Enhabit Home Health

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure clinical documentation was complete and appropriately authenticated and dated in accordance with currently accepted standards of practice for 2 patients (#7 and #17), out of a total sample of 17 patients. Findings include: Review of the agency Standard Operating Procedure, Discipline-Specific Documentation, reviewed 3/11/25, indicated the following: *For visits performed during normal business hours, visits should be completed and synched by 10:00 P.M. on the same day of service delivery. *For visits performed after normal business hours, visits should be completed and synched by 10:00 A.M. the following day. 1. Patient #7 was admitted to the agency in November 2025 with a diagnosis of nontraumatic intracerebral hemorrhage (bleeding directly into the brain tissue). Review of the physician ordered Home Health Certification and Plan of Care (POC) for certification period 11/10/25 through 1//8/26 indicated the following: Skilled Nurse (SN) visit: once a week for 3 weeks. Review of the clinical record indicated the following; -Discharge SN Note initiated on 12/5/25, signed and dated on 12/8/25. 2. Patient #17 was admitted to the agency in November 2025 with a diagnosis of right hand laceration (tear or cut in skin). Review of the physician ordered Home Health Certification and POC for certification period 11/1/25 through 12/30/25 indicated the following: SN visit: once a week for 1 week, 2 times a week for 2 weeks, three times a week for 1 week, once a week for 1 week. Speech Therapy (ST) visit: effective 11/9/25, once a week for 2 weeks, once a week every 2 weeks for 6 weeks. Review of the clinical record indicated the following: -11/1/25 SN visit, note signed and dated on 11/3/25. -11/20/25 ST visit, note signed and dated on 11/24/25. During an interview on 12/31/25 at 1:15 P.M., after reviewing the clinical records for Patients #7 and #17, the Branch Director said the clinical notes were late and not completed within the required timeframe.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure the Notice of Medicare Non-Coverage (NOMNC-an official Centers for Medicare and Medicaid Services {CMS} form that informs beneficiaries when their Medicare-covered skilled services, home health or outpatient rehabilitation services are ending and explains the right to appeal the decision) was provided prior to discharge for 2 patients (#3 and #5), out of a total sample of 17 patients. Findings include 2. Patient #5 was admitted to the agency in October 2025 with a diagnosis of intervertebral disc disorder (spinal discs degenerate) with lumber region radiculopathy (pinched nerve in the lower back). Review of the physician ordered Home Health Certification and POC for certification period 10/12/25 through 12/10/25 indicated the following: -SN visit: 2 times a week for 1 week, 1 time a week for 3 weeks. -PT visit: two times a week for 1 week, 1 time a week for 7 weeks. -Occupational Therapy (OT) visit: effective 10/19/25, 1 time a week for 1 week. Review of the clinical record indicated the patient was seen by PT on 11/13/25 and was discharged from the agency. Further review of the clinical record indicated no evidence that the NOMNC had been provided to the patient before discharge. During an interview on 12/30/25 at 3:30 P.M., the Branch Director said a NOMNC was not provided to Patient #5 prior to discharge, as required. Review of the agency’s policy entitled, Transfer and Discharge, dated 7/2/24, indicated the following: *When the treatment team agrees a patient is appropriate for discharge, the branch director will ensure the NOMNC, per state and federal regulation time frames, is presented to the patient. The home health must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that they received the notice and understand that the termination decision can be disputed. 1.Patient #3 was admitted to the agency in October 2025 with a diagnosis of aftercare following joint replacement surgery. Review of the physician ordered Home Health Plan of Care (POC) for certification period 10/22/25 through 12/20/25, indicated the following: -Skilled Nurse (SN) visit: once a week for 3 weeks. -Physical Therapy (PT) visit: 2 times a week for 3 weeks. Review of the clinical record indicated the patient was seen by PT 11/7/25 and was discharged from the agency after meeting his/her goals. Further review of the clinical record indicated no evidence that the NOMNC had been provided to Patient #3 before PT discharged him/her. During an interview on 12/30/25 at 3:25 P.M., the Branch Director said Patient #3 was not issued NOMNC prior to being discharged from the agency, as required. 2. Patient #5 was admitted to the agency in October 2025 with a diagnosis of intervertebral disc disorder (spinal discs degenerate) with lumber region radiculopathy (pinched nerve in the lower back). Review of the physician ordered Home Health Certification and POC for certification period 10/12/25 through 12/10/25 indicated the following: -SN visit: 2 times a week for 1 week, 1 time a week for 3 weeks. -PT visit: two times a week for 1 week, 1 time a week for 7 weeks. -Occupational Therapy (OT) visit: effective 10/19/25, 1 time a week for 1 week. Review of the clinical record indicated the patient was seen by PT on 11/13/25 and was discharged from the agency. Further review of the clinical record indicated no evidence that the NOMNC had been provided to the patient before discharge. During an interview on 12/30/25 at 3:30 P.M., the Branch Director said a NOMNC was not provided to Patient #5 prior to discharge, as required.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure that services were provided as ordered by the physician or allowed practitioner as indicated in the plan of care, for 1 patient (#4), out of a total sample of 17 patients. Findings include: Review of the agency’s policy entitled, Physician’s Role, dated 8/19/25, indicated the following: *Staff develops and maintains the plan of care in consultation with the physician or qualified non-physician practitioner and follows established procedures. *Staff administers medications and treatments only as ordered by the physician. Patient #4 was admitted to the agency in November 2025 with a diagnosis of aphasia (a language disorder caused by brain damage) following nontraumatic intracerebral hemorrhage (bleeding in the brain). Review of a verbal physician order, dated 11/6/25, indicated the following: -Effective 11/5/25 Physical Therapy (PT) visit: once a week for 4 weeks. Review of the clinical record indicated the patient had a PT visit 11/6/25, 11/18/25, and 11/25/25. A weekly PT visit was not provided as ordered for the week of 11/9/25. During an interview on 12/30/25 at 4:25 P.M., the Branch Director said that a PT visit was not provided as ordered for the week of 11/9/25. She said the physician’s order was not followed.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure staff communicated with the physician involved in the plan of care, related to the current plan of care, for 1 patient (#4), out of a total sample of 17 patients. Findings include: Review of the agency’s policy entitled, General Branch Procedures, dated 2/12/25, indicated the following: *Physicians must always be notified of visits that are missed as they represent a failure to follow the patient’s plan of care. *Clinicians must document the missed visit in a missed visit coordination note which includes: contact with the patient prior to the missed visits, attempts to find an alternative caregiver, and the reason for the missed visit. Patient #4 was admitted to the agency in November 2025 with a diagnosis of aphasia (a language disorder caused by brain damage) following nontraumatic intracerebral hemorrhage (bleeding in the brain). Review of a verbal physician order, dated 11/6/25, indicated the following: -Effective 11/5/25 Physical Therapy (PT) visit: once a week for 4 weeks. Review of the clinical record indicated the patient had a PT visit 11/6/25, 11/18/25, and 11/25/25. A weekly PT visit was not provided as ordered for the week of 11/9/25. Further review of the clinical record did not include a missed PT visit coordination note and no evidence that the physician was notified of the missed visit. During an interview on 12/30/25 at 4:25 P.M., the Branch Director said that a PT visit was not provided as ordered for the week of 11/9/25. She said PT did not document a missed visit note, nor notify the physician, as required.”