Centerwell Home Health

The agency failed to maintain documentation of all the components of drills, tabletop exercises, and emergency events.

The agency failed to electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the CMS system every 30 days.

The agency failed to conduct an initial assessment within 48 hours of referral or on the physician ordered start of care for one patient (P) (P#3) of 18 sampled patients (P#1, P#2, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18).

The agency failed to ensure that the patients' plan of care (POC), contained complete, concise and clear documentation of all services, including dialysis interventions to monitor dialysis site for infection or bleeding after dialysis procedures, and management of anticoagulant with teaching…

The agency failed to have physician sign patient plan of care (POC), for two patients (P) (P#2, P#5) out of eighteen sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18).

The agency failed to complete patient weights, and failed to document the weights as ordered for one Patient (P) (P#3) out of 18 sampled patients (P#1, P#2, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18).

The agency failed to notify physician of weight not completed for one Patient (P) (P#3) out of 18 sampled patients (P#1, P#2, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18).

The agency failed to ensure that patient's medication profile was updated to reflect current medications at the time of the comprehensive assessment for 2of 7 (#3 and #4) patients observed during home visits.

The agency failed to provide services as ordered by the physician in the plan of care for 3 of 17 (#9 , #7, and #11) sampled patients.

The agency failed to ensure documentation in the clinical records included all interventions and responses to the interventions in accordance with professional standards for 4 of 17 (#4, #9, #11 and #15) sampled patient.