Centerwell Home Health

The agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 2 of 5 sampled patients.

The agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 1 of 2 sampled patients receiving home health aide services (Patient #17).

The agency failed to ensure accurate and through completion of pertinent components of the initial comprehensive assessment for 1 of 3 sampled patients with wounds at start of care and received therapy only services.

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies and equipment used by the patient to meet their needs and an accurate list of the patient's current medications for 4 of 17 sampled patients (Patients #3, #5, #6and #7).

The agency failed to ensure agency nursing clinical staff accurately completed a drug regimen review which included a review of all medications taken by the patient within the required time frames as part of the comprehensive assessment for 3 of 5 sampled patients (Patients #1, #4 and #5).

The agency failed to ensure agency staff completed all required components of the discharge comprehensive assessment within 2 calendar days of identification of the need to discharge a patient for 1 of 3 sampled patients requiring a discharge comprehensive assessment (Patient #3).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including medications and the identification of medical equipment/supplies used to meet the patient's individualized needs for 3 of 5 sampled patients (Patients #1, #3 and #4).

The agency failed to ensure the development of a policy and procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation.

The agency failed to ensure agency staff contacted the patient's physician to notify the physician of the possible need to make changes due to an inability to follow the plan of care for 3 of 18 sampled patients (Patients #11, #12 and #17).

The agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 2 of 4 sampled patients receiving home health aide services (Patients #9 and #10).

Agency policy review and staff interview the hospice failed to ensure all clinical entry notes included a date and time and staff signature with title for 12 of 18 sampled patients (Patients #1, #2, #6, #7, #10, #11, #12, #14, #15, #16, #17 and #18).

The agency failed to accurately complete a drug regimen review (DRR), including completion of all required components and identification of any findings within the required time frames as part of the comprehensive assessment for 5 of 18 sampled patients (Patients #13, #14, #15, #16 and #17).

Agency clinicians failed to complete updates to the comprehensive assessment at recertification in the last 5 days of each certification period for 3 of 5 sampled patients requiring a recertification assessment (Patients #1, #12 and #13).

The agency failed to ensure the timely completion of all pertinent components of the update to the comprehensive assessment at the resumption of care within 48 hours of the agency's knowledge of the patient's return home from an inpatient facility for 1 of 4 sampled patients requiring a resumption…

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including frequency and duration and duration of visits to be made, patient specific interventions, medications, and/or equipment/supplies used to meet the patient's individualized needs for 6 of 18…

The agency failed to administer treatments only as ordered by the physician for 1 of 6 sampled patients with wound care orders (Patient #7).

The agency failed to ensure the patient's clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 4 of 18 sampled patients (Patients #7, #12, #14 and #16).

The agency failed to obtain informed consent from the patient/ patient representative and/ or provide the patient representative with a description of the patient's rights as identified by regulation prior to providing any hands provision of care for patients no longer able to make decisions…

The agency failed to complete a drug regimen review, including all required components, with each discharge comprehensive assessments for 4 of 4 sampled patients requiring discharge comprehensive assessments (Patients #10, #11, #12 and #13).

The agency failed to ensure the Plan of Care contained all medications for 2 of 5 patients with home observation visits performed (Patients #1 and #2).