Enhabit Home Health

“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, observation, and interview, the agency failed to ensure proper written notice was provided to the patient, in advance of terminating on-going care in one (Patient # 1) of three inactive patient records reviewed in that: The agency failed to provide Patient # 1 with the Centers for Medicare and Medicaid form titled “Notice of Medicare Non-Coverage (NOMNC)”. The failure placed the patient’s health and safety at risk and could result in harm due to lack of consistency and continuing care in the patient’s post discharge needs. The failure caused the patient to not have written advance notice to appeal the discharge decision. Findings include: During presurvey on 08/15/2025, review of TULIP (a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) revealed a provider investigation report (for Intake 1015355) dated 06/09/2025 and submitted by the Admin on 06/17/2025. Review of the investigation report revealed the following: the agency self-reported a complaint of misappropriation of property of Patient # 1 to HHSC regarding missing medication. Continued review of the investigation report revealed that Family member # 1 stated that the last nurse that visited from the agency # 1 took medication from the home. During an onsite investigation on 08/21/2025, review of agency’s complaint records revealed a complaint report dated 06/09/2025 for Patient # 1 and processed by DON/BD B on 06/12/2025. Review of the complaint report revealed the description of the complaint as, “[Family member, # 1] called to office and states that patient’s [medication] is missing and states that the nurses at last visit took it…He is unsure of when the medication went missing. He also does not know when the medication was obtained or how many boxes or quantity of [medication] patient had…Follow-up comments…Notified [Patient # 1’s nurse practitioner, Identifier 600] who states to discharge [patient] from services and to please make an [Adult Protective Services] report as patient needs a higher level of care. She states that she is going to contact [family member, # 1] and notify him that she requested [home health] discharge…” Inactive Clinical Record # 1: Record review of the clinical record for Patient # 1 revealed a POC for the certification period of 04/24/2025 to 06/22/2025. Review of the POC revealed a start of care date of 04/24/2025 with diagnoses of urinary tract infection (bacteria in the bladder, kidneys, or tubes that connect the bladder and kidneys), type 2 diabetes with chronic kidney disease (high levels of sugar in the blood can lead to damage of the kidneys and cause them to lose function), and bed confinement (when a patient cannot get out of bed without assistance). Review of the POC revealed that RN B signed and dated the POC on 04/24/2025. Continued review of the POC revealed that it contained an order for skilled nursing visits one time per week for one week, two times per week for one week, and one time per week for seven weeks; physical therapy visits effective 04/27/2025 for one time per week for one week and two times per week for four weeks. Further review of the record revealed a RN discharge visit note signed by RN B and dated 06/11/2025. Review of the discharge visit note revealed a discharge date of 06/13/2025. Continued review of the discharge note revealed that the “[discharge] decision [was] made after visit (on 06/11/2025).” Further review of Patient # 1’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 06/13/2025. The record did not include a written NOMNC. Review of Patient # 1’s record did not include an Adult Protective Services referral on or after 06/12/2025 (the date Patient # 1’s nurse practitioner, Identifier 600 ordered the referral). During a home visit observation and interview on 09/03/2025 at approximately 9:15 a.m. with Patient # 1 and family member (1), the surveyor asked Family Member # 1 why the agency stopped providing services to Patient# 1. Family Member # 1 stated that the agency got upset with him because he let them know that Patient # 1 had medication missing. Family Member # 1 stated that he was not going to fire the agency, he just wanted to let them know about the missing medication. The surveyor asked if the agency provided a written notice of intent to discharge to Patient # 1 or the legally authorized representative. Family Member # 1 stated that the agency “just stopped coming out here. They [did not say anything]. They did not tell me they were not coming again.” Family Member # 1 stated that the agency did not give him a written notice but might have given it to Patient # 1’s POA. The surveyor observed Patient # 1 reclining in a hospital bed. The surveyor asked Patient #1 if the agency provided a written notice of intent to discharge. Patient # 1 stated that the agency did not provide a written notice for her. Patient # 1 stated that her POA had to find another home health agency and the POA had a hard time finding another agency. The surveyor observed that a home health agency staff (from home health agency # 2) was in the home providing wound care treatment. During an interview on 09/04/2024 at 10:12 a.m. with Patient # 1’s POA, the surveyor asked if the agency had provided a written notice of intent to discharge Patient # 1. The POA replied, “No, they did not give me anything. I had to call the office to ask what was going on. They did not give a list of other home health agencies. They told me they were discharging [Patient # 1] (after they stopped providing services). I asked why. They said something about them (Patient # 1 and Family Member # 1) accusing the staff of stealing medicine. I had to look up and find help for my [Patient # 1]. The POA stated that Patient # 1 and family member (1] called the POA and stated that the agency staff were no longer going to the home of Patient # 1. During an interview on 09/09/2025 at 3:09 p.m. with RN B, the surveyor asked if RN B discharged Patient # 1. RN B replied, “Yes, I did it from a previous visit.” The surveyor asked why Patient # 1 was discharged. RN B replied, “I think her [family member] requested the discharge.” The surveyor asked what the agency’s discharge process was. RN B replied, “Try to make a physical visit. We do desk discharge from previous visit if patient refuse visit or we can’t contact patient.” The surveyor asked if RN B provided a written discharge notice to Patient # 1. RN B replied, “I personally did not, no.” The surveyor asked why RN B did not provide written notice at least 2 days prior to stopping ongoing care. RN B replied, “When I left [the] home on previous visit, I did not know the [Patient # 1] would be discharged. From my branch director, [BD B] I was told [family member, # 1] thought we had taken something from the home and did not want us to come back.” The surveyor asked how the failure could adversely affect the patient. RN B replied, “So that they know the plan of care and what to do or where to go if they have a medical emergency. They will have an opportunity to appeal that discharge if needed.” During an interview on 09/09/2025 2: 02 p.m. with BD B the surveyor reviewed the findings and asked why Patient # 1 was discharged. BD B replied, “The [family member, # 1] called [about a medication that was missing]. I called [nurse practitioner, Identifier 600]. She advised us (the agency # 1) that the patient discharge for non-safety in the home…due to need higher level of care (for the patient). [The N. P] stated that she would call [Family Member # 1].” The surveyor asked if BD B had provided written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for Patient # 1. BD B replied, “I did not. The [nurse practitioner of Patient # 1) aid she would notify [Family Member # 1].” The surveyor asked why BD B did not provide the required notice of intent to discharge. BD B replied, “We give the five-day here. As far as I know our policy says to give five-day unless physician discharge of patient request.” BD B stated that [BD B] was not aware of the two-day NOMNC. The surveyor asked what the agency process was for discharging patients. BD B stated that the agency followed the process of state regulation. BD B replied, “I had heard of the two-day, but thought it was just another term for another state.” The surveyor asked if BD B gave a written notice to Patient # 1’s POA. BD B replied, “No, I did not.” The surveyor asked how the failure could adversely affect the patient. BD B stated that the failure would affect, “Patient’s rights, their care; to give the patient the opportunity to continue care. It could put their health in jeopardy.” The surveyor asked what should have been done differently. BD B replied, “I, we should have…continue following up with the physician for coordination of care.” Review of agency policy titled, “Transfer or discharge from services” last revised on 08/05/2024 read in part: “ 1.0 Purpose…To allow patients to challenge/appeal their provider’s decision to discharge…Policy…3.2 The Agency will consider transfer or discharge of the client form Agency services if: 3.2.1 The transfer or discharge is necessary for the client’s welfare because the Agency and the physician who is responsible for the home health plan of care agree that the agency can no longer meet the client’s needs, based on the client’s acuity. The Agency must arrange for a safe and appropriate transfer to other care entities when the needs of the client exceeded the Agency’s capacities…3.3.1 The Agency will provide notice to eligible patients of their right to expedited determinations when their period of covered care ends. 3.23.2 The Agency will deliver the generic notice (a prescribed CMS notice) to the patient (or authorized representative), no less than two days prior to the end of the covered period [in other states]…no less than five days prior to the end of the covered period in Texas…4.1.1.1.1Texas…In the event a 5-day notice is not needed, per above exceptions, the Generic Notice [NOMNC] is still required…””

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview, observation, and record review, the agency failed to ensure wound care treatments were administered only as ordered by a physician, in that: the agency’s employee (RN A) for one (Patient # 2) of three patient records reviewed for following wound care orders, RN A failed to provide wound care as ordered by the physician (Identifier 100) when RN A used the wrong wound care supplies. The failure placed the patient at an increased risk of degression [degression is a decline or decrease in the healing of the wound], infection of the wound, and continued or further neglect. Findings include: During presurvey on 08/15/2025, review of TULIP (a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) revealed a provider investigation report (for Intake 1016576) dated 06/13/2025 and submitted by the Admin on 06/20/2025. Review of the investigation report revealed, “… [Wound clinic staff, Identifier 200] report that when they removed the dressing from patients’ wound, the wound dressing was not per physicians orders and the wound had digressed since last visit…Patient name, [Patient # 2] …Staff name [RN A]…” During an onsite investigation on 08/21/2025, review of agency’s complaint records revealed a complaint report dated 06/13/2025 for Patient# 2 and processed by DON/BD A on 07/03/2025. Review of the complaint report revealed the description of the complaint as, “Wound [Clinic] reported digression [degression is a decline or decrease in the healing of the wound] and incorrect orders followed…Intervention/resolution comments: [Family member] reported that the wound clinic stated the wound was larger…BD followed up with wound evolution and family. Wound clinic reported incorrect supplies were used telfa (dressing) instead of ABD (abdominal dressing) pad…” Patient# 2: Record review of Patient# 2’s clinical record revealed a POC with a SOC date of 08/31/2024 and a treatment period of 04/28/2025 to 06/26/2025. Review of the POC revealed that RN A signed and dated the POC on 04/23/2025. Continued review of the POC revealed type 2 diabetes (chronic high levels of sugar in the blood and the body cannot utilized or make enough insulin to maintain health levels of sugar in the blood) with other skin ulcers (wound), chronic left lower leg and foot ulcer (wound), and right foot ulcer (wound). Further review of the POC revealed an order for skilled nurses to visit two times per week for nine weeks to perform wound care to Patient # 2’s lower extremities (legs and feet). Continued review of the record revealed an order dated 06/09/2025 that read in part: “…Cleanse [left lower leg] vashe soak 3-5 minutes, A& D to periwound (around the wound) to help prevent ABD (dressing) from sticking, Santyl, hydrofera blue, ABD, confirm tape, lambs wool between toes…left posterior heel…cleanse vashe soak 3-5 minutes, Santyl, ABD, Kerlix, lamb’s wool between toes…” Continued review of Patient# 2’s record revealed a skilled nurse visit note dated 06/11/2025 and signed by RN A. Review of the visit note revealed the following: “…[skin] assessment findings; ulcer/wounds present…Narrative…Wound care provided as ordered…patient continues to require wound care due to impaired circulation…” Further review of the record did not reveal any records or description of the wound care that was provided or wound measurements for 06/11/2025. During a home visit and interview on 08/28/2025 at 2:30 p.m. with Patient# 2 and Patient # 2’s family members (2) and Patient # 2 stated that they were satisfied with the services that the agency provided. Family Member # 2 stated that the wound care clinic stated that the agency nurse [RN A] used the wrong wound care supplies. Family Member # 2 stated that the complaint had been resolved and that mistakes are made sometimes. Patient# 2 and Family Member # 2 denied any concerns or complaints regarding current neglect. During an interview on 09/09/2025 at 9:19 a.m. with the wound clinic staff, (Identifier 300), Identifier 300 stated that the wound clinic’s physician (Identifier 100’s) had written a note for 06/13/2025 and stated that Patient# 2’s wound seemed to get a little larger that (wound clinic visit on 06/13/2025). Identifier 300 stated that the note said due to improper dressing placement. During an interview on 09/09/2025 at 9:40 a.m. with RN A, the surveyor asked RN A to describe the wound care that was provided for Patient# 2 on 06/11/2025. RN A replied, “I told them (the agency) what I told the wound center. If my initials were not on the dressing, it was not mine. I always checked the orders. Sometimes the family changed the wound dressing. The surveyor asked what the last wound care orders were for Patient# 2. RN A replied, “I don’t remember. The family often wanted the orders changed…I had to call [the physician] a lot…because the family wanted different dressings frequently.” The surveyor asked why RN A did not document the specific treatment that was provided and wound measurements on 06/11/2025 (as at other visits (04/30, 05/07, 05/12, 05/14, 05/19, 05/26, 05/30, and 06/09/2025 in the client’s record). RN A replied, “Here is what I told (the agency) there is some kinda computer glitch. You can’t close out the note without documenting the wound note.” The surveyor asked how often RN A was required to document the specific wound treatment and wound measurements. RN A stated the specific wound treatment was supposed to be documented every visit unless the patient refused the treatment and the measurements weekly. The surveyor asked how the failure could adversely affect the client. RN A replied, “I can’t answer that specifically. How am I supposed to remember a visit from June, when there was a computer glitch? This is a company issue that they need to fix.” During an interview on 09/10/2025 at 12:10 p.m. with the Admin and DON/BD A the surveyor asked how the agency ensured that wound care orders were current. DON/BD A replied, “[The nurses] are supposed to check the most current orders prior to entering the home. Orders are faxed [to the agency] and sometimes [the orders are left in the home]. We enter it into the computer. I encourage [the nurses] to check the orders at night before the visit.” The surveyor asked when the orders were uploaded into the patient’s record. DON/BD A replied, “The minute they come in. the RN reviews it and then enters it into the records.” The interview continued 09/10/2025 at 12:18 p.m. and the surveyor asked what the agency’s process was for the agency nurses to document specific wound treatment and wound measurement. DON/BD A replied, “It should be documented exactly what they did. [The] wound measurements once weekly or as needed.” The surveyor asked what the wound clinic said when the DON/BD spoke with them on 06/13/2025. DON/BD A stated that the clinic staff reported that the wound care supplies used were not followed as the physician ordered (the nurse used telfa dressing instead of abdominal dressing). The surveyor asked how the failure affected the client. DON/BD A stated, “Possible infection and degression of the wound.” Review of agency policy titled, “Physician’s role” with original issue date of 01/2000 revealed the following: “…Policy…3.6 Care delivery…Staff administers …treatments only as ordered by the physician...””