Every finding on record at Centerwell Certified Healthcare Corp.

An emergency preparedness plan (EPP) survey was conducted from August 25, 2025 to August 27, 2025, in conjunction with a recertification survey at CenterWell Home Health of South Charleston. It was determined the facility is in compliance with the Emergency Preparedness Conditions of Participation for Home Health Agencies.

AMENDED A recertification survey was conducted at CenterWell Home Health of South Charleston from August 25, 2025 to August 27, 2025. It was determined the agency is not in compliance with the requirements of 42 CFR, Part 484 - The Medicare Conditions of Participation for Home Health Agencies, with deficiencies cited at G0590 and G0682.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: The Home Health Agency (HHA) failed to comply with 484.60(c)(1) for one (1) of three (3) patients observed during a skilled nursing (SN) visit (Patient #5). The HHA failed to complete a head to toe assessment following falls experienced by the patient on two (2) consecutive days in order to notify the relevant physician(s) to any changes in the patient’s condition or needs and/or determine that the plan of care should be altered. Findings include: An observation was conducted at the home of patient #5 on 08/26/25 starting at 9:07 a.m., accompanied by staff #3. The patient was in [his/her] bedroom, sitting on the chair by the window, and eating breakfast. Per an adult family member, the patient fell yesterday and today (08/25/25 and 08/26/25) for unknown reasons. The family member called emergency medical services (EMS) for help assisting the patient off the floor; and the patient was put back on the chair both days. When staff #3 asked the non-verbal patient what [he/she] was trying to do when [he/she] fell, the patient pointed to the portable bedside commode. Staff #3 took vital signs, reviewed medication, and discussed with the family member if the patient would benefit from a hospital bed. The adult family member agreed with staff #3’s suggestions. The nurse failed to do a physical head to toe assessment of the patient after it was reported they had fallen for two (2) consecutive days. A medical record review was conducted for patient #5, start of care (SOC) date 07/21/25, with a diagnosis that included ileus. Patient #5 received skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) services from the HHA. A review of the Visit Note Report with a visit date of 08/26/25, revealed in part: “[Primary care physician (PCP)] attempted x 3 [times three]. Office closed with no acceptance of non emergent needs. SN to reattempt with next opening.” And: “Patient/caregiver educated on importance of daily head to toe assessment with reporting any new findings of skin impairment or medical concern to CWHH [CenterWell Home Health]...” An interview was conducted on 08/26/25 at 10:16 a.m. with staff #1 regarding patient #5 falling two (2) consecutive days. Staff #1 stated: “[Staff #3] is a Registered Nurse (RN) and should have completed a head to toe assessment on [patient #5], I don’t know why [he/she] didn’t. We are going to have PT to assess [him/her] tomorrow.” Staff #1 confirmed that the PCP should have been notified and stated: “I believe [he/she] tried to notify the PCP, but the office was closed. [He/She] may be out of the country, [he/she] does that sometimes.”

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: The Home Health Agency (HHA) failed to comply with 484.70(a) for one (1) of three (3) patients observed during a skilled nursing (SN) visit (Patient #4). The HHA failed to prevent the potential transmission of infection by placing a urine soaked adult brief over a new sacral decubitus dressing. Findings include: An observation was conducted at the home of patient #4 on 08/25/25 starting at 3:15 p.m., accompanied by staff #2. The patient was bedbound and lying in bed, alert and oriented. The sitter was present and was with the patient for eight (8) hours a day. The patient was friendly. Staff #2 did vital signs, verified medication, and tried to connect a new wound vac to a decubitus wound on the sacrum, but did not have success. Staff #2 stated the wound vac was different and [he/she] didn't have knowledge of how to set it up or calibrate it. Staff #2 made a telephone call to the supply company with no answer and left a voice message. Staff #2 assessed and cleaned the wound and applied a clean dressing on the patient's sacral area. Staff #2 then secured the adult brief back without applying a new one, even though it was visibly soaked with urine. The sitter helped staff #2 turn the patient throughout the dressing change. By the time staff #2 completed the dressing change, the wound vac supply company had not returned the call. A medical record review was conducted for patient #4, SOC date 06/09/25, with a diagnosis that included pressure ulcer of sacral region, stage four (4). Patient #4 received SN and PT services from the home health agency. A review of the Visit Note Report with a visit date of 08/25/25, revealed in part: “...Wound vac arrived but needs set up. Contacted [medical supply company] and notified them via VM [voice mail] that wound vac needs set up by provider before vac can be placed. Previous WC [wound care] orders implemented, CG [caregiver] in home not able to change dressing daily…WC [wound care] performed and documented. Reviewed wound zone tool…” An interview was conducted on 08/26/25 at 3:40 p.m. with staff #1 regarding the wound vac for patient #4. Staff #1 stated: “The [medical equipment company] will send the wound vac and all of the equipment needed. The company trains our staff annually, or more often if the equipment changes. [He/she] had a wound vac previously that was discontinued, but we were putting it back per the family request. The problem that [staff #2] had was that the machine settings were wrong and [he/she] couldn’t get the suction to work. [Patient #4] went to the wound clinic today and they got it applied and working.” Regarding leaving a urine soaked adult brief on the patient following the dressing change, staff #1 stated: “They should never have done that. They know better. It could increase the risk of infection.”

An emergency preparedness survey was conducted at Kindred at Home from 3/1/21 to 3/3/21 as part of a recertification survey conducted during the same survey period. The agency is in compliance with the Emergency Preparedness Conditions of Participation for Home Health and no deficiencies were found as a result of the survey.

A recertification survey was conducted at Kindred at Home from 3/1/21 to 3/3/21. The agency provides skilled nursing, physical therapy, occupational therapy and medical social work services to Clay, Fayette, Kanawha, Lincoln, Jackson and Putnam counties. At the time of the survey the agency had an active patient census of four hundred and fifty-one (451) and the unduplicated admissions for the past twelve (12) months were one thousand five hundred and forty-four (1,544). A total of seventeen (17) clinical records were reviewed and seven (7) telephone visits were made. Three (3) standard level deficiencies were cited at G 572, G 590 and G 682.

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 document review, record review and staff interview it was determined the agency failed to ensure all skilled nursing and physical therapy home health visits ordered on the plan of care for two (2) of seventeen (17) patients were completed (patients #4 and 9). This failure has the potential to negatively affect all patients receiving home health visits. Findings include: 1. A review of the facility policy entitled "Missed Visit Documentation," last revised 01/21, revealed in part: "Missed visits should be documented within the treatment week and sent to office immediately ... A Missed Visit Notification Coordination Note must be completed based on the missed visit reason." 2. A review of the facility policy entitled "Physician's Orders," last revised 09/28/18, revealed in part: "If fewer visits are provided during the week than ordered, the physician will be notified with documentation in the clinical record that the physician is aware of the missed visit." 3. A review of Patient #4's medical record revealed an order on the plan of care for "SN EFFECTIVE 1/31/21 1WK3, 2 PRN for Cardiac Complications". The visit notes revealed no skilled nursing visits were conducted until 2/23/21. A coordination of care note was entered on 2/9/21 which stated the patient had been exposed to COVID-19 and was to be tested the next day and there would be no visits until test results were known. There was no follow up documentation of test results or documentation of missed visits between 1/31/21 and 2/23/21. 4. A review of Patient #9's medical record revealed an order on the plan of care for "PT EFFECTIVE 1/24/21 2WK1, 1WK1, 1WK2, 1WK2". The visit notes revealed no physical therapy visits were made the week of 2/7/21. There was no missed visit documentation for physical therapy for the week of 2/7/21 in the medical record. 5. An interview was conducted on 3/2/21 at approximately 8:45 a.m. with the Executive Director and she verified the missing skilled nursing visits for Patient #4. 6. An interview was conducted on 3/3/21 at approximately 12:20 p.m. with the Executive Director and she verified they were "layering therapy" for patient #9, the order on the plan of care had been changed and a correction order needed to be sent to the physician.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on document review, record review and staff interview it was determined the agency failed to ensure changes to the physical therapy home health visits ordered on the plan of care for one (1) of seventeen (17) patients were communicated to the physician (patient #9). This failure has the potential to negatively affect all patients who have changes to the plan of care for physical therapy patients. Findings include: 1. A review of the facility policy entitled "Physician's Orders," last revised 09/28/18, revealed "Change orders will be obtained to modify physician orders for disciplines, services, office-administered medications, frequency, or duration prior to making the change." 2. A review of Patient #9's medical record revealed an order on the plan of care for "PT EFFECTIVE 1/24/21 2WK1, 1WK1, 1WK2, 1WK2". The visit notes revealed no physical therapy visits were made the week of 2/7/21. There was no missed visit documentation for physical therapy for the week of 2/7/21 in the medical record. 3. An interview was conducted on 3/3/21 at approximately 12:20 p.m. with the Executive Director and she verified they were "layering therapy" for patient #9, the order on the plan of care had been changed and a correction order needed to be sent to the physician. The correction order was sent on 3/3/21.

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, staff interview and document review it was determined the facility failed to ensure appropriate policies and procedures were in place to prevent the spread of Coronavirus Disease-19 (COVID-19). This failure places all patients at risk for serious illness due to infection. Findings include: 1. Upon entrance to the facility's building on 3/1/21 at 10:45 a.m. it was observed there was no signage listing the signs and symptoms of COVID-19 and the facility itself (housed on the second floor) had no signage listing the signs and symptoms of COVID-19, how to proceed if experiencing any signs or symptoms or respiratory etiquette to prevent disease transmission. A Clinical Manager greeted the surveyors. She did not screen the state surveyors in accordance with Centers for Disease Control and Prevention (CDC) guidelines until she was questioned if this was the facility's usual practice. 2. An interview was conducted 3/3/21 at 8:33 a.m. with a Certified Occupational Therapy Assistant (COTA). The COTA stated that at one point since the beginning of the COVID-19 pandemic, she had to wear an N95 mask daily. The COTA stated she alternated between two (2) N95 masks during that period of time. She stated this occurred over a consecutive two (2) week period. She stated she works twenty-four (24) hours a day/forty (40) hours a week. The COTA stated she sprays the N95 masks with a disinfectant between uses then stores them in a plastic Ziploc bag. 3. An interview was conducted 3/3/21 at 9:45 a.m. with the Executive Director (ED). She stated that when the COVID-19 pandemic started, the facility required staff to self-screen and phone in to the facility the results before each shift. She stated the facility transitioned to Home Care Home Base computer system in December 2019 and staff began electronic self-screening before each shift. 4. An interview was conducted 3/3/21 at 11:38 a.m. with the ED. She stated the facility uses the CDC as its source of nationally recognized infection control guidelines. She stated the facility has not been in a supply crisis situation at any time since the beginning of the COVID-19 epidemic. She stated the facility has not deemed re-use of personal protective equipment necessary at any point during the COVID-19 pandemic. She stated it would be acceptable for an N95 mask to be reused if they are appropriately stored. She stated her expectation is a used N95 mask would be stored in a non-crimped manner in a paper bag. She stated one (1) N95 mask would be good for one (1) week's wear. She stated the facility issues N95 masks from several different manufacturers. She stated she is not aware of any N95 manufacturer whose directions for use include disinfection of the N95 mask using a spray disinfectant. She concurred the practice of disinfecting an N95 mask with a spray disinfectant is not acceptable. She concurred storing an N95 mask in a plastic bag is not acceptable. 5. During survey exit on 3/3/21 at 2:40 p.m. the Regional Vice President of Clinical Operations stated the current self-screening tool used by staff has not evolved along with CDC guidelines. She stated she would consult with others in the corporation to try to address this issue. 6. Review of a document titled "Symptoms of Coronavirus CDC," updated 2/22/21, revealed current CDC guidelines state in part: "Watch for symptoms ... Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting and diarrhea." 7. Review of a document titled "Non-Visit Activity Report," dated 1/4/21 through 3/3/21, revealed the criteria used by staff for self-screening do not include all the signs and symptoms of COVID-19 as recognized by the CDC. 8. Review of a document titled "COVID-19 EMPLOYEE SCREENING QUESTIONNAIRE," dated 3/31/20, revealed a list of screening questions which do not include all the signs and symptoms of COVID-19 as recognized by the CDC. The facility used this tool to screen the surveyors on entry into the facility on 3/1/21. 9. Review of a document titled "COVID-19 Attestation Homecare Homebase," revised 10/21/20, revealed in part: "Screening Questions: 1. Have you completed international travel within the last 14 days? 2. Do you have signs/symptoms of respiratory infection, such as fever, cough, sore throat? 3. In the last 14 days, have you had contact with someone with or under investigation for COVID-19 or are ill with respiratory illness? 4. My temperature is not above 100.4 (under 65) or 99.5 (over 65)? 5. Have you visited a care provider/physician in the past 7 days due to not feeling well? 6. Do you have NEW onset loss of taste and smell?" 10. Review of a document titled "CDC COVID-19 Strategies for Optimizing the Supply of N95 Respirators," updated 2/10/21, revealed in part: "N95 respirators are intended to be used once and then properly disposed of and replaced with a new N95 respirator ... Limited re-use of N95 respirators ... During times of crisis, practicing limited re-use while also implementing extended use can be considered ... This amount between uses should exceed the 72 hour expected survival time for SARS-CoV-2 (the virus that causes COVID-19)."