Every finding on record at Enhabit Home Health

No deficiencies were cited during a recertification survey completed 04/06/21 for the federal requirements of 42 CFR 484 for Emergency Preparedness for Home Health Agencies.

The following deficiencies were cited during a Recertification completed on 04/06/21 for the requirements 45 CFR 484 for the requirements of Home Health Agencies. A COVID-19 Focused Infection Control Survey was conducted by the New Mexico Department of Health Division of Health Improvement on 04/06/21. The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on record review and interview the facility failed to have a confidential clinical record. providing access to or release of patient information and clinical records as permitted in accordance with 45 CFR parts 160 and 164 requirements of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") for 2 (P#3 and P#9) of 8 patient records reviewed. This deficient practice increases the likelihood of not maintaining a confidential and complete clinical record. The findings are: A. Record review for P#3 date of admission 08/11/2020 reveals a Release of Information form revealing blank checkboxes on method of communication. B. Record review for P#9 date of admission 01/27/2021 reveals a Release of Information form that is completely blank except for patient signature. C. On 04/06/2021 at 9:00 am during interview S#1(Branch Director) confirmed the presence of the blanks on the Release of Information forms in P#3 and P#9 records. S#1 stated, "This should never happen, these forms have been removed from the record and the staff responsible has been advised of the mistake and will be provided education on this matter".

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 review and interview the facility failed to provide a plan of care that identifies patient-specific measurable outcomes and goals for 11 (P#1-P#11) of 11 patient charts reviewed.. This deficient practice increases the likelihood of patient receiving care that is not specific, measurable and does not meet their treatment needs. The findings are: A. Record review for P#1-P#11 Plan of Care revealed goals from a drop down menu that are not specific to patients and do not show measurable outcomes. 1. P#1 record review date of admission 08/01/2020 reveals patient goals: a. A patient-centered plan of care will be established and updated as necessary to address medically necessary skilled nursing services. b.Central vascular access device will remain secure and free of infection. c.Patient/caregiver will understand ways to reduce patient's risk for acute care hospitalization as evidenced by verbalization. 2. P#2 record review date of admission 02/25/2020 reveals patient goals: a.A patient-centered plan of care will be established and updated as necessary to address medically necessary skilled nursing services. b.Patient will remain free of hospitalization, exacerbation/decompensation (worsening symptoms/ failure of an organ) during this episode of care. Will be able to teach back signs/symptoms, ACH/ER (Acute Care Hospital/Emergency Room) cavoidance measures, medication management, pathophysiology, risk factor modification, self-management and wellness principles related to cardiovascular disease process. c.Teach back signs/symptoms, ACH/ER avoidance measures, medication management, pathophysiology, risk factor modification, self-management and wellness principles related to respiratory disease process. d.Patient/caregiver will teach back strategies to prevent falls and will remain free of falls during this episode of care. e.Patient/caregiver will understand ways to reduce patient's risk for acute care hospitalization as evidenced by no ER/hospitalization. 3. P#3 record review date of admission 08/11/2020 reveals patient goals: a.A patient-centered plan of care will be established and updated as necessary to address medically necessary skilled nursing services. b.Patient/caregiver will teach back strategies to prevent falls and will remain free of falls during this episode of care. c.Endocrine system will be evaluated and exacerbations identified with intervention implemented to minimize complications. Patient/caregiver will verbalize/demonstrate tolerance to blood sugar testing and insulin administration. d.Patient/caregiver will understand ways to reduce patient's risk for acute care hospitalization as evidenced by utilizing nurse on call. 4. P#4 record review date of admission 08/26/2020 reveals patient goals: a.A patient-centered plan of care will be established and updated as necessary to address medically necessary skilled nursing services. b.Patient/caregiver will teach back strategies to prevent falls and will remain free of falls during this episode of care. c.Increased pain or pain control measures will be identified and promptly reported to the physician. d.Patient/caregiver will verbalize understanding of pharmacologic and non-pharmacologic pain control measures. e.Patient/caregiver will understand ways to reduce patient's risk for acute care hospitalization as evidenced by no ER/hospitalization. 5. P#5 record review date of admission 01/03/2021 reveals patient goals: a.A patient-centered plan of care will be established and updated as necessary to address medically necessary skilled nursing services. b.Patient/caregiver will teach back strategies to prevent falls and will remain free of falls during this episode of care. c.Patient/caregiver will understand ways to reduce patient's risk for acute care hospitalization as evidenced by no ER/hospitalization. d.Telehealth visits will reduce risk of exposure to covid-19 (Coronavirus called SRS-CoV-2) improve adherence/self-management of patient condition related to in-person visits and establish goals, and prevent worsening of adverse symptoms. 6. P#6 record review date of admission 02/22/2021 reveals patient goals: a.A patient-centered plan of care will be established and updated as necessary to address medically necessary skilled nursing services. b.Patient and/or caregiver will be able to teach back diabetic foot ulcer (an open sore or wound that occurs in approximately 15 percent of patients with diabetes) mitigation techniques by verbalization. c.Patient/caregiver will teach back strategies to prevent falls and will remain free of falls during this episode of care. d.Patient will remain free of hospitalization, exacerbation/decompensation during this episode of care. Will be able to teach back signs/symptoms, ACH/ER avoidance measures, medication management, pathophysiology, risk factor modification, self-management and wellness principles related to respiratory disease process. e.Patient/caregiver will understand ways to reduce patient's risk for acute care hospitalization as evidenced by utilizing nurse on call. f.Telehealth visits will reduce risk of exposure to covid-19, improve adherence/self-management of patient condition related to in-person visits and establish goals, and prevent worsening of adverse symptoms. 7. P#7 record review date of admission 12/05/2020 reveals patient goals: a.A patient-centered plan of care will be established and updated as necessary to address medically necessary skilled nursing services. b.Patient will remain free of hospitalization, exacerbation/decompensation during this episode of care. Will be able to teach back signs/symptoms, ACH/ER avoidance measures, medication management, pathophysiology, risk factor modification, self-management and wellness principles related to cardiovascular disease process. c.Patient will remain free of hospitalization, exacerbation/decompensation during this episode of care. Will be able to teach back signs/symptoms, ACH/ER avoidance measures, medication management, pathophysiology, risk factor modification, self-management and wellness principles related to respiratory disease process. d.Patient/caregiver will teach back strategies to prevent falls and will remain free of falls during this episode of care. e.Patient will remain free of hospitalization, exacerbation/decompensation during this episode of care. Will be able to teach back signs/symptoms, ACH/ER avoidance measures, medication management, pathophysiology, risk factor modification, self-management and wellness principles related to genitourinary disease process. f. Patient/caregiver will understand ways to reduce patient's risk for acute care hospitalization. g. A physical therapy evaluation will be completed and a plan of care will be established for the physician's signature for the enhancement of the patient's rehabilitation potential, elimination of structural barriers, and improved safety to increase functional independence. 8. P#8 record review date of admission 03/11/2021 reveals patient goals: a.A patient-centered plan of care will be established and updated as necessary to address medically necessary skilled nursing services. b.Patient will remain free of hospitalization, exacerbation/decompensation during this episode of care. Will be able to teach back signs/symptoms, ACH/ER avoidance measures, medication management, pathophysiology, risk factor modification, self-management and wellness principles related to respiratory disease process. c.Patient/caregiver will teach back strategies to prevent falls and will remain free of falls during this episode of care. d.A physical therapy evaluation will be completed and a plan of care will be established for the physician's signature for the enhancement of the patient's rehabilitation potential, elimination of structural barriers, and improved safety to increase functional independence. e.An occupational therapy evaluation will be completed and a plan of care will be established for the physician's signature for the enhancement of the patient's rehabilitation potential, elimination of structural barriers, and improved safety to increase functional independence. 9. P#9 record review date of admission 01/07/2021 reveals patient goals: a.A patient-centered plan of care will be established and updated as necessary to address medically necessary skilled nursing services. b.Endocrine system will be evaluated and exacerbations identified with intervention implemented to minimize complications. Patient/caregiver will verbalize/demonstrate tolerance to blood sugar testing and insulin administration. c.Patient/caregiver will understand ways to reduce patient's risk for acute care hospitalization. d.Patient will remain free of hospitalization, exacerbation/decompensation during this episode of care. Will be able to teach back signs/symptoms, ACH/ER avoidance measures, medication management, pathophysiology, risk factor modification, self-management and wellness principles related to cardiovascular disease process. 10. P#10 record review date of admission 11/03/2020 reveals patient goals: a.A patient-centered plan of care will be established and updated as necessary to address medically necessary skilled nursing services. b.Patient and/or caregiver will be able to teach back diabetic foot ulcer mitigation techniques by verbalization. c.Patient will remain free of hospitalization, exacerbation/decompensation during this episode of care. Will be able to teach back signs/symptoms, ACH/ER avoidance measures, medication management, pathophysiology, risk factor modification, self-management and wellness principles related to cardiovascular disease process. d.Patient/caregiver will understand ways to reduce patient's risk for acute care hospitalization as evidenced by verbalization. 11. P#11 record review date of admission 12/15/2020 reveals patient goals: a.A patient-centered plan of care will be established and updated as necessary to address medically necessary skilled nursing services. b.Patient will remain free of hospitalization, exacerbation/decompensation during this episode of care. Will be able to teach back signs/symptoms, ACH/ER avoidance measures, medication management, pathophysiology, risk factor modification, self-management and wellness principles related to cardiovascular disease process. c.Patient/caregiver will teach back strategies to prevent falls and will remain free of falls during this episode of care. d.Patient/caregiver will understand ways to reduce patient's risk for acute care hospitalization. e.Patient will remain free of hospitalization, exacerbation/decompensation during this episode of care. Will be able to teach back signs/symptoms, ACH/ER avoidance measures, medication management, pathophysiology, risk factor modification, self-management and wellness principles related to respiratory disease process. f. Patient will receive medications as prescribed. Patient/caregiver will demonstrate knowledge of all medications. B. On 04/06/2021 at 9:30 am during interview S#1(Branch Director) confirmed the electronic medical record system the facility utilizes has a dropdown menu for choosing patient goals and clarified the system does allow additions to the goals to make them measurable and patient specific.