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 observations, interviews and record reviews, the agency failed to ensure the plan of care contained the required elements to cover all supplies and equipment required, patient specific interventions and education, and safety measures to protect against injury for 2 of 17 patients reviewed for plan of care. (Patient#1, Patient#2) The agency did not ensure the plan of care included the type and Size of Patient #1’s tracheostomy (an opening (stoma) in the neck into the trachea (windpipe) to provide a direct airway). The agency did not ensure the plan of care for Patient #2 included the location of his dialysis fistula (a surgically created connection between an artery and vein, typically in an arm, designed to provide long term access for hemodialysis (treatment for kidney failure), or indicate Patient #2 had a peritoneal dialysis (a home-based, daily kidney failure treatment that uses the abdomen’s lining (peritoneum) to filter waste from the blood using a surgically placed catheter) access site. This failure could place patients at risk of injury, improper care and instruction leading to complications and hospitalization. Findings included: 1. Record review of a plan of care dated 4/7/2026-6/5/2026 indicated Patient #1 was admitted on 2/6/2026 with diagnosis including attention to tracheostomy (an opening (stoma) in the neck into the trachea (windpipe) to provide a direct airway), malignant neoplasm of the supraglottis (cancer arising in the upper larynx (organ in the neck that enables breathing) above the vocal cords), and chronic kidney disease stage 3 (moderate kidney damage). The plan of care indicated Patient #1 was ordered skilled nursing visits once every 2 weeks for 2 weeks, then then once a week for 1 week, then once every 2 weeks for 6 weeks. The plan of care indicated the skilled nurse would provide skilled teaching/reinforcement of management of tracheostomy care including stoma care, suctioning, tracheostomy care, and dressing change. The plan of care indicated the skilled nurse may provide tracheostomy care as needed at each visit. The plan of care did not indicate the type of tracheostomy or size of tracheostomy Patient #1 required. 2. Record review of a plan of care dated 4/7/2026-6/5/2026 indicated Patient #2 was admitted on 4/7/2026 with diagnosis including encounter for surgical orthopedic aftercare, type 2 diabetes (high blood sugar), end stage renal disease, and dependence on renal dialysis (removes extra fluid and waste products from your blood when the kidneys are not able to). The plan of care indicated Patient #2 was ordered skilled nursing visits 1 time a week for 9 weeks. The plan of care included orders for the skilled nurse to observe and assess chronic kidney disease. Skilled nurse may provide teaching reinforcement on some or all of these best practices: management of signs and symptoms, medication management, nutrition and end stage renal disease management. The plan of care indicated the skilled nurse to was to assess for bruit (blowing or swooshing vascular sound) and thrill (palpable, buzzing vibration felt) to fistula site with every visit. The plan of care did not include where the fistula site was located and did not indicate Patient #2 had a peritoneal dialysis access site. The plan of care included end stage renal disease precautions but did not include precautions regarding which arm blood pressure or blood draws should not be done in relation to the location of Patient #2’s fistula site or assessment/precautions of the peritoneal dialysis access site. Record review of a Visit Note Report for Patient #2 dated 04/07/26 indicated it was an Admission and OASIS (assessment) visit. The report indicated Patient #2 had a peritoneal dialysis catheter (a soft, flexible tube surgically placed in the abdominal cavity) and performed dialysis exchanges each night. Further review indicated dialysis access to left (fore)arm was positive for bruit and thrill (meaning that the fistula was working). During a home visit observation and interview with Patient #2 on 04/28/26 at 11:20 a.m., Patient #2 said he did peritoneal dialysis at home. Patient #2 had a Bandaid to his abdomen (stomach) which LVN D removed and assessed the site, then replaced the Bandaid. LVN D assessed Patient #2’s fistula to his left lower arm. Patient #2 said he had the fistula for 2 and a half years, but it had never been used, and it was only for safety. During an interview on 4/29/2026 at 11:00 a.m., RN A said Patient #1 had a disposable inner cannula (removable, single use tubes placed inside a tracheostomy tube (outer cannula) to prevent obstruction from secretions and reduce infection risk). RN A said a supply company sent Patient #1 his tracheostomy supplies except for the tracheostomies, cleaning trays, saline, inner cannulas and gauze which the home health supplied. RN A said the home health kept extra tracheostomies in the home and the patient and family were educated to call prior to running low so some could be delivered to the home. RN A said Patient #1 did not require oxygen to sustain breathing and Patient #1 was independent in his tracheostomy care. RN A said Patient #1’s plan of care should include respiratory (breathing) status monitoring, supplies, name of the company providing the patient any additional supplies, and the type and size of Patient #1’s tracheostomy. During an interview on 5/3/2026 at 11:40 a.m., RN B said she was a case manager with the agency, and she completed assessment visits and build the plan of care for patients. RN B said she was the case manager for Patient #2. RN B said Patient #2 did peritoneal dialysis at home. She said Patient #2 did have a fistula in his left forearm that had never been used. RN B said the access was assessed at each nurse visit along with the peritoneal dialysis site. She said the assessment of both sites should be documented in the narrative of nurse notes. RN B said she felt like the location of Patient #2’s fistula should be on the plan of care to ensure the nurses knew what and where to assess as some patients may have one or more sites, and maybe one worked and one did not. RN B said she did not currently have a patient who had a tracheostomy tube but the plan of care for a patient with a tracheostomy tube should include assessment and cleaning of site, emergency procedures, size and type of tracheostomy tube. RN B said it was important for everyone to have a comprehensive individualized care plan due to the different nature of every patient, and it was a good road map for the nurses to be able to properly care for patients. During an interview on 5/3/2026 at 11:50 a.m., RN C said she was the clinical team lead and reviewed the plan of cares that came through from the field nurses. She said Patient #1 had a tracheostomy but she did not know the size and type at this time. RN C said she ordered disposable cannulas (removable, single use tubes placed inside a tracheostomy tube (outer cannula) to prevent obstruction from secretions (bodily fluids) and reduce infection risk), collars (device used to secure a tracheostomy tube in place), and cleaning supplies for Patient #1. RN C said the plan of care for a tracheostomy patient should include the type and size of tracheostomy. RN C said she did not know why this information was not on Patient #1’s plan of care. RN C said this information was important to be on the plan of care for ordering processes and in the event, something were to happen to the tracheostomy. RN C said any patient who received dialysis should have teaching related to end stage renal disease, orders to assess the thrill and bruit (both assessed using a stethoscope to confirm proper open function in a dialysis fistula), and weights. RN C said the location of a patients fistula should be documented on the plan of care and she was not sure why Patient #2 fistula location had not been documented on the plan of care. RN C said it was important for nurses to know the location of a dialysis fistula so they could use proper precautions when seeing patients with them. During an interview on 5/3/2026 at 12:11 p.m., the DON said the plan of care for a tracheostomy should include the type of tracheostomy and the size, any respiratory supplies and precautions, oxygen orders and precautions if ordered. The DON said the agency kept extra tracheostomy tubes both in the patients homes and at the office. The DON said when Patient #1 was first admitted to home health they did not know the size and type of his tracheostomy tube, but an addendum order should have been written to include this information and an order had not been added. The DON said the plan of care for any patient on dialysis should include the chronic kidney disease pathway, type and location of dialysis access site, orders to assess the thrill and bruit on each visit, precautions, any fluid restrictions, safety precautions for no blood pressure or blood draws to whatever size the access site is on. The DON said Patient #2’s fistula site was inadvertently left off the plan of care and not caught in the review process because it had not been used but it still should have been documented because precautions still needed to be taken for that site. The DON said every patient was different and the plan of care needed to be individualized as they required different orders, supplies, and precautions and so that everyone in the home could see what was going on with each patient in a glance. During an interview on 4/29/2026 at 1:38 p.m., the Administrator said everyone was responsible for ensuring the plan of care was complete and individualized. The Administrator said Patient #1 should have tracheostomy orders, respiratory precautions, infection control and standard precautions. The Administrator said supplies included gloves, gauze, sterile water, cleaning trays, and cannulas. The Administrator said the size and type of tracheostomy should be documented on the plan of care. The Administrator said patients on dialysis should have a plan of care that included a renal diet, location of fistula, orders to assess the thrill and bruit of the fistula, and precautions that included what arm blood pressures and blood draws should not be done on, and any fluid restrictions. The Administrator said all of this was important for patient safety and the plan of care was a guide for each nurse to follow when in the home providing patient care. Record review of an undated policy titled Physicians Role indicated 2.1 the plan of care is a written plan developed with the participation of professional staff and the patient, in consultation with and authorized by the physician that supports the patients medical, nursing and psychosocial needs in the home setting and services as the basis of care delivery. 2.1.1 The plan of care includes all pertinent diagnoses, mental status, types of services and equipment required, frequency and duration of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirement, medications, allergies, interventions, treatments, safety measures to protect against injury, goals, measurable outcomes, instructions related for timely discharge or referral, a description of the patients emergency department visits and rehospitalizations with all necessary interventions to address the underlying risk factors, information related to any advance directives and any other appropriate items. Record review of a website accessed on 5/3/2026 https://theprotectedairway.com/tracheostomy-tubes-tools-of-the-trade/#:~:text=Whether%20you’re%20in%20the,can%20have%20big%20clinical%20consequences. Indicated understanding tracheostomy design is not a minor detail-its essential to safe care. Whether the tube is cuffed or uncuffed, its size, the presence of an inner cannula, and whether it is fenestrated all directly effect how you suction, ventilate, communicate, and manager emergencies, knowing this information is a core part of trach management. Record review of Hemodialysis Access dated 2026 and accessed at https://www.kidney.org/atoz/content/hemoaccess#keeping-your-access-working on 5/4/2026 indicated “…an access that is not working well can decrease the amount of dialysis you receive… Check the blood flow several times each day by feeling for a vibration, also called a pulse or thrill. If you do not feel this, or if there is a change, call your doctor or your dialysis center. Do not wear tight clothes or jewelry on your access arm. Do not carry anything heavy or do anything that would put pressure on the access. Do not sleep with your head on the arm that has your access. Do not let anyone use a blood pressure cuff on your access arm. Do not let anyone draw blood from your access arm…””