Every finding on record at Centerwell Health Services (Certified) Inc

A complaint survey for Complaint #2026004331 was conducted April 22, 2026 through April 23, 2026 at Centerwell Home Health, a home health agency in Shalimar, Florida. Complaint allegations were substantiated with current deficiencies identified. The agency was not in compliance with Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

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 record reviews, staff interview, and patient family interview the agency Registered Nurse (RN) failed to promptly alert the physician of a change in patient condition (a witnessed fall) for 1 of 3 sampled patients, Patient #1. The findings are: Interview on 04/22/2026 at 9:10 AM with the daughter of Patient #1 revealed the patient experienced a fall in her home during a visit by agency Staff A, a RN, on 09/10/2025. The patient was taken via Emergency Medical Services (EMS) to a local hospital where she was treated and released. The daughter stated Staff A called her after the patient fell and reported that he caught her and eased her to the floor. Staff A insisted the patient did not hit her head during the fall. The daughter stated her mother began experiencing increased confusion later the same night and was taken by ambulance to another hospital, where it was determined she had a brain bleed. She was then transported via EMS back to another local hospital and was admitted. She subsequently passed away at the hospital on 09/17/2025. Review of the clinical record for Patient #1 revealed a skilled nurse clinical note dated 09/10/2025 written by Staff A. The section titled "Clinical Summary" notes "Patient recently recovered from a right hip fracture. She did unfortunately fall on me while I was in the home. She said she had been having issues with her vertigo, I needed to get a urine culture from her. She stood up and I asked her to get her head level, she said she felt good. Started to walk toward the bathroom, I turned around to grab some gloves out of my bag and she yelled my name and started to fall backwards. I jumped over her rocker and was only able to catch her head. She did hit the left side of her body on the floor - 911 was then called and she was brought to the hospital." The section titled "Care Coordination Physician/Provider contacted" is marked "Pending". The section titled "Document details related to contacting physician/provider" is marked "Will contact physician". Further review of the clinical record revealed no documentation that the physician was ever contacted to notify of the patient's fall. Review of hospital records from both hospitals confirmed the patient was treated for a ground level fall on 09/10/2025 and 09/11/2025 with subsequent admission to FWBMC on 09/11/2025 where she expired on 09/17/2025. Interview with the Branch Director of the agency office in Crestview on 04/22/2026 revealed her statements that she had not been aware of Patient #1's fall until 11/11/2025 when the patient's daughter called to request licensure information for Staff A. She stated that at that time, Staff A was no longer working at the agency and was not available for interview, but she performed a record review for Patient #1 at that time and confirmed a fall occurred on 09/10/2025. She also confirmed there is no documentation or evidence to indicate Staff A reported the fall to either the Case Manager, Clinical Manager, or the patient's physician.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on record reviews and staff interview the agency failed to provide services in accordance with current clinical practice guidelines and accepted professional standards of practice by failing to report a patient fall in accordance with agency policies and procedures for 1 of 3 sampled patients, Patient #1. The findings are: Review of the clinical record for Patient #1 revealed a skilled nurse clinical note dated 09/10/2025 written by Staff A. The section titled "Clinical Summary" notes "Patient recently recovered from a right hip fracture. She did unfortunately fall on me while I was in the home. She said she had been having issues with her vertigo, I needed to get a urine culture from her. She stood up and I asked her to get her head level, she said she felt good. Started to walk toward the bathroom, I turned around to grab some gloves out of my bag and she yelled my name and started to fall backwards. I jumped over her rocker and was only able to catch her head. She did hit the left side of her body on the floor. 911 was then called and she was brought to the hospital." Review of hospital records from both hospitals confirmed the patient was treated for a ground level fall on 09/10/2025 and 09/11/2025 with subsequent admission to hospital on 09/11/2025 where she expired on 09/17/2025. Review of agency Occurrence Reports (the method used for staff to report unusual occurrences and incidents) for the past 9 months revealed no evidence of a report documenting Patient #1's fall on 09/10/2025. Interview with the Branch Director of the agency office in Crestview on 04/22/2026 revealed her statements that she had not been aware of Patient #1's fall until 11/11/2025 when the patient's daughter called to request licensure information for Staff A. She stated that at that time, Staff A was no longer working at the agency and was not available for interview, but she performed a record review for Patient #1 at that time and confirmed a fall occurred on 09/10/2025. She also confirmed there is no documentation or evidence to indicate Staff A ever completed an Occurrence Report nor is there any evidence to indicate Staff A reported the fall to the Case Manager, Clinical Manager, or the patient's physician. Review of the agency policy "05-18 Patient Occurrence Reporting and Adverse Events" revealed: Purpose is to ensure timely identification, documentation, investigation, and resolution of all incidents and occurrences that deviate from routine operations and may impact patient safety, associate welfare, or home health agency compliance. Supports regulatory compliance with CMS, state health departments, and accrediting bodies. Definition of Occurrence: Any event that is not consistent with the routine care of a patient or to standard Company procedures/operations. Also referred to as an incident; may include adverse events and near misses; Occurrences/incidents must be documented and investigated. Defines investigation/root cause analysis. Policy ranks occurrences by severity: Critical Incident: An event that poses an immediate threat to health, safety, or welfare and may require external reporting. Level 1 Incident: No deviation from the standard of care. Example: Patient fall incident as a result of not using their assistive device. Level 2 Incident: Confirmed quality issue without the potential for significant adverse effects on a patient. Example: Failure of an associate to follow established policy, procedure, protocol. Level 3 Incident: Confirmed quality issue with the potential for significant adverse effects on a patient. Level 4 Incident: Confirmed quality issue with confirmed significant adverse effects on a patient. Level 5 Incident: Death, not related to the primary diagnosis. Sentinel Event: Any unexpected occurrence or incident involving death or serious physical psychological injury, or any risk of death or serious injury Associates must report incidents/occurrences immediately to Branch Director/Administrator Clinical Manager, or on-call clinician if an incident occurs after hours. An Incident Report Form must be completed within 24 hours of discovery. Administrator or designee must review all reports within 24 hours. Incidents meeting state or CMS reporting thresholds must be submitted to the appropriate authority. When an incident may involve potential (Level 3) or actual major injury or death of a patient (Level 4, Level 5), the agency’s Branch Director/Administrator will immediately notify the Regional Clinical and Operational Team and Escalation Team. Examples of reportable Events: (Includes) Patient falls (witnessed or unwitnessed) Notification: Notify patient’s physician and family (if applicable). Notify regulatory bodies as required. Documentation: All reports and investigations are logged in the Occurrence Report in the EMR. Include in QAPI reviews for trend analysis and performance improvement. Failure of Staff A to report the witnessed fall of Patient #1 led to failure of the agency to appropriately implement an adequate investigation of the incident, and inability of the Quality Improvement Program to address potential issues and possible prevent future falls.

During the recertification survey conducted on 4/14/2021 at Kindred at Home, a Home Health Agency, Emergency Preparedness was reviewed. Kindred at Home is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A recertification survey was conducted on 4/14/2021 at Kindred at Home. The agency was not in compliance with Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency skilled nurse failed to prepare accurate and clear clinical notes related to wound care provided for 1 of 3 sampled patients who received wound care, (pt. #5). The findings include: A record review for patient #5 revealed a start of care physician order, dated 3/10/21 for the skilled nurse (SN) to provide wound care for the stage IV pressure ulcer to the patient's left buttock. The order directed the SN to cleanse the wound with wound cleaner, prepare peri wound area with skin prep, fill entire cavity with black foam, apply tubing and cover with transparent drape. Secure with transparent tape. Apply negative pressure device (a method of drawing out fluid and infection from a wound) at 125 mm hg (millimeters of mercury). Change dressing twice weekly, may use wet to dry moist dressing as an alternative for dislodgement. A physician order dated 3/19/21 revealed the SN to discontinue the wound vac (negative pressure device), cleanse the wound with normal saline or wound cleanser and 4x4 (gauze dressing). Pat the wound dry, apply skin prep to peri wound and gently pack the wound with aquacel AG (a waterproof and bacterial wound dressing), cover with foam surgical tape, bordered optifoam gentle or bordered mepilex. A review of the SN visit note dated 4/2/21 revealed a section titled, "wound care provided" with the following documentation: "Per written order, SN to provide wound care as follows: Home Health to change Tuesdays and Fridays' with as needed visits for soiling or issues with wound. Skin Barriers or peri wound care, skin prep twice and allow to dry. Cleanse with normal saline apply aquacel AG or like product, and foam adhesive. Discontinue negative pressure wound therapy, roho cushion for wheelchair, turn and reposition every 2 hours, patient tolerated procedure well". A review of the SN visit note, section titled, "Narrative" revealed the following documentation: Wound care, assessment and education on care of wound dressing, diet measures that promote healing, repositioning schedule. Patient tolerated procedure well." A review of the SN visit note dated 4/9/21 revealed a section titled, "wound care provided" with the following documentation: "Per written order, SN to provide wound care as follows: Home Health to change Tuesdays and Fridays' with as needed visits for soiling or issues with wound. Skin Barriers or peri wound care, skin prep twice and allow to dry. Cleanse with normal saline apply aquacel AG or like product, and foam adhesive. Discontinue negative pressure wound therapy, roho cushion for wheelchair, turn and reposition every 2 hours, patient tolerated procedure well". A review of the SN visit note, section titled, "Narrative" revealed the following documentation: "Assessment performed, and education provided by SN on medication and signs and symptoms infection; wound care provided by SN and documented in wound record". It is not clear from the documentation found on the visit notes what actual wound care was provided by the SN on the 4/2/21 and 4/9/21 visits. The wound vac (negative pressure wound therapy) was discontinued per the order dated 3/19/21. The documentation under the "wound care provided" section appears to be a repeat/copy of the physician's order related to wound care and other wound management interventions but does not describe the actual wound care that was provided. An interview was conducted with the Administrator on 4/13/21 at approximately 3:20 PM. The Administrator confirmed her expectation is the nurse documents the wound care that was performed; and confirmed the computer automatically adds the order to "wound care provided" section of the medical record. The administrator reviewed the notes dated 4/2/21 and 4/9/21 and confirmed the notes did not meet the expectations for wound care documentation.