Every finding on record at Centerwell Home Health

The following reflects the findings of the California Department of Public Health during a EMERGENCY PREPAREDNESS SURVEY conducted 7/26/22 through 7/28/22. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 38834 HFEN, 17069 HFEN, 34980 HFEN, 36681 The agency reported 3594 unduplicated annual admissions. The patient sample size was 18 and 7 home visits were conducted. The Department was unable to substantiate a violation of the regulations.

The following reflects the findings of the California Department of Public Health during a RECERTIFICATION SURVEY conducted 7/26/22 through 7/28/22. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 38834 \ HFEN, 17069 HFEN, 34980 HFEN, 36681 The agency reported 3594 unduplicated annual admissions. The patient sample size was 18 and 7 home visits were conducted.

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 interview, record review, and policy review, the Home Health Agency (HHA) failed to ensure Skilled Nurse (SN) visits were followed as indicated on the individualized written plan of care (POC, a document that includes patients’ needs, services and the frequency of these services according to a physician's order). In addition, the facility failed to ensure the written plan of care was reviewed and approved by the physician within 30 days for 4 of 18 sampled patients (Patient 10, Patient 16, Patient 6 and Patient 11). These failures placed patients at risk for unidentified complications and for services provided that were not approved by their physician, which could affect their overall health status. 1. Review of Patient 10’s clinical record indicated she had a start of care date of 6/5/22 and diagnoses included high blood pressure and heart disease. Review of Patient 10's “Home Health Certification and Plan of Care” for the certification period of 6/5/22-8/3/22 contained an order for SN visits “1WK8" (one time a week for 8 weeks). Review of Patient 10's clinical record indicated no SN visit was made the week of 7/17/22 to 7/23/22. In an interview with the Branch Director on 7/26/22 at 3:13 p.m. she confirmed there was no documentation a SN was made during the week of 7/17/22 to 7/23/22, as ordered. She also confirmed there was no documentation the physician was notified of the missed visit. Review of the agency’s policy “Missed Visit Documentation,” revised 01/2021 indicated, “If unable to re-schedule the visit in the same treatment week, the clinical will document the Missed Visit in PointCare..." "A Missed Visit Coordination Note must be completed based on the missed visit reason..."All ordered visits are medically necessary to ensure patient needs are met and they remain safe. Describe how care needs will be met with missed visit or physician contacted and care plan altered." 2. Review of Patient 16’s clinical record indicated he had a start of care date of 6/18/22 and diagnoses included change or removal of nonsurgical wound dressing. Review of Patient 16's “Home Health Certification and Plan of Care” for the certification period of 6/18/22-8/16/22 contained an order for SN visits “3WK8" (three times a week for 8 weeks). Review of Patient 16's clinical record indicated only two SN visits were made the week of 7/17/22 to 7/23/22, instead of three as ordered. In an interview with the Branch Director on 7/26/22 at 3:13 p.m. she confirmed only two SN visits were made the week of 7/17/22 to7/23/22, instead of three as ordered. She also confirmed there was no documentation the physician was notified of the missed visit. Review of the agency’s policy “Missed Visit Documentation,” revised 01/2021 indicated, “If unable to re-schedule the visit in the same treatment week, the clinical will document the Missed Visit in PointCare..." and "A Missed Visit Coordination Note must be completed based on the missed visit reason..."All ordered visits are medically necessary to ensure patient needs are met and they remain safe. Describe how care needs will be met with missed visit or physician contacted and care plan altered." A review of Patient 11’s clinical record indicated a start of care (SOC) dated 5/16/22 and diagnoses included surgical encounter following surgery of the digestive system. A review of Patient 11’s Home Health Certification and Plan of Care (POC) indicated a certification period from 5/16/22 to 7/14/22. There was no physician signature on the POC. In a interview with the Clinical Manager (CM) on 7/28/22 at 11:25 a.m., the CM confirmed Patient 11’s plan of care was not signed by the physician within 30 days from the SOC. A review of the agency's policy titled "Physician/Provider Orders,” revised 1/22, indicated, “Physician or Allowed Practitioner orders must be obtained for services …Orders will be countersigned by the authorized practitioner within 30 days from date orders are received or from the start of care (SOC).” A review of Patient 6's clinical record indicated a start of care (SOC) date of 4/12/22 with multiple diagnoses which included lung and heart diseases. A review of Patient 6's plan of care from 4/12/22 to 6/10/22 included orders for the skilled nurse (SN) to assess/evaluate health conditions, identify changes and intervene to minimize complications, for physical therapy (PT) to provide balance retraining, and for occupational therapy (OT). The POC indicated. “Skilled nurse to evaluate and develop plan of care to be countersigned by physician …Physical therapy …to develop …therapy plan to be signed by the physician …Occupational therapist to …develop plan of care for physician signature.” The POC from 4/12/22 to 6/10/22 did not contain the physician's signature indicating the plan of care was reviewed and approved by patient’s physician. The section of the POC indicating “Date HHA Received Signed POC” was blank. A review of Patient 6’s plan of care from 6/11/22 to 8/9/22 included orders for SN and PT services. The POC indicated, “Skilled nurse to evaluate and develop plan of care to be countersigned by physician …Physical therapy …to develop …therapy plan to be signed by the physician.” The POC did not include the physician's signature indicating the plan of care was reviewed and approved by patient’s physician. The section of the POC indicating “Date HHA Received Signed POC” was blank. During a concurrent interview and record review on 7/26/22, at 2:35 p.m., the Branch Director (BD) stated the clinicians obtained verbal orders from the physician during the initial visit. The BD stated her expectation was that the POC was reviewed and signed by the physician within seven (7) days. The BD was not able to provide documented evidence the physician had reviewed and approved the POC for skilled nursing, physical, and occupational therapy services rendered from 4/12/22 to 6/10/22. The BD confirmed there was no documented evidence that the POC orders for skilled nursing and physical therapy services from 6/11/22 to 8/9/22 were reviewed and signed by the physician. A review of the agency's policy titled "Physician/Provider Orders,” revised 1/22, indicated, “Physician or Allowed Practitioner orders must be obtained for services …Orders will be countersigned by the authorized practitioner within 30 days from date orders are received or from the start of care (SOC).”

The following reflects the findings of the California Department of Public Health during the investigation of complaint #CA00705934. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 38834 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the agency.

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 refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the Plan of Care (POC) was followed for 3 of 4 sampled patients (Patient 1, Patient 2, and Patient 3) when, 1. For Patient 1 the agency did not provide education and instructions regarding swallowing precautions (safe swallowing practices helping to prevent food or fluids getting into patient's lungs). This failure resulted in Patient 1 not receiving needed education and had the potential to affect her safety and health. 2. For Patient 2 and Patient 3 visits by the skilled nursing were not completed per their POC and as ordered by their physicians. These failures had the potential to compromise Patient 2's and Patient 3's health. Findings: 1. A review of Patient 1's clinical record indicated a start of care (SOC) date of 4/17/20. Patient 1 was admitted with multiple diagnoses which included recent stroke and dysphasia (difficulty swallowing due to abnormal muscle control which can lead food or fluids get into the airways causing trouble breathing or pneumonia (lung infection); a common condition after a stroke). Patient 1's plan of care (POC), dated 4/17/20, indicated skilled nursing (SN) were to visit patient once a week for one week, then twice a week for two weeks, then once a week for one week. Patient 1's plan of care section titled "Focus of Care" instructed nurses to provide patient and/or caregiver with education and instructions regarding swallowing precautions. Review of Patient 1's clinical records for the entire certification period from 4/17 through 6/12/10, including SN visit notes failed to demonstrate any documented evidence that nurses instructed Patient 1 and/or provided any education regarding swallowing precautions. During a review of the agency's policy and procedure titled, "Care Planning," revised 5/13/20, indicated, "Skilled Professionals (RN) ...must assume responsibility for, but not restricted to the following: - Ongoing interdisciplinary assessment of the patient: - Providing services that are ordered by the physician as indicated in the Plan of Care; - Patient and caregiver education; - Communication with all physicians involved in the Plan of Care." During an interview and concurrent Patient 1's clinical record review with the Clinical Manager (CM) on 10/1/20 at 3:45 p.m., the CM confirmed that Patient 1 was as increased risk for aspiration due to dysphasia and difficulties with swallowing which were "relatively new diagnoses." The CM was not able to find any documented evidence of agency's providing instructions for swallowing precautions. Review of the article from US National Library of Medicine, National Institute of Health, titled "Aspiration Pneumonia After Stroke," dated 2011, retrieved on 12/5/20 from www.ncbi.nim.nih.gov > pmc >articles>PMC3726080, indicated, "Most available data suggests ... post-stroke patients ... with an impaired swallowing due to neurological injury are at especially high risk ...for aspiration ...As many as one-third aspirate ....Among patients that aspirate, one-third develop pneumonia ...Pneumonia causes the highest attributable mortality of all medical complications following stroke." 2 a. A review of Patient 2's clinical records indicated he was admitted to the agency in 2019 with multiple diagnoses, including infection of the skin and right hip pressure ulcer stage 4 (very deep wound involving muscle and bone and causing extensive tissues, tendons, and joints damage ). Patient 2's records indicated he had multiple recertification periods. Review of Patient 2's POC for the certification period starting 3/6/20, contained an order for SN visits once a week for one week, then two times per week for 3 weeks, three times per week for one week, two times per week for one week, three times per week for three weeks, and one visit in the last week. According to the POC, the SN were directed to assess patient's wound and perform pressure ulcer care. Review of Patient 2's clinical record revealed documentation that two SN visits were made the week of 3/29/20 instead of ordered 3, and for the period from 4/12 until 4/30/20, Patient 2 had two visits a week instead of 3 visits. During an interview and concurrent Patient 2's clinical record review with the clinical manager (CM) on 10/1/20 at 3:15 p.m., the CM confirmed that Patient 2 had two visits the week of 3/29/20 instead of 3, and that two visits were made the weeks of 4/12, 4/19, and 4/26/20 instead of three. The CM was not able to find any documentation the missed visits were rescheduled. The CM confirmed there was no documented evidence that the clinical supervisors or physician was notified of the missed visits nor was there documentation as to why the SN missed the visits. 2 b. A review of Patient 3's clinical record indicated a SOC date of 7/16/20. Patient 3 was admitted to the agency with multiple diagnoses with the main focus on diabetes (high blood sugar) and foot ulcer (wound). Review of Patient 3's POC, for the certification period starting 7/16/20, contained an order for SN to visit patient once a week for 6 weeks weeks and two additional visits as needed for wound, diabetes, and/or high blood pressure complications. The SN were directed to monitor Patient 3's blood glucose level, provide teaching for management of high blood pressure, and to perform and teach wound care to foot ulcers. The SN were to change dressing on Patient 3's right foot every week. Review of Patient 3's clinical record did not indicate that SN visits were made the week of 8/2, 8/16, and 8/30/20. There was no documented evidence the missed visits were reported to the clinical supervisors or patient's physician. During an interview and concurrent Patient 2's clinical record review with the Director of Patient Care Services (DPCS) on 10/1/20 at 2:55 p.m., the DPCS stated Patient 3 did not have his wound care performed the week of 8/2, 8/16, and 8/30/20 as there were no SN visits made on those weeks. The DPCS was not able to find any documentation as to why visits were not made and if the physician was notified of missed visits. During a review of the agency's policy and procedure titled, "Physician's Orders," revised 9/28/19, indicated, "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 missed visit."

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on interview, clinical record review, and review of the agency's policy and procedure, the agency failed to ensure interdisciplinary case conferences (a conference involving all skilled professionals involved in a patient's care) were conducted according to the agency's policy and procedure for 3 of 4 sampled patients (Patient 1, Patient 2, and Patient 3). This failure resulted in no communication between the disciplines and clinicians and created the potential for a decline in the patients' health to occur due to the lack of effective coordination of care. Findings: 1. During a review of Patient 1's clinical record indicated Patient 1 had a start of care (SOC) date of 4/17/20, with a certification period of April 17, 2020 to June 15,2020. Patient 1's multiple diagnoses included heart failure, diabetes (abnormally high blood glucose), complications from a recent stroke including hemiplegia (paralysis of the entire side of the body), dysphasia (difficulty swallowing due to abnormal muscle control), and history of falling. Patient 1's records indicated she had multiple disciplines involved in her plan of care, including skilled nursing (SN) to manage patient's nursing needs, physical therapy (PT), and occupational (OT) therapy to improve patient's strength and functional mobility to prevent further falls. During a review of the clinical record for Patient 1, indicated an admission case conference with two SN staff was conducted on 4/17/20. Review of the records indicated that during the 8 weeks Patient 1 was on service with the HHA, there was no documented evidence that further case conferences were conducted where SN, PT, and OT discussed patient's progress toward plan of care goals or any barriers toward reaching the goals. A review of the agency's policy titled "Coordination of Care - Case Conferences," revised 3/19/20, indicated, "Interdisciplinary personnel ...must maintain close communication to ensure that the patient receives coordinated, complimentary care that meets his or her needs and supports the objectives identified in the Plan of Care ...A representative from each discipline providing care must participate in case conferences ...for planning and evaluating care ...The clinical record or minutes of meetings will document coordination of care." During a concurrent interview and clinical records review with the Director of Patient Care Services (DPCS) on 10/1/20, at 12:40 p.m., the DPCS stated case conferences were held every Wednesday. The DPCS stated the clinicians were supposed to discuss patients' issues, any concerns, progress or why patient was not progressing. The DPCS stated clinical managers, all nurses, therapists involved in patients' care should be attending the case conferences every week. The DPCS stated Patient 1 had lots of health issues and her care was complex, but was not able to find any documented evidence of the interdisciplinary case conferences for the patient after 4/17/20 until she was discharged on 6/12/20. The DPCS confirmed Patient 1's health issues and goals were never discussed during the entire certification period. 2. During a review of Patient 2's clinical records indicated he was admitted to the agency in 2019 with multiple diagnoses, including infection of the skin and right hip pressure ulcer stage 4 (very deep wound involving muscle and bone and causing extensive tissues, tendons, and joints damage). A review of Patient 2's plan of care (POC) for the certification period starting 3/6/20 and ending 5/4/20, contained an order for SN visits. According to the POC, the SN were directed to assess patient's wound and perform pressure ulcer care. The POC indicated Patient 2 verbalized his goal, "I want to regain my health and heal my right hip wound." A review of the clinical records for Patient 2 indicated his initial visit on 3/6/20 was conducted by a registered nurse who did an initial assessment on patient's wound. The rest of the visits for wound care were conducted by licensed vocational nurses. Continued review of Patient 2's clinical records revealed there was no documented evidence of the case conferences conducted between all team members for the next 2 months that the patient was on service with the agency. During a concurrent interview and clinical records review with the DPCS on 10/1/20, at 4:40 p.m., the DPCS stated Patient 2's hip wound did not get heal and he was recertified for another 60 days of services. When the DPCS was asked if there were any care conferences where licensed nurses reported their concerns to registered nurses why Patient 2's wound was not progressing and not healing during the entire certification period, the DPCS stated, "I don't see any." 3. A review of Patient 3's clinical record indicated a SOC date of 7/16/20. Patient 3 was admitted to the agency with multiple diagnoses including depression, diabetes (lack of insulin produced resulting in high blood sugar), and foot ulcer (wound). Review of Patient 3's POC, for the certification period starting 7/16/20, contained an order for SN to visit patient once a week for 6 weeks and two additional visits as needed for wound, diabetes, and/or high blood pressure complications. The SN were directed to monitor Patient 3's blood glucose level, provide teaching for management of high blood pressure, and to perform and teach wound care to foot ulcer. The SN were to assess Patient 3's foot ulcer every week and change a dressing. In addition, Patient 3's POC indicated the week of 7/19/20 he was to be evaluated by medical social worker (MSW) to assess social and emotional factors related to patient's illness. Further review of Patient 3's clinical records revealed there was no documented evidence of the nursing and social worker communication regarding Patient 3's needs and/or depression. There was no evidence of the case conferences between the nurses were conducted for the next 2 months that the patient was on service with the agency. During a concurrent interview and clinical records review with the DPCS on 10/1/20, at 4:20 p.m., the DPCS was not able to find records of the case conferences or any documented evidence of the communication between team members involved in Patient 3's care. The DPCS stated case conferences should have been conducted regularly and should include all clinicians involved in a patient's care. A concurrent interview and review of the documents titled, "Case Conference," dated 9/2, 9/16, and 9/23/20 were provided by the DPCS on 10/1/20 at 3:45 p.m. The DPCS explained the documents were the records of the care conferences for the month of September, 2020. A review of the documents contained clinicians names and indicated their titles. There were check marks beside some of the names and DPCS explained it meant that clinicians attended the care conferences over the phone. The DPCS verified that documents did not have any patients' concerns, issues, or progress toward the goal recorded and was not able to name any of the concerns discussed during those two case conferences. A review of the agency's policy titled "Coordination of Care - Case Conferences," revised 3/19/20, indicated, "Interdisciplinary personnel ...must maintain close communication to ensure that the patient receives coordinated, complimentary care that meets his or her needs and supports the objectives identified in the Plan of Care ...Case conferences for patients who are receiving skilled visits to provide wound care will occur a frequently as needed, but no less often than every two weeks to review current treatments and status of wound healing ...Case conferences will consist of a review of patient care and coordination items ...Communication with other team members ...will be documented in each patient's clinical record."

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to communicate to the physician the need for Speech Therapy (ST, a specialist trained on identifying swallowing problems and teaching skills for safe swallowing) for one of 4 sampled patients (Patient 1) when the patient and her daughter requested ST consult but did not receive ST from 4/17 to 6/12/20. This failure resulted in Patient 1 not receiving requested services and had the potential for affect her safety and health. Findings: A review of Patient 1's clinical record indicated a start of care (SOC) date of 4/17/20, with multiple diagnoses which included recent stroke and dysphasia (difficulty swallowing due to abnormal muscle control; can lead food or fluids get into the airways causing trouble breathing or lung infection; a common condition after a stroke). Patient 1's plan of care (POC), dated 4/17/20, included skilled nursing visits once a week for one week, then twice a week for two weeks, then once a week for one week. The POC was reviewed and signed by Patient 1's physician on 4/27/20. During a review of nursing documentation in the POC, dated 4/17/20, the nurse recorded the following, "Daughter and patient ... requesting for ST [speech therapy]." Review of Patient 1's clinical records , failed to demonstrate patient's request for ST was communicated to her physician and patient never received ST services from the date agency's services were started until Patient 1 was discharged on 6/12/20. During an interview and concurrent Patient 1's clinical record review with the Clinical Manager (CM) on 10/1/20 at 3:45 p.m., the CM stated that Patient 1 did not receive ST and stated patient's physician should have been contacted regarding Patient 1's request. The CM stated that Patient 1 was as increased risk for aspiration due to dysphasia and difficulties with swallowing which were "relatively new diagnoses." Review of US National Library of Medicine, National Institute of Health, "Aspiration Pneumonia After Stroke," dated 2011, retrieved on 12/5/20 from www.ncbi.nim.nih.gov > pmc >articles>PMC3726080 indicated, " "Most available data suggests ... post-stroke patients ... with an impaired swallowing due to neurological injury are at especially high risk ...for aspiration ...As many as one-third aspirate ....Among patients that aspirate, one-third develop pneumonia ...Pneumonia causes the highest attributable mortality of all medical complications following stroke."