Every finding on record at Synergy Home Care-Northeastern Region, Inc.

The CenterWell Home Health is in compliance with the federal emergency preparedness requirements.

Recertification Survey

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 record reviews and interviews, the Home Health agency failed to ensure the patient’s written individualized plan of care (POC) was followed for 2 (#4 and #6) of 4 (#3, #4, #6, and #8) patients reviewed for therapy services. The home health agency failed to provide documentation of speech and physical therapy visits for patients #4 and #6. Findings: Patient #4 Review of patient #4’s medical record revealed a referral date of 11/07/2023. Further review of the medical record revealed patient #4 had a primary diagnosis of Parkinson’s disease with dyskinesia, without mention of fluctuations. Review of patient #4’s POC revealed a certification period dated 03/12/2024 to 05/10/2024. The POC further revealed that patient #4 was to receive speech therapy four times a week for one week, starting on 03/19/2024 and three times a week for three weeks. Review of patient #4’s medical record revealed no documented evidence of patient #4 receiving a fourth speech therapy visit during the week of 03/19/2024 and no completed visits for the week of 03/24/2024. Review of the speech therapy visit notes dated 04/11/2024 and 04/12/2024 revealed the therapy visits had been canceled due to bad weather. There was no documented evidence of the missed visits being rescheduled. Review of patient #4’s medical record revealed a physician’s order dated 04/16/2024 to add a speech therapy evaluation the week of 04/15/2024. There was a second order dated 04/22/2024 for a speech therapy evaluation the week of 04/22/2024. Further review revealed a third order dated 04/29/2024 for speech therapy to evaluate the week of 04/29/2024. Review of patient #4’s medical record revealed there was no documented evidence of a speech therapy evaluation being completed for patient #4 during the weeks of 04/15/2024 and 04/22/2024. Review revealed the last speech therapy visit note was dated 04/05/2024. During an interview with S1Administrator on 05/01/2024 at 1:30 p.m., she confirmed there was no documented evidence of a physical therapy visit being completed during the week of 04/21/2024 and further confirmed the last physical therapy visit was completed on 04/17/2024. S1Administrator confirmed that patient #4 had not received speech and physical therapy services in accordance with the patient’s written individualized plan of care. Patient #6 Review of patient #6’s individualized plan of care revealed a referral date of 03/15/2024. Further review of the medical record revealed patient #4 had a primary diagnosis of atrial fibrillation. Review of the physician’s orders dated 03/25/2024 revealed an order for speech therapy to evaluate (Referring to patient #6) the week of 03/25/2024 one time per week for 5 weeks. Review of patient #6’s medical record revealed no documented evidence of a speech therapy visit during the weeks of 03/31/2024, 04/07/2024, and 04/14/2024. On 04/30/2024 at 10:30 a.m., S1 Administrator was notified of the findings identified. During an interview on 05/01/2024 at 2:15 p.m., S1Administrator confirmed that she was aware of the missed visits. She further confirmed that patient #6 had not received speech therapy visits in accordance with the patient’s written individualized plan of care.