Every finding on record at Eh Home Health of the Mid Atlantic, LLC

Based on the findings of a home health agency complaint investigation survey completed on March 8, 2023, Enhabit Home Health, was found to not be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based upon clinical record (CR) review, policy and procedure review, and an interview with the agency Branch director, it was determined the agency failed to ensure a transfer summary to be sent to the hospital for agency patients transferred and admitted to a hospital for two (2) out of three (3) CR's reviewed (CR#1 and CF#2) and failed to ensure a discharge summary was sent to the physician within five (5) days of discharge for two (2) out of three (3) CR's reviewed (CR#1 and CF#2). Review of “Transfer and Discharge Procedure” on 3/8/23 at approximately 12:00 PM states: "Standard: Transfer and Discharge: Contents of Clinical Record....iii A completed transfer summary that is sent to the health care facility within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer…….When to Send Discharge summaries to physician/practitioner: A completed discharge summary is sent to the primary care physician/practitioner after discharge from the Home Health agency within 5 business days of the patient’s discharge….The medical records specialist documents confirmation of the episode summary sent to the physician in the physician communication coordination/discharge notification note. Include in the note how the summary was a sent (fax, by hand) and to whom the summary was sent...... When a patient transfers to a facility and then does not return before the end of the episode: Complete the transfer summary per process, CTL will receive workflow that the patient is still hospitalized at end of episode and should be discharged, once discharged, MRS will be prompted to send an episode summary (discharge summary) to the physician." Review of CR#1 (Start of care: 6/24/2022) on 3/8/23 at approximately 1:30 PM revealed the following: Admission to hospital on 10/04/2022. No documentation in the clinical record of a transfer summary sent to the admitting hospital. Documentation revealed the agency to discharge the patient on 10/06/2022. No discharge summary sent to the physician until 10/20/2022; fourteen (14) days after known discharge. Review of CR#2 (Start of care: 10/10/2022) on 3/8/23 at approximately 2:00 PM revealed the following: Admission to hospital on 11/11/2022. No documentation in the clinical record of a transfer summary sent to the admitting hospital. Certification period ending on 12/08/2022 while patient remained hospitalized. No documentation of a discharge summary sent to the physician. An interview with the Branch Director on 3/08/2023 at approximately 2:30 PM confirmed the above findings.

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 upon clinical record (CR) review, policy and procedure review, and an interview with the agency Branch director, it was determined the agency failed to ensure discharge communication to the patient/patient representative and to the hospital where the patient was transferred for one (1) out of three (3) CR's reviewed (CR#1). Review of “Transfer and Discharge Procedure” on 3/8/23 at approximately 12:00 PM states: "Standards of Practice....Appropriate transition planning is developed and implemented…." Review of CR#1 (Start of care: 6/24/2022) on 3/8/23 at approximately 1:30 PM revealed the following: Admission to hospital on 10/04/2022. A “Hospital Hold” order, dated 10/06/2022, Order description: TIF and DC patient admitted to hospital 10/04/2022. Not taking back on service. There was no documentation in the clinical record of the patient, patient representative, or admitting hospital was informed of the agencies intent to not take the patient back on service. An interview with the Branch Director on 3/08/2023 at approximately 2:30 PM confirmed the above findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based upon clinical record (CR) review, policy and procedure review, and an interview with the agency Branch director, it was determined the agency failed to ensure a transfer summary to be sent to the hospital for agency patients transferred and admitted to a hospital for two (2) out of three (3) CR's reviewed (CR#1 and CF#2) and failed to ensure a discharge summary was sent to the physician within five (5) days of discharge for two (2) out of three (3) CR's reviewed (CR#1 and CF#2). Review of “Transfer and Discharge Procedure” on 3/8/23 at approximately 12:00 PM states: "Standard: Transfer and Discharge: Contents of Clinical Record....iii A completed transfer summary that is sent to the health care facility within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer…….When to Send Discharge summaries to physician/practitioner: A completed discharge summary is sent to the primary care physician/practitioner after discharge from the Home Health agency within 5 business days of the patient’s discharge….The medical records specialist documents confirmation of the episode summary sent to the physician in the physician communication coordination/discharge notification note. Include in the note how the summary was a sent (fax, by hand) and to whom the summary was sent...... When a patient transfers to a facility and then does not return before the end of the episode: Complete the transfer summary per process, CTL will receive workflow that the patient is still hospitalized at end of episode and should be discharged, once discharged, MRS will be prompted to send an episode summary (discharge summary) to the physician." Review of CR#1 (Start of care: 6/24/2022) on 3/8/23 at approximately 1:30 PM revealed the following: Admission to hospital on 10/04/2022. No documentation in the clinical record of a transfer summary sent to the admitting hospital. Documentation revealed the agency to discharge the patient on 10/06/2022. No discharge summary sent to the physician until 10/20/2022; fourteen (14) days after known discharge. Review of CR#2 (Start of care: 10/10/2022) on 3/8/23 at approximately 2:00 PM revealed the following: Admission to hospital on 11/11/2022. No documentation in the clinical record of a transfer summary sent to the admitting hospital. Certification period ending on 12/08/2022 while patient remained hospitalized. No documentation of a discharge summary sent to the physician. An interview with the Branch Director on 3/08/2023 at approximately 2:30 PM confirmed the above findings.