Every finding on record at Centerwell Certified Healthcare Corp

A recertification survey of CenterWell Home Health was conducted on March 17 - 31, 2025. After the review of the agency's emergency preparedness program, the agency was found to be out of compliance with Conditions of Participation found at 42 CFR (Code of Federal Regulations) Part 484.102.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: The agency failed to establish and maintain a comprehensive emergency preparedness program for all its locations. The absence of a complete, location-specific plan poses a risk to the agency’s ability to respond effectively to emergencies and safeguard patients, staff, and operations during disaster situations. The findings include: 1) A review of administrative records on 03/20/2025 revealed that the agency did not have a comprehensive emergency preparedness plan in place for calendar years 2021, 2022, 2023, and 2024 for any of its four operational locations: Columbia (parent), Towson, Silver Spring, and Annapolis (branch offices). 2) The only document presented was titled "Emergency Preparedness Guide Book," which did not meet the regulatory requirements for a location-specific and comprehensive emergency preparedness program. Cross-reference to tags E0004 - E0036.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: The agency failed to develop, maintain, review, and update an emergency preparedness plan at least every two years as required. The absence of an updated plan for each agency location limits the ability to respond effectively to emergency situations, posing risks to patient safety, staff coordination, and operational continuity. The findings include: 1) A review of administrative records on 03/20/2025 revealed that the agency did not maintain a reviewed or updated emergency preparedness plan for calendar years 2021, 2022, 2023, and 2024 for any of its operational locations, including the parent office in Columbia and the branch offices in Towson, Silver Spring, and Annapolis. 2) The only document presented during the review was titled "Emergency Preparedness Guide Book," which did not contain an individualized or dated emergency plan for any location and failed to demonstrate a review or update had occurred within the required two-year timeframe.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: The agency failed to conduct a facility-based and community-based risk assessment for each location, as required under the all-hazards approach. The lack of individualized assessments limits the agency’s ability to identify and plan for specific risks affecting each site, compromising emergency preparedness across the organization. The findings include: 1) A review of administrative records on 03/20/2025 revealed that the agency provided a general "Hazard and Vulnerability Assessment Tool" for each year from 2021 through 2024. However, the tools were not completed for each individual location. 2) No individualized risk assessments were developed or maintained for the Columbia, Towson, Silver Spring, or Annapolis locations. 2) The agency did not demonstrate that risk assessments were facility-based or tailored to the community-based threats relevant to each branch, as required by regulation.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: The agency failed to develop and maintain an emergency preparedness plan that contained required elements, including strategies for the patient population (including persons at-risk), the type of services the agency can provide during an emergency, and continuity of operations planning, including delegations of authority and succession plans. The findings include: A review of administrative records on 03/20/2025 revealed that the agency failed to develop an emergency preparedness plan that contained all required elements and addressed all of the agency's locations: Columbia (parent), Towson, Silver Spring, and Annapolis (branches). As a result, the agency did not demonstrate compliance with the requirement to address patient population needs, emergency service capabilities, or continuity of operations during an emergency.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: The agency failed to develop and maintain a process for cooperation and collaboration with local, State, regional, and Federal emergency preparedness officials. The absence of such a process limits the agency’s ability to coordinate effectively during emergency situations and ensure an integrated community response. A review of administrative records on 03/20/2025 revealed that there was no documentation demonstrating that the agency had developed or maintained a process for cooperation and collaboration with local, State, regional, or Federal emergency preparedness officials for any of its four locations: Columbia (parent), Towson, Silver Spring, and Annapolis (branches).

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: The agency failed to develop and maintain an emergency communication plan that met the requirements under §484.102(c). The plan did not include procedures for coordinating patient care within the agency and across healthcare providers, or for collaborating with state and local public health departments and emergency management agencies to ensure patient health and safety during a disaster. The findings include: A review of administrative records on 03/20/2025 revealed that the agency provided a document titled “Emergency Communication Plan.” The document did not meet regulatory requirements, as it did not outline how the agency coordinates patient care within and across healthcare providers or with State and local public health departments. The document lacked procedures for coordination with emergency management agencies and systems to support continuity of care and protect patient health and safety during a disaster. No documentation was provided to demonstrate that the communication plan had been reviewed or updated at least every 2 years for the agency’s four locations: Columbia, Towson, Silver Spring, and Annapolis.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: The agency failed to develop and maintain an emergency communication plan that included all required names and contact information for essential personnel and service partners, as well as a structured communication process to support emergency response efforts. The findings include: A review of administrative records on 03/20/2025 revealed that the agency did not provide a communication plan that included the required names and contact information for staff, contracted service providers, patients’ physicians, or other healthcare facilities for its four operational locations: Columbia, Towson, Silver Spring, and Annapolis. The documentation submitted did not contain a phone tree or any structured method for emergency communication.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: The agency failed to develop and maintain an emergency preparedness training and testing program that included all required components and staff participation across all locations. The program lacked full implementation and did not ensure that staff were trained or tested in accordance with regulatory requirements. The findings include: 1) A review of administrative records on 03/20/2025 revealed that the Towson location experienced an actual emergency event on 03/06/2024. The Columbia location held a tabletop exercise in 2024; however, documentation showed that only Branch Directors attended the exercise. There was no documentation showing that training or testing activities were conducted with staff at any location, including Silver Spring and Annapolis. 2) A review of staff training records on 03/31/2025 revealed that Employee #6 and Physical Therapist #1 did not complete emergency preparedness training. 3) Telephone interviews were conducted with six randomly selected employees on 03/24/2025. Statements from Employee #3, Employee #4, Employee #5, and Employee #6 indicated that they had not participated in any emergency preparedness training, tabletop exercise, or drill and were not aware of the agency’s emergency preparedness policies or procedures.

A recertification survey was completed at CenterWell Home Health, located in Columbia, Maryland, on March 17 - 31, 2025, to determine if the agency was in compliance with federal requirements for home health agencies. The survey included a review of administrative records and patient documentation. Interviews were conducted with patients, the agency's administrator, and the clinical manager. Three home visits were conducted with the Home Health Aide, Physical Therapist, and Registered Nurse. A total of 17 clinical records were reviewed during the survey. This represented the scope of services as follows: Skilled Nursing Services - 10 Home Health Aide - 2 Physical Therapy Services - 14 Occupational Therapy Services - 8 Social Work- 1 The following requirements of 42 CFR Part 484 were not met.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: The agency failed to ensure the timely submission of OASIS assessments to the CMS system. This failure may affect the accuracy of patient data, impact regulatory compliance, and compromise the effectiveness of patient care planning. The findings include: A review of administrative records on 03/18/2025 revealed the agency’s Error Report 3330 from 01/01/2024 to 12/31/2024 documented that 4,314 OASIS assessments were submitted late, failing to meet the required 30-day submission deadline.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on a review of clinical documentation, the agency did not initiate home health services within 48 hours of referral or on the physician-ordered start date, as required. There was no documentation explaining the reason for the delays or any communication with the referring provider to justify changes in the start of care date. The findings include:A review of medical records on 03/28/2025 revealed that multiple patients had a start of care exceeding 48 hours from the referral date or physician-ordered start date, with no documented explanation for the delay, as outlined below. a) Patient #1: Referral date 10/28/2024, start of care 10/31/2024; b) Patient #2: Referral date 02/18/2025, start of care 12/23/2024; c) Patient #6: Referral date 01/10/2025, start of care 01/16/2025; d) Patient #7: Referral date 08/28/2024, start of care 09/3/2024; e) Patient #9: Referral date 02/26/2025, start of care 03/06/2025; f) Patient #10: Referral date 02/11/2025, start of care 02/25/2025; g) Patient #11 : Referral date 11/08/2024, start of care 11/19/2024; h) Patient #15 : Referral date 03/20/2025, start of care 03/25/2025.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: The agency failed to ensure that plans of care were properly established, signed by the physician, and fully implemented as ordered. Multiple plans of care lacked required physician signatures, and ordered services were missed without documented clinical justification. These deficiencies placed patients at risk for receiving services without medical authorization and disrupted treatment continuity. The findings include: 1) A review of clinical documentation on 03/28/2025 revealed that the plan of care (CMS-485) for Patient #6, whose start of care date was 01/16/2025, was not signed by the physician. The absence of the physician’s signature rendered the plan of care incomplete and not compliant with regulatory requirements. 2) A review of clinical documentation on 03/28/2025 also revealed that the physician did not sign the plan of care (CMS-485) for Patient #13. 3) A review of clinical documentation on 03/18/2025 revealed that Patient #7 had a physician’s order dated 11/03/2024 for occupational therapy (OT) once weekly for four weeks. No OT visit was documented during the week of 11/10/2024, and there was no documentation explaining the missed visit. Aide services were also ordered to begin on 11/03/2024, once weekly for five weeks. Documentation showed that aide visits were not provided during the week of 11/24/2024 or afterward, resulting in only three out of five ordered visits being completed. There was no documentation explaining the missed aide visits.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: The agency failed to ensure that a physical therapist followed accepted standards of practice during the provision of home care services. This failure resulted in a breakdown of infection control precautions and created a risk for cross-contamination and the transmission of infectious agents. The findings include: An observation during a home visit on 03/25/2025 revealed that a physical therapist did not maintain separate clean and dirty fields while providing care. Clean supplies were initially placed on a barrier; however, after use, soiled items were returned to the same barrier, contaminating the clean field.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: The agency failed to maintain documentation of written competency evaluations for home health aides. Without documented competencies, the agency cannot demonstrate that aides were evaluated and determined competent to furnish home health services in accordance with regulatory requirements. The findings include: A review of personnel records on 03/31/2025 revealed that Aides #1, #2, and #3 did not have written competency documentation in their respective personnel files.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: The agency failed to ensure that home health aides received and documented 12 hours of in-service training annually. The submitted records did not clearly differentiate between in-service education and other required annual training, and the total number of in-service training hours completed by each aide was not documented. The findings include: A review of personnel records on 03/31/2025 revealed the following: 1) Aides #1, #2, and #3 did not have documentation verifying the completion of 12 hours of in-service training during the most recent 12-month period. 2) The agency submitted training transcripts with various topics marked as in-service using a star notation. However, several of the topics marked, including infection control, emergency preparedness, and biomedical waste, are required annual trainings and not categorized by the agency as in-service education. 3) The agency did not maintain a clear delineation between in-service education and other mandatory annual trainings. The documentation also did not specify the number of in-service hours completed by each aide.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: The agency failed to ensure the consistent participation of home health aides in case conferences, as required to maintain communication and a coordinated plan of care. This failure limited interdisciplinary collaboration and risked disruption to the continuity and quality of patient services. The findings include: 1) A review of administrative records on 03/18/2025 for case conferences held since January 2025 revealed that at the Columbia location, the home health aide participated in only 3 out of approximately 11 case conferences. For the Annapolis location, the home health aide participated in only 4 out of approximately 11 case conferences. 2) Additionally, during a case conference observed on 03/19/2025 at 8:30 a.m. at Columbia location, no home health aide was in attendance.

Direct support and administrative control CFR(s): 484.105(d)(2) The parent HHA provides direct support and administrative control of its branches. This ELEMENT is not met as evidenced by: The parent HHA failed to provide adequate oversight and supervision to ensure that its branch locations complied with the emergency preparedness requirements outlined in the Conditions of Participation. The lack of coordination and uniform implementation across locations compromised the agency’s ability to ensure patient and staff safety during emergency events. The findings include: A review of administrative records on 03/20/2025 revealed that the parent location (Columbia) did not ensure that its branches in Towson, Silver Spring, and Annapolis had current, location-specific emergency preparedness plans for the years 2021 through 2024. Documentation also showed that the branches lacked individualized risk assessments, communication plans, hazard vulnerability tools, and staff training and testing. Only branch directors participated in limited tabletop activities, and no comprehensive emergency preparedness documentation or drills involved other staff. These deficiencies were consistent across the branches and demonstrated a lack of centralized oversight from the parent agency.

A standard home health agency re-certification survey was conducted at Kindred At Home in Columbia, Maryland, on June 8 - 9, 2021. The survey included the following: a review of clinical records; a review of the complaint/incident reports; a review of on-call documentation; a review of admission documentation including patient bill of rights; a review of personnel files including professional licenses and expiration dates; a review of Quality Assurance Project Plan and Reports (QAPI) & Potentially Avoidable Event Report; a review of the organizational chart; a review of the CLIA waiver, and interviews with the agency's administrative staff. The agency's emergency preparedness program and plan were reviewed. A total of fifteen randomly selected patient records were reviewed during the survey. The scope of services included the following: Skilled Nursing Services - fourteen Physical Therapy Services - ten Occupational Therapy Services - five Medical Social Worker - one Home Health Aide Services - none Other Services - two No home visit observations were conducted during the survey. Findings in this report were based on data present in the clinical records at the time of the reviews. The agency's administrative and clinical staff were kept informed of the survey findings as the survey progressed. The agency's staff were given the opportunity to present information relative to the findings during the survey. The exit conference was conducted with the agency personnel on June 9, 2021. The findings of the Medicare re-certification survey were reviewed; a patient identification key-code was provided to the agency's administrator.

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on clinical record review and review of the agency's policies and procedures, the agency's skilled nurse (SN) failed to complete an assessment of the patient's wound. This places the patient at risk for not receiving the appropriate treatments/interventions and at risk for adverse healthcare outcomes. Patient: #5 Findings include: 1. On 6/8/2021, a review of patient #5 clinical record revealed, on 3/16/2021, there was a start of care visit-subsequent visits on 3/19/2021, 3/22/2021, 3/23/2021, 3/26/2021, and 3/29/2021 occurred without an assessment of the patient's wound. The wound assessment occurred on the 3/30/2021 visit. 2. Plan of care orders indicated dressing changes every Monday, Wednesday Friday. 3. On 6/9/2021, a review of the agency's policy entitled "03-51 Wound Care Assessment and Clinical Oversight" s revealed, in part: The registered nurse (RN) performs the initial assessment for open wounds and surgical incisions upon admission and as ordered by the physician. Wound dressings will be removed in order to assess the wound (except for the primary surgical dressing post-operatively). Wound assessments will be performed as ordered by the physician but no less than once weekly. 4. On 6/9/2021, the agency's administrative staff was given the opportunity to provide additional information related to the patient's care. No further information was provided. Wound assessments are essential because it provides the objective data for healthcare providers so that the patient plans of care can be developed also contributes to decisions the healthcare providers make related to treatments and interventions the patient receives.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on a review of medical records, the agency's administration failed to ensure that an assessment of the patient by nursing or rehabilitation therapy occurred within 48 hours of referral for 3 out of 15 patients. The agency not performing assessments timely placed the patients' at risk for delays in care and adverse health care outcomes. Patients: #8, #11, and #14 The findings include: 1. On 6/8/2021, Patient #8 medical record review showed the referral date as 3/5/2021. The patient's start of care (SOC) was 3/10/2021. There was no documentary evidence to support that a physician ordered a change to the SOC. On 6/8/2021, the agency's administrative staff was allowed to provide additional information related to this finding. No further information was provided. 2. On 6/8/2021, Patient #11 medical record review showed the referral date as 4/22/2021. The patient's SOC was 4/27/2021. There was no documentary evidence to support that a physician ordered a change to the SOC. On 6/8/2021, the agency's administrative staff was allowed to provide additional information related to this finding. No further information was provided. 3. On 6/8/2021, Patient #14 medical record review showed the referral date as 4/2/2021. The patient's start of care (SOC) was 4/7/2021. There was no documentary evidence to support that a physician ordered a change to the SOC. On 6/8/2021, the agency's administrative staff was allowed to provide additional information related to this finding. No further information was provided. Initial assessments must occur within 48 hours of referral, a patient's return home, or the physician-ordered start of care date. An agency shall not request a change of the patient's SOC to accommodate the agency's convenience.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: The agency's staff failed to adhere to the patient's written plan of care (POC) for ordered treatments and ordered visit frequencies. The POC not being followed placed patients at risk for not receiving appropriate treatments/interventions timely and at risk for adverse outcomes. Patient: #2 and #10 Findings include: 1. A review of patient #2 clinical record revealed, the patient was scheduled for an occupational therapy (OT) visit during week #4 of care. This did not occur. The patient's clinical record does not document the reason for the missed visit nor that the agency's staff notified the patient's physician of the missed visit. 2. On 6/9/2021, a review of the agency's policy entitled "03-12 Physician's Orders: Notices to the Physician" revealed, in part: If fewer visits are provided during the week than ordered, the physician will be notified with documentation in the clinical record that the physician is aware of the missed visit unless the physician has authorized missed visits under specific circumstances. 3. A review of patient #10 clinical record revealed, on 5/22/2021, the patient received a new wound care order. The order changed to cleanse the stage 2 pressures ulcer to the right buttock, pat dry, and apply duoderm every 3 days or when soiled or PRN (as needed). The previous order was documented as still being followed for visits after 5/22/2021 (5/25, 5/27, and 6/2). 4. On 6/9/2021, the agency's administrative staff was given an opportunity to provide additional information related to these deficient practices. No further information was provided.