Enhabit Home Health

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on interview and review of the Home Health Agency’s (HHA’s) emergency preparedness (EP) plan, the HHA failed to ensure the plan included a process to engage in collaborative planning with local, tribal, regional, State, and Federal emergency officials during an emergent event for an integrated emergency response. This had the potential to affect the 270 patients currently receiving services from the HHA. Findings include: Review of the HHA’s EP plan revealed no evidence the HHA had a process to ensure cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials to ensure an integrated response during a disaster or emergency. Review of the HHA’s undated Emergency Preparedness Plan policy E06, Section 4.1.4 indicated, “. . . The Agency will cooperate and collaborate with local, regional, state, and federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation . . .” The policy further indicated, “. . . The Agency will document its efforts to contact these entities, and any participation in cooperative and collaborative planning efforts . . .” During an interview with the Branch Director (BD) on 05/16/25 at 2:05 PM, the BD stated the HHA participates in some community activities, but the BD could not provide any documentation to show this participation. The BD stated the HHA has not reached out to any hospitals, fire, police, or any other entities to be involved with their drills in order to develop a collaborative and cooperative plan as part of emergency preparedness.”

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based on interview and a review of the Home Health Agency’s (HHA) emergency preparedness (EP) plan, the HHA failed to develop or maintain a level of pre-coordination activity with state and local emergency officials or to work with their state and local officials to determine how to coordinate the reporting of staff or patients who cannot be contacted during an emergency or disaster. This had the potential to affect the 270 patients currently receiving services from the HHA and 59 employees. Findings include: Review of the HHA’s undated policy, E06, section 4.1.4. indicated, “. . . the Agency will coordinate with emergency preparedness officials for each county they serve to assist with evacuation of patients from their residences at any time due to an emergency or natural disaster, based on the patient’s medical and psychiatric condition and home environment . . .” Review of the HHA’s EP plan revealed no evidence that the HHA had developed or was maintaining pre-coordination activities or was working with state and local officials relative to the procedure for reporting staff or patients that cannot be contacted during an emergency or disaster. The EP plan did not include policies to notify state and local emergency officials of patients in need of evacuation during an emergency. During an interview with the Branch Director (BD) on 05/16/25 at 2:00 PM, the BD stated when we (the HHA) identify a patient is at risk at the time of evacuation, we let them know (police, fire). The BD stated had not reached out to any community resources, hospitals, or other local agencies to ensure there is a procedure in place to notify state and local officials of patients or staff that need to be evacuated during an emergency or disaster.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview, policy review, and review of the agency’s submission data, the Home Health Agency (HHA) failed to encode and transmit Oasis (Outcome and Assessment Information Set) data within 30 days of completing the assessment of the beneficiary. Findings include: Review of the HHA’s policy A22, section 4.3.1, dated 10/11/21 and titled, “OASIS data collection,” indicated, “. . . the Agency completes encoding; editing and locking of OASIS data within seven days of when the assessment is completed . . .the Branch Director (BD) and/or his/her designee is responsible for reviewing the Start of Care / Resumption of Care Assessment, Follow-Up Assessment, Transfer to lnpatient Facility Assessment, Discharge Assessment, and Death at Home assessments for completeness and accuracy prior to the OASIS being locked and Sent . . . Branch Director and/or his/her designee locks OASIS for submission to the State . . .”Review of the agency’s Oasis submission data report, dated 05/05/25, revealed the agency’s percentage of assessments submitted late was as follows: 2022, Quarter 1 – 13% (121 of 932) 2022, Quarter 2 – 15% (119 of 795) 2022, Quarter 3 – 17.2% (152 of 886) 2024, Quarter 1 – 10% (92 of 917) 2024, Calendar Year – 5.51% (176 of 3,197) During an interview with the BD on 05/16/25 at 4:45 PM, the BD stated she had worked at the agency for approximately eight years. She stated the Agency currently had an outside vendor who completes the coding and transmitting of the OASIS data. The BD stated prior to that the BD was doing coding and sending. The BD stated that once the OASIS data has been coded and reviewed, it goes back to the physician for review. The BD stated if the Physician does not approve the issues or drags their feet, the submission can be late. The BD reviewed the dates reported to be late during 2022 and 2024 and stated the report was accurate and the submissions of the OASIS data during that time were late. The submission documents for 2022 and 2024 were stored in Dallas and were not readily available on Friday 05/16/25 at 4:45 PM.”