Every finding on record at Centerwell Certified Healthcare Corp

Recertification survey conducted on 12/29/2023. Standard level deficiencies cited. An investigation was conducted on 12/29/2023 for complaint #IL29332/131049. Complaint was unsubstantiated.

Disclosure of ownership and management info. CFR(s): 484.100(a) Standard: Disclosure of ownership and management information. The HHA must comply with the requirements of part 420 subpart C, of this chapter. This STANDARD is not met as evidenced by: Based on staff interview it was determined that Agency failed to inform the State Agency about the recent change of the Administrator and Clinical Manager. Findings include: 1. During the entrance interview on 12/26/23 at 9:00 AM, the Administrator stated that in November 2023, the Agency had a change of Administrator and Clinical Manager. During the same interview, a request was made for documentation indicating the State Agency was informed of the recent change in Administration. The Agency lacked documentation relative to notifying the State Agency of the change in Administration. 2. During an interview with the Administrator on 12/28/23 at 10:30 AM. The Administrator stated and confirmed, the State Agency was not notified of the change in the Agency's Administration in November.

Recertification survey completed. Standard level deficiencies cited. A focused Infection Control Survey (FIC) was conducted on 1/28/21. The facility was in compliance with the requirements for Infection control for COVID-19. Abbreviations: # = number AM = morning SN = Skilled Nurse SOC = Start of care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients PT = Physical Therapy/Therapist

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records , Vaccination History Report and staff interview, it was determined the Agency failed to assess the need for influenza and/or pneumonia immunization. This was found in 9 of 10 (Pts. #5, #6, #7, #3, #4, #10, #8, #9 and #1) clinical records reviewed. Findings include: 1. Pt. #5. SOC 1/08/21 Diagnosis: Major Depressive Disorder. The clinical record of Pt. #5 was reviewed on 1/26/21 at 10:30 AM. The record included a SOC comprehensive assessment form completed by RN dated 1/08/21 and required: "Indicate Immunizations History: Mark All That Apply and record in vaccination section" to which the RN entered the response, "Up to date." The record lacked documentation of which immunizations Pt. #5 received and when they were administered. 2. Pt. #6. SOC 12/01/20 Diagnosis: Other Pulmonary Embolism. The clinical record of Pt. #6 was reviewed on 1/26/21 at 11:00 AM. The record included a SOC comprehensive assessment form completed by RN dated 12/01/20 and required: "Indicate Immunizations History: Mark All That Apply and record in vaccination section" to which RN entered the response, "Up to date." The record lacked documentation of which immunizations Pt. #6 received and when they were administered. 3. Pt. #7. SOC 1/28/21 Diagnosis: Encounter for surgical aftercare following surgery on the circulatory system. The clinical record of Pt. #7 was reviewed on 1/26/21 at 11:30 AM. The record included a SOC comprehensive assessment form completed by RN dated 1/28/21 and required: "Indicate Immunizations History: Mark All That Apply and record in vaccination section." to which RN entered the response, "Up to date." The record lacked documentation of which immunizations Pt. #7 received and when they were administered. 4. Pt. #3. SOC 1/13/21. Primary Diagnosis: Hemiplegia Following Cerebral Infarction Affecting Left Nondominant Side. The clinical record was reviewed on 1/26/21 at 10:15 AM. The record contained the SOC comprehensive assessment form completed by the RN and dated 1/13/21 that required: "Indicate Immunizations History: Mark All That Apply and Record in Vaccination Section)." The RN entered the response: "Up To Date". The record lacked documentation indicating which vaccines were "Up To Date", and when the vaccines were administered. 5. Pt. #4. SOC 12/23/20. Primary Diagnosis: Fracture Unspecified Part of Right Clavicle, Subsequent Encounter for Fracture with Routine Healing. The clinical record was reviewed on 1/26/21 at 11:30 AM. The record contained the SOC comprehensive assessment form completed by the RN and dated 12/23/20 that required: "Indicate Immunizations History: Mark All That Apply and Record in Vaccination Section)." The RN entered the response: "Up To Date". The record lacked documentation indicating which vaccines were "Up To Date", and when the vaccines were administered. 6. Pt. #10. SOC 4/28/20. Primary Diagnosis: Zoster with Other Complications. The closed clinical record was reviewed on 1/25/21 at 2:50 PM. The record contained the SOC comprehensive assessment form completed by the RN and dated 12/23/20 that required: "Indicate Immunizations History: Mark All That Apply and Record in Vaccination Section)." The RN entered the response: "Pneumonia." The SOC comprehensive assessment lacked documentation indicating whether the Pt. requested, received or the Agency arranged for the Pneumococcal Pneumonia vaccine. The Discharge Comprehensive Assessment completed by the RN and dated 5/6/20 also lacked documentation indicating the patient's Pneumonia vaccine status. 7. Pt. #8. SOC 1/26/20. Primary Diagnosis: Hemiplegia following Cerebral Infarct affecting Right Dominant Side. The clinical record was reviewed on 1/26/21 at 10:30 AM. The record contained the SOC comprehensive assessment form completed by the RN dated 1/26/20, and the discharge comprehensive assessment completed by the PT dated 3/11/20. The assessments/ record lacked documentation related to the patient's pneumococcal pneumonia immunization status. 8. Pt. #9 SOC 2/28/20. Primary Diagnosis: Displaced Fracture of base of neck of left femur. The clinical record was reviewed on 1/26/21 at 2:00 PM. The record contained the SOC comprehensive assessment completed by the RN dated 2/28/20, and the discharge comprehensive assessment completed by the PT dated 4/23/30. The assessments/record lacked documentation related to pneumococcal pneumonia immunization status. 9. Pt. #1. SOC 6/30/20. Primary Diagnosis Multiple Sclerosis. The clinical record was reviewed on 1/26/21 at 11:00 AM. The record included the SOC comprehensive assessment form dated 6/30/20 completed by the PT that required: "Indicate Immunizations History ... and record in vaccination section" to which the PT entered the response "unknown." During a review of the agency's "Vaccination History Report" on 1/26/2021 at 2:00 PM, Pt. #1 was not listed. During an interview with the Administrator and Clinical Manager on 1/27/21 from 10:30 AM to 11:15 AM, the Administrator stated the "unknown" documentation in the comprehensive assessment of Pt. #1 should have been followed up with the patient's physician. The Agency failed to address the need for influenza and pneumonia immunizations. 10. During an interview with the Administrator and Clinical Manager on 1/27/21 from 10:30 AM to 11:45 AM and 2:25 to 3:00 PM, the Administrator stated all patients are to be assessed at the SOC on pneumonia and influenza vaccinations. The Administrator also stated they do not have a policy for influenza and pneumonia immunizations for patients. During the same interview with the Administrator and Clinical Manager, the above findings were confirmed.