Every finding on record at Centerwell Certified Healthcare Corp.

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 complete an initial assessment within 48 hours of referral, signed physician orders or the patient's return home for 1 of 10 patients (Patient 5). The census was 66. Findings are: A. Review of the agency policy and procedure titled 03-05 Patient Assessments, reviewed 9/2025, revealed the initial assessment must be completed on or before the start of care date and within 48 hours from the date of referral or facility discharge (whichever is later) unless otherwise ordered by the physician/allowed practitioner. B. Review of Patient 5's clinical record revealed: 1. A Client Coordination Note Report to the patient's physician requesting orders for home health care Physical Therapy (PT) and Occupational Therapy (OT) for the patient. The order was signed by the physician on 11/28/25. 2. The Home Health Certification and Plan of Care revealed that the start of care date was 12/1/25 (the date the initial and comprehensive assessment was completed by the agency). C. During an interview on 12/29/25 at 3:30 PM, the Administrator confirmed the start of care/initial assessment was not completed for Patient 5 within 48 hours of receiving the signed physician order.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient 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 include information about the patients progress towards the goals identified by the home health agency (HHA) and the patient on the revised/updated plan of care for 4 of 4 patients (Patient 1, 3, 7, and 8) who had a revised/updated plan of care. The census was 66. Findings are: A. Review of the agency policy and procedure titled 03-11 Care Planning, revised 9/2024, revealed: 1. The plan of care was to contain measurable outcomes and goals. 2. The plan of care was to be reviewed and updated as necessary to meet the changing needs of the patient in the most effective and efficient manner to achieve the desired outcomes. 3. The policy failed to include the requirement to include information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA, and the patient, in the plan of care. B. Review of clinical records revealed: 1. Patient 1's Revised/Updated Home Health Certification and Plan of Care for the certification period of 11/4/25 through 1/2/26 did not include information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient. 2. Patient 3's Revised/Updated Home Health Certification and Plan of Care for the certification period of 11/2/25 through 12/31/25 did not include information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient. 3. Patient 7's Revised/Updated Home Health Certification and Plan of Care for the certification period of 12/24/25 through 2/21/26 did not include information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient. 4. Patient 8's Revised/Updated Home Health Certification and Plan of Care for the certification period of 6/16/25 through 8/14/25 did not include information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient. C. During an interview on 12/29/25 at 3:30 PM, the Administrator confirmed the agency did not include information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA, and the patient, in the revised/updated plan of care.