Every finding on record at Centerwell Certified Healthcare Corp

An unannounced Home Health Agency recertification survey was conducted on March 21-23, 2022 by one (1) Medical Facilities Inspector from The Office of Licensure and Certification, Virginia Department of Health. In conjunction with this survey, the agency's emergency preparedness plan was reviewed. The agency was found to be in compliance with 42 CFR 484.102 Conditions of Participation Emergency Preparedness for Home Health Agencies.

An unannounced Home Health Agency recertification survey was conducted on March 21-23, 2022 at the above captioned agency by one (1) Medical Facilities Inspector from The Office of Licensure and Certification, Virginia Department of Health. The agency reported an unduplicated census of 1415 in the last twelve (12) months with an active census of 404 patients. The following were completed/reviewed in conjunction with the survey: Seven (7) home visits, seventeen (17) clinical records, seven (7) personnel files, review of selected policies and procedures, complaint log, emergency preparedness plan, Covid vaccination records and interviews were conducted. The agency was found to be out of compliance with 42 CFR 484, Conditions of Participation for Home Health Agencies (HHAs). Deficiencies were identified, cited and will follow in this report.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on a review of clinical records, observations during home visits and staff interviews it was determined the agency failed to ensure the patient's individualized plan of care included all medications and treatments for two (2) of seventeen patients whose clinical records were reviewed in the survey sample (clinical records #11 and 15). The findings were: 1. Clinical record #11 was reviewed for the certification period of 2/20/2022 through 4/20/2022. The plan of care contained skilled nursing interventions to instruct in oxygen use, however the medication list failed to list oxygen with a dose and route of administration. A home visit was conducted on 3/22/2022 at 9:45 am. The patient was observed to have oxygen in use in the home. 2. Clinical record #15 was reviewed for the certification period of 3/19/2022 through 5/17/2022. The plan of care contained skilled nursing interventions to instruct in oxygen use, however the medication list failed to list oxygen with a dose and route of administration. A home visit was conducted on 3/22/2022 at 1:45 PM. The patient had an oxygen concentrator in the home that was not in use. The skilled nurse visiting the patient asked about the use of oxygen and the patient stated only needing it occasionally. An interview was conducted with the administrator on 3/23/2022 at approximately 12:30 PM. The administrator acknowledged the deficient practice.