Every finding on record at Centerwell Home Health

An unannounced recertification survey was completed on January 14, 2025, through January 16, 2025, at Centerwell Home Health. The provider had deficiencies at the time of the visit according to Home Health Agency Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

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 observation, record review and interview the facility failed to provide in accordance with current clinical practice guidelines and accepted professional standards of practice Intravenous Therapy for 2 of 2 patients observed (Patient#1 and Patient #10 ) by not checking patency of Peripherally Inserted Central Catheter (PICC) line prior to flushing and drawing blood for laboratory samples and 1 of 2 patients (Patient #1) for not purging extension line of air prior to attaching extension line to PICC line and flushing PICC line with 10 milliliters (ml) of normal saline (NS) (double lumen ports) two separate extension ports. Findings include: Review of Patient #1’s clinical record documented Patient #1 was admitted on 9/7/2024 with diagnoses including Sepsis [ infection in the blood]. Review of Patient #1'sphysician orders dated 9/7/2024 read “Skilled nurse to collect blood specimen …via PICC and report to physician [Physician name]. Review of Patient #1's visit note report dated 1/15/2025 read “SN [skilled nurse] removed old PICC line dressing from RUE [right upper extremity]and discarded in trash. Using sterile technique, SN [skilled nurse] cleansed around PICC site with Alcohol and chloral-prep swab stick and allowed to dry, applied new stat lock and bio-patch. Patient tolerated well” Review of Patient #1's Client Coordination note report dated 1/15/2025 read “Late entry visit done 1.14.25 Patient has PICC line to RUE, Double lumen SN obtain lab from PICC line right upper extremity, accessed red port line. Alcohol wipe injection cap. Flushed with 5cc [cubic centimeter also known as ml] of NSS [normal saline solution], wasted 5cc of mixed blood, discarded in biohazard container. SN flushed PICC line with 20ml, SN changed extensions, and injection cap… “ During an observation on 1/14/2025 at 09:22 AM Staff A, License Practical Nurse (LPN) observed to clean double lumen ports and flush Patient #1’s (PICC) double lumen ports. Blue tip port and red tip port (double lumen -2 ports) with 10 ml of NS without aspirating blood back into the syringe to confirm a free flow of blood return prior to flushing. 10 ml blood obtained, wasted and an additional 10 ml blood obtained via syringe for laboratory testing and the PICC line flushed with 10ml NS. During an observation on 1/14/2025 at 10:35 AM Staff A, LPN observed removing extension tubing from sealed package and attaching extension tubing on PICC double ports, a red port and blue port, without out flushing the extension tubing to evacuate the air and no aspiration of blood into the extension port prior to flushing double lumen PICC ports with 10 ml NS solution. During an interview on 1/14/2025 at 10:42 AM with Staff A, LPN stated “No, we do not aspirate blood prior to flushing we just flush the PICC. “I did not flush the extension lines prior to attaching to the PICC ports and flushing, I missed that step. The extension lines should be flushed prior to attaching to the patient to evacuate all the air in the line. Then the lines should be attached to the patients PICC line and flushed.” During an interview on 1/15/2025 at 12:55 PM with Staff B, LPN stated “prior to using a PICC line the line has to be checked for patency by aspiration of blood prior to flushing the PICC line. All tubing must be primed prior to attaching to PICC line and prior to flushing ports. Lines are always checked by aspiration of blood for patency prior to flushing with NS”. Review of Patient #10’s Clinical Record documented Patient #10 was admitted 1/11/2025 with the diagnosis Acute osteomyelitis, right ankle and foot”. Review of Patient #10’s physician orders dated 1/13/2025 read “Skilled nurse to collect blood specimen …2 x a week through 2/20/25 via PICC line or venipuncture and report to doctor… “Blood draws…Flush line with NS 10ml, obtain 10ml of blood for discard, flush lumen with 10ml .9% and 5ml of heparin flush after blood draw”. During an observation on 1/16/2025 at 08:15AM with Staff D, observed to clean port with alcohol pad and attach 10ml NS syringe to port, flushed without aspiration of blood prior to flush to check for placement. Withdrew 10 ml blood product and wasted prior to attaching Vacutainer (devise used to obtain blood) and retrieved 2 vials of blood. Port flushed with 10ml NS syringe and then antibiotics initiated. During an interview on 1/16/2025 at 08:22 AM with Staff D, RN stated “I do not normally aspirate sometimes I do. I just flush the line with NS” During an interview on 1/14/2025 at 3:06 PM with Staff C, Registered Nurse Clinical Manager stated “The expectation is that blood is aspirated to check for patency prior to flushing the line. The Intravenous line must be purged of air prior to flushing”. During an interview on 1/14/2025 at 4:00 PM with the Director of Nursing/Administrator stated, “extension tubing, any tubing should be flushed prior to attaching to the patient’s’ PICC and aspiration of blood in the line prior to flushing to check the line for patency. Review of facilities policy and procedure dated 7/2024 titled “Peripherally inserted central catheter (PICC) flushing and locking, home care”. Read “Maintenance of peripherally inserted central catheters (PICC) in the home care setting is necessary to provide timely and therapeutic infusion that are required by patients. PICCs are used in the home care setting to administer medications blood products, chemotherapy, IV fluids, and parenteral nutrition. Aspirating for a blood return and flushing a PICC are routine steps for assessing catheter patency before use. Flushing also prevents mixing incompatible medication and solutions after infusion and catheter occlusion after blood sampling... Review of facilities policy and procedure dated 7/2024 titled “Infusion Therapy Requirements and Guidelines” read “…Section 1… Skills competency should be documented at least annually” … Section 2: Infusion Therapy Practice Clinical Competency…flushing procedure for vascular access devices… Review of facilities procedure (Based on Springhouse recommendation) Aspirating for a blood return and flushing a PICC are routine steps for assessing catheter patency before use. Flushing also prevents mixing incompatible medication and solutions after infusion and catheter occlusion after blood sampling..." Review of the internet website page titled “Peripherally inserted Central Catheters (PICCs): Best Practice dated September 7, 2022, read … Prior to using a PICC, it should always be checked for patency. This is done by gently drawing back on the syringe and confirming of a swift blood aspirate. If blood aspiration is not possible, or is sluggish, a small amount of saline can be instilled (Denton, 2016; Gorski, 2021). The use of saline at this stage will not cause the patient harm. Gorski et al. (2021) also suggests that a small barrel syringe can be used to attempt blood aspirate. The use of a small syringe will exert less negative pressure and might improve the success..."

An unannounced complaint surveys complaint numbers 2021009859 and 2021012048 was conducted from 10/7/2021to 10/8/21 at Kindred at Home Health Lady Lake, a home health facility. Kindred at Home of Lady Lake Home Health was not in compliance.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on interviews and record reviews the agency failed to initiate a grievance/complaint after it was brought to the agency employee's attention on 7/15/21. During an interview on 10/8/21 at 8;03 AM, with Patient #3 spouse stated, the Registered Nurse came to the house on 7/11/21 to start his care with the home health agency. The nurse stated to him in my presence that the order does not say to remove the drain or not to remove the drain so I have decided to remove the drain. His area started to redden and started to have a large amount of drainage with pus. He could not leave the house, swim or exercise after the drainage tube was removed because of the drainage. When he returned to the doctor on 7/15/21 he had to be started on oral antibiotics. The doctor said had he not come in when he did he would have been septic within the next couple of days." During an interview on 10/8/21 at 8;30 AM, with Staff B a Licensed Practical Nurse (LPN) stated, "when I arrived at the patients home on 7/15/21 he informed me that he had been to his primary care physician prior to my arrival and the physician was upset and he was upset because the Registered Nurse had removed his JP drainage tube at the start of care on 7/11/2021. He stated the RN told him I do not see an order to take the JP drainage tube out, but it doesn't say I can't remove it so I am going to remove it. He told me that his physician had to restart him on antibiotic medications and that he would need to follow-up with the Surgeon. I thought I had reported this to the office case Manager. I cannot really remember. During an interview on 10/8/21 at 9:02 AM, with the Branch Manager she stated, "I was made aware by patient # 3 on 7/29/21 that it had taken the patient this long to calm down that there was a problem with one of the agencies Registered Nurses. He asked if I was aware of what happened and I reviewed his chart and could not find why the patient was upset. The Patient informed me that one of the agencies Registered Nurses (RN) had removed his JP drainage tube at the start of care on 7/11/21. He stated he had told the other nurse what had happened (Staff B LPN). The Registered Nurse was interviewed and admitted that she had removed the patients JP drainage tube, however she did not document that she had removed the drainage tube. The RN was advised that she needed to enter a late note in the patients chart to reflect that she had removed the drainage tube, however, I can see that she did not document this. The LPN Staff B was interviewed and admitted the patient had told her what happened on 7/15/21 and she thought she had filed a grievance on the patients behalf. The LPN was counseled with regarding reporting patients concerns and grievances. He stated he no longer wanted to receive services from this home health agency. " A review of the policy and procedure titled Incident Reporting read, All incidents are categorized. Incident reporting is the formal process to report and investigate any unusual incidents, occurrences, or accidents that occur to our patients while they are receiving our services. As soon as you are aware of an incident you must call the office immediately from the patient's home (if possible) and report it directly tp a clinical manager.

Investigation of complaints CFR(s): 484.50(e)(1) Standard: Investigation of complaints. The HHA must-- This STANDARD is not met as evidenced by: Based on interviews and record reviews the agency failed to initiate a grievance/complaint after it was brought to an agency employee's attention on 7/15/21. During an interview on 10/8/21 on 8:03 AM, with Patient #3 spouse stated, the Registered Nurse came to the house on 7/11/21 to start his care with the home health agency. The nurse stated to him in my presence that the order does not say to remove the drain or not to remove the drain so I have decided to remove the drain. His area started to redden and started to have a large amount of drainage with pus. He could not leave the house, swim or exercise after the drainage tube was removed because of the drainage. When he returned to the doctor on 7/15/21 he had to be started on oral antibiotics. The doctor said had he not come in when he did he would have been septic within the next couple of days." During an interview on 10/8/21 with Staff B, Licensed Practical Nurse (LPN) stated, "when I arrived at the patients home on 7/15/21 he informed me that he had been to his primary care physician prior to my arrival and the physician was upset and he was upset because the Registered Nurse had removed his JP drainage tube at the start of care on 7/11/2021. He stated the RN told him I do not see an order to take the JP drainage tube out, but it doesn't say I can't remove it so I am going to remove it. He told me that his physician had to restart him on antibiotic medications and that he would need to follow-up with the Surgeon. I thought I had reported this to the office case Manager. I cannot really remember. During an interview on 10/8/21 at 3:24 PM, with the Director stated, "I was made aware by patient number 3 on 7/29/21 that it had taken the patient this long to calm down that there was a problem with one of the agencies Registered Nurses. He asked if I was aware of what happened and I reviewed his chart and could not find why the patient was upset. The Patient informed me that one of the agencies Registered Nurses (RN) had removed his JP drainage tube at the start of care. He stated he had told the other nurse what had happened. The Registered Nurse was interviewed and admitted that she had removed the patients JP drainage tube, however she did not document that she had removed the drainage tube. The RN was advised that she needed to enter a late note in the patients chart to reflect that she had removed the drainage tube, however, I can see that she did not document this. The LPN, Staff B was interviewed and admitted the patient had told her what happened and she thought she had filed a grievance concern. The LPN was counseled with regarding reporting patients concerns and grievances. He stated he no longer wanted to receive services from this home health agency. " A review of the policy and procedure titled Incident Reporting read, All incidents are categorized. Incident reporting is the formal process to report and investigate any unusual incidents, occurrences, or accidents that occur to our patients while they are receiving our services. As soon as you are aware of an incident you must call the office immediately from the patient's home (if possible) and report it directly tp a clinical manager.

Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This ELEMENT is not met as evidenced by: Based on interviews and record reviews the home health agency failed to obtain a physicians order for a nurse to remove a patients JP drainage tube for patient #3 of three patients reviewed. During an interview on 10/8/21 at 9:00 AM, with Staff B a Licensed Practical Nurse (LPN) she stated, when I arrived at the patients home on 7/15/21 the patient told me that he was surprised to see me since the Registered Nurse that came out to do his start of care treatment on 7/11/21 had removed his JP drainage tube and that was the reason he was receiving home health treatment. The patient did not have a JP drainage tube when I arrived at his home on 7/15/21 to provide his care. During an interview on 10/8/21 at 9:02 AM, with the Branch Manager stated, we reached out to the registered nurse that was directly involved in the removal of the patients JP drainage tube and she admitted that she removed the patients drainage tube at the start of care visit on Sunday 7/11/21. The nurse stated she removed the drainage tube because she thought she saw an order to remove the JP drain if the patient had less than 40 CC of drainage on Monday 7/12/21. A record review of the patients chart to include additional physicians orders did not show a physicians order to remove the patients JP drain. The nurse reviewed the chart to see if she could located the order that she thought was there and she admitted she could not find the order. The JP drainage tube was removed without a physicians order. A review of the policy and procedure last reviewed 6/2021 read Physician or allowed Practitioner orders must be obtained for services by all healthcare personnel if required by state regulation.

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 upon interviews and record reviews the agency failed to follow a patients plan of care for one ( Patient # 1) of three patients charts reviewed. During an interview on 10/8/21 at 3:24 PM, with the Administrator she stated a review of the patients plan of care that was written and verified on 7/11/ 2021 showed no documentation that patient #3 plan of care read that his JP drainage tube was supposed to be removed by nursing staff. The patients plan of care was for 7/11/21 to 9.8.21 certification period. The Registered Nurse at the start of care on 7/11/2021 removed the drainage tube which had no physician order to remove. The patients chart was reviewed extensively and no order was found on the plan of care to remove the JP drainage tube. A review of the plan of care dated 7/11/21 read start of care. Nursing staff to provide care and services for wound care. The plan of care showed no documentation that the JP drainage tube was to be removed by the nursing staff. A review of the policy and procedure read, Physicians or allowed practitioner orders must be obtained for services by all healthcare personnel if required by state regulation.

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on record review and interview the facility failed to Coordinate care between members of the health team for 1 ( Patient # 3) of 3 sampled patients. Record review of the Patient Profile showed the Patient was admitted to the agency on 7/11/21. Record review of the Home Health Certification and Plan of Care showed a certification and plan of care for the period of 7/11/21-9/8/21. The clinical record revealed communication problems between disciplines. During an interview with the Branch Director on 10/8/21 at 9:02 AM she stated, the SOC ( Start of Care) was 7/11/2021. The Registered Nurse removed the patients JP drainage tube. The RN did not coordinate with the Clinical Manager at the start of care. The nurse is supposed to ensure there is a physicians order in the patient's record to provide care. The physician was not notified by Registered Nurse that the patients JP drainage tube had been removed.. A review of the policy and procedure titled, "Coordination of Care-Case conferences 03-16" revised 06/21 read, the Clinical Manager is responsible for ensuring a case conference will be conducted for each patient at the time of admission. At the time of admission, the case conference will review any discrepancies in assessment documentation, will clarify physician/authorized practitioner orders if necessary, or review if consultation is needed regarding the decision to admit the patient. Communication may include but is not limited to contact between team members involved in the care of the patient. Any/all contact with the patient's physician. Communication of changes in the planned care. All communication will be documented in the patient's clinical record. Class III

2021004174 A complaint survey for complain number 202100417, was conducted on 04/13/2021 at Kindred At Home, a Home Health Agency. The facility was not in compliance with 42 CFR 484 Sub part A-C, Requirements for Home Health Agencies.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review the agency fail to do an initial visit within 48 hours of referral. Finding During an interview on 4/13/21 at 8:55 AM, with Administrator, stated once a referral is accepted and patient is discharged from the hospital, we have 48 hours to evaluate. The patient should be seen as soon as possible providing we have an order. We get the Primary Care Physician/Provider (PCP) involved as soon as possible. That is what I am used to, you have an order to evaluate and then you can get that clarification, that can happen simultaneously, you have the initial order to evaluate. Administrator stated "my expectation is to lay eyes on patient within 48 hours and at that time after an evaluation was done, we can get orders from the PCP or another doctor for subsequent care. No subsequent care or treatment can be provided without PCP orders. Due diligence is to absolutely make an effort to call from patients' home and after the evaluation is complete to see what the need is." Still we go out to see patient we have that eval order, we take ownership of what happened. Policy titled: 03-05: Initial and Comprehensive Assessment Policy All patient receiving skilled services must have an initial on-site professional assessment. The assessment must be completed on or before start of care and within 48 hours from the date of referral or facility discharge (whichever is later), unless otherwise ordered by Primary Care Provider (PCP). Additional professional assessments will be completed as appropriate. Record review of Patient 1 chart revealed referral was accepted on 3/17/21 and was admitted to HHA services on 3/20/21. No wound care orders were observed on patients plan of care. Review of the plan of care revealed that skin integrity issues were to monitor, observed and changes reported. Review of Plan of Care SOC 3/20/21 Certification Period 3/20/21 to 5/18/21 Skilled nurse to observe/assess integumentary system identify changes and intervene to minimize complications. Skilled nursing to teach related to altered skin integrity including disease process, nutrition, medications, activities and personal/environment factors. Significant changes in status will be reported to physician. Nursing assessment to be performed by Registered Nurse (RN). Licensed Practical Nurse to observe and report changes to RN. Skilled nursing focus of care is infection control measures, maintenance of skin integrity, medication/diet teaching, disease process management of hypertension, safety/fall precautions. Review of the Home Health Policy Manual, Revised: 09/28/2018 under 03-12 Physician's Orders reads: Policy - 2. Patients needing skilled or personal care services who do not have an attending physician or other healthcare professional authorized to order home care service may receive an evaluation visit.