Every finding on record at Enhabit Home Health

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of New Mexico Healthcare Authority. An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 07/22/24 to 07/23/24 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Condition of Participation under CFR 484.102.

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of New Mexico Health Care Authority. An unannounced on-site Recertification survey conducted at the above-named Home Health Agency (HHA) from 07/22/24 to 07/23/24 resulted in finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CRF 484 Subparts A through C and the following standard-level deficiencies listed below.

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 interview, record review and policy review, the facility failed to ensure a comprehensive assessment was completed for two of seven sampled patients (Patient (P)2 and P3) reviewed for vaccination information. This failure had the potential to affect the ability for the 170 patients receiving services from the HHA to receive necessary vaccinations. Findings include: Review of the agency’s undated policy titled, “Referral Process & Guidelines,” revealed, “Receiving a referral, when a referral comes into the office it is forwarded to the intake coordinator (IC) or designee …any referral information is attached to the patients record …the appropriate licensed professional will be scheduled with an initial visit to complete the referral process.” 1. Review of P2's electronic medical record (EMR) revealed P2 had a "Start of Care" date of 06/22/24 for diagnoses of fracture femur, urinary tract infection, and dementia. Review of P2’s "Initial Assessment" dated 06/22/24 located in P2's EMR, revealed the vaccination section was not completed and was blank. 2. Review of P3's EMR revealed a "Start of Care" date of 11/27/23 for diagnoses of a fracture femur, urinary tract infection and dementia Review of P3’s "Initial Assessment" dated 06/22/24 located in P3's EMR, revealed the vaccination section was not completed and was blank. During an interview on 07/22/24 at 4:03 PM, the Branch Manager confirmed P2 and P3's vaccination information was not completed. The Branch Manager was asked what the agency's expectation was for obtaining vaccination information for a new admission. The Branch Manager stated, “Get the information. Get a hold of the family or something if the patient can’t answer.” During an interview on 07/22/24 at 4:13 PM, the Director of Operations was asked what the process was for obtaining vaccination information on admission. The Director of Operations stated, “The intake person first gets the information from the physician and inputs that information in the record. If the information is not sent with the referral, then the staff should be getting the information with the initial assessment.”

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 observation, record review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the Registered Nurse (RN) conducted a medication reconciliation during homecare visits for one of four sampled patients (Patient (P) 9) reviewed for medication reconciliation. This deficient practice had the potential to affect all 170 patients receiving services from the HHA receive the appropriate medication. Findings include: Review the agency's policy dated 06/24/24 titled, "Medications" revealed, "The registered nurse notifies the physician only if there are any problems that could detrimentally affect the prescribed medication regimen but ensures these are listed on the medication profile." Observation during a homecare visit performed by RN1 on 07/23/24 at 9:45 AM revealed that P9's "Medication List," found in P9's Electronic Medical Record (EMR), did not accurately reflect the medications found in P9's home. The medication list indicated that on 07/16/24, P9 was prescribed oxycodone 5 milligram (mg) (pain medication) as needed for pain. Oxycodone was not found in P9's home. Medications found in P9's home included acetaminophen/codeine (pain medication) 300 mg/30 mg. that was filled on 06/25/24, and estrogen/methyltestosterone (hormone replacement) 0.625 mg./1.25 mg. that was filled on 12/15/23. The medications were not included on P9's current "Medication List." During an interview on 07/23/24 at 9:50 AM, P9 indicated that he/she never picked up the oxycodone because "it was too strong of a pain medication" and stated, "I take the 'codeine' when I have pain." P9 also indicated that he/she has been taking the estrogen/methyltestosterone for "a while." During an interview on 07/23/24 at 2:20 PM, the Director of Operations indicated that medications should be reconciled by the nurse at every visit. The Director of Operations stated the RN should have removed the oxycodone from the medication list and added the acetaminophen/codeine and estrogen/methyltestosterone to P9's medication list.

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, policy review, and interview, the agency failed to ensure missed nursing visits for one of seven sampled patients (Patients (P) 2) were communicated to the attending physician. This deficient practice had the potential to affect all 170 receiving services from the agency to miss monitoring and treatment without the physician’s knowledge. Findings include: Review of the undated agency policy titled, “Physician Notification of Missed Visits,” revealed, “Home Health will notify the patients physician of missed visits to be in compliance with Medicare and State Regulations. Guidelines- 1. Physician notification of missed visits is a Medicare requirement and documentation of completing this procedure is required for survey. 2. Physicians must always be notified of visits that are missed as they represent a failure to follow the patient's plan of care. 3. Clinicians must document the missed visit in a missed visit coordination note which includes: contact with the patient prior to the missed visits, attempts to find an alternate caregiver and the reason for the missed visit. …" Review of P2's electronic medical record (EMR) revealed P2 had a "Start of Care" date of 06/22/24 for diagnoses of fracture femur, urinary tract infection, and dementia. Review of the "Skilled Nursing Visits" documentation, located in the EMR revealed nursing visits were scheduled for once a week and missed visits occurred on 06/27/24, 07/05/24 and 07/11/24. Review of documentation failed to indicate the physician was notified when the visits were missed. During an interview on 07/22/24 at 4:03 PM, the Branch Manager confirmed the missed visits and was asked about the physician not being notified. The Branch Manager stated, “The expectation is that the physician is called each time a visit is missed.” During an interview on 07/22/24 at 4:13 PM, the Director of Operations was asked about the missed visits. The Director of Operations confirmed the visits were missed on 06/27/24, 07/05/24 and 07/11/24 and stated, “A report of missed visits is sent to the physicians monthly. The physician should be called the day of the missed visit when the clinician misses it. There is a template, and in the template, a note pops up that they should call the provider.”

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, policy review, and interview, the Home Health Agency (HHA) failed to ensure the Registered Nurse (RN) provided education regarding the risk of bleeding when taking a blood thinning medication for one of 10 sampled patients (Patient (P) 4) reviewed for medication regime. This deficient practice had the potential to affect all 170 patients receiving services from the HHA who require education on medication side effects. Findings include: Review of the agency's policy dated 10/18/23 titled, "Coordination of Services" revealed, "The Agency has established procedures regarding admission, planning and ongoing provision of services, assignment and supervision of staff, documentation, and communication which promote coordination of services. 3.3.1 Staff implement actions which reflect coordination, including 3.3.1 .1 Interdisciplinary communication, reporting, education, and supervision. 3.3.1.2 Education or supervision of the patient or family regarding the plan of care." Review of the agency's policy dated 06/24/24 titled, "Medications" revealed, "The licensed professional provides ongoing medication assessments and teaches the patient and/or caregiver about use, actions, interactions and side effects of medications he/she is taking, according to their documented knowledge base deficits. High risk medications will be reviewed on Admission and Resumption of Care to ensure patient safety with these medications. Ongoing education will also be provided. These high-risk medications are identified on the patient medication profile via the mobile device and education is provided on admission." Review of P4's "Home Health Certification and Plan of Care" found in P4's Electronic Medical Record (EMR) revealed P4 had a diagnosis of "Long Term (Current) Use of Anticoagulants (blood thinner)."The Registered Nurse (RN) documented, "Anticoagulation Precautions" under the section titled "Safety Measures." Review of P4's "Visit Notes" found in P4's EMR, revealed visits were conducted on 05/04/24, 05/14/24, 05/23/24, 05/28/24, and 06/04/24. Review of the notes failed to include documentation the RN provided education regarding the increased risk of bleeding associated with taking a long-term anticoagulation medication During an interview on 07/23/24 at 2:20 PM, the Director of Operations confirmed P4's EMR did not include documentation the RN provided education for increased risk of bleeding. The Director of Operations confirmed the RN should have educated P4 on the increased risk of bleeding when taking an anticoagulant medication.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, record review, policy review, and interview, the Home Health Agency (HHA) failed to ensure that a verbal order for wound care, and wound care performed by the Licensed Practical Nurse (LPN) was properly documented for one of four sampled patients (Patient (P) 10) observed for wound care. This deficient practice had the potential to affect all 170 patients receiving services from the HHA who have changes in physician orders. Findings include: Review of the agency's policy dated 05/09/22 titled, "Wound Ulcer Management" revealed, "…Physician's orders - Agency personnel shall address the following areas, applicable when utilizing adjunctive therapies for wound/ulcer management: 3.2.1 Physician Order is required. 3.2.2 Physician's order must contain specific modalities of treatment implementation. At minimum, the order must address the following: 3.2.2.1 Frequency of the treatment. 3.2.2.2 Duration of the treatment…." Observation during P10's homecare visit performed by LPN1 on 07/23/24 at 12:30 PM revealed that Licensed Practical Nurse (LPN) 1 completed wound care to a surgical site on P10's right lower extremity. The care included cleaning the surgical site with normal saline solution (NSS) and applying a kerlix dressing with an elastic bandage wrap covering. During wound care, LPN1 stated to P10, "I received a new verbal order for wound care from your doctor." Review of P10's medical record on 07/23/24 at 2:00 PM (after the visit occurred) revealed that LPN1 completed the "Skilled Nursing Visit" documentation. LPN1 did not document the physician's verbal order for wound care and did not document the specific wound care that was provided to P10 in the "Skilled Nursing Visit" documentation. During an interview on 07/23/24 at 2:20 PM, the Director of Operations confirmed that the LPN should have documented the physician's verbal wound care order when he/she immediately received it and should have documented the specific wound care provided to P10 during the skilled nursing visit.

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, record review, policy review, and interview, the facility failed to ensure proper handwashing and glove changes during a dressing change for one of two sampled patients (Patient (P) 7) observed for wound care. This deficient practice had the potential to affect all patients who receive wound care by the HHA. Findings include: Review of the policy titled, “Infection Surveillance, Standard Precautions,” revised 10/05/23 revealed, “Purpose: 1.1 Reduced potential cross contamination that may occur through staff/patient contact with provider care and to safeguard the health of the care giver and patient. 1.2 To provide a consistent and uniform approach for health care staff in the prevention of transmission of infection while working with any home care. …" During an observation on 07/23/24 at 9:00 AM, Licensed Practical Nurse (LPN) 2 was observed to put on a pair of gloves and remove the dressing on P7's left lower leg venous ulcer. LPN2 reached in the gauze bag with the gloved hands and pulled out a gauze and began spraying the gauze with wound cleanser. LPN2 wiped P7’s left leg ulcer while wearing the same gloves he/she wore to remove the soiled dressing. LPN2 removed the gloves, performed hand hygiene and put on new gloves. LPN2 retrieved supplies out of a carboard box. Once the supplies were retrieved, LPN2 placed cream on one gloved hand and rubbed the cream on P7’s left leg. During an interview on 07/23/24 at 9:40 AM, LPN2 was asked about removing the soiled dressing and using the same gloves to wipe P7's left leg ulcer with wound cleanser. LPN2 stated, “You are absolutely correct. I should not have done that.” LPN2 was asked about gathering supplies while wearing gloves and then using the same gloves to place cream on the patient’s left leg ulcer. LPN2 stated, “Your right. I did that. I was a little nervous.” During an interview on 07/23/25 at 11:15 AM, the Director of Operations was asked about LPN2's failure to use gloves per infection control practices during P7's dressing change. The Director of Operations stated, “There should have been glove changes after the soiled dressing was removed and after touching supplies."

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Encompass Home Health Agency (HHA) on 06/02/2021 resulted in compliance with Emergency Preparedness under 42 CFR 484.102 for Home Health.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Encompass Home Health Agency (HHA) on 06/02/2021 resulted in noncompliance under 42 CFR 484, Subpart A through C A COVID-19 Focused Infection Control Survey was conducted by the New Mexico Department of Health, Division of Health Improvement on 06/02/2021. The facility was not found to be in compliance with 42 CFR §484.70 Condition of participation: Infection prevention and control Regulations and Guidelines for Home Health Agencies and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on record review and interview the facility failed to document efforts made to resolve the problem(s) expressed in the complaint process (process for recording patient problems or issues of concern) for four (4) Complaint Reports (form used to track problems and efforts made to resolve them) received in 2021. This failed practice can result in poor patient care due to lack of resolution of patient complaints. The findings are: A. Record review of Complaint Report dated 01/18/2021 reveals under "Intervention/Resolution Comments" - section blank. B. Record review of Complaint Report dated 01/20/2021 reveals under "Intervention/Resolution Comments" - section blank. C. Record review of Complaint Report dated 01/21/2021 reveals under "Intervention/Resolution Comments" "Added RN (Registered Nurse) visit to be scheduled within 24 hours to re-assess the situation. Notified RN that APS(Adult Protective Services) needed to be contacted and provided the number" No mention of any resolution with the complainant. D. Record review of Complaint Report dated 03/19/2021 reveals under "Intervention/Resolution Comments" - section blank. E. On 06/02/2022 at 8:55 am during interview, S1 (Facility Administrator) confirmed "There should be interventions and plans for resolution documented on all the complaints".

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 facility failed to provide a plan of care that identifies patient-specific measurable outcomes and goals for 7 (P#1-P#7) of 7 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#7 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 04/25/2020 reveals patient goals: a. Wound will decrease in size, be free of infection, decreased drainage from wound, absence of infection, and decreased pain. b. Rehab section of Plan of care states "fair to meet goals by end of healthcare episode". 2. P#2 record review date of admission 01/20/21 reveals patient goals: a. Wound will decrease in size, be free of infection, decreased drainage from wound, absence of infection, and decreased pain. b. Rehab section of Plan of care states "fair to meet goals by end of healthcare episode". 3. P#3 record review date of admission 05/07/21 reveals patient goals: a. Wound will decrease in size, be free of infection, decreased drainage from wound, absence of infection, and decreased pain. b. Rehab section of Plan of care states "fair to meet goals by end of healthcare episode". 4. P#4 record review date of admission 03/06/21 reveals patient goals: a. Wound will decrease in size, be free of infection, decreased drainage from wound, absence of infection, and decreased pain. b. Rehab section of Plan of care states "fair to meet goals by end of healthcare episode". 5. P#5 record review date of admission 03/16/21 reveals patient goals: a. Wound will decrease in size, be free of infection, decreased drainage from wound, absence of infection, and decreased pain. b. Rehab section of Plan of care states "fair to meet goals by end of healthcare episode". 6. P#6 record review date of admission 05/22/21 reveals patient goals: a. Wound will decrease in size, be free of infection, decreased drainage from wound, absence of infection, and decreased pain. b. Rehab section of Plan of care states "fair to meet goals by end of healthcare episode". 7. P#7 record review date of admission 10/01/2019 reveals patient goals: a. Wound will decrease in size, be free of infection, decreased drainage from wound, absence of infection, and decreased pain. b. Rehab section of Plan of care states "fair to meet goals by end of healthcare episode". B. On 6/2/2021 at 11:00am, interview with S1 (Facility Administrator) revealed that the plan of care section currently includes items checked off from selection list provided in the system. It is not entered manually, therefore not individualized. S1 stated that in-depth wound care tracking is done in a different area of the system

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 observations and interview, the facility failed to adhere to Federal Regulatory Infection Control Guidelines (Focused COVID Survey) regarding the critical elements of reducing COVID-19 (coronavirus, respiratory infection) transmission. This failed practice is likely to lead to potential infectious diseases, being spread through asymptomatic (spreading the infectious agent without showing signs of infection) or symptomatic transmission and failure to identify potentially exposed parties. The findings are: A. On 06/01/2021 at 1:00 pm, observation of no COVID symptom screening (a process for identifying signs and symptoms of COVID) completed by facility for visiting surveyors from the New Mexico Department of Health, Division of Health Improvement. No signage noting that visitors with potential signs or symptoms of COVID-19 (cough, fever, or shortness of breath) should not enter facility. B. On 06/01/21 at 1:15 pm, interview with S2 (Receptionist), revealed that when asked about the screening of employees acknowledged that temperatures were taken daily but did not conduct screening questionnaire.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation and interview, the facility failed to maintain a sanitary environment (environment that is hygienic, clean, and conducive to infection prevention) as boxes of supplies on the floor of the storage room. This deficient practice is likely to lead to contamination and potential infection control issues within the setting. A. On 06/02/2021 at 2:00 pm, Observation during supply room inspection revealed the following: 1. Cardboard boxes on the floor in training room observed. Cardboard boxes must be stored off the ground due to their potential to grow and perpetuate bacteria, mold, or insects. B. On 06/02/2021 at 2:05 pm, Interview with S1 (Administrative Director), revealed that when asked about the boxes on the floor, S1 acknowledged the boxes on the floor and cited lack of space for them.