Every finding on record at Centerwell Home Health

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at CenterWell Home Health Home Health Agency (HHA) on 04/29/2026 found that your facility was in substantial compliance with the Conditions of Participation (CoPs) under 42 CFR 484.102.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at CenterWell Home Health Home Health Agency (HHA) on 04/29/2026 resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited:

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the facility failed to provide all services ordered on the plan of care for 1[P(patient) 4] of 13 (P1-P13) charts reviewed. This failure has the potential to negatively impact patient outcomes due to lack of care coordination and incomplete provision of ordered services. The findings are: A. Record review of the facility’s policy, Patient Rights/Notice of Privacy Practices, revised 04/2022, item 14, stated that the patient has the right to, “Receive all services outlined in their plan of care” B. Record review of P4’s medical record dated 03/22/26 revealed a provider-ordered plan of care that included PT (Physical Therapy), SN (Skilled nursing services) and MSW (Medical social work) services. C. Record review of a clinical note dated 04/02/26 documented by S(staff)7, clinical, revealed that the MSW attempted to contact P4 three times without success. S7 documented that the provider was notified by telephone, and the provider requested a faxed notification. The MSW then faxed a notification to the provider stating that the MSW visit would be rescheduled. D. Record review of the Episode Summary Report dated 04/16/2026 revealed that P4 was discharged from services. The report included “Medical Social Work for evaluation” as an ordered service; however, there was no documented evidence that the MSW evaluation was completed prior to discharge. E. During an interview conducted on 04/28/26 at 4:00 PM, S1, non-clinical, confirmed that the electronic medical record contained a fax to the physician dated 04/05/26 indicating that the MSW evaluation would be rescheduled. S1 verified that there was no documentation demonstrating the evaluation had been completed. S1 stated that P4 was discharged from the agency on 04/16/26 because the patient no longer met homebound criteria.

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 and interview, the agency failed to ensure that supplies were consistently monitored to confirm they were available and ready for use for all patients receiving care. This deficient practice increases the risk for infection. The findings are: A. During an observation on 04/27/26 at 12:15 PM in the storage closet at the home health agency office, the listed supplies were identified as having deficiencies. 1. 1 box of Medline Skintegrity wound gel expired 12/2024. 2. 1 box of Medline lubricating jelly expired 05/31/24. 3. 1 box of Curad oil emulsion dressing expired 11/01/25. 4. 1 Medline latex Foley catheter size 22 French expired 09/28/24. 5. Medline urethral catheter 12 French the package was ripped open. B. During an interview on 04/27/26 at 12:20 PM with S(staff)1, non-clinical, the expiration dates and open package were confirmed. S1 stated supplies should be checked monthly.

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Mexico Department of Health. An unannounced on-site Recertification survey at the above-named Home Health Agency (HHA) from 12/12/22 to 12/14/22 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation (CoP) under 42 CFR 484.102.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Mexico Department of Health. An unannounced on-site recertification survey conducted at the above-named Home Health Agency (HHA) from 12/12/22 to 12/14/22 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below. Survey Dates: 12/12/22 to 12/14/22 Survey Census: 153 Sample Size: 17

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency failed to conduct an initial patient assessment within 48 hours of the referral, or within 48 hours of the patient's return home, or on the physician ordered start of care date for two of 17 patients (Patient (P)5 and P14). This failure had the potential for the immediate care needs to not be addressed and could affect the health and wellbeing of the patient. 1. Review of P5's referral information located in the electronic medical record (EMR) in the section for uploaded scanned documents revealed the patient had a history of multiple cerebrovascular accidents (CVA or strokes) and chronic obstructive pulmonary disease (COPD) who was referred for wound care due to recent trauma to right foot fifth digit that developed into dry gangrene leading to autoamputation. The referral information does not specify the date it was sent to the agency. Review of P5's "Home Health Certification and Plan of Care" (POC) located in the "Orders" section of EMR revealed the start of care (SOC) date as 11/30/22. Review of the "Visit" section in the EMR revealed the first visit was the "Comprehensive Assessment" completed by a Registered Nurse (RN) dated 11/30/22. During an interview on 12/14/22 at 12:00 PM, the Branch Director (BD) confirmed the referral for P5 was received by the agency on 11/25/22 and that P5 was seen for the initial assessment more than 48 hours after the referral. 2. Review of P14's referral information dated 11/07/22 located in the EMR in the section for uploaded scanned documents revealed referral for skilled nursing, physical therapy, and occupational therapy and a primary diagnosis of metastatic breast cancer. Review of P14's POC located in the "Orders" section of the EMR revealed the SOC date as 11/11/22. Review of the "Visit" section in the EMR revealed the first visit was the "Comprehensive Assessment" completed by a RN dated 11/11/22 During an interview on 12/14/22 at 12:00 PM, the BD confirmed P14 was seen for the initial assessment more than 48 hours after the referral. Review of the agency policy titled, "Initial and Comprehensive Assessment," dated 01/2022 revealed, "All patients receiving skilled services must have an initial on-site professional assessment. The assessment must be completed on or before start of care and within 48 hours from the date of referral or facility discharge (whichever is later), unless otherwise ordered by Primary Care Provider (PCP) or referring provider."

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record reviews, staff interviews and review of the agency Admissions packet, and agency policy, the agency failed to ensure two of 17 patients (Patients (P11 and P15) and caregivers/representatives of these patients were provided with a copy of written information to include visit schedules, and written information of frequency of visits the Home Health agency personnel would be providing. By not ensuring clear written visit schedules are provided by the Home Health Agency to the patients, and caregivers/representatives, would affect their quality of life and day to day living. Review of the agency "Admission Packet" revealed a document under the "Section 1: Home Healthcare-Scheduling visits." revealed, "Visits are scheduled according to physician or other authorized practitioner orders and patient needs. Under "Section 2: Patient rights and responsibilities", it indicated, "As a patient of the agency, you have the right to: participate in, and be informed in advance about…the frequency of visits." Review of the agency "Home Health Policy Manual 03-02 Assignment of Clinicians" revised 07/2022, indicated, "Schedule and Assignment of Clinicians and Patients-A schedule will be maintained for every patient and every clinician…Schedules will reflect scheduled care, supervisory visits, and comprehensive assessments." Review of the agency "Home Health Policy Manual 03-11 Care Planning" revised 09/2022, indicated, "The patient or caregiver will be provided a copy of the POC [plan of care] and/or other form of written instructions outlining: Visit schedule, disciplines and frequency of visits." 1.Review of P11's "Oasis [Outcome and Assessment Information Set/the standardized assessment tool used for home health agency admissions]" located in the Electronic Medical Record (EMR)dated 12/08/22, indicated the SOC [Start of Care] began on 12/08/22. The document indicated, "Frequency/Duration of Visits"- PT [Physical Therapy] 1x [times] /week for 1 week, then 3x/week for 2 weeks, and OT [Occupational Therapy] effective 12/11/2022 1x/week for 1 week." During a home visit to P11's home on 12/12/22 from 11:00 AM to 11:45 AM, the white folder that was provided to the patient and caregiver/representative upon admission revealed no written information to include visit schedules, or written information of frequency of visits the home health agency personnel would be providing. The folder further revealed a blank white board calendar at the back of the folder with no schedule listed. During an interview on 12/12/22 at 11:05 AM, when P11 was asked if he had received a written schedule of visits or the frequency of visits the home health agency would be providing, P11 stated, "No, I don't recall getting anything like that. I don't have anything written down. The schedules were discussed verbally from what I remember, but I don't have an actual schedule of when they are coming out." During an interview on 12/12/22 at 11:07 AM, the Family Member (FM1) was asked if she had received a written schedule of visits or the frequency of visits that that home health agency would be providing, FM1 stated, "No, we didn't receive anything in writing. I have to ask him (P11) when and what times do you have PT? We don't have an actual calendar or schedule to show what days they are coming out." During an interview on 12/12/22 at 11:15 AM, the PT was asked about written documentation of the frequency of visits that are provided, the PT stated, "It was done verbally. I know there is a calendar in the folder, but I didn't write anything down." During an interview on 12/14/22 at 1:00 PM, regarding written information pertaining to the frequency/schedule of visits the home health agency staff would be providing in the home, the Clinical Manager (CM3) stated, "For [name of P11] the Physical Therapist did the evaluation on 12/08/22 and the patient should have had a calendar in his binder that showed when his visits could be." 2. Review of the "Oasis" located in the EMR for P15, dated 11/16/22, indicated the SOC began on 11/16/22. The document indicated, "Frequency/Duration of Visits"- SN 1x/week for 7 weeks, PT 1x/week for one week, and OT effective 11/20/22 1x/week for one week." During a home visit to P15's home on 12/13/22 from 12:00 PM to 1:15 PM, the white folder provided to the patient and caregiver/representative upon admission revealed no written information to include visit schedules, or written information of frequency of visits the home health agency would be providing. The folder further revealed a blank white board calendar at the back of the folder with no information listed. During an interview on 12/13/22 at 12:30 PM, P15 stated was asked if she had received a written schedule of visits or the frequency of visits the home health agency would be providing, P15 stated, "I do not have a calendar or schedule in my home. We haven't been using anything like that." During an interview on 12/14/22 at 8:30 AM, regarding written information pertaining to the frequency/schedule of visits the home health agency staff would be providing in the home, the Area Director of Operations (ADOP2) stated, "Our staff should be writing the schedule of visits on the calendar. Those are also discussed at the start of care when our frequency of visits would be. Our clinicians should be updating the calendars in the home as well if there are any changes."

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record reviews, staff interviews, and review of the agency policy, the agency failed to ensure three of 17 patients (Patients (P11, P13, and P17) received written information from the home health agency of medication administration regimen instructions written in plain language to include schedule/instructions, including medication names, dosage and frequency and which medications will be administered by the Home Health Agency personnel. By not providing this information, patients may not know what changes have been made and could lead to potential missed medications. Review of the agency "Home Health Policy Manual 03-11 Care Planning" revised 09/2022, indicated, "The patient or caregiver will be provided a copy of the POC (plan of care) and/or other form of written instructions outlining: Patient medication schedule/instructions to include medication name, dosage, frequency and which medications will be administered by the home health agency clinician or other person acting on behalf of the agency." 1.Review of P11's "Oasis [Outcome and Assessment Information Set/the standardized assessment tool used for home health agency admissions]" provided by Human Resource (HR) dated 12/08/22, indicated the SOC [Start of Care] began on 12/08/22. Review of P11's"Home Health Certification and Plan of Care" provided by HR dated 12/08/22 listed medications prescribed for P11. Review of P11's "Client Medication Report" provided by HR also listed medications prescribed for P11. During a home visit to P11's home on 12/12/22 from 11:00 AM to 11:45 AM, the white folder that was provided to the patient and caregiver/representative upon admission revealed no written information from the home health agency regarding P11's medications. There was no written information pertaining to the medication names, dosage, frequency, or diagnosis. During an interview on 12/12/22 at 11:05 AM, P11 was asked if he had a written medication list that was provided to him from the home health agency, P11 stated, "I only have a list of what I got from the hospital. I don't have anything from the agency. " During an interview on 12/12/22 at 11:15 AM, the Physical Therapist (PT) was asked if there was a written medication list that was provided from the home health agency to P11. PT stated, "No, I don't see one." During an interview on 12/13/22 at 11:00 AM, the Branch Director (BD) stated, "When the start of care is done by the clinician, we are looking at all the medications the patient is taking while in the home. After the SOC is completed, a "Patient Instruction Report" (PIR) is generated which should have the patient's medications listed with name, dose, and frequency of the medications to be taken by the patient. The clinicians will take the PIR to the home, and they are supposed to put it in the patient's folder. They are also supposed to ask about it at every visit and if there have been any changes to their medications. We are supposed to be updating their list when a new medication order is generated and taking out the old PIR and putting in a new one in their folder." The BD then stated, "With [name of P11], he came on services on 12/08/22 and there should have been an updated medication list in his folder." 2.Review of P13's "Oasis provided by HR, dated 11/19/22, indicated the SOC began on 11/19/22. Review of P13's "Home Health Certification and Plan of Care" provided by HR dated 11/19/22, listed medications prescribed for P13. Review of the "Client Medication Report" provided by HR also listed medications prescribed for P13. During a home visit to P13's home on 12/12/22 from 4:00 PM to 5:15 PM, there was no white folder with documentation of a current medication list observed in the home that had been provided to the patient and caregiver/representative upon admission. During the home visit, there was also no written information from the home health agency regarding P13's medications to include name, dosage, or frequency of medications. During an interview on 12/12/22 at 4:15 PM, P13 was asked if he had a written medication list that was provided to him from the home health agency, P13 stated, "I only have a list from my primary. I don't have anything from the home health agency." During an interview on 12/13/22 at 11:00 AM, the Branch Director (BD) stated, "[name of P13] should have had a medication list in his home. If there was not one, our clinicians are supposed to get a Patient Instruction Report and make sure all the medications are listed on it. This is also supposed to be in the home so we can compare what medications they are on, and if there have been any new medication changes. Our staff should have followed up with us since his start of care and we should have had a new medication list generated and kept in the home." 3. Review of P17'ss "Oasis located in the EMR dated 11/04/22, indicated the SOC began on 11/04/22. Review of P17's "Home Health Certification and Plan of Care" provided by HR dated 11/04/22, listed medications prescribed for P17. Review of P17's "Client Medication Report" provided by HR also listed medications prescribed for P17. During a Home visit to P17's home on 12/14/22 from 9:45 AM to 10:45 AM, the white folder that was provided to the patient and caregiver/representative upon admission revealed no written information from the home health agency regarding P17's medications. There was no written information pertaining to the medication names, dosage, frequency, or diagnosis. During an interview on 12/14/22 at 10:00 AM, the Occupational Therapist (OT) stated, "We are supposed to have a list of the medications in the home, but I'm not seeing one. We will need to get you your own medication list." When the OT was reviewing the white folder provided by the home health agency, the OT confirmed there was no medication list identified with what P17 was taking. During an interview on 12/14/22 at 10:05 AM, P17 was asked if he had any documentation from the home health agency of medications he was currently taking with the name, dosage, or frequency, P17 stated, "No, I wasn't aware of one. I only have what I got from my last doctor's appointment on11/29/22. I guess I don't have an updated list from the agency anywhere." During an interview on 12/14/22 qt 11:20 AM, the Branch Director (BD) stated, "He should have had a new list of all his medications in the home. We need to take him one and make sure of any changes that are made, are also updated."

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, staff interviews, and review of the agency policy and agency guide, the agency failed to ensure two employees of the Home Health Agency performed appropriate hand hygiene to include use of hand sanitizer, glove use, and appropriate bag technique. Both employees were observed wearing gloves without performing hand hygiene prior to entering the homes of two of 17 Patients (P11 and P12). Failure to maintain proper infection control techniques during care could lead to infections for all 153 patients receiving care from this agency. Review of the agency policy titled, "Standard Precautions, Home Care" revised August 19, 2022, indicated, "Implementation-Perform hand hygiene before and after patient care; before putting on and after removing gloves…and after contact with inanimate objects in the patient's environment…Change your gloves and perform hand hygiene...Avoid touching your face, body, and other surfaces and items not needed for direct patient care with your gloved hands to reduce the risk of transmitting infectious organisms." Review of the agency guide titled, "Bag technique, Home Care "dated May 20, 2022, indicated, "A bag is commonly used by home health care workers to transport patient care equipment and supplies to and from patient's homes…Bag technique is a process used by home health care workers to prevent the transmission of microorganisms that may be present on the outside or the inside of the bag. Bag technique involves proper hand hygiene, placement, cleaning, maintenance of equipment and supplies…Implementation: Perform hand hygiene before entering the bag…Never remove items from the bag wearing gloves. If supplies are needed, remove gloves, perform hand hygiene, and remove additional supplies…" 1.During a home visit to P11's home on 12/12/22 from 11:00 AM to 11:45 AM, the Physical Therapist (PT) was observed walking from her personal vehicle into P11's home wearing purple gloves. At this time, prior to entering P11's home the PT was observed not removing the gloves or using any hand sanitizer. Upon entering the home, the PT was observed sanitizing both gloved hands with hand sanitizer and reaching into her blue agency issued medical bag while wearing the same gloves and taking out a white barrier to put the bag on. While still wearing the same gloves, the PT continued to take out medical supplies from the blue bag such as a blood pressure cuff, stethoscope, and pulse oximeter (a device that is usually placed on a fingertip which uses light beams to estimate the oxygen saturation of the blood and pulse rate), and digital thermometer and place all items on the white barrier. It was at this time; the PT then took off the gloves and used hand sanitizer on both of her hands. 2. During a home visit to P12's home on 12/12/22 from 1:00 PM to 1:45 PM, the Physical Therapy Assistant (PTA)1 was observed exiting her personal vehicle wearing purple gloves. Upon entering the Assisted Living facility, PTA1 picked up a pen off a table to sign the guest book while still wearing the same gloves. After signing the book, the PTA1 did not remove the gloves or sanitize hands prior to going to P12's room. PTA1 reached into her agency issued blue bag wearing the same gloves and took out a white barrier pad to place her bag on the patient's bed. PTA1 still wearing the same gloves proceeded to use hand sanitizer. PTA1 was then observed reaching into the blue bag with the same gloves and taking out medical supplies such as a blood pressure cuff, stethoscope, digital thermometer, and pulse oximeter and placing them on a white barrier. PTA1 took P12's vital signs, then wiped down each piece of equipment while wearing the same gloves. Afterwards, PTA1 used hand sanitizer on the gloves again and never removed the gloves. Once done, PTA1 proceeded to grab P12's front wheeled walker while wearing the same gloves and placed it in front of P12. PTA1 grabbed a gait belt from the agency issued blue bag and placed it around P12. PTA1 touched both of P12'sshoulders, the wheelchair that P12 was seated in, both hand rests of the wheelchair, and walker while still wearing the same gloves. PTA1 used hand sanitizer on the gloves again. During this time, P12 had a bandage on the left hand/wrist in which PTA1 touched while still wearing the same gloves. After doing so, PTA1 was observed using hand sanitizer again on her gloved hands. At this time, PTA1 was then observed putting her arms around both shoulders and waist of P12 in trying to assist her to stand. After doing so, PTA1 was observed touching the back of both of P12's legs still wearing the same gloves. During this entire observation, PTA1 never took off the purple gloves to sanitize her hands. During an interview on 12/12/22 at 1:30 PM, regarding hand sanitizing or changing of gloves, PTA1 stated, "As soon as I'm done, I will change them. I wear the same pair for the whole visit. If they get gross, then I will change my gloves. We were told we could either taken them off, use hand sanitizer, then put a fresh pair on, or we can sanitize between each use while keeping the gloves on." During an interview on 12/12/22 at 2:20 PM, regarding hand hygiene and glove use, the Branch Director (BD) stated, "I would not expect the staff to have gloves on when getting out of their vehicles. Staff should be sanitizing their hands before getting into their bags to take out equipment. Anytime they are wearing a dirty pair of gloves, I would expect them to take that dirty pair off, sanitize their hands before donning a new pair on." The BD stated, "You never want to go in the bag while wearing dirty gloves. After getting out all the equipment, then they would put gloves on before they touch the patient." The BD stated, "After they are done, they should remove their gloves. I would also expect the staff to change gloves after wiping down their equipment, and of course sanitizing their hands."

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on policy review, observation, and interview, the agency failed to ensure staff who had an approved exemption for the Corona Virus Disease (COVID)-19 vaccination followed the agency policy and the Center for Medicare and Medicaid Services (CMS) memo QSO-23-02 related to procedures for unvaccinated staff to mitigate the potential spread of disease. This failure had the potential to affect the 153 current patients admitted to the agency for services. Review of the agency policy titled, "Centers for Medicare & [and] Medicaid Services (CMS) Required Coronavirus Disease (COVID-19) Vaccination," dated 09/2022 revealed, "Company Associates who are not fully vaccinated but are granted an exemption must comply with the measures taken by the Company to protect patients and others from potential exposure to COVID-19 including but not limited to: Wearing personal protective equipment (PPE) – including gloves and masks-during all patient visits. An N-95 face mask is recommended for staff providing direct patient care … Receiving a negative COVID-19 test as directed … Socially distancing by at least six feet at all times … Adhering to all other requirements set forth by the Company, State, and Federal Guidelines and standards." Review of the Center for Medicare and Medicaid Services (CMS) QSO-23-02-All memo titled, "Revised Guidance for Staff Vaccination Requirements," Attachment G: Home Health Agencies dated 10/26/22 revealed, "The HHA policies and procedures must be implemented … The policy must also ensure those staff who are not yet fully vaccinated, or who have been granted an exemption or accommodation as authorized by law, or who have a temporary delay, adhere to additional precautions that are intended to mitigate the spread of COVID-19." Review of the CDC website for COVID-19 by County shows Albuquerque was at a "Medium" risk for the disease. Review of the agency staff COVID-19 vaccination surveillance showed a total of 36 employees including three employees with approved exemptions for a total of one-hundred percent compliance with the requirements for vaccination. During the entrance conference interview on 12/12/22 at 8:30 AM, the Branch Director (BD) stated, "There are a few employees that have exemptions and if they have an exemption, they should be wearing an N-95 mask at all times." The BD confirmed that is the requirement of the agency. During an interview on 12/13/22 at 10:30 AM, the BD stated of the employees that have exemptions, there is a "Home Health Specialist, Sr., who is our Sales Representative. This person goes to all the referral sources such as the hospitals to get initial referrals and comes into the office to drop off paperwork. [He/she] does not work in the office but would be required to wear a N-95 mask at all times, whether in the office or not." During an observation on 12/13/22 at 3:30 PM, the Home Health Specialist was observed in the office conversing with the BD and other office staff before leaving. The Home Health Specialist was observed not to be wearing an N-95 as the BD stated would be required. During interview on 12/13/22 at 4:00 PM, the BD confirmed the Home Health Specialist was not wearing a mask and that the agency required all staff who are not vaccinated to wear an N-95 in the office. The BD stated, "[He/she] usually wears a mask when [he/she] comes into the building. [He/she] is required to wear an N-95."

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on interview, document review, review of agency policy and Bylaws and review of Governing Body minutes, the agency failed to ensure that the Administrator reported directly to the Governing Body without any intermediaries. This had the potential to affect the legal responsibilities, provision of services provided, and priorities addressed for the agency which could affect all 153 current patients. During the entrance conference on 12/12/22 at 8:30 AM, the Branch Director (BD)/Administrator stated that he/she does not report directly to the Governing Body but reports to the Regional Director of Operations. Review of an untitled document provided by the BD/Administrator to show the reporting process for the agency revealed the Administrator reports to the Area Director of Operations who reports to the Area Vice President of Operations who reports to the President who reports to the Governing Body. Review of agency policy titled, "Governing Body," dated 06/2021 and "Governing Body Bylaws, " dated 04/2021 failed to identify how the Administrator reports directly to the governing body. Review of the "Governing Body Meeting" minutes dated 12/13/21 identified the Governing Body and Committee members present. The attendees did not include the BD/Administrator or any individual on the untitled document provided by the BD/Administrator which outlined the reporting process. The meeting minutes did not include any specific reference to the home health agency being surveyed. During an interview with the BD/Administrator and Area Director of Operations (ADOP2) on 12/14/22 at 12:00 PM, the BD/Administrator confirmed that [he/she] does not report directly to the Governing Body.