home visit on 1/31/2023 at approximately 11:00 AM, a review of Pt #7’s medications were reviewed with the Occupational Therapist (E #3) and the facility’s Administrator. The Assisted Living Facility’s medication list dated 1/30/2024 was compared to the Agency’s medications for the 1/5/2024 to 3/4/2024 certification period. The Assisted Living facility indicated an order for Melatonin Oral Tablet give 1 tablet by mouth at bedtime for sleep with a start date of 12/13/2023.The Facility’s medication list lack the order for Melatonin. A review of the Facility Visit Notes dated 12/18/2023 by PT, 12/19/2023 by OT indicated ”No new/changed medications since last visit.” The recertification done by PT on 1/2/2024 for recertification period 1/5/2024 to 3/4/2024 lacked the order for Melatonin Oral Tablet give 1 tablet by mouth at bedtime for sleep with a start date of 12/13/2023. 2. On 1/31/2024 at approximately 1:00 PM, the policy titled “Medication Review and Documentation” (revised 10-2022), was reviewed. The policy required “Medication assessment will be performed each Clinical Associate visit to ensure medications are current, accurate and documented on the medication profile within the patient’s medical record.” A Drug Regime Review (DRR) and medication reconciliation will include all medications and be performed during the initial comprehensive assessment, each comprehensive assessment thereafter and when a new medication is added to the patient plan of care. 3. On 1/31/2023 at approximately 10:00 AM, an interview was conducted with the Administrator (E #2). E #2 stated, “our policy is to ask about new medications or changed with each visit and to review the medications at certification. This is apparently not being done and the medication list is not current.”

The Emergency Preparedness requirements were evaluated in conjunction with the Recertification survey on 02/04/2021. The Home Health Agency was in compliance with the Condition 42 CFR 484.22, Establishment of the Emergency Program, for this survey.

A recertification survey was conducted in conjunction with an Emergency Preparedness survey and a Focused Infection Control Survey on 02/04/2021. The Agency was in compliance with the requirements for Infection Control for COVID-19 and Emergency Preparedness, for this survey. The Agency was not in compliance with the Standards, 42 CFR 484, for Home Health Agencies as evidenced by: Abbreviations: E- Employee OASIS- Outcome and Assessment Information Set PN- Pneumonia Pt- Patient SOC- Start of Care

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on observation and interview, it was determined for 5 of 5 (Pt #1, Pt #2, Pt #3, Pt #4, Pt #5) home visits conducted, the Agency failed to ensure a written notice of expected charges for services, expected financial coverage and expected patient financial responsibility, was given to the patient/patient representative. This has the potential to affect all patients who receive services by the Agency with a current census of 147 patients. Findings include: 1. Pt #1 Start of Care (SOC): 1/20/2021 Diagnosis: Aftercare Joint Replacement. A Home Visit was conducted on 2/2/2021 at approximately 12:00 PM. The admission folder was observed and lacked written documentation of expected charges for services, expected financial coverage and expected patient financial responsibility. During the home visit, Physical Therapist (E#2) stated, "All of that (expected charges for services, expected financial coverage and expected patient financial responsibility) is discussed with the patient at the start of care. The patient's sign the electronic consent form with that (expected charges for services, expected financial coverage and expected patient financial responsibility) information on it. We don't sign the paper forms anymore and/or leave a copy in the home." 2. Pt #2 SOC: 1/7/2021 Diagnosis: Congestive Heart Failure. A Home Visit was conducted on 2/2/2021 at approximately 2:00 PM. The admission folder was observed and lacked written documentation of expected charges for services, expected financial coverage and expected patient financial responsibility. During the home visit, Pt #2 asked the Skilled Nurse (E#3) "How much money is this going to cost me (for home health services)?" 3. Pt #3 SOC: 2/1/2021 Diagnosis: Parkinson's Disease. A Home Visit was conducted on 2/3/2021 at approximately 9:00 AM. The admission folder was observed and lacked written documentation of expected charges for services, expected payment from Medicare and expected patient financial responsibility. 4. Pt #4 SOC: 12/30/2020 Diagnosis: Atherosclerosis. A Home Visit was conducted on 2/3/2021 at approximately 12:00 PM. The admission folder was observed and lacked written documentation of expected charges for services, expected payment from Medicare and expected patient financial responsibility. 5. Pt #5 SOC: 1/27/2021 Diagnosis: Aftercare Joint Replacement. A Home Visit was conducted on 2/3/2021 at approximately 1:00 PM. The admission folder was observed and lacked written documentation of expected charges for services, expected payment from Medicare and expected patient financial responsibility. 6. During an interview on 2/4/2021 at approximately 10:30 AM, Executive Director (E#1) stated "We realized a written copy (expected charges for services, expected financial coverage and expected patient financial responsibility) was not being left in the home. We are suppose to be mailing them but obviously, if they (written document with the expected charges for services, expected financial coverage and expected patient financial responsibility) aren't being placed in the folder, I don't know that the process is working."

Incorporate OASIS items CFR(s): 484.55(c)(8) Incorporation of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary. The OASIS data items determined by the Secretary must include: clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management, emergent care, and data items collected at inpatient facility admission or discharge only. This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined for 3 of 5 (Pt #1, Pt #4, Pt #5) records reviewed, the Agency failed to ensure patient's immunization history was accurately incorporated into the OASIS (Outcome and Assessment Information Set) data set. This has the potential to affect all patients who receive services by the Agency with a current census of 147 patients. Findings include: 1. Pt #1 Start of Care (SOC): 1/20/2021 Diagnosis: Aftercare Joint Replacement. The record was reviewed on 2/2/2021 at approximately 3:00 PM. The Client Vaccination History Report noted the influenza vaccination was administered on 8/17/2020 and lacked documentation of Pneumococcal vaccination. The OASIS Visit Note Report dated 1/27/2021 noted the immunization history was "up to date". 2. Pt #4 SOC: 12/30/2020 Diagnosis: Atherosclerosis. The record was reviewed on 2/3/2021 at approximately 3:15 PM. The Client Vaccination History Report noted the pneumococcal vaccination was administered on 1/22/2020 and lacked documentation of the Influenza vaccination. The OASIS Visit Note Report dated 12/30/2020 noted the immunization history of "Flu" and "PN" (Pneumonia) were administered. 3. Pt #5 SOC: 1/27/2021 Diagnosis: Aftercare Joint Replacement. The record was reviewed on 2/3/2021 at approximately 4:00 PM. The Client Vaccination History Report noted the influenza vaccination was administered on 9/7/2020 and lacked documentation of Pneumococcal vaccination. The OASIS Visit Note Report dated 1/27/2021 noted the immunization history was "up to date". 4. During an interview on 2/4/2021 at approximately 10:30 AM, Executive Director (E#1) stated "The patient's immunization history is documented in the Client Vaccination History Report within the electronic medical record." E#1 reviewed Pt #1, Pt #4 and Pt #5's records and verbally agreed the OASIS data was not accurately completed and should have been.