Enhabit Home Health

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on policy review, medical record review and interview, the agency failed to alert the physician of changes in condition for 2 Patient’s (#16,#17) of 17 patients reviewed. The findings include: Review of the agency policy titled, “Service delivery Physician’s role,” dated 12/2/2024, revealed “...Professional staff notifies the physician...and documents according to...Changes in the patient’s condition...Any problems identified during the assessment of medications the patient may take...” Review of the medical record revealed Patient #16 was admitted to the agency on 2/8/2024 with diagnoses including Type 2 Diabetes Mellitus and Chronic Kidney Disease. Review of the medical record Home Health Certification and Plan of Care dated 2/8/2024-4/7/2024 revealed “...skilled nurse to assess/evaluate co-morbid conditions including...Diabetes Mellitus...to identify changes and intervene to minimize complications...SN [Skilled Nurse] may perform finger stick blood sugar as needed...as part of the diabetic assessment...Licensed Professional to report vital signs falling outside the following...FBS [Fasting Blood Sugar] and RBS [Random Blood Sugar] > [less than] 70 and [less than] 70 and < [greater than] 180...DME [Durable Medical Equipment] and Supplies...Diabetic Supplies...” Review of a Skilled Nurse note dated 9/12/2024, revealed Patient #17’s “...Glucometer not present...” Continued review revealed no documentation the physician had been notified the blood sugar had not been obtained or the patient did not have a glucometer. Review of a Skilled Nurse note dated 9/18/2024, revealed Patient #17’s “...Does not have glucometer wife states it should be coming...” Continued review revealed no documentation the physician had been notified the blood sugar had not been obtained or the patient did not have a glucometer. During an interview on 4/29/2025 at 2:50 PM, the Administrator and Director of Operations confirmed there was no documentation the physician was alerted of the elevated random blood sugar or that the patient did not have a glucometer to obtain blood sugar readings.”

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This Element is not met as evidenced by: Based on policy review, medical record review, and interview, the agency failed to provide documentation of notification of agency transfer discharge for 1 Patient (#15) of 5 discharged patients reviewed. The findings include: Review of the agency policy titled, “Transfer or Discharge From Services,” dated 8/5/2024, revealed “...licensed professional obtains an order for discharge and provides discharge instructions to the patient in writing. In case of transfer to another home health provider...completes the discharge documentation and notifies regarding discharge status...” Review of the medical record revealed Patient #15 was admitted to the agency on 3/27/2024 with diagnoses including Pneumonia and Pressure Ulcer of Sacral Region, Stage 2. Review of the medical record Home Health Certification and Plan of Care dated 3/27/2024-5/25/2024 revealed “...Resume care if patient is transferred to an inpatient facility...Discharge summary will be sent to the primary care physician...after discharge within five business days of the date of the order...” A physician’s order for skilled nursing visits to begin 3/31/2024 and ending 5/25/2024 at 2 times a week for 1 week and 1 time a week for 7 weeks. Physical therapy visits at 1 time a week for 1 week, 2 times a week for 4 weeks, and 1 time a week for 2 weeks. The patient was admitted to the hospital on 4/17/2024 and with a resumption of care scheduled for 4/24/2024. Review of a Coordination Note dated 4/29/2025 [Entered as a late entry], revealed Patient #15 was discharged from the agency on 4/22/2024. Continued review showed “...Late Entry...Patient [#15] decided to go back to home health that she had prior to our services...Patient was discharged...” Continued review revealed no documentation the discharge or transfer summary had been sent to the physician. During an interview on 4/29/2025 at 2:45 PM, the Director of Operations and Administrator confirmed there was no documentation of the notification of transfer discharge or that the physician had been notified.”