Centerwell Home Health

The agency failed to ensure that all completed Outcome and Assessment Information Set assessments (M0090) were transmitted to the State/Centers for Medicare and Medicaid Services when completed.

The agency failed to ensure the OASIS data accurately reflects the patient's status at the time of the assessment.

The agency failed to ensure the clinician conducted an initial assessment of the patient within forty-eight (48) hours of referral, the patient's return home, or on the physician-ordered start of care date.

The agency failed to ensure the initial comprehensive assessment if of sufficient scope to identify patient needs.

Failure to conduct a complete medication review and to ensure the medication regime is appropriate has the potential for patient harm.

Staff interviews for two (2) of seventeen (17) patients (Patient #’s 10 and 17) the agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients.

The agency failed to ensure services and treatments are administered in accordance with physician orders.

The agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest the plan of care may need to be altered.

The agency failed to ensure updated plans of care reflect current information from the patient’s updated comprehensive assessment.

The agency failed to ensure there was communication with all physicians involved in the patient's care following the patient's physician appointment.

For one (1) of seventeen (17) patients (Patient #17) the agency failed to ensure effective communication and coordination of patient care occurred between disciplines.

The Skilled Nurse (SN) failed to prepare or document complete clinical and progress notes.

The agency failed to ensure that a comprehensive assessment consistent with the patient's needs was performed within five (5) calendar days after the Start of Care (SOC).

The agency failed to ensure the OASIS data accurately reflects the patient's status at the time of the assessment.

The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs.

The agency failed to provide services in accordance with physician orders and the Plan of Care (POC).

The agency failed to ensure the Plan of Care (POC) is reviewed and revised to reflect the patient's current status.

Failure to conduct a complete medication review and to ensure the medication regime is appropriate has the potential for the patient harm.

The agency failed to develop individualized plans of care (POCs) that are complete and accurate and address the total needs of the patients.

The agency failed to ensure services and treatments are administered in accordance with physician orders.

The agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest that the Plan of Care (POC) may need to be altered.

Staff interview for one (1) of seventeen (17) patients (Patient #4) the agency failed to ensure the Skilled Nurse (SN) provided the patient’s caregiver with appropriate education regarding the care and services identified in the plan of care (POC).

The agency failed to ensure ongoing interdisciplinary assessments and communication between skilled professionals occurred to meet the patient's needs and goals.

The agency failed to ensure clinicians prepare and document complete and accurate clinical and progress notes.

Staff interview for one (1) of seventeen (17) clinical records (Patient #12) the agency failed to ensure agency staff communicated with the patient's physician regarding a missed patient visit.

The agency failed to ensure the OASIS data accurately reflects the patient's status at the time of the assessment.

The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs.

The agency failed to provide services in accordance with physician orders and the Plan of Care (POC).

The agency failed to ensure all documentation by professional staff is appropriately authenticated in accordance with accepted standards of practice.

The agency failed to ensure that a comprehensive assessment, consistent with the patient's needs, was performed within five (5) calendar days after the Start of Care (SOC).

The agency failed to ensure the initial comprehensive assessment is of sufficient scope to identify patient needs.

The clinical records lacked documented evidence of a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns.

The agency failed to ensure a comprehensive Plan of Care (POC), based on clinical assessments, was developed to meet the individualized needs of the patients.

The agency failed to ensure services and treatments are administered in accordance with physician orders.

The agency failed to promptly alert the physician to any changes in the patient's condition or needs to suggest that the Plan of Care (POC) may need to be altered.

Staff interview for one (1) of seventeen (17) patients (Patient #12) the agency failed to ensure the Skilled Nurse (SN) provided the patient with appropriate education regarding the care and services identified in the plan of care (POC).

The agency failed to ensure ongoing interdisciplinary assessments and communication between skilled professionals occurred to meet the patient's needs and goals.

The agency failed to prepare and document complete clinical progress notes.

The agency failed to follow agency policies and procedures, current clinical practice guidelines and accepted professional standards when providing services.