Every finding on record at Enhabit Home Health

E000 A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of New Mexico Department of Health. An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 03/08/22 to 03/10/22 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

327172_220310_ G000 A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of New Mexico Department of Health. An unannounced onsite Recertification survey conducted at the above-named Home Health Agency (HHA) facility from 03/08/22-03/10/22 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under42 CFR 484 Subparts A through C with the following standard-level deficiencies listed below.

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: G536 – Encompass Health Home Health Based on record review, interview, and review of the agency policy, the home health agency (HHA) failed to ensure the agency's policy which addressed the admission medication review process was consistent with the regulation and failed to ensure a HHA nurse documented a medication review for four of four patients (Patient (P)1, P2, P12, and P13) who were admitted for services by therapy. This failure had the potential for patients receiving home health services from the agency to experience medication side effects, duplicate drug therapy, adverse reactions, or significant drug interactions. Findings include: Review of an agency policy titled, "Admission Process and Patient Assessment," dated 03/01/21, revealed, "During the initial evaluation/assessment, the admitting professional … As a part of the admission process, the admitting professional completes the medication profile and OASIS assessment and selects the appropriate nursing diagnosis problems. The licensed professional then completes the remainder of the admission documentation and admission process … Assesses any medication the patient may be taking to identify possible ineffective drug therapy, significant side effects, duplicated drug therapy, drug allergies, and noncompliance with drug therapy." Under the heading "Definitions" in the policy it states, "Admitting professional is the licensed professional who performs the initial evaluation/assessment visit." The policy does not identify a HHA nurse must complete the medication review when a therapist completes the admission process in the patient's home. Review of P1's "Home Health Certification and Plan of Care" (POC) located in the "physician orders" section of the electronic medical record (EMR) revealed an admission date of 01/04/22 and diagnoses included osteoarthritis, chronic pain, psoriasis, long-term drug therapy, and low back pain. Review of the "Current Medication Report" completed during the admission revealed "Enter your signature below to acknowledge that you have reviewed the medications(s) for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy" signed by Physical Therapist (PT)1. There was no signature to show that a HHA nurse reviewed the medications at the time of the admission. Review of P2's POC located in the "physician orders" section of the EMR revealed an admission date of 11/18/21 and diagnoses included aftercare following joint replacement, abnormalities of gait, history of falling, presence of left and right artificial knee, and long-term use of anticoagulants. Review of the "Current Medication Report" completed during the admission revealed "Enter your signature below to acknowledge that you have reviewed the medications(s) for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy" signed by PT2. There was no signature to show that a HHA nurse reviewed the medications at the time of the admission. Review of P12's POC located in the "physician orders" section of the EMR revealed an admission date of 12/02/21 and diagnoses included aftercare following joint replacement, abnormalities of gait, history of falling, presence of left and right artificial knee, and long-term use of anticoagulants. Review of the "Current Medication Report" completed during the admission revealed "Enter your signature below to acknowledge that you have reviewed the medications(s) for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy" signed by PT1. There was no signature to show that a HHA nurse reviewed the medications at the time of the admission. Review of P13's POC located in the "physician orders" section of the EMR revealed an admission date of 01/18/22 and diagnoses included arthritis right hip, spinal stenosis, spondylolisthesis, intervertebral disc degeneration, radiculopathy, and pain in right and left hips. Review of the "Current Medication Report" completed during the admission revealed "Enter your signature below to acknowledge that you have reviewed the medications(s) for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy" signed by PT2. There was no signature to show that a HHA nurse reviewed the medications at the time of the admission. During an interview on 03/10/22 at 9:00 AM, the Administrator confirmed the "Current Medication Report" for the four patients admitted by PT were signed by the PT as having been reviewed and were not signed by a HHA nurse. The Administrator stated, "I do review the POC, and the medications are listed there also." The Administrator confirmed that the POC does not identify that the medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy.

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: G684 – Encompass Health Home Health Based on record review, policy review, interview, and review of the agency Quality Assurance Performance Improvement (QAPI) program, the home health agency failed to engage in infection surveillance which included investigation, analysis, interpretation, evaluation of the data and root cause analysis for eight of eight patients (Patient (P)4, P14, P15, P16, P17, P18, P19, and P20) infection report forms. This failure had the potential to miss opportunities for improved care practices and could expose all patients who receive home health services to potential infectious diseases. Findings include: Review of an agency policy titled, "Infection Prevention and Control Plan," dated 11/18/21 revealed, "Administrators and Branch Directors will tack and trend infection rates and compliance with infection control practices within the agency on a quarterly basis to reduce the risk for acquiring and spreading infections. These trends will be analyzed by the QAPI committee for recommendations and to develop action plans for improvement." During an interview on 03/08/22 at 1:45 PM, the Administrator stated the staff person will inquire about any changes in condition, signs/symptoms of infection, and changes in medication during a home visit and if the patient had a recent infection the staff person will complete an "Infection Report" in the electronic medical record (EMR). Review of a sample of eight (P4, P14, P15, P16, P17, P18, P19, and P20) "Infection Report" forms printed from the EMR revealed the form included sections to add the following information: site of infection, signs/symptoms, whether the patient was seen by a physician or admitted to the hospital, name of an antibiotic ordered to treat the infection, x-ray results if relevant, laboratory results, and any other treatment. Four (P17, P18, P19, P20) of the "Infection Reports" identified a urinary tract infection (UTI) and two (P17, P19) of those identified an antibiotic was started for the infection. None include laboratory results to confirm the diagnosis. Two (P18, P20) indicated the patient was seen by a physician. The form does not identify if the patient with a UTI had a urinary catheter or any other factors that might contribute to a UTI. The remaining four (P4, P14, P15, P16) "Infection Reports" involved patients that had been diagnosed with COVID-19. All four identified a positive COVID-19 test. Three (P14, P15, P16) identified an antibiotic that was started. Based on review of the diagnosis for the four patients who tested positive only one (P14) was admitted with a diagnosis of recent COVID. Review of documentation of the fourth quarter 2021 QAPI meeting revealed the only component that addressed infection surveillance and evaluation was a graph that indicated the total number of infections over time. The graph did not include any additional information. The QAPI documentation did not include observation and evaluation of services from all disciplines which might identify sources or causative factors of infection, tracking patterns, and trends or investigation, analysis, interpretation, and evaluation of the data. During an interview on 03/09/22 at 10:30 AM, the Administrator stated "QAPI pulls the graph" which contained the total number of infections from the EMR. The Administrator confirmed there was no further documentation to indicate the infection control and surveillance information presented in QAPI included potential causative factors, tracking patterns, trends, analysis, or root cause analysis of the data.