Enhabit Home Health

“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 clinical record review, agency policy, home visits, and interviews with patients and staff the Plan of Care [POC] failed to include all/correct/current medications the patient was using for 4 of 17 patients [#7, 8, 9, 17]. The findings included: The policy, Medications [revised date 6/24/24], was provided by the area vice president on 8/21/24 at 8:25 am. The policy states, “...The clinical record includes appropriate physician orders for all medications prescribed by the physician...” 1. Patient # 7 had a Start of Care [SOC] date of 1/25/24 with admitting diagnoses of type 2 diabetes with diabetic peripheral angiopathy without gangrene [blood vessel disease that occurs when high blood sugar levels damage cells in the blood vessels], chronic kidney disease [diabetes damages the blood vessels in the kidneys that filter waste from the blood], and chronic systolic [congestive] heart failure [heart stops pumping adequately]. Review of the Plan of Care [POC] for the certification period 7/23/24-9/20/24 included orders for SN [skilled nursing] 1 time a week for 3 weeks and PT [physical therapy] 2 times a week for 3 weeks with a supplemental order written on 8/12/24 for PT to see the patient 2 times a week for 6 weeks. On 8/20/24 at approximately 1 pm a joint visit was made the PTA # 1. During that visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed diflorasone 0.05% topical ointment [corticosteroid indicated for inflammatory and pruritic manifestations] use every 6 hours PRN [as needed] to the neck. During an interview with the patient, the patient stated he had never used the diflorasone cream. Eliquis [anticoagulant] 5 mg take 1 capsule 2 times a day was also listed on the medication profile. During the interview with the patient, he stated he had been switched to Xeralto 15 mg each day and he no longer used the Eliquis. Famotidine [used for reflux] 20 mg take 2 times a day was also on the medication profile. During an interview with the patient, he stated he had never used the medication. Ipratropium 0.5 mg-albuterol 3 mg [2.5 mg base]/3 ml nebulization solution take 3 ml every 8 hours as needed for shortness of breath was also included on the medication profile. The patient stated he used a “puffer” when he needed one but did not use a nebulizer. Lorazepam [used for anxiety] 0.5 mg take 1 every 8 hours as needed for anxiety was included on the medication profile. The patient advised the surveyor he no longer used this and didn’t need it after he had surgery at the beginning of the year. The medication profile also listed Tresiba insulin 100 units per ml take 30-50 units every pm. The patient stated, “I check my blood sugar, and I gage the amount of insulin to give myself based on the blood sugar reading. I usually give myself between 8-15 units.” During an interview with PTA # 4 after the visit, it was confirmed the medication on the POC were incorrect. 2. Patient # 8 had a Start of Care date of 6/13/24 and an admitting diagnosis of infection/inflammation reaction due to internal fixation of left tibia [shin bone]. Review of the Plan of Care [POC] for the certification period 8/12/24-10/10/24 included orders for SN [skilled nursing] 3 times a week for 3 weeks, 2 times a week for 1 week, 3 times a week for 4 weeks, 2 times a week for 1 week. On 8/20/24 at approximately 1 pm a joint visit was made with LPN # 2. During the visit, a medication review was completed using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Cyclobenzaprine [muscle relaxer] 5 mg tablet. Take 1 tablet 3 times a day. During an interview with the patient, she stated she took the medication 2 times per day. The medication profile listed Cipro [antibiotic] 500 mg 2 times per day. During the interview the patient stated she no longer takes Cipro but was taking Bactrim [antibiotic] 800-120 mg 2 times per day. The Bactrim was not listed on the medication profile. The medication profile listed Metronidazole [antibiotic] 500 mg 2 times per day. The patient reported she had completed this medication “a few weeks back”. During the visit, LPN # 2 completed a wound vac change to the left lower leg. The LPN applied santyl [debriding agent] to the wound bed during the dressing change. The medication profile did not include santyl. During an interview with the agency area vice president on 8/21/24 at approximately 2 pm, the VP [vice president] confirmed the POC did not include the correct/current medications. 3. Patient # 9 had a Start of Care date of 6/23/24 and an admitting diagnosis of other sequelae of cerebral infarction [stroke]. Review of the Plan of Care [POC] for the certification period 6/23/24-8/21/24 included orders for PT [physical therapy] 3 times a week for 1 week, 2 times a week for 7 weeks. On 8/20/24 at approximately 3 pm a joint visit was made with PT # 3. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Lipitor [high cholesterol] 10 mg take every 12 hours. Review of the directions on the bottle dated 6/8/24 revealed the patient should only take the medication 1 time per day. The patient reported she takes the medication at bedtime only. The medication profile listed Magnesium Oxide [supplement] 400 mg take 1 tablet daily. During an interview with the patient she reports, “I don’t take those anymore.” The medication profile listed Pantoprazole [reflux] 20 mg take 1 tablet 2 times a day. During the interview with the patient she stated, “I don’t take that pill anymore.” During an interview with the agency area vice president [VP] on 8/21/24 at approximately 3 pm, the VP confirmed the medications were not correct on the POC. 4. Patient # 17 had a Start of Care date of 8/2/24 and an admitting diagnosis of sepsis due to methicillin resistant staphylococcus aureus [blood infection due to bacteria]. Review of the Plan of Care [POC] for the certification period 8/2/24-9/30/24 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 5 weeks, 1 time a week for 3 weeks and “SN to ...flush PICC [peripherally inserted central catheter] with 10 ml normal saline, flush with 5 ml of 100 unit/ml heparin [blood thinner...Insulin Lispro 100 unit/ml subcutaneous pen take 4 times daily per sliding scale...” Review of the POC revealed the normal saline nor the heparin were included on the POC. Further review revealed the dosage related to the sliding scale insulin was not included on the POC. During an interview with the area vice present on 8/21/24 at approximately 3:30 pm she confirmed the medications [normal saline and heparin] and the dosage of the insulin should have been included on the POC.”

“Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This Element is not met as evidenced by: Based on clinical record review, agency policy, and staff interviews the SN [skilled nurse] developed a Plan of Care [POC] with orders to change a urinary catheter monthly for 1 of 1 patients [#14] who saw a urologist for catheter changes. The findings included: The policy, Physician’s Role [revised 10/18/23], was provided by the area vice president on 8/20/24 at approximately 8:10 am. The policy stated, “...Plan of care is a written plan developed with the participation of professional staff and the patient, in consultation and authorized by the physician that supports the patient’s medical, nursing and psychosocial needs...” Patient # 14 had a Start of Care date of 1/10/24 with admitting diagnoses of pressure ulcer of sacral [at the base of the spine] stage 3 [full thickness loss of skin that extends to the subcutaneous tissue], pressure ulcer of left buttock, stage 3, and encounter for fitting and adjustment of urinary device. Review of the Plan of Care [POC] for the certification period 1/10/24-3/9/24 included orders for SN [skilled nursing] 2 times a week for 9 weeks and “skilled nurse for insertion of foley catheter using catheter 16 fr [french] 10 cc balloon, nurse to change Q [every] month and PRN [as needed] …” Review of the clinical record revealed no evidence the foley catheter was changed from 1/10/24-3/9/24. Further review of the clinical record revealed the POC from 7/8/24-9/5/24 included orders for SN 3 times a week for 8 weeks, 1 time a week for 1 week and “skilled nurse for insertion of foley catheter using catheter 16 fr 10 cc balloon, nurse to change Q [every] month and PRN [as needed] ...”. The catheter was not changed during the month of July, and the catheter had not been changed as of 8/19/24. During an interview with the area vice president of the agency on 8/21/24 at 3 pm, the VP [vice president] stated, “Our nurses do not change the catheter. The patient goes to the urologist and went to the urologist yesterday and had the catheter changed. I don’t know why it was included as a physician’s order on the POC.””

“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 clinical record review and staff interviews the skilled nurse failed to complete wound care as ordered for 1 of 1 patient with an infected wound [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 10/7/23 with an admitting diagnosis of type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of left foot with fat layer exposed, and non-pressure chronic ulcer of left heel and midfoot with fat layer exposed. Review of the Plan of Care [POC] for the certification period 10/7/23-12/5/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 1 weeks, 2 times a week for 4 weeks, 1 time a week for 1 week “Skilled nurse to perform wound care to pressure ulcer/pressure injury to left heel. Cleanse with wound cleanser and pat dry. Apply hydrofiber silver. Cover with gauze using clean/aseptic technique. Wrap with roll gauze/tape...” RN # 8 completed the admission visit on 10/7/23 and documented wound care to the left heel was completed per the physician’s order. The RN also documented a stage II pressure ulcer to the left distal plantar [the bottom of the foot] with measurements of 0.5x2.5x0.1. RN # 8 documented, “...first aid care only pending orders from physician. Cleansed with NS [normal saline and applied dry dressing...” Further review of the clinical record revealed the patient received SN visits on 10/10/23, 10/12/23, 10/17/23 and 10/19/23 with no specific wound care completed to the left plantar area which was identified by RN # 8 at the time of admission. On 10/19/23, LPN # 5 documented the following information, “..._____ from ____ [name of the wound clinic] returned my call yesterday and said because she hasn’t been seen since 9/14/23 provider wouldn’t give any orders...” LPN placed a dry dressing on the area. The patient was seen at the would clinic on 10/24/23 and the clinical record included an order to “Cleanse wound [left plantar] with wound cleanser. Apply calcium alginate with silver, cover with 4x4 gauze, roll gauze and secure with tape. Change dressing every third day...” Further review of the clinical record revealed the patient received 7 SN visits from 10/26/23-11/21/23 and the orders from the wound clinic were never written as an order. The patient continued to receive a dry dressing to the left plantar area from the time of admission until the patient was discharged to the hospital on 11/23/23. During an interview with the area vice president [VP] on 8/21/24 at approximately 3:30 pm, the area VP stated, “The patient never did get the treatment to the wound that was ordered at the wound clinic.””

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on clinical record review, agency policy review, and staff interviews, the skilled nurse educated a patient on taking a medication without a physician’s order for 1 of 1 patient with and infected wound [#1]. The findings included: The policy, Physician’s role [revised date 10/18/23], was provided by the area vice president on 8/20/24 at approximately 8:15 am. The policy stated, “...Staff develops and maintains the plan of care in consultation with the physician and follows established procedures...” Patient # 1 had a Start of Care [SOC] date of 10/7/23 with an admitting diagnosis of type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of left foot with fat layer exposed, and non-pressure chronic ulcer of left heel and midfoot with fat layer exposed. Review of the Plan of Care [POC] for the certification period 10/7/23-12/5/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 1 weeks, 2 times a week for 4 weeks, 1 time a week for 1 week. Review of the clinical record revealed LPN # 5 conducted a routine visit on 10/31/23 and documented the following information, “...patient informs she had xray left foot plantar wound and cultures of wound obtained with last visit at ____ [wound clinic]…Patient informs she is on and ABX [antibiotic therapy]…medication list updated...Educated patient needs to take probiotic because ABX will be long term and will need to “protect” digestive tract...” Further review of the clinical record revealed no order for a probiotic or any evidence the LPN notified the physician prior to advising the patient to use a probiotic. During an interview with the agency vice president [VP] on 8/21/24 at approximately 3:30 pm, the VP advised there was no order or a probiotic”

“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 clinical record review, agency policy, direct observation and staff/patient interviews the physical therapy assistant failed to notify the physician of a change in condition for 1 of 2 patients who received dialysis [#7]. The findings included: The policy, Coordination of Care [revised 10/18/23], was provided by the area vice president on 8/20/24 at approximately 8 am. The policy stated, “ Promptly alert the physician to any change which suggest a need to modify the plan of care...” Patient # 7 had a Start of Care [SOC] date of 1/25/24 with admitting diagnoses of type 2 diabetes with diabetic peripheral angiopathy without gangrene [blood vessel disease that occurs when high blood sugar levels damage cells in the blood vessels], chronic kidney disease [diabetes damages the blood vessels in the kidneys that filter waste from the blood], and chronic systolic [congestive] heart failure [heart stops pumping adequately]. Review of the Plan of Care [POC] for the certification period 7/23/24-9/20/24 included orders for SN [skilled nursing] 1 time a week for 3 weeks and PT [physical therapy] 2 times a week for 3 weeks with a supplemental order written on 8/12/24 for PT to see the patient 2 times a week for 6 weeks. On 8/20/24 at approximately 1 pm a joint visit was made the PTA # 1. During the visit the patient explained he had had dialysis the previous day on 8/19/24. He proceeded to tell the clinician the dialysis nurse was unable to access his graft for the dialysis and when she removed the needle he began to bleed “a lot”. He stated the nurse held firm pressure on his right antecubital area for a significant length of time. He reported while she was holding the pressure he felt “a lot of pain.” He then showed the PTA his arm. His right arm was swollen tightly and had extensive purple bruising. The patient reported he was unable to extend his arm completely. The patient stated the arm was painful. During the visit, the PTA did not examine his arm. Review of the clinical record revealed the PTA did not contact the physician or the PT to report the changes in the patient’s right arm. During an interview on 8/21/22 at approximately 11 am, the PTA advised the incident happened while he was at dialysis, and he was scheduled to go back to dialysis on 8/21/24 and she felt the dialysis nurse would assess his right arm. On 8/21/24 at approximately 3:30 pm the area vice president confirmed there was no coordination with the physician or the PT regarding the patient’s right arm.”