Enhabit Home Health

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on the record reviews and interviews, the agency failed to have a signed plan of care (POC) or a verbal POC order from the primary physician prior to providing services and treatments to patients for 14 of 17 patients, with the potential to affect all patients on service. (Patient #1, #3, #4, #5, #7, #10, #11, #12, #13, #14, #15, #16, #17, #18) Findings include: 5. The record review for Patient #4, certification period 07/21/2023 to 09/01/2023, revealed patient care was provided to Patient #4 without a verbal order or physician-signed order for the following days: 10/22/2023, 10/26/2023, 10/27/2023, 10/28/2023, 11/01/2023, 11/03/2023, 11/04/2023. 6. The record review for Patient #5, certification period 09/18/2023 to 11/16/2023, revealed patient care was provided to Patient #5 without a verbal order or physician-signed order for the following days: 09/19/2023, 09/20/2023, 09/26/2023, 09/27/2023. 7. The record review for Patient #7, certification period 10/16/2023 to 12/14/2023, revealed patient care was provided to Patient #7 without a verbal order or physician-signed order for the following days: 10/18/2023, 10/23/2023, 10/24/2023, 10/26/2023, 10/27/2023, 10/31/2023, 11/01/2023, 11/03/2023. 10. The record review for Patient #12, certification period 10/16/2023 to 12/14/2023, revealed patient care was provided to Patient #12 without a verbal order or physician-signed order for the following days: 10/20/2023, 10/24/2023, 10/26/2023, 10/31/2023, 11/02/2023. 12. The record review for Patient #14, certification period 11/02/2023 to 12/31/2023, revealed patient care was provided to Patient #14 without a verbal order or physician-signed order for the following days: 11/03/2023, 11/04/2023, 11/07/2023, 11/08/2023, 11/14/2023, 11/16/2023, 11/20/2023, 11/21/2023, 11/29/2023, 12/01/2023. 13. The record review for Patient #15, certification period 08/17/2023 to 10/15/2023, revealed patient care was provided to Patient #15 without a verbal order or physician-signed order for the following days: 08/22/2023, 08/23/2023, 08/24/2023, 08/29/2023. 410 IAC 17-13-1(a) 1. A 10/18/2023 revised policy, titled Coordination of Services indicated the agency staff should coordinate services and review the POC with the physician. 2. A 10/18/2023 revised policy, titled Physician’s Role indicated a verbal order was an order communicated from the physician before rendering services and must be signed by the professional individual who received a verbal order and countersigned by the physician. 3. The record review for Patient #1, certification period 12/01/2023 to 01/29/2023, revealed patient care was provided to Patient #1 without a verbal order or physician-signed order for two visits on 12/05/2023 and one visit on 12/07/2023 and no signed POC to-date. 4. The record review for Patient #3, certification period 07/19/2023 to 09/16/2023, revealed patient care was provided to Patient #3 without a verbal order or physician-signed order for visits on 07/25/2023 and on 07/27/2023. 8. The record review for Patient #10, certification period 10/27/2023 to 12/25/2023, revealed patient care was provided to Patient #10 without a verbal order or physician-signed order for the visit on 10/31/2023. 9. The record review for Patient #11, certification period 11/30/2023 to 01/28/2023, revealed patient care was provided to Patient #11 without a verbal order or physician-signed order for the visit on 11/27/2023. 11. The record review for Patient #13, certification period 11/04/2023 to 01/02/2024, revealed patient care was provided to Patient #11 without a verbal order or physician-signed order for the visit on 11/07/2023, 11/09/2023, 11/10/2023, 11/14/2023, 11/16/2023, 11/20/2023 and 11/21/2023. 14. The record review for Patient #16, certification period 11/18/2023 to 01/16/2024, revealed patient care was provided to Patient #16 without a verbal order or physician-signed order for the following visit: 11/21/2023, 11/22/2023, 11/30/2023 and 12/02/2023. 15. The record review for Patient #17, certification period 12/07/2023 to 02/04/2023, revealed patient care was provided to Patient #17 without a verbal order or physician-signed order for the following visit: 12/08/2023, 12/11/2023, and 12/12/2023. 16. The record review for Patient #18, certification period 11/22/2023 to 01/20/2024, revealed patient care was provided to Patient #18 without a verbal order or physician-signed order for the following visit: 11/22/2023, 11/29/2023, 11/30/2023, 12/04/2023, 12/06/2023 and 12/07/2023. 17. During an interview on 12/12/2023 at 3:00 PM, Occupational Therapist (OT) 1 indicated, that they do contact the physician’s office on the same day as start of care (SOC), resumption of care (ROC) or on recertification. OT 1 indicated they would call and report the frequency of OT visits and what OT would be working on with the patient. They would get orders from whoever answered the phone at the physician’s office, sometimes this was the receptionist. OT 1 indicated this would be documented in the coordination note as a verbal order for POC. 18. During an interview on 12/12/2023 at 6:20 PM, Registered Nurse (RN) 2 indicated, that they would call the physician within 24 hours of SOC, ROC, or Recertification. RN 2 would speak with whoever answered the phone and would provide the disciplines who would be involved in POC, the frequency, and medication taken by the patient, and request wound care if needed. They indicated this would be documented in the visit under the coordination of care. 19. During an interview on 12/13/2023 at 12:56 PM, the Administrator indicated staff was contacting doctors during SOC, ROC, and recertification. They indicated the information communicated with the primary physician would be documented in the visit note report, at which point the Administrator pointed out in Patient # 10’s “Visit Note Report” dated 10/24/2023 an area labeled “PLAN OF CARE/CARE MGMT/CARE COORDINATION”, which indicated RN 2 documented Veterans Affairs (VA) was notified about recertification, that skilled nursing services would be provided, with a weekly visit frequency. The area did not provide documentation of who RN 2 spoke with or details related to what would be provided on the plan of care until the physician’s signature was obtained on the plan of care. The Administrator provided a second example of documentation on Patient #17’s “Visit Note Report” dated 11/28/2023 under the area labeled “PLAN OF CARE/CARE MGMT/CARE COORDINATION”, which indicated OT 1 documented coordination of care with Daughter regarding the patient having to undergo surgery. There were no verbal orders, received from the primary physician, regarding the services the agency would be providing until the POC was signed by the physician. The Administrator was unable to locate any other documentation in patient charts related to communicating with the primary physician to obtain orders for services and treatments that would be provided by the agency until the physician signed the POC. The Administrator disagreed, indicating the information staff wrote on the Visit Note Report under the coordination area was enough to confirm all services and interventions being provided to patients until POC is signed and does demonstrate staff are communicating with the primary physician the details of all areas of the plan of care.”

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure written medication and home health aide instructions outlining care were provided to the patient for 1 of 1 home health aide visit. (Patient #12) Findings include: A policy titled “Clinical Record” indicated the agency maintains a record in the home that includes home health service information and a medication profile. During a home visit on 12/13/2023 at 12:00 PM, Patient #12 did not have a copy of medication instructions or home health aide instructions in the home. At that time, Patient #12 and their Power of Attorney (POA) were not sure where the agency medication list or the home health aide plan of care instructions were. Licensed Practical Nurse (LPN) 1 stated the items should be in the admission packet but were not. During an interview on 12/13/2023 at 3:30 PM, the Administrator stated that a copy of the medication list and home health aide care plan should be left in the home.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure all medications were checked for drug reactions and side effects for 4 of 4 skilled nurse home visit observations. (Patients #10, #15, #17, #18) Findings include: 3. During an interview on 12/12/2023 at 6:00 PM, Patient #10 reviewed the current medication list brought to visit by RN 2. Patient #10 indicated he/she was no longer taking the following medication listed on the current medication list: Chloraseptic Throat Spray (used for sore throat and mouth pain), Ensure (Nutritional Supplement), Promethazine (used for allergy symptoms such as rash, itching, and runny nose), and Rosuvastatin (used for elevated Cholesterol). He/She also indicated the prescription for Melatonin (used for insomnia and improving sleep) he was taking PRN and He/She has been taking Hydromorphone Hydrochloride (used for pain relief) since starting on service. 4. During an interview on 12/12/2023 at 2:00 PM, Patient #17’s Daughter reviewed the current medication list in the patient’s home with the list on the plan of care (POC), both were found to be incorrect. The Daughter indicated the following medications are no longer being taken: Mucinex (used for chest congestion), Percocet (used for pain relief), Glimepiride (used for high blood sugar levels), Metformin (used for diabetes) or the Fleet enema (used for constipation), which the Daughter indicated was a one-time dose after first surgery. Patient #17’s Daughter indicated patient is taking Aleve (used for pain relief) as needed (PRN) which was not on the medication list or POC. 5. During an interview on 12/12/2023 at 3:00 PM, Patient #18’s Daughter reviewed the current medication list in the home with the medication list on POC, both were found to be incorrect. The Daughter indicated the Gabapentin (used for nerve pain) dose of 300 mg and should be 100 mg. 1. A policy titled Medications indicated the agency was to consolidate all pertinent orders for medications into the plan of care at the time the medication was prescribed or for over-the-counter medications at the time that they are found in the home and assess all medications a patient may be taking to identify possible ineffective drug therapy or adverse reactions. 2. The record review for Patient #15, start of care date 08/17/2023, certification period 10/16/2023 to 12/14/2023, included a plan of care (POC) and a medication profile. Both failed to list Cranberry + Vitamin C (urinary supplement), D-Mannose (urinary supplement), and Lidocaine topical cream (numbing). During a home visit on 12/13/2023 at 9:00 AM, Patient #15 informed Registered Nurse (RN) 3 that they had been taking Cranberry+ Vitamin, D-Mannose, and Lidocaine cream since February 2023. RN 3 reviewed Patient #13’s medication list on their tablet. RN 3 stated the medications were never added to the POC or medication profile. RN 3 stated RN 4 reviewed the medications for potential adverse effects and drug reactions on 10/11/2023, 10/20/2023, and 10/25/2023 but either did not add or was unaware of the three medications found on the home visit. 410 IAC 17-14-1(a)(1)(B)”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to maintain an updated individualized plan of care (POC) for 4 of 7 record reviews. (Patient #10, #15, #17, #18) Findings include: The record review for Patient #15, start of care date 08/17/2023, certification period 10/16/2023 to 12/14/2023, included a plan of care (POC) and a medication profile. Both failed to list Cranberry + Vitamin C (urinary supplement), D-Mannose (urinary supplement), and Lidocaine topical cream (numbing). During a home visit on 12/13/2023 at 9:00 AM, Patient #15 informed Registered Nurse (RN) 3 that they had been taking Cranberry+ Vitamin, D-Mannose, and Lidocaine cream since February 2023. RN 3 reviewed Patient #15’s medication list on their tablet. RN 3 stated the medications were never added to the POC or medication profile. RN 3 stated RN 4 reviewed the medications for potential adverse effects and drug reactions on 10/11/2023, 10/20/2023, and 10/25/2023 but either did not add or was unaware of the three medications found on the home visit. 410 IAC 17-13-1(a)(1)(B) 410 IAC 17-13-1(a)(1)(C) 410 IAC 17-13-1(a)(1)(D)(i-xiii) 1. A 10/18/2023 revised policy, titled Physician’s Role indicated the POC should include all pertinent diagnoses and medications. 4. The record review for Patient #17, certification period 12/07/2023 to 02/04/2023, reviewed on 12/11/2023, Patient #17 POC has a diagnosis for a left shoulder fracture, but the patient’s injury is to the right shoulder. 5. During an interview on 12/12/2023 at 6:00 PM, Patient #10 reviewed the current medication list brought to visit by RN 2. Patient #10 indicated he was no longer taking the following medication listed on the current medication list: Chloraseptic Throat Spray (used for sore throat and mouth pain), Ensure (Nutritional Supplement), Promethazine (used for allergy symptoms such as rash, itching, and runny nose), and Rosuvastatin (used for elevated Cholesterol). They also indicated the prescription for Melatonin (used for insomnia and improving sleep) he was taking PRN and they have been taking Hydromorphone Hydrochloride (used for pain relief) since starting on service. 6. During an interview on 12/12/2023 at 2:00 PM, Patient #17’s Daughter reviewed the current medication list in the home with the list on POC. The Daughter indicated the following medications are no longer being taken: Mucinex (used for chest congestion), Percocet (used for pain relief), Glimepiride (used for high blood sugar levels), Metformin (used for diabetes) or the Fleet enema (used for constipation), which Daughter indicated was a one-time dose after first surgery. Patient #17’s Daughter indicated patient is taking Aleve (used for pain relief) as needed (PRN) which was not on the medication list or POC. 7. During an interview on 12/12/2023 at 3:00 PM, Patient #18’s Daughter reviewed the current medication list in the home with the medication list on POC. The Daughter indicated the medication dose of 300 mg for Gabapentin (used for nerve pain) was incorrect and should be 100 mg. 8. During an interview on 12/13/2023 at 10:00 AM, the Administrator indicated medication should be reviewed every visit, compared to the current list on the system, if different then a call to the physician should be made to confirm the medication is prescribed to the patient. Then an order for the new medication or changes made to existing medication would be placed in the system and the medication list associated with the POC would be updated. The handwritten medication list in the patient’s home would also be updated by staff.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on record reviews and interviews, the Administrator failed to ensure physical therapy services were provided for 1 of 10 record reviews with physical therapy services (Patient #16) and failed to ensure staff completed all documentation on the day patient visits were assigned for 7 of 17 record reviews. (Patient #3, #10, #13, #14, #16, #17, #18) Findings include: 6. The record review for Patient #14, certification period 11/02/2023 to 12/31/2023, reviewed on 12/12/2023, revealed late documentation on visits outside of the range set by the agency on the following days: 11/04/2023. 410 IAC 17-12-1(b)(3) 410 IAC 17-12-1( c)(1) 1. A 10/20/2023 revised policy, titled Admission process & patient assessment indicated the agency will evaluate for licensed professional services as ordered by the physician. 2. A document dated 11/27/2023 titled Performance Improvement Project (PIP) indicated the agency is aware of late documentation on home visits but has not assigned a start date or check date/frequency of follow-up to the project. There were no other documents provided to verify PIP is in place and being monitored. 3. The record review for Patient #3, certification period 07/19/2023 to 09/16/2023, reviewed on 12/11/2023, revealed late documentation on visits, outside of the range set by agency, on the following days: 07/19/2023 and 08/02/2023. 4. The record review for Patient #10, certification period 10/27/2023 to 12/25/2023, reviewed on 12/11/2023, revealed late documentation on visits, outside of the range set by agency, on the following days: 11/02/2023, 11/14/2023, 11/21/2023 and 11/28/2023. 5. The record review for Patient #13, certification period 11/04/2023 to 01/02/2024, reviewed on 12/12/2023, revealed late documentation on visits, outside of the range set by agency, on the following days: 11/04/2023, 11/09/2023, 11/07/2023, 11/14/2023, 11/27/2023 and 12/07/2023. 7. The record review for Patient #16, certification period 11/18/2023 to 01/16/2024, reviewed on 12/12/2023, revealed late documentation on visits, outside of the range set by agency, on the following days: 11/18/2023, 11/21/2023, and 12/08/2023. The record review also revealed a physician order at the start of care (SOC) for physical therapy (PT) service, which was not provided as of 12/14/2023. 8. The record review for Patient #17, certification period 11/04/2023 to 01/02/2024, reviewed on 12/12/2023, revealed late documentation on visits, outside of the range set by agency, on the following days: 12/07/2023 and 12/08/2023. 9. The record review for Patient #18, certification period 11/22/2023 to 01/20/2024, reviewed on 12/12/2023, revealed late documentation on visits, outside of the range set by agency, on the following days: 11/20/2023 and 11/22/2023. 10. During an entrance conference on 12/11/2023 at 10:00 AM, the Alternate Administrator indicated all documentation should be completed within the same day as the visit, including SOC. They also indicated all visit information and documentation should be incorporated into the patient’s records on the same day as the visit. 11. During an interview on 12/12/2023 at 3:00 PM, Occupational Therapist (OT) 1 indicated, that documentation of visits needs to be completed and submitted by 9:00 PM on the day visit is assigned. 12. During an interview on 12/12/2023 at 10:20 AM, Certified Occupational Therapist Assistant (COTA) 1 indicated, that all documentation of visits needs to be completed during the home visit and submitted by 10:00 PM the same day as the visit. 13. During an interview on 12/13/2023 at 3:33 PM, the Administrator indicated she was aware there was a late visit documentation issue, and all visits should be completed by 9:00 PM on the same day the visit is assigned. 14. During an interview on 12/14/2023 at 10:45 AM, the Administrator indicated there is a Performance improvement project (PIP) in place to improve completion of visit documentation. 15. During an interview on 12/14/2023 at 12:55 PM, the Administrator indicated they was unable to confirm why PT services were not provided to patient #16. They did confirm there was an order at SOC for PT, but they was unable to locate documentation in the chart for the reason PT services were not offered to the patient.”