Centerwell Home Health

Safe and adequate discharge planning was not provided to all patients of the agency.

Care planning, coordination of services, and quality of care were not provided to all patients of the agency as evidenced by the failure to ensure: - services were provided according to the physician ordered plan of care (G572) - an individualized care plan that included all medications and…

The agency failed to ensure all encoded OASIS (Outcome Assessment Information Set) assessments in 2 of 19 patients, (patients #3 and 17) accurately reflected the patient's status at the time of assessment.

For 7 of 8 discharged patients (patients # 2, 13, 14, 15, 16, 18, and 19) the agency failed to develop and implement an adequate discharge plan, that involved the patient, patient caregiver, and physician, to ensure continuity of care.

In 4 of 19 records, (patients #3, 6, 8, and 13), the agency failed to ensure each patient received care and services as written in the plan of care.

The agency failed to track all adverse patient events to determine through subsequent analysis whether they were the result of errors that should have been preventable to reduce the likelihood of such events in the future.

Following a review of the Professional Advisory Committee meeting minutes and interview with the Administrator and Director of Patient Services, the agency failed to maintain an ongoing program for quality improvement and implement actions that are evaluated for effectiveness.

In 2 of 7 visits (patients #2 and 7), staff failed to adhere to accepted standards and practices to prevent the transmission of infection.

The agency failed to maintain a coordinated, agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as an integral part of the agency’s quality assessment and performance improvement plan.

In 1 of 2 records, (patient #8) the skilled nurse failed to develop complete and accurate aide care plans.

The agency failed to identify, investigate, and develop a plan to address voiced concerns.

Evidence as follows: Patient #17 was admitted to the agency on 03/13/24 with diagnoses of coronary artery disease with acute myocardial infarction (heart attack), bilateral foot drop, Alzheimer’s dementia, adult failure to thrive, dysphagia (difficulty swallowing), and protein-calorie malnutrition.

In 10 of 19 records, (patients # 2, 3, 5, 6, 7, 10, 11, 12, 17, and 18) ), the Plan of Care was incomplete and/or failed to reference all pertinent information.

In 6 of 19 records, (patients #3, 5, 11, 14, 16, and 17), the skilled nurse failed to communicate with the physician when changes in the patient's condition occurred.

In 3 of 19 patients (patients # 14, 15, and 17) the agency staff failed to provide coordinated care to meet the needs of the patients.

In 3 of 19 records, (patients #11, 12 and 17) the agency failed to educate patients and caregivers.

For 8 of 17 records (Patients # 1, 2, 3, 4, 5, 8, 15 and 16), the agency failed to ensure comprehensive assessments were of sufficient scope to ensure all patient needs were identified.

The skilled nurse (SN) failed to follow accepted standards of infection control practices.

In 8 out of 17 records (Patients # 1, 2, 3, 4, 5, 8, 9 and 11) the agency failed to develop individualized plans of care that were complete, accurate and addressed the total needs of the patients.

For 2 out of 17 records (Patients # 9 and 16) the skilled clinicians failed to consult with the physician when changes in patient condition occurred.

The Skilled Nurse (SN) failed to follow accepted standards of infection control practices.

In 15 out of 17 records, (Patients #1-8 and 11-17) that comprehensive assessments were not of sufficient scope to ensure that all patient's needs are identified.

In 8 out of 17 records (Patients # 2, 4, 6, 9, 11, 13, 15, and 17) the agency failed to develop individualized plans of care that were complete, accurate, and addressed the total needs of the patients.

In 6 of 17 records (Patients #1, 4, 5, 12, 14, and 16) the agency failed to ensure the patient's plan of care was effectively coordinated: This was evidenced by: HV 1. Patient # 1 was admitted to the agency on 01/03/19 with diagnoses of hemiplegia (paralysis) of the right side following a stroke…