Every finding on record at Care South HHA Holdings of South Carolina, LLC

An onsite unannounced Emergency Preparedness Program Survey was conducted at Enhabit Home Health and Hospice from 6/03/24 to 6/05/24. The facility is in substantial compliance with the Medicare Conditions at 42 CFR 484.102 (Establishment of the Emergency Program).

An unannounced onsite Recertification Survey was conducted at Enhabit Home Health and Hospice from 06/03/24 to 06/05/24. The facility is in substantial compliance with the Medicare Conditions at 42 CFR PART 416. Standard level deficiencies were cited.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) staff failed to keep an updated, accurate medication list for 1 of 4 patient home visits observations (Patient #6). Findings include: Review of Patient #6’s medical record on 6/04/2024 at 4:02 PM revealed discrepancies between the HHA medication list and the facility Medication Administration Record (MAR) and duplications on the HHA listing. HHA medication lists Vitamin B Complex one tablet by mouth daily and B Complex-Vitamin B one tablet by mouth daily. This is a duplication. HHA medication lists Lyrica 75 mg 1 capsule by mouth two times daily and Pregabalin 75 mg one capsule by mouth twice a day. This is also a duplication. HHA medication lists Nystatin 100,000 unit/Gram topical ointment four times daily to mouth sore. MAR reports Nystatin 100,000 unit/GM topical ointment three times a day to groin for rash. MAR reports Ferosul 325 mg one tablet by mouth daily and this medication is not on the HHA list. HHA medication lists Culturelle 15 billion cell sprinkle one capsule by mouth daily and Digestive Advantage Probiotic Gummy 250 million cell chewable one tablet by mouth daily of which both are not documented in the MAR. During an interview on 6/05/2024 at 11:05 AM, the DOO (Director of Operations) stated that "The medication lists should be accurate".

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 record review and interview, the Home Health Agency (HHA) failed to ensure the plans of care included all pertinent patient information for two of ten records reviewed, Patients #5 and #8. Findings: Review of Patient #8's record on 06/04/24 at 12:00 PM revealed Patient #8 was admitted to the Home Health Agency on 04/19/24. Review of the initial nursing assessment on 04/19/24, as well as all other nursing visit notes (04/22/24, 04/25/24, 04/30/24, 05/05/24, 05/06/24, 05/07/24, 05/10/24, and 05/13/24) revealed the primary skilled nursing services provided each visit was wound care, including a wound vac (negative pressure device to decrease drainage) to Patient #8's sacral area (some nursing notes indicated the wound was at the sacrum and other nursing notes indicated the wound was at the rectum). The plan of care dated 04/19/24 to 06/17/24 indicated, "...SKILLED NURSE TO CLEANSE WOUND TO SACRUM WITH WOUND CLEANSER. PREPARE PERI-WOUND AREA WITH SURE PREP. FILL ENTIRE CAVITY WITH BLACK FOAM. APPLY TUBING AND COVER WITH TRANSPARENT DRAPE. APPLY NEGATIVE PRESSURE DEVICE AT 125 MM/HG CONTINUOUS. CHANGE DRESSING MONDAY AND THURSDAY BY SN (Skilled Nurse)..." The first diagnosis on the plan of care was Malignant Neoplasm of Colon, Unspecified, and the second diagnosis was Encounter for Attention to Ileostomy (an opening in the abdomen at the location of the ileus for stool elimination). There were no diagnoses in the plan of care for a sacral wound. In an interview with the Branch Director (BD) and the Director of Operations (DO) on 06/05/24 at 10:30 AM, the BD confirmed wound care to Patient #8's sacrum was the primary reason the SN was visiting Patient #8 and the BD confirmed there were no diagnoses for the sacral wound in Patient #8's plan of care. The DO reviewed Patient #8's record and printed the Operative Note dated 02/05/24. Concurrent review the Operative Note revealed Patient #8 had surgery to remove a rectal mass which required surgical incision near the sacrum. Review of Patient #5’s medical record on 06/04/2024 at 2:01 PM showed Physical Therapist (PT) #2 failed to provide a full assessment for mental status. The admission paperwork documents “none” under mental status. During an interview on 06/05/2024 at 10:49 AM, DOO stated that mental status was incorrectly documented and verified the finding.

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 and record review, the Home Health Agency (HHA) staff failed to follow physician orders for wound care and weights for 2 out of 10 patients. (Patient #3 and Patient #6). Findings include: Review of Patient #3’s medical record on 6/04/2024 at 4:02 PM showed wound care orders for right malleolus “Cleanse with wound cleanser apply Aquacel AG cover with foam dressing using clean/aseptic technique”. Registered Nurse (RN) note dated 3/29/2024 documents “SN (Skilled Nurse) cleaned wound with wound cleanser. Patted dry. Applied Aquacel AG. Covered with foam dressing. Secured with kerlix and Tubigrip”. SN note dated 3/06/2024 documents “SN cleansed wound with wound cleanser. Applied Aquacel. Covered with Sorbion Absorbant Dressing. Secured with Kerlix.” During an interview on 6/05/2024 at 10:44 AM, the Director of Operations (DOO) stated that wound care orders were not followed and verified the findings. Review of Patient #6’s medical record on 6/04/2024 at 4:02 PM showed physician orders for licensed professional to report weights less than 135 pounds and greater than 145 pounds. Occupational Therapy (OT) visit dated 5/20/2024 revealed no documentation of a weight for the patient. Physical Therapy Assistant (PTA) visit dated 5/24/2024 revealed no documentation of a weight for the patient. During an interview on 6/05/2024 at 10:50 AM,the DOO stated that, Weights should have been recorded at each visit" and verified the findings.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview and policy review, the Home Health Agency (HHA) failed to ensure standard precautions for infection control were observed for 3 of 4 home visits observed. (Patients #4, #5, and #6). Observation visit on 06/04/2024 between 10 AM and 11 AM for Patient #5 showed Physical Therapy (PT) #1 having patient sign electronic tablet but failed to sanitize the tablet before leaving patient’s home. During an interview on 06/05/2024 at 10:49 AM, DOO stated the tablet should have been sanitized. Observation visit on 06/04/2024 between 11 AM and 11:58 AM for Patient #6 showed PT #2 removing electronic device used to time patient during the assessment from uniform pocket and replacing the device into the uniform pocket with ungloved, un-sanitized hand. Patient singed electronic tablet, PT #2 placed the electronic tablet under left arm, then sanitized the tablet. During an interview on 06/04/2024 at 11:58 AM, PT #2 agreed with this surveyor about sanitizing equipment. Findings: On 06/04/24 from 9:18 AM to 10:00 AM a home visit was made to Patient #4 to observe a nursing visit by Licensed Practical Nurse (LPN) #1. While providing care, LPN #1 was observed to re-enter the nursing bag without performing hand hygiene. Also, LPN #1 did not disinfect the electronic tablet she/he used during the visit. In an interview with LPN #1 at 10:00 AM, she/he confirmed the findings. In an interview with the Branch Director (BD) on 06/05/24 at 10:00 AM, he/she confirmed the findings and stated the staff's electronic tablets are supposed to be disinfected right after the vital signs equipment used during the visit is disinfected and before leaving the patient's home.

A survey of the Home Health Agency's (HHA) Emergency Preparedness Program (EPP) was conducted from 10/11/2021 to 10/14/2021. Based on observations, record reviews, interviews, and review of the HHA's EPP and policies and procedures, it was determined that standard level deficiencies resulted from the Emergency Preparedness Program Survey.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record reviews, interview and the review of the facility's policies and procedures, the facility failed to provide documentation of Emergency Preparedness training for ten (10) of 10 personnel files reviewed. The findings are: On 10/14/21 at 9:31:00 AM, the review of the Home Health Agency's (HHA) Emergency Preparedness Manual, interview, and the review of personnel files, the HHA failed to provide documentation of staff training regarding Emergency Preparedness for 10 of 10 staff members. The findings were verified by Branch Director 1, "I don't think we have that here." The facility's policy and procedure titled "Emergency Preparedness Plan" reads "....3.5....All staff will receive information during orientation and annually during safety training to ensure their continued safety during a disaster....".

The Home Health Agency's (HHA) Recertification Survey was conducted in conjunction with the COVID-19 focused Infection Control requirements from 10/11/2021 to 10/14/2021. Based on observations, record reviews, interviews, review of the COVID -19 requirements, and review of the HHA's policies and procedures, it was determined the HHA is in compliance with the COVID - 19 focused Infection Control requirements, and determined that standard level deficiencies resulted from the HHA's Recertification Survey.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record reviews and interview, the Home Health Agency (HHA) staff failed to ensure all patient goals on the plan of care were measurable for 13 of 13 patient records reviewed. (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13). Patient #3 On 10/12/2021 at 8:44 AM, a review of Patient #3’s chart reveals the plan of care did not have all goals measurable (receive medications prescribed, demonstrate knowledge of medications, reduce risk for acute care hospitalization, physical therapy evaluation, occupational therapy evaluation, and a patient centered plan of care will be established.). This finding is verified by Branch Director #2 and Registered Nurse (RN) #1 at 10:37 AM on 10/14/2021. Patient #4 On 10/12/2021 at 9:10 AM, a review of Patient #4’s chart reveals the plan of care did not have all goals measurable (patient centered plan of care, speech therapy evaluation will be completed, and medical social worker evaluation will be completed). This finding is verified by Branch Director #2 and RN #1 at 10:47 AM on 10/14/2021. Patient #5 On 10/12/2021 at 9:48 AM, a review of Patient #5’s chart reveals the plan of care did not have all goals measurable (speech therapy evaluation, medical social worker evaluation, patient centered plan of care, avoidance measures and medication management, diabetic foot ulcer mitigation, and reduce risk for acute care hospitalization). This finding is verified by Branch Director #2 and RN #1 at 10:50 AM on 10/14/2021. Patient #6 On 10/12/2021 at 12:28 PM, a review of Patient #6’s chart reveals the plan of care did not have all goals measurable (patient centered plan of care, avoidance measures and medication management, increased pain control measures, verbalize understanding of pharmacologic pain control, demonstrate knowledge of medications, ways to reduce risk for acute care hospitalization, and physical therapy evaluation). This finding is verified by Branch Director #2 and RN #1 at 9:55 AM on 10/14/2021. Patient #7 On 10/12/2021 at 1:02 PM, a review of Patient #7’s chart reveals the plan of care did not have all goals measurable (receive medications as prescribed, demonstrate knowledge of medications, patient centered plan of care, avoidance measures and medication management). This finding is verified by Branch Director #2 and RN #1 at 10:12 AM on 10/14/2021. Patient #8 On 10/13/2021 at 9:54 AM, a review of Patient #8’s chart reveals the plan of care did not have all goals measurable (patient centered plan of care). This finding is verified by Branch Director #2 and RN #1 at 10:21 AM on 10/14/2021. Patient #13 On 10/13/2021 at 10:10 AM, a review of Patient #13’s chart reveals the plan of care did not have all goals measurable (patient centered plan of care, risk for acute care hospitalization and avoidance measures and medication management). This finding is verified by Branch Director #2 and RN #1 at 10:30 AM on 10/14/2021. Patient # 1 On 10/13/2021 at 9:30 AM, a review of Patient #1’s chart reveals the plan of care did not have all goals measurable (patient centered plan of care, ability to perform wound care, wound status, increased pain or pain control, understanding pain control measures). This finding is verified by Branch Director #2 and Registered (RN) #1 at 11:10 AM on 10/14/2021. Patient # 2 On 10/13/2021 at 8:30 AM, a review of Patient #2’s chart reveals the plan of care did not have all goals measurable (patient centered plan of care, skin integrity, medication regime, increased pain or pain control, understanding pain control measures, occupational therapy evaluation, physical therapy evaluation, speech therapy evaluation ). This finding is verified by Branch Director #2 and Registered (RN) #1 at 11:12 AM on 10/14/2021. Patient # 9 On 10/13/2021 at 10:30 AM, a review of Patient # 9’s chart reveals the plan of care did not have all goals measurable (patient centered plan of care). This finding is verified by Branch Director #2 and Registered (RN) #1 at 11:14 AM on 10/14/2021. Patient # 10 On 10/13/2021 at 11:00 AM, a review of Patient #10’s chart reveals the plan of care did not have all goals measurable (patient centered plan of care, reduce risk for hospitalization, increased pain or pain control, understanding pain control measures). This finding is verified by Branch Director #2 and Registered (RN) #1 at 11:03 AM on 10/14/2021. Patient 11 On 10/12/2021 at 12:53 PM, a review of Patient 11’s chart reveals the plan of care did not have all goals measurable (patient centered plan of care, diabetic foot ulcer mitigation, cardiovascular disease process, free of hospitalization, receive medications as prescribed, increased pain or pain control, understanding pain control measures, occupational therapy evaluation, physical therapy evaluation). This finding is verified by Branch Director #2 and Registered (RN) #1 at 11:15 AM on 10/14/2021. Patient # 12 On 10/12/2021 at 1:44 PM, a review of Patient # 12’s chart reveals the plan of care did not have all goals measurable (patient centered plan of care for physical therapy, patient centered plan of care for occupational therapy). This finding is verified by Branch Director #2 and Registered (RN) #1 at 11:20 AM on 10/14/2021.