Every finding on record at Centerwell Certified Healthcare Corp

An unannounced Medicare/Medicaid Home Health Recertification survey was conducted at the above noted agency October 6-7, 2021 and October 12-13, 2021 by one Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health. As part of the inspection process, the agency's Emergency Preparedness Plan was reviewed. The agency was found to be in compliance with 42 CFR 484.113, the Condition of Participation - Emergency Preparedness for Home Health Agencies.

An unannounced Medicare/Medicaid Home Health Recertification survey was conducted at the above noted agency October 6-7, 2021 and October 12-13, 2021 by one Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health. The agency identified 1064 unduplicated admissions for the past twelve (12) months. In conjunction with the survey, (17) clinical records and five (5) personnel files were reviewed. Seven (7) home visits were also conducted. The agency was found to be out of compliance with the Federal requirements of 42 CFR 484, the Medicare/Medicaid Conditions for Certification of Home Health Agencies. Deficiencies were identified and cited in this report.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, it was determined the agency failed to ensure that a resumption of care occurred within 48 hours of each patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on a physician's or allowed practitioner's ordered resumption date. Specifically, the agency failed to conduct a timely resumption of care within 48 hours of a patient's return home from a hospital admission of more than 24 hours for one (1) of one (1) patient's who had a resumption of care and whose clinical record was reviewed as part of the survey sample: (Clinical record #1). The findings: Seventeen (17) clinical records were reviewed with read only access on 10/6/2021 and 10/12/2021 with the following findings: 1. The clinical record for patient #1 was reviewed for the certification period of 8/31/2021 to 10/29/2021. A Physical Therapy note dated 9/28/2021 contained documentation of the patient being sent to a local hospital on 9/26/2021 for COVID and was discharged home 9/28/2021. A Physical Therapist completed a resumption of care (ROC) on 10/04/2021 (5 days later). On 10/12/2021 at 2:00 PM, the MFI (Medical Facilities Inspector) asked the Branch Director if the clinical record contained any evidence of a physician-ordered ROC date of 10/04/2021. The Branch Director confirmed that the clinical record failed to contain a physician ordered ROC date of 10/04/2021 and stated, we failed to provide timely initiation of care. The agency failed to complete the ROC within 48 hours of the patient's return home from the hospital. The above noted findings were reviewed and acknowledged with the Branch Director and the Clinical Manager on 10/13/2021 at 11:30 AM.

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: Based on review of clinical records and staff interview, it was determined the agency staff failed to ensure home health services were provided according to the patient's individualized plan of care for (10) of (17) clinical records that required assessment of patient weights and notification to physician when visits were missed and reviewed in the survey sample (Clinical record #s 3, 5, 6, 7, 8, 9, 10, 11, 14 and 17). Based on review of clinical records and staff interview, it was determined the agency staff failed to ensure home health services were provided according to the patient's individualized plan of care for (10) of (17) clinical records that required assessment of patient weights and notification to physician when visits were missed reviewed in the survey sample (Clinical record #s 3, 5, 6, 7, 8, 9, 10, 11, 14 and 17). The findings: Seventeen (17) clinical records were reviewed with read only access on 10/6/2021 and 10/12/2021 with the following findings: 1. The clinical record for patient #3 was reviewed for the recertification period of 9/10/2021 to 11/8/2021. The patient's plan of care contained orders as follows: Skilled Nurse to report weight gain of 2-3 lbs/day (pounds per day) or 5 lbs/week (pounds per week). The clinical record failed to contain documentation that the nurse assessed the patient's weight as listed in the plan of care orders. On 10/12/2021 at 11:00 AM the Branch Director verified the lack of documentation on the patient's weight and stated, there needs to be a parameter attached to that order to signify to the clinician that a weight is needed. 2. The clinical record for patient #5 was reviewed for the certification period of 9/16/2021 to 11/14/2021. The patient's plan of care contained orders for Skilled Nursing (SN) three (3) times a week for three (3) weeks starting week 2. The clinical record contained documentation of two (2) SN visits the week of 9/18/2021 through 9/24/2021 (week 2 for SN), and one (1) SN visit the week of 9/25/2021 through 10/01/2021 (week 3 for SN). The clinical record failed to contain documentation the patient's physician was notified of the visit not being provided in accordance with the patient's plan of care orders. On 10/13/2021 at 10:50 AM, the Branch Director verified the missed visits and stated, they should have changed the frequency and wrote an order to decrease the frequency of visits. 3. The clinical record for patient #6 was reviewed for the certification period of 3/26/2021 to 5/24/2021. The patient's plan of care contained orders as follows: Skilled Nurse to report weight gain of 2-3 lbs/day (pounds per day) or 5 lbs/week (pounds per week). The clinical record failed to contain documentation that the nurse assessed the patient's weight as listed in the plan of care orders. 4. The clinical record for patient #7 was reviewed for the certification period of 8/14/2021 to 10/12/2021. The patient's plan of care contained orders as follows: Skilled Nurse to report weight gain of 2-3 lbs/day (pounds per day) or 5 lbs/week (pounds per week). The clinical record failed to contain documentation that the nurse assessed the patient's weight as listed in the plan of care orders. 5. The clinical record for patient #8 was reviewed for the certification period of 6/01/2021 to 7/30/2021. The patient's plan of care contained orders as follows: Skilled Nurse to report weight gain of 2-3 lbs/day (pounds per day) or 5 lbs/week (pounds per week). The clinical record failed to contain documentation that the nurse assessed the patient's weight as listed in the plan of care orders. In addition, the patient's plan of care contained orders for Skilled Nursing (SN) one (1) time a week for nine (9) weeks 1-9. The clinical record contained documentation of zero (0) SN visit the week of 6/19/2021 through 6/25/2021 (week 4 for SN). The clinical record failed to contain documentation the patient's physician was notified of the visit not being provided in accordance with the patient's plan of care orders. On 10/13/2021 at 10:55 AM the Branch Director verified the missed visits and stated, the missed visit communication note was not put in for that week. 6. The clinical record for patient #9 was reviewed for the certification period of 7/06/2021 to 9/03/2021. The patient's plan of care contained orders as follows: Skilled Nurse to report weight gain of 2-3 lbs/day (pounds per day) or 5 lbs/week (pounds per week). The clinical record failed to contain documentation that the nurse assessed the patient's weight as listed in the plan of care orders. 7. The clinical record for patient #10 was reviewed for the certification period of 7/20/2021 to 9/17/2021. The patient's plan of care contained orders as follows: Skilled Nurse to report weight gain of 2-3 lbs/day (pounds per day) or 5 lbs/week (pounds per week). The clinical record failed to contain documentation that the nurse assessed the patient's weight as listed in the plan of care orders. 8. The clinical record for patient #11 was reviewed for the recertification period of 8/21/2021 to 10/19/2021. The patient's plan of care contained orders as follows: Skilled Nurse to report weight gain of 2-3 lbs/day (pounds per day) or 5 lbs/week (pounds per week). The clinical record failed to contain documentation that the nurse assessed the patient's weight as listed in the plan of care orders. In addition, the patient's plan of care contained orders for Skilled Nursing (SN) one (1) time a week every other week for (6) starting week 2. The clinical record contained documentation of zero (0) SN visit the week of 9/25/2021 through 10/01/2021 (week 6 for SN). The clinical record failed to contain documentation the patient's physician was notified of the visit not being provided in accordance with the patient's plan of care. On 10/13/2021 at 10:45 AM the Branch Director verified the missed visits and stated, missed that visit and should have wrote an order that we would visit the following visit. 9. The clinical record for patient #14 was reviewed for the certification period of 8/18/2021 to 10/16/2021. The patient's plan of care contained orders for Skilled Nursing (SN) three (3) times a week for two (2) weeks starting week 1-2. The clinical record contained documentation of two (2) SN visit the week of 8/21/2021 through 8/22/2021 (week 2 for SN). The clinical record failed to contain documentation the patient's physician was notified of the visit not being provided in accordance with the patient's plan of care. 10. The clinical record for patient #17 was reviewed for the recertification period of 10/01/2021 to 11/29/2021. The patient's plan of care contained orders as follows: Skilled Nurse to report weight gain of 2-3 lbs/day (pounds per day) or 5 lbs/week (pounds per week). The clinical record failed to contain documentation that the nurse assessed the patient's weight as listed in the plan of care orders. The above noted findings were reviewed and acknowledged by the Branch Director and the Clinical Manager on 10/13/2021 at 11:30 AM.

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 a review of clinical records and staff interview, it was determined the agency failed to send the patient's discharge summary to the primary care physician or primary care practitioner within 5 business days from the date of the final visit and failed to send the patient's transfer summary within 2 business days of becoming aware of an unplanned transfer for two (2) of five (5) closed clinical records reviewed in the survey sample. (Clinical record #'s 6 and 7). The findings: Five (5) closed clinical records were reviewed with read only access on 10/6/2021 and 10/12/2021 with the following findings: 1. The clinical record for patient #6 was reviewed for the certification period of 3/26/2021 to 5/24/2021. The record revealed that the patient was discharged from the agency on 5/13/2021. No discharge summary was sent to the primary physician. On 10/13/2021 at 11:05 AM the Branch Director verified the failed discharge summary to the primary physician and stated, we had an internal audit May 26, 2021 and found out the person who was completing this task did not complete the second task so that is part of our quality improvement now. 2. The clinical record for patient #7 was reviewed for the certification period of 8/14/2021 to 10/12/2021. The record revealed that the patient was transferred from the agency on 8/27/2021 and a transfer summary was sent to the primary physician on 9/16/2020; 20 days later. The lack of providing a discharge summary within 5 business days of the patient's discharge and a transfer within 2 business days was acknowledged prior to and during the exit conference with the Branch Director and the Clinical Manager on 10/13/2021 at 11:30 AM.