Centerwell Home Health

The agency failed to ensure adverse patient events were measured, analyzed, and tracked.

The agency failed to ensure the registered nurse prepared a complete and accurate aide care plan for 1 of 2 patients (Patient #9) who received aide services and whose records were reviewed.

The agency failed to make efforts to resolve identified problems prior to discharging patients for cause for 1 of 1 patients (Patient #2), who were discharged for cause and whose records were reviewed.

The agency failed to ensure the initial comprehensive assessment accurately identified interventions to meet patients' needs in 1 of 1 patients (Patient #11) who received therapy only services and whose records were reviewed.

The agency failed to ensure medications were reconciled for 1 of 5 patients (Patient #8) whose home health care was observed, and whose records were reviewed.

The agency failed to ensure POCs were individualized and inclusive of required content for 6 of 13 patients (#2, #5, #6, #7, #9, #11) whose home health records were reviewed.

The agency failed to ensure encoded OASIS data was accurate at the time of the SOC assessment for 2 of 17 patients (#6 and #17) whose records were reviewed.

The agency failed to ensure QAPI activities tracked adverse patient events, analyzed their causes, and implemented preventive actions.

Written patient care instructions were incomplete and lacked specificity for 1 of 1 patient (Patient #6) whose aide care was observed.

The agency failed to ensure initial assessments included the patient's current health, psychiatric, and psychosocial status for 2 of 17 patients (#11 and #12), whose records were reviewed.

The agency failed to ensure medications were reconciled at the time of admission and a medication list was kept current and reconciled for 3 of 17 patients (#1, #2, and #3) whose records were reviewed.

The agency failed to ensure POCs were complete for 3 of 17 patients (#5, #6, and #15) whose medical records were reviewed.

The agency failed to ensure verbal orders were put in writing for 1 of 17 patients (Patient #2) whose records were reviewed.

The agency failed to ensure staff promptly alerted the physician that patients' POC should be altered, for 1 of 17 patients (Patient #2) whose records were reviewed.

The agency failed to ensure care was coordinated to meet the needs of the patient for 1 of 17 patients (Patient #2) whose records were reviewed.

The agency failed to ensure skilled professional staff assumed care responsibility for and developed a comprehensive POC for 1 of 17 patients (Patient #12) whose records were reviewed.

The agency failed to ensure a home health aide provided services included in the plan of care for 1 of 1 patient (Patient #6) whose aide care was observed.

The agency failed to ensure a discharge/death summary was sent to the primary practitioner for 1 of 1 patient (Patient #15) who had died and whose record was reviewed.