Centerwell Home Health

The agency failed to ensure services were provided in accordance to the ordered visit frequency for 1 (P-13) of 2 patients order to have Home Health Aide services, from a total of 13 sampled records reviewed, resulting in the potential for poor grooming and unmet care needs.

The Agency failed to ensure the Skilled Nurse prepared clear written patient care instructions for the home health aide regarding client needs, and precautions prior to the provision of care in 1 (P-13) of 2 records in which Home Health Aide services were ordered, from a total of 13 sampled records…

The Agency failed to ensure that 1 (P-12) of 2 patients observed during home visits, from a total of 13 sampled records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, and failed to ensure…

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 6…

The Agency failed to ensure the patient's Activity of Daily Living needs were adequately met in the patient's home for 2 (P-11, P-12) patients assessed as needing assistance with grooming, from a total of 13 sampled records reviewed, resulting in the potential for poor hygiene, psychological…

The agency failed to ensure the comprehensive assessment included a review of all medications the patient was currently taking for drug allergies in 1 (P-2) of 13 sample records reviewed, potentially resulting in unknown complications related to an allergic reaction and poor patient outcomes.

The agency failed to ensure the Plan of Care included allergies, objectively measurable and individualized goals in 8 (P-2, P-6, P-7, P-8, P-9, P-10, P-12, P-13) of 13 records reviewed resulting in a potential for failure to measure progress toward achievement of desired outcomes.

The agency failed to ensure the Home Health Aide provided care in accordance with the plan of care for 1 (P-9) of 2 patients in which Home Health Aide services were provided, resulting in the potential for patients to receive sub-standard services from the agency.

The agency failed to ensure the aide care plan included pertinent patient safety measures to alert the aide to known safety issues for 2 of 2 (MR# 7 & 13) records reviewed with aide services, resulting in the potential for unmet safety needs for these patients.

The Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, measurable data to use as a baseline for future assessments…

The agency failed to ensure the plan of care included safety measures and functional limitations for 3 of 3 (MR#s 5, 8 and 13) records reviewed with upper extremity fractures, and failed to include parameters for weight gain for a patient with primary diagnosis of Congestive Heart Failure (MR#5)…

The agency failed to ensure the plan of care included patient specific objectively measurable goals and outcomes in 6 of a total of 13 sampled records reviewed (MR#s: 1, 2, 3, 4, 5, and 6), resulting in difficulty determining the patient's progress toward the achievement of goals.

The agency failed to publish an accurate home address on the Plan of Care to ensure the correct address that home care services are provided for 1 of 5 patients (MR# 3) with planned joint surveyor home visits, resulting in late arrival of staff to conduct scheduled home visits, Findings included…

The agency failed to develop and maintain contact information for volunteers, resulting in the lack of essential information in the event of an actual emergency for the agency's current 148 patients.

The agency failed to ensure the registered nurse prepared written patient care instructions for the Home Health Aide that included a visit frequency and safety measures for 3 of 3 patients (MR's #14, 17, 11) in which aide services were provided, from a total of 17 sampled records, resulting in the…

The Agency failed to ensure that 1 of 1 patient (MR #13) observed on the floor by the Physical Therapist post fall, received appropriate care and treatment; and failed to ensure timely care and services were furnished in 1 of 1 documented Complaint of a reported fall (#1) (unrelated to MR #13)…

The agency failed to ensure the patient's Activity of Daily Living needs were adequately met in the patient's home for 1 of 17 patients (MR #1) assessed as needing assistance with Activity of Daily Living, resulting in potential for poor hygiene, psychological decline and potential for injury.

The agency failed to ensure the plan of care was patient specific and individualized to the patient's identified needs, covered all pertinent interventions with reportable parameters and goals for 3 of 17 records reviewed (MR#'s 1, 14, 16,), resulting in patients not receiving care specific to…

The Agency failed to ensure the physician was promptly notified regarding 1 of 1 patient (MR #13) who was directly observed on the floor by agency staff just after a fall; and failed to promptly notify the physician in one of one documented Complaint of a reported fall (#1) (unrelated to MR #13)…

The agency failed to ensure the interdisciplinary team assigned to provide care, conducted an initial and thorough assessment and re-assessment of the patient's health status after a fall, including wound appearance, neurological status and potential nursing needs for 1 of 1 patient (MR #13) who…

The agency failed to ensure services were provided as ordered in the plan of care in 2 of 17 records reviewed (MR# 10, 12) out of a total sample of 17 records reviewed, resulting in the potential for negative patient outcomes for patients.

The agency failed to ensure the Physical Therapist prepared complete and accurate records in 2 of 17 records (MR #4 and 13) reviewed, resulting in not having a complete clinical picture of the patient's care.

The Agency failed to ensure the physician was promptly notified of the patient's abnormal vital signs for 2 patient's (MR #1 and 2) of a total of 17 records, resulting in untreated health issues and the potential for poor patient outcomes.

The Home Health Agency failed to ensure the plan of care included individualized measurable goals and outcomes, and the staff visit notes failed to document the patient's progress towards achieving those identified goals in 11 of 17 records reviewed (MR# 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) out of a…

The Agency failed to ensure the discharge summary was complete, provided the patient's current health status at the time of discharge, sent to the physician within 5 business days, and documented progress toward goals in 2 (MR# 2, 9) of 3 discharged records, from a total of 17 records reviewed…

Immediate jeopardy existed because the agency failed to ensure a patient was treated with respect by fully investigating an adverse event and patient complaint to ensure staff had all education and resources necessary to provide optimal care when conducting patient assessments that could result in…

The agency failed to ensure a patient was treated with respect by fully investigating an adverse event and patient complaint to ensure staff had all education and resources necessary to provide optimal care when conducting patient assessments that could result in patient injury in 1 of 1 record…

The agency failed to ensure all complaints, including the complaint of a serious injury to the patient, were fully investigated in 1 of 1 complaints reviewed out of a total sample of 1 complaint that involved serious injury to a patient (MR #1), which resulted in the potential for substandard care…

The agency failed to document the existence and the resolution of a written complaint filed by a patient who sustained a fractured femur bone (thigh bone) in 1 of 1 complaints reviewed (MR#1) out of a total sample of 1 complaint in which the patient sustained a serious injury during the provision…

The agency failed to take any actions to prevent injury to patients while a complaint could be investigated in 1 of 1 complaints reported to the agency that involved the patient sustaining a fractured leg during the provision of nursing care out of a total sample of 1 complaint in which a patient…