Every finding on record at Centerwell Certified Healthcare Corp.

CenterWell Home Health is in compliance with the requirements of 42 CFR 484.102 Conditions of Participation for Home Health Agencies.

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 and procedure review, and staff interview, the agency failed to ensure an initial assessment of patient's immediate needs were completed within 48 hours of referral, and there was no documentation in the record to request to extend the initial assessment beyond 48 hours from referral date for 2 of 17 patient records reviewed (Patient 4 and 12). The census was 175. Findings are: A. Review of the agency’s policy and procedure titled, 03-15 Patient Assessments, revised 9/28/18, revealed: 1. The agency was to complete an initial assessment visit to the patient within 48 hours from the date of referral for services unless otherwise ordered by the physician/allowed practitioner. 2. If the agency receives a referral and cannot conduct the initial assessment within 48 hours of the referral, the agency will contact the respective physician/allowed practitioner or referral entity. Approval will be obtained for a specific start of care date or a referral to another home health agency provider for services. B. Review of Patient 4’s clinical record review revealed: 1. The agency received a referral electronically on 1/21/26 from Think Whole Person Healthcare. 2. The patient’s start of care was 1/27/26 (6 days after receipt of the referral). 3. There was no documentation in the record to extend the initial assessment beyond 48 hours from the referral date. C. Review of Patient 12’s clinical record review revealed: 1. The agency received a referral electronically on 11/25/25 from Methodist Health System. 2. The patient’s start of care was 12/3/25 (8 days after receipt of the referral). 3. There was no documentation in the record to extend the initial assessment beyond 48 hours from the referral date. D. During an interview on 3/24/26 at 4:00 PM, the Administrator and Registered Nurse (RN) back up administrator confirmed: 1. The agency failed to follow the agency’s policy and procedure to complete the initial assessment within 48 hours of referral or within 48 hours of patient's return home. 2. Staff were to document in the clinical record the reason to extend the start of care and/or initial assessment, and when contact was made with the patient and/or the physician/approved practitioner. 3. The start of care and initial assessment are completed during the same visit.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure the patient's medication profile (a real-time document used by the agency, as part of the plan of care, that lists the patient’s medications, including new and updated orders received between the certification periods) was accurate and included all medication orders received by the agency for 4 of 17 patients records reviewed (Patient 1, 2, 4, and 6). The census was 175. Findings are: A. Review of the agency’s policy and procedure titled 03-11 Care Planning, revised 1/19/18, revealed: 1. Each patient must receive an individualized written Plan of Care including ongoing updates and/or additions related to patient findings. 2. The Plan of Care must include all medications. B. Review of the agency’s policy and procedure titled 03-41 Medication Review and Documentation, revised 5/31/17, revealed: 1. Medication review was to be performed by a Clinical Associate during each visit to ensure medications were current, accurate and documented on the medication profile within the patient’s medical record. 2. The Clinical Associate was required to follow-up with the physician/allowed practitioner for all medication discrepancies. C. Review of Patient 1’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period 1/28/26 through 3/28/26, and the POC's medication profile revealed: a. Amlodipine (used to treat high blood pressure) 5 mg (milligrams) 1 tablet daily. b. Vitamin D3 (supplement), 1000 unit capsule, 1 capsule daily. 2. An after visit summary from CHI Health, dated 1/26/26, included orders: a. Amlodipine 10 mg, 1 tablet daily. b. Vitamin D3 1000 units, 4 tablets daily. 3. The patient’s POC and POC's medication profile failed to include updated orders for Amlodipine and Vitamin D3 as ordered from CHI Health. 4. The agency failed to follow up with the physician/allowed practitioner and document the medication discrepancies. D. Review of Patient 2’s clinical record review revealed: 1. The discharge orders from Old Mill Rehabilitation, received via fax to the agency on 5/16/25, included orders: a. Calmoseptine (ointment used to treat skin irritation), apply topically to buttocks 2 times daily. b. Zyrtec (used to treat allergy symptoms) 10 mg, 1 tablet daily. 2. The POC for the certification period of 11/16/25 through 1/14/26 and 1/15/26 through 3/15/26, and the POC’s medication profile failed to include Calmoseptine and Zyrtec, and the record did not include orders to discontinue the Calmoseptine and Zyrtec. 3. The agency failed to follow up with the physician/allowed practitioner and document the medication discrepancies. E. Review of Patient 4’s clinical record review revealed: 1. The referral orders from Think Whole Person Healthcare, received by the agency electronically on 1/16/26, included orders: a. Colace (stool softener) 100 mg, 1 capsule 2 times daily, twice weekly. b. Magnesium Oxide (supplement) 400 mg, 1 tablet, 2 times daily. 2. The POC for the certification period of 1/27/26 through 3/27/26 and the POC’s medication profile revealed: a. Colace 100 mg, 1 capsule, daily. b. Magnesium Oxide 400 mg, 1 tablet daily. 3. The agency failed to follow up with the physician/allowed practitioner and document the medication discrepancies. F. Review of Patient 6’s clinical record review revealed: 1. The POC for the certification period of 1/28/26 through 3/28/26 and the POC’s medication profile revealed: a. Furosemide (diuretic) 20 mg, 1 tablet daily. b. GI Balance (supplement) 6 capsules daily. 2. An office visit note from Neurology Clinic, dated 12/4/25, received via fax to the agency on 1/21/26, included orders: a. Ferrous Sulfate (iron supplement) 325 mg, 1 tablet every other day. b. Magnesium Hydroxide (laxative) 400 mg/5 ml (milliliter), 30 ml daily as needed for constipation. c. Magnesium Oxide (supplement) 400 mg, 1 tablet, 2 times daily. d. Polyethylene glycol (laxative) 17 grams daily as needed for constipation. e. Metamucil (laxative) 3.4 grams/5.4 gram powder daily. f. Tamsulosin (used to treat enlarged prostate) 0.4 mg, 1 capsule daily. g. The office visit note orders, dated 12/4/25, did not include Furosemide and GI Balance, as listed on the patient’s POC and the POC's medication profile. 3. The patient’s POC and the POC's medication profile failed to include Ferrous Sulfate, Magnesium Hydroxide, Magnesium Oxide, Polyethylene glycol, Metamucil, and Tamsulosin, as ordered on the office visit note, dated 12/4/25. 4. The agency failed to follow up with the physician/allowed practitioner and document the medication discrepancies. G. During an interview on 3/24/26 at 4:00 PM, the Administrator and Registered Nurse (RN) back up administrator confirmed the agency failed to follow the agency’s policies and procedures to ensure the patient's medication orders on the POC and the POC's medication profile, were accurate for 4 of 17 patient records reviewed (Patient 1, 2, 4, and 6).

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 record review, policy and procedure review, observation of the provision of care, and staff interview, the agency failed to ensure 2 of 7 staff (Staff C and D), observed during the provision of care for 2 of 7 patients (Patient 1 and 2), performed proper cleaning of equipment, according to the agency's policy and procedure. The total sample size was 17. The census was 175. Findings are: A. Review of the agency’s policy and procedure titled Bag Technique and Equipment Cleaning Job Aid, revised 6/29/22, revealed after obtaining the patient’s signature at the end of the visit, staff were to clean the tablet and case with a disinfectant wipe. B. Review of Patient 1’s Home Health Certification and Plan of Care (POC), for the certification period of 1/28/26 through 3/28/26, included orders for Occupational Therapy (OT) 1 time weekly x 3, 1 time every 2 weeks x 4, to establish a home exercise program and provide therapeutic exercises and activities to improve functional strengthening/ endurance, range of motion, and flexibility. C. Review of Patient 2’s POC, for the certification period of 1/15/26 through 3/15/26, included orders for Skilled Nurse (SN) 1 time weekly to perform wound care to the patient’s right knee. D. The observation of the provision of care for Patient 1 on 3/11/26 at 8:30 AM, revealed Staff C failed to clean the tablet and the stylus pen, after obtaining the patient’s signature on the tablet and returning the stylus pen into the holder on the tablet. E. The observation of the provision of care for Patient 2 on 3/11/26 at 12:50 PM, revealed Staff D failed to clean the tablet and the stylus pen, after obtaining the patient’s signature on the tablet and returning the stylus pen into the holder on the tablet. F. During an interview on 3/24/26 at 4:00 PM, the Administrator and Registered Nurse (RN) back up administrator confirmed Staff C and D failed to follow the agency’s policy and procedure for proper cleaning of equipment during the provision of care for Patient 1 and 2 respectively.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to conduct Registered Nurse (RN) onsite supervisory visit at least every 14 days of Home Health Aides, for 2 or 3 patients (Patients 10 and 17) receiving Home Health Aide services. The total sample size was 17. The census was 175. Findings are: A. Review of the agency’s policy and procedure titled 03-17 Patient Care Supervision, revised 9/28/18, revealed when patients are receiving skilled nursing services, a Registered Nurse (RN) will perform onsite supervisory visits to each patient at least every 14 days. B. Review of Patient 10’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period 11/19/25 through 1/17/26 and 1/18/26 through 3/18/26, included orders for Skilled Nurse (SN) every 2 weeks and Home Health Aide 1 time weekly. 2. The agency failed to conduct RN onsite Home Health Aide supervisory visits, at least every 14 days, from 1/28/26 through 2/11/26 and 2/24/26 through 3/10/26. C. Review of Patient 17’s clinical record revealed: 1. The POC for the certification period 12/17/25 through 2/14/26 included orders for Skilled Nurse (SN) every 1 time weekly x 2, 2 times weekly x 1, 3 times weekly x 2, then 5 times weekly x 4, and Home Health Aide 1 time weekly starting the week of 1/4/26. 2. The agency failed to conduct RN onsite Home Health Aide supervisory visits, at least every 14 days, from 1/8/26 through 1/22/26. D. During an interview on 3/24/26 at 4:00 PM, the Administrator and the Registered Nurse (RN) back up administrator, confirmed the agency failed to follow the agency’s policy and procedure for conducting RN onsite Home Health Aide supervisory visits, at least every 14 days, for Patients 10 and 17.

CenterWell Home Health is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

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 and procedure review, and staff interview, the agency failed to ensure an initial assessment of patient's immediate needs were completed within 48 hours of referral, or within 48 hours of the patient's return home, and the agency's process failed to ensure timely completion of the initial assessment as required by this regulation for 5 of 17 patient records reviewed (Patient 6, 11, 12, 15, and 17). The census was 372. Findings are: A. Review of the agency policy and procedure titled, 03-05 Initial and Comprehensive Assessment, revised 9/28/18, revealed: 1. The agency is to complete an initial on-site assessment visit to the patient within 48 hours of referral for services, or within 48 hours of the patient's discharge to home, or a physician specified start of care. 2. If the agency is not able to meet the required time frame, the office is to contact the provider, with knowledge of the patient's current condition, for direction and obtain a specific start of care date, or refer the patient to another provider for services. B. Review of Patient 6's clinical record revealed: 1. A referral received via fax on 10/19/22 to begin home health physical therapy (PT). 2. First documentation of patient contact to set-up up time for a visit was recorded on a coordination note dated 10/24/22 (5 days after receipt of referral). 3. The patient's start of care was 10/25/22 (6 days after the receipt of referral) C. Review of Patient 11's clinical record revealed: 1. A referral received via fax on 12/30/22 for PT to evaluate and treat and bath aide assistance. 2. First documentation of patient contact to set-up up time for a visit was recorded on a New Referral Form dated 1/4/23 (5 days after receipt of referral). 3. A verbal order received on 1/5/23 for PT to evaluate and treat received from the patients primary care physician (6 days after receipt of referral). 4. A order to delay start of care until 1/9/23 with no reason provided for the delay. 5. The patient's start of care date was 1/9/23 (9 days after receipt of referral). D. Review of Patient 12's clinical record revealed: 1. A referral received via fax on 12/21/22 with request for Registered Nurse (RN), PT, and Occupational Therapy (OT) to evaluate. 2. A verbal order was received on 12/28/22 to admit patient (7 days after receipt of referral). 3. A verbal order received on 1/3/23 to delay start of care until 1/5/23 per family request (order received 13 days after receipt of referral). 4. The patient's start of care was 1/5/23. E. Review of Patient 15's clinical record revealed: 1. A referral received via fax on 12/6/22 for PT and OT to evaluate. 2. The patient's start of care date was 12/13/22 (7 days after receipt of referral). 3. There was no documentation in the clinical record the patient or physician requested a delay in the start of care. F. Review of Patient 17's clinical record revealed: 1. A referral received via fax on 10/26/22 for PT. 2. The patient's start of care was 10/30/22 (4 day after receipt of referral). 3. There was no documentation in the clinical record that the patient or physician requested a delay in the start of care. G. During an interview on 3/14/23 at 11:30 AM, the Administrator and the Area Director of Operations (ADOO) confirmed: 1. The agency policy is to complete the initial assessment within 48 hours of referral or within 48 hours of patient's return home. 2. The agency process currently in place could cause a delay of greater than 48 hours from receipt of referral until the initial assessment is completed. 3. Staff are to document the reason for the delay in the start of care and/or initial assessment and when contact is made with the patient and/or the physician, in the clinical record. 4. The start of care and initial assessment are completed during the same visit.

An unannounced complaint investigation was completed on 9/28/22. An allegations of the complaint was substantiated and a deficiency was cited at G596. The agency census was 340.

Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner's issuing orders for the HHA plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to inform the patient and/or caregiver of a change in patient condition for 1 of 4 clinical records reviewed (Patient-3). The census was 340. Findings are: A. Review of the agency policy and procedure titled, Care Planning, reviewed 9/2022, revealed staff are to notify the physician, patient, patient representative, and caregiver if any changes are identified in the patient’s conditions. B. Review of the agency policy and procedure titled, General Information, reviewed 9/2022, revealed documentation supporting the care planning process was to include case communication/care coordination notes. C. Review of Patient 3’s clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 5/28/22 through 7/26/22 included orders for Skilled Nurse (SN) 1 time per week for 1 week, then 2 times per week for 2 weeks, then 1 time a week for 3 weeks, then 1 time every other week for 4 weeks. 2. The Home Health Certification and Plan of Care for the certification period of 7/27/22 through 9/24/22 included orders for SN 1 time a week for 2 weeks, then 1 time every 2 weeks for 4 weeks, then 2 times every 2 weeks for 2 weeks. 3. A COVID-19 Test was ordered on 7/26/22. 4. COVID-19 Test results received by the agency on 7/27/22, revealed the patient was positive for COVID-19. 5. There was no documentation in the clinical record the patient was notified of the COVID-19 positive test results. D. During an interview on 9/28/22 at 9:30 AM, the Administrator confirmed there was no documentation in the clinical record that the patient and/or caregiver was notified of the patient change in condition to COVID-19 positive. The Administrator also confirmed it is the agency expectation that staff document communication with the patient and/or caregiver in the patient’s clinical record.