Every finding on record at Centerwell Certified Healthcare Corp

A Recertification survey was conducted at Centerwell Home Health, located at 95 Elm St, West Springfield, MA., 01089, on February 4, 2026 and February 5, 2026, for compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies. As a result of this survey, it was determined the agency was in compliance with these requirements. No deficiencies were cited.

A Recertification survey was conducted at Centerwell Home Health, located at 95 Elm St., West Springfield, MA., 01089, on February 4, 2026 and February 5, 2026, for compliance with CFR Part 484 Requirements for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance with these requirements. Deficiencies were cited.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on patient admission documentation review and interview, the agency failed to ensure the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local home health agencies (HHA) was provided when a patient was admitted. Findings include: Review of the facility's admission packet included a My Home Health Resource Booklet. Further review of this booklet indicated the section titled, State Home Health Hotline Number, was blank, and did not include contact information that would allow a patient to do the following: *Report a complaint about CenterWell Home Health. *Report the local CenterWell Home Health agency's implementation of the patient's advanced directives (if any). *Request information about home health providers. During an interview on 2/5/26 at 1:15 P.M., the Clinical Manager said the booklet was incomplete, and the hotline number should have been included.

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 record review, policy review and interview, the agency failed to ensure the initial assessment was completed 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, for 2 patients (#1 and #3), out of total sample of 7 patients. Findings include: Review of the agency's policy entitled, Patient Assessments, revised September 2025, indicated the following: *Initial Assessments: -Must be performed in a patient's place of residence to determine eligbiltiy and immediate care/support needs of the patient. -Must be completed on or before the Start of Care (SOC) date and within 48 hours from the date of the referral or facility discharge (whichever is later) unless otherwise ordered by the physician/allowed practitioner. -Medicare beneficiaries will be assessed for coverage eligibility under the Medicare home health benefit during the initial assessment and comprehensive assessment. 1. Patient #1 was admitted to the agency in April 2025 with diagnosis of major depressive disorder. Review of the clinical record indicated the patient was referred to the agency for home health services on 4/23/25, and indicated the patient was to be discharged from the hospital on 4/24/25. Further review of the clinical record indicated the initial SOC assessment was completed on 4/30/25, 7 days after the referral, and 6 days after being discharged from the hospital. 2. Patient #3 was admitted to the agency in April 2025 with a diagnosis of Schizophrenia (a brain disorder causing distorted perception of reality). Review of the clinical record indicated the patient was referred to the agency for home health services on 4/10/25, and indicated the patient was to be discharged from the hospital on 4/11/25. Further review of the clinical record indicated the initial SOC assessment was completed on 4/15/25, 5 days after the referral and 4 days after being discharged from the hospital. During interviews on 2/4/26 at 4:15 P.M., and again on 2/5/26 at 8:55 A.M., the Clinical Manager said neither of Patient #1 nor Patient #3's initial SOC assessment were completed within 48 hours of each patient's discharge from the hospital, as required. She said neither record had documentation to indicate why there were delays for initial SOC assessment.

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: Based on observation, policy review, and interview, the agency failed to ensure the tablet computer (a portable, touchscreen device) used to document patient visits was sanitized after use and infection control guidelines were maintained during home visit observations for 2 patients (#6 and #7), out of a total sample of 3 patient home visits. Findings include: Review of the agency policy entitled, Disinfecting Tablet Computers, revised 7/2025, indicated the following: Disinfection Process: *After each patient care visit Clinical Associates will disinfect all exposed exterior surfaces of the tablet (and if applicable, the protective case) using: -70% isopropyl alcohol (examples: alcohol wipes, prep pads, swabs). -Germicidal wipes approved by the Centers for Disease Control and Prevention (CDC) or the Occupational Safety and Health Administration (OSHA). Review of the agency policy entitled, Home Care Bag Technique, revised 5/19/25, indicated the following: *Placement of the bag and supplies in a patient's home: -Place a nonwheeled bag on a flat surface that appears clean and dry. Use a fluid-impermeable pad as a barrier beneath the bag..... *Clinical alert: -Using a fluid-impermeable pad as a barrier between the bag and the patient's home environment demonstrates respect for the patient's property and health by reducing the risk of contamination... 1. Patient #6 was admitted to the agency in March 2017 with a diagnosis of bipolar disorder (a mental health condition that causes extreme mood swings). During a home visit on 2/5/26 at 10:45 A.M., the surveyor observed Nurse #1 place a tablet directly on top of a cabinet. She did not place a barrier pad prior to placing the tablet computer on top of the cabinet. She prepared the patient's medications and medicated the patient. After completing the visit, she handed the tablet to the patient. The patient digitally signed the tablet and handed it back to the nurse. Nurse #1 never cleansed the tablet and exited the home. During an interview on 2/5/26 at 11:00 A.M., Nurse #1 said she did not place a barrier pad on the cabinet prior to placing the tablet computer on it and she did not cleanse the tablet computer after the visit, as required. 2. Patient #7 was admitted to the agency in February 2021 with a diagnosis of schizoaffective disorder (a mental health condition with symptoms of schizophrenia and a mood disorder). During a home visit on 2/5/26 at 10:45 A.M., the surveyor observed Nurse #2 place a tablet directly on top of a cabinet. She did not place a barrier pad under the tablet prior to placing the tablet on top of the cabinet. After completing her visit, she removed a stylus from her bag, cleansed the stylus with a cleansing wipe, and handed the tablet and stylus to the patient. The patient signed the tablet with the stylus and handed the stylus and tablet back the nurse. Nurse #1 then cleansed the stylus with a cleansing pad and placed it into her bag. She did not cleanse the tablet after the patient's use and exited the home. During an interview on 2/5/26 at 11:00 A.M., Nurse #2 said she guesses she could have used a barrier pad. She further said she had cleansing pads in her bag and could have cleansed her tablet after completing the visit, but she did not. During an interview on 2/5/26 at 2:00 P.M., the Clinical Manager said a barrier pad is required before staff put a tablet down in a patient's home. She said the tablet needs to be cleansed after a home visit. She further said Nurse #1 and #2 did not follow infection control guidelines, as required.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure that services were provided as ordered by the physician or allowed practitioner, as indicated in the plan of care, for 7 patients (#2, #4, #6, #7, #1, #3 and #5), out of a total sample of 7 patients. Findings include: 5. Patient #1 was admitted to the agency in April 2025 with a diagnosis of major depressive disorder. Review of the physician ordered Home Health Certification and POC, dated 10/27/25 through 12/25/25, indicated the following: -SN visit: 2 times a week for 8 weeks and 3 times a week for 1 week. Review of the clinical record indicated one SN visit was provided, not 2 as ordered, for the weeks of 1/18/25 and 1/25/25. During an interview on 2/5/26 at 8:55 A.M., the CM said 2 SN visits were not provided, as ordered, per the plan of care, and there was not any documentation to indicate why the visits were not provided. 6. Patient #3 was admitted to the agency in April 2025 with a diagnosis of Schizophrenia (a serious brain disorder causing a distorted perception of reality). Review of the physician ordered Home Health Certification and POC, dated 8/13/25 through 10/11/25, indicated the following: -SN visit: 4 times a week for 1 week, 7 times a week for 7 weeks, and 8 times a week for 1 week. Review of the clinical record indicated 3 SN visits were provided, not 7 as ordered, for the week of 9/14/25, and no SN visits were provided for the week of 9/21/25. During an interview on 2/5/26 at 8:55 A.M., after reviewing the clinical record, the CM said 7 SN visits were not provided, as ordered, per the plan of care for the week of 9/14/25. She said there was a missed visit note for 9/19/25, however no other missed visit notes for 9/17/25, 9/18/25 nor 9/20/25. She said for the week of 9/21/25, there were no visits provided. She also said there was a missed visit note for 9/22/25, and documentation on 9/23/25 that indicated the patient was in the hospital, but a SN visit should have been provided on 9/21/25. 7. Patient #5 was admitted to the agency in August 2019 with a diagnosis of schizoaffective disorder. -SN visit: 4 times a week for 1 week, and 5 times a week for 8 weeks Review of the clinical record indicated 4 SN visits were provided, not 5 as ordered, for the week of 12/21/25. During an interview on 2/5/26 at 11:20 A.M., the CM said 1 SN visit was not provided, as ordered, per the plan of care, and there was not any documentation to indicate why the visit was not provided for the week of 12/21/25. Review of the agency policy entitled, Care Planning, revised 9/2024, indicated the following: *The Plan of Care (POC): -Serves as the patient's care-planning document. -Will be developed in collaboration with the physician/allowed practitioner and Home Health Clinical Associates following the initial /comprehensive assessment and will contain integrated orders from all physicians or allowed practitioners involved in the POC to assure coordination of all services and interventions provided to the patient. 1. Patient #2 was admitted to the agency in January 2026 with a diagnosis of bipolar disease (a mental health condition that causes extreme mood swings). Review of the Home Health Certification and POC, dated 1/6/26 through 3/6/26, indicated the following: -Skilled Nurse (SN) visit: 5 times a week for 9 weeks. Review of the clinical record indicated one missed SN visit the weeks of 1/18/26 and 1/25/26. 2. Patient #4 was admitted to the agency in January 2025 with a diagnosis of bipolar disease. Review of the Home Health Certification and POC, dated 7/7/25 through 9/4/25, indicated the following: -SN visit: 1 time a week for 8 weeks, and 3 times week for 1 week. Review of the clinical record indicated one missed SN visit the week of 7/6/25. 3. Patient #6 was admitted to the agency in March 2017 with a diagnosis of bipolar disorder. Review of the Home Health Certification and POC, dated 11/16/25 through 1/14/26, indicated the following: -SN visit: 4 times a week for 8 weeks, and 3 times a week for 1 week. Review of the clinical record indicated one missed SN visit the week of 1/11/26. Review of the Home Health Certification and POC, dated 1/15/26 through 3/15/26 indicated the following: -SN visit: 2 times a week for 1 week, and 4 times a week for 8 weeks. Review of the clinical record indicated 3 missed SN visits the week of 1/18/26, and one missed SN visit the week of 1/25/26. 4. Patient #7 was admitted to the agency in February 2021 with a diagnosis of schizoaffective disorder (a mental health condition with symptoms of schizophrenia and a mood disorder). Review of the Home Health Certification and POC, dated 11/21/25 through 1/19/26, indicated the following: -SN visit: 1 time a week for 1 week, 5 times a week for 8 weeks, and three times a week for 1 week. Review of the clinical record indicated one missed SN visit the week of 12/9/26, 2 missed SN visits the week of 12/14/25, 1 missed visit the week of 12/21/25, one missed SN visit the week of 12/28/25 and one missed SN visit the week of 1/4/26. During an interview on 2/5/26 at 3:00 P.M., after reviewing the clinical records for Patients #2, #4, #6 and #7, the Clinical Manager (CM) said the POC was not followed relative to all the missed SN visits.

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 record review, policy review and interview, the agency failed to ensure staff communicated with the physician involved in the plan of care (POC), related to the current POC, for 7 patients (#2, #4, #6, #7, #1, #3 and #5), out of a total sample of 7 patients. Findings include: 5. Patient #1 was admitted to the agency in April 2025 with a diagnosis of major depressive disorder. Review of the physician ordered Home Health Certification and POC, dated 10/27/25 through 12/25/25, indicated the following: -SN visit: 2 times a week for 8 weeks and 3 times a week for 1 week. Review of the clinical record indicated one SN visit was provided, not 2 as ordered, for the weeks of 1/18/25 and 1/25/25. During an interview on 2/5/26 at 8:55 A.M., the CM said 2 SN visits were not provided, as ordered, per the plan of care, and there was no documentation indicating that the physician was notified of the missed visits 6. Patient #3 was admitted to the agency in April 2025 with a diagnosis of Schizophrenia (a serious brain disorder causing a distorted perception of reality). Review of the physician ordered Home Health Certification and POC, dated 8/13/25 through 10/11/25, indicated the following: -SN visit: 4 times a week for 1 week, 7 times a week for 7 weeks, and 8 times a week for 1 week. Review of the clinical record indicated 3 SN visits were provided, not 7 as ordered, for the week of 9/14/25, and no SN visits were provided for the week of 9/21/25. During an interview on 2/5/26 at 8:55 A.M., the CM said there was no documentation for the missed visits on 9/17/25, 9/18/25 and 9/20/25, and the physician had not been notified of these missed visits, as required. She also said for the week of 9/21/25, there was no documentation for the missed visit on 9/21/25 and the physician had not been notified of the missed visit, as required. 7. Patient #5 was admitted to the agency in August 2019 with a diagnosis of schizoaffective disorder. Review of the physician ordered Home Health Certification and POC, dated 10/28/25 through 12/26/25, indicated the following: -SN visit: 4 times a week for 1 week, and 5 times a week for 8 weeks Review of the clinical record indicated 4 SN visits were provided, not 5 as ordered, for the week of 12/21/25. During an interview on 2/5/26 at 11:20 A.M., the CM said a SN visit was not provided on 12/25/25, and there was no documentation to indicate why the visit was not provided and the physician had not been notified of the missed visit, as required. Review of the agency policy entitled, Management of Missed Visits, revised 7/18/22, indicated the following: *The CenterWell Home Health standard of practice is that missed visits will occur infrequently and for patient related reasons only. Coordination of care standards require scheduling and/or reassigning a visit to comply with the physician ordered frequency. If a "true missed visit" occurs the physician will be notified, and documentation of a missed visit will be completed in a timely manner. 1. Patient #2 was admitted to the agency in January 2026 with a diagnosis of bipolar disease (a mental health condition that causes extreme mood swings). Review of the Home Health Certification and Plan of Care (POC), dated 1/6/26 through 3/6/26, indicated the following: -Skilled Nurse (SN) visit: 5 times a week for 9 weeks. Review of the clinical record indicated one missed SN visit the weeks of 1/18/26 and 1/25/26. Further review of the clinical record did not contain any documentation that the physician had been notified of the missed visits. 2. Patient #4 was admitted to the agency in January 2025 with a diagnosis of bipolar disease. Review of the Home Health Certification and POC, dated 7/7/25 through 9/4/25, indicated the following: -SN visit: 1 time a week for 8 weeks, and 3 times week for 1 week. Review of the clinical record indicated one missed SN visit the week of 7/6/25. Further review of the clinical record did not contain any documentation that the physician had been notified of the missed visit. 3. Patient #6 was admitted to the agency in March 2017 with a diagnosis of bipolar disorder. Review of the Home Health Certification and POC, dated 11/16/25 through 1/14/26, indicated the following: -SN visit: 4 times aa week for 8 weeks, and 3 times a week for 1 week. Review of the clinical record indicated one missed SN visit the week of 1/11/26. Review of the Home Health Certification and POC, dated 1/15/26 through 3/15/26 indicated the following: -SN visit: 2 times a week for 1 week, and 4 times a week for 8 weeks. Review of the clinical record indicated one missed SN visit for the week of 1/11/26, 3 SN visits missed for the week of 1/18/26 and one missed SN visit for the week of 1/25/26. Further review of the medical record did not contain contain any documentation that the physician had been notified of any of the missed SN visits. 4. Patient #7 was admitted to the agency in February 2021 with a diagnosis of schizoaffective disorder (a mental health condition with symptoms of schizophrenia and a mood disorder). Review of the Home Health Certification and POC, dated 11/21/25 through 1/19/26 indicated the following: -SN visit: 1 time a week for 1 week, 5 times a week for 8 weeks, and three times a week for 1 week. Review of the clinical record indicated one missed SN visit the week of 12/7/26, 2 missed SN visits the week of 12/14/25, one missed SN visit the week of 12/21/25, one missed SN visit the week of 12/28/25 and one missed SN visit the week of 1/4/26. Further review of the clinical record did not contain any documentation that the physician had been notified of any of the missed visits. During an interview on 2/5/26 at 3:00 P.M.,M after reviewing the clinical records for Patients #2, #4, #6 and #7, the Clinical Manager (CM) said there was no documentation found to indicate the physician had been notified of any of the missed visits, as required.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure a clinical note was completed after a Skilled Nurse (SN) visit for one patient (#4), out of a total sample of 7 patients. Findings include: Review of the agency policy entitled, Documentation Submission, indicated the following: *Electronic documentation will be submitted/transmitted via a Company-approved secure Electronic Medical Record (EMR) vendor/system via the internet within 24 hours following receipt of documents or completion of a patient visit in order to secure the documents in the patient medical record and facilitate coordination of patient csre. Patient #2 was admitted to the agency in January 2026 with a diagnosis of bipolar disease (a mental health condition that causes extreme mood swings). Review of the Home Health Certification and Plan of Care (POC), dated 1/6/26 through 3/6/26, indicated the following: -Skilled Nurse (SN) visit: 5 times a week for 9 weeks. Review of the clinical record indicated a SN visit was completed on 1/27/26 but no visit documentation was found. During an interview on 2/5/26 at 2:00 P.M., after reviewing the clinical record, the Clinical Manager said a SN visit was conducted on 1/27/26 as evidenced by a screenshot of Patient #2 calendar which indicated a SN visit was done but is incomplete as no evidence of a documented visit was found.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure a completed discharge summary was sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the home health agency (if any) within 5 business days of the patient's discharge, for 1 patient (#3), out of a total sample of 7 patients. Findings include: Review of the agency's policy entitled, Patient Discharge or Transfer, revised March 2025, indicated the following: *Discharge/transfer summary documents completed by the Home Health agency will be sent within the Centers for Medicare and Medicaid Services (CMS)-mandated time frames, and company policy. Patient #3 was admitted to the agency in April 2025 with a diagnosis of schizophrenia (a serious brain disorder causing a distorted perception of reality). Review of the clinical record indicated Patient #3 was discharged from the agency on 10/11/25, and a Discharge/Transfer Summary Report was completed at that time, however, there was no documentation of it being sent to Patient #3's physician. During an interview on 2/5/26 at 11:10 A.M., the Clinical Manager said the Discharge/Transfer Summary Report had not been sent to the physician, as required.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure that all entries were legible, clear, complete, and appropriately authenticated, dated, and timed, for 7 patients (#1, #3, #5, #2, #4, #6 and #7), out of a total sample of 7 patients. Findings include: 4. Patient #2 was admitted to the agency in January 2026 with a diagnosis of bipolar disease (a mental health condition that causes extreme mood swings). Review of the Home Health Certification and POC, dated 1/6/26 through 3/6/26, indicated the following: -SN visit: 5 times a week for 9 weeks. Review of the clinical record indicated the following: *1/6/26 SN visit, note signed on 1/9/26. *1/7/26 SN visit, note signed on 1/10/26. *1/8/26 SN visit, note signed on 2/2/26. *1/9/26 SN visit, note signed on 2/2/26. *1/12/26 SN visit, note signed on 1/17/26. *1/15/26 SN visit, note signed on 1/17/26. *1/16/26 SN visit, note signed on 1/19/26. *1/19/26 SN visit, note signed on 1/25/26. *1/21/26 SN visit, note signed on 1/24/26. *1/23/26 SN visit, note signed on 1/27/26. 5. Patient #4 was admitted to the agency in January 2025 with a diagnosis of bipolar disease. Review of the Home Health Certification and POC, dated 1/8/25 through 3/8/25, indicated the following: -SN visit: 4 times a week for 1 week, 5 times a week for 7 weeks, and 7 times a week for 1 week. Review of the clinical record indicated the following: *1/8/25 SN visit, note signed on 1/14/25. Review of the Home Health Certification and POC, dated 7/7/25 through 9/4/25, indicated the following: -SN visit: 1 time a week for 8 weeks, and 3 times week for 1 week. Review of the clinical record indicated the following: *8/5/25 SN visit, note signed on 8/12/25. *8/12/25 SN visit, note signed on 8/14/25. *8/20/25 SN visit, note signed on 8/26/25. *8/26/25 SN visit, note signed on 8/29/25. *9/2/25 SN visit, note signed on 9/4/25. Review of the Home Health Certification and POC, dated 9/5/25 through 11/3/25, indicated the following: -Effective 9/7/25, SN visit: 1 time a week for 7 weeks, and 3 times a week for 1 week. Review of the clinical record indicated the following: *9/9/25 SN visit, note signed on 9/16/26. *9/16/26 SN visit, note signed on 9/22/25. 6. Patient #6 was admitted to the agency in March 2017 with a diagnosis of bipolar disorder. Review of the Home Health Certification and POC, dated 11/16/25 through 1/14/26, indicated the following: -SN visit: 4 times aa week for 8 weeks, and 3 times a week for 1 week. Review of the clinical record indicated the following: *1/12/26 SN visit, note signed on 1/17/26. *1/13/26 SN visit, note signed on 1/19/26. *1/14/26 SN visit, note signed on 2/4/26. Review of the Home Health Certification and POC, dated 1/15/26 through 3/15/26, indicated the following: -SN visit: 2 times a week for 1 week, and 4 times a week for 8 weeks. Review of the clinical record indicated the following: *1/30/26 SN visit, note signed on 2/1/26. 7. Patient #7 was admitted to the agency in February 2021 with a diagnosis of schizoaffective disorder. Review of the Home Health Certification and POC, dated 11/21/25 through 1/19/26, indicated the following: -SN visit: 1 time a week for 1 week, 5 times a week for 8 weeks, and three times a week for 1 week. Review of the clinical record indicated the following: *12/10/26 SN visit, note signed on 12/12/25. *12/11/25 SN visit, note signed on 1/3/26. *12/12/25 SN visit, note signed on 12/14/25. *12/15/25 SN visit, note signed on 1/3/26. *12/17/25 SN visit, note signed on 12/19/25. *12/24/25 SN visit, note signed on 12/26/25. *12/26/25 SN visit, note signed on 12/29/25. *1/2/26 SN visit, note signed on 1/6/26. *1/9/26 SN visit, note signed on 1/12/26. *1/15/26 SN visit, note signed on 1/19/26. Review of the Home Health Certification and POC, dated 1/20/26 through 3/20/26, indicated the following: -SN visit: 4 times a week for 1 week, and 5 times a week for 8 weeks. Review of the clinical indicated the following: *1/23/26 SN visit, note signed on 1/28/26. *1/27/26 SN visit, note signed on 2/4/26. During an interview on 2/5/26 at 3:00 P.M., after reviewing the clinical records for Patients #1, #2, #3, #4, #5, #6 and #7, the Clinical Manager said all the Skilled Nurse visit notes were signed beyond the required 24 hour timeframe. Review of the agency's policy entitled, Documentation Submission, revised September 2024, indicated the following: *Electronic documentation will be submitted/transmitted via a Company-approved secure Electronic Medical Record (EMR) vendor/system via the internet with 24 hours following receipt of documents or completion of a patient visit in order to secure the documents in the patient medical record and facilitate coordination of patient care. 1. Patient #1 was admitted to the agency in April 2025 with a diagnosis of major depressive disorder. Review of the physician ordered Home Health Certification and Plan of Care (POC), dated 10/27/25 through 12/25/25, indicated the following: -SN visit: 2 times a week for 8 weeks and 3 times a week for 1 week. Review of the clinical record indicated the following: *12/12/25 SN visit, note signed on 12/14/25. *12/19/25 SN visit, note signed on 12/27/25. *12/23/25 SN visit, note signed on 12/29/25. Review of the physician ordered Home Health Certification and POC, dated 12/26/25 through 2/23/26, indicated the following: -SN visit: once a week times 1 week, 2 times a week for 8 weeks and once a week for 1 week. Review of the clinical record indicated the following: *12/26/25, and 12/19/25 SN visits, both notes signed on 1/3/26. *1/2/26 SN visit, note signed on 1/6/26. *1/7/26 SN visit, note signed on 1/9/26. *1/9/26 SN visit, note signed on 1/12/26. *1/12/26 SN visit, note signed on 1/16/26. *1/16/26 SN visit, note signed on 1/19/26. *1/23/26 SN visit, note signed on 1/27/26. *1/29/26 SN visit, note signed on 2/2/26. 2. Patient #3 was admitted to the agency in April 2025 with a diagnosis of shizophrenia (a serious brain disorder causing a distorted perception of reality). Review of the physician ordered Home Health Certification and POC, dated 8/13/25 through 10/11/25, indicated the following: -SN visit: 4 times a week for 1 week, 7 times a week for 7 weeks, and 8 times a week for 1 week. Review of the clinical record indicated the following: *9/7/25 SN visit, note signed on 9/14/25. 3. Patient #5 was admitted to the agency in August 2019 with a diagnosis of schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania). Review of the physician ordered Home Health Certification and POC, dated 10/28/25 through 12/26/25, indicated the following: -SN visit: 4 times a week for 1 week, and 5 times a week for 8 weeks Review of the clinical record indicated the following: *12/11/25 and 12/12/25 SN visits, both notes signed on 12/14/25. *12/23/25 SN visit, note signed on 12/29/25. Review of the physician ordered Home Health Certification and POC, dated 12/27/25 through 2/24/26, indicated the following: -SN visit: 5 times a week for 8 weeks, and 4 times a week for 1 week, and 2 as needed (PRN) visits. Review of the clinical record indicated the following: *1/1/26 SN visit, note signed on 1/4/26. *1/26/26 SN visit, note signed on 1/28/26.

A Recertification survey was conducted at CenterWell Home Health on 2/8/23 through 2/9/23 for compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies. As a result of this survey, it was determined the agency was in compliance with these requirements. No deficiencies were cited.

A Recertification survey was conducted at CenterWell Home Health on 2/8/23 through 2/9/23 to determine compliance with the 42 CFR Part 488 requirements for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance with these requirements. Deficiencies were cited.

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: Based on observation, record review and interview, the Agency failed to ensure its staff conformed with the Physician's order for two Patients (#3 and #4), out of a total sample of seven patients. Specifically, (1) for Patient #3, the Agency staff failed to review the Medication Profile and reconcile the medications prior to administration, as ordered and (2) for Patient #4, the Agency staff failed to adhere to Universal Precautions (the practice of avoiding contact with patients' bodily fluids by means of wearing gloves and handwashing) prior to medication administration, as ordered. Findings include: 1. Patient #3 was admitted to the Agency in November 2018 with a diagnosis of Schizoaffective Disorder, Bipolar Type (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression). Review of the Home Health Certification and Plan of Care for certification period 12/24/22 through 2/21/23 indicated a Physician's order for the Skilled Nurse to review the Medication Profile (list of prescribed medications) and Reconcile Medications (process of comparing the medication list against the Physician orders). Review of the Agency policy titled Medication Review and Documentation, revised 10/2022, included, but not limited to: -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 electronic record. During a home visit observation on 2/9/23 at 9:30 A.M., Nurse #1 did not review the Medication Profile and did not reconcile the medications that were listed in the electronic device (tablet) while preparing the medications for administration. The surveyor asked Nurse #1 if he looked at the Medication Profile as he was preparing the medications and he said "I have been doing this for a long time and I know all the medications by heart for Patient #3. During an interview on 2/9/23 at 9:50 A.M, Nurse #1 said he did not review the Medication Profile and did not reconcile the medications, as ordered. 2. Patient #4 was admitted to the Agency in March 2018 with a diagnosis of Borderline Personality Disorder ( a mental disorder characterized by unstable moods, behavior and relationships). Review of the Agency Competency Evaluation Job Aid, revised 7/17/21, indicated to Follow Universal Precautions/Infection Control, the employee must perform handwashing: -upon entering the home, -before and after hands on care, -as appropriate during wound care, -upon completion of care, -just prior to leaving the patient's home. Review of the Home Health Certification and Plan of Care for certification period 12/15/22 through 2/16/23 indicated a Physician's order to adhere to Universal Precautions. During a home visit observation on 2/9/23 at 10:00 A.M., Nurse #1 donned (applied) gloves before preparing medications for administration. While wearing the gloves, Nurse #1 retrieved an empty medication bottle that he had thrown in the trash container. Nurse #1 did not change his gloves and did not sanitize his hands. Nurse #1 gave Patient #4 the prepared medications with his gloved hands. Nurse #4 exited the home while still wearing the original gloves that he had donned when he entered the home. During an interview on 2/9/23 at 10:20 A.M., Nurse #1 said he did not follow Universal Precautions and did not don/doff gloves and sanitize his hands, as required. During an interview on 2/9/23 at 12:15 P.M., the Clinical Manager said Universal Precautions are now called Standard Precautions and hands should be sanitized and gloves should be donned and doffed (removed), as required.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the Agency failed to ensure its staff administered medications as ordered by the Physician for one Patient (#4), out of a total sample of seven patients. Findings include: Patient #4 was admitted to the Agency in March 2018 with a diagnosis of Borderline Personality Disorder ( a mental disorder characterized by unstable moods, behavior and relationships). Review of the Agency policy titled, Medication Review and Documentation, revised 10/2022, included, not not limited to: -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 electronic medical record. -When conducting medication assessments Clinical Associates must complete the following actions with the patient/caregiver and/or staff interview regardless of where the patient resides. -Examine medication bottles, prescriptions and current med lists provided by the patient. When handling patient medications/bottles, never leave the patient/caregiver line of vision. Review medication lists from physician/allowed practitioner and/or inpatient facility within the last 30 days and compare to home medications found to ensure complete accurate medication availability to the patient. Review of the Home Health Certification and Plan of Care for certification period 12/19/22 through 2/16/23 indicated a Physician order for Aripiprazole (an antipsychotic) 2 milligram (mg) every AM (morning) and Aripiprazole 5 mg every AM. During a home visit observation on 2/9/23 at 10:00 A.M., Nurse #1 did not review the medication list and did not examine the Aripiprazole medication bottles while he prepared medications for administration. Patient #4 checked the poured medications and noticed that there were two Aripiprazole 5 mg tablets and not one 5 mg and one 2 mg tablet, as ordered. Patient #4 made Nurse #1 aware of the incorrect dose prior to swallowing the medications. Nurse #1 then repoured the corrected Aripiprazole tablets to equal the ordered dose. During an interview on 2/9/23 at 10:20 A.M., Nurse #1 said he did not review the medication list nor the medication bottles for accuracy, while he was preparing the medications, as required.