Every finding on record at Enhabit Home Health

A Recertification Survey was conducted by Healthcare Management Solutions, LLC, on behalf of the New Mexico Health Care Authority (HCA). An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 06/02/25 to 06/04/25 resulted in no deficiency citations respective to the Emergency Program Condition of Participation under 42 CFR 484.102.

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of New Mexico. An unannounced on-site Recertification survey conducted at the above-named Home Health Agency (HHA) facility from 06/02/25 to 06/04/25 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 deficiency listed below.

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 ensure services were provided as established in the written care of plan for one of 10 (Patient (P)9) sampled patients. A visit was not conducted per the physician signed plan of care and the physician was not notified in a timely manner. This deficient practice had the potential to cause the patient's needs to not be met. Findings include: Review of the undated facility policy titled, "Clinical records" revealed, "Purpose: Establish guidelines for maintaining the individual record for every patient in accordance with professional standards . . . Missed Visit Coordination note is the documentation of services by the nurse, therapist. . . which includes. . . Notification to the agency and physician of the reason for the missed visit. . . " Review of P9’s "Home Health Certification and Plan of Care," located under the "Orders" tab in the electronic medical record (EMR), revealed a start of care (SOC) date of 02/15/25 with diagnoses of acute pain due to trauma, pain in left arm, Further review of the undated "Home Health Certification and Plan of Care" revealed Physical Therapist (PT) visits were to occur once a week for nine weeks, The plan of care was signed by the physician on 04/21/25. Review of the calendar, located under the "Medical Record" tab in the EMR, revealed missed visits on 04/16/25, 04/18/25 by the PT assistant and on 05/07/25 by the PT. The notes did not indicate notification to the physician for the missed visits. Review of the "Missed Visit Report" dated 05/14/25, provided by the facility indicated the physician was notified on 05/15/25 via fax. The notification went out 29 days after the first missed visit. During an interview on 05/21/25 at 8:15 AM, the Director of Operations (DOO) was asked about the missed visits and notification to the physician. The DOO stated that the patient cancelled the visits. The DOO also stated that the physician who are notified via fax should be every seven days, but the Administrative Assistant had been out, and they did not go out per the seven-day notification.

0000 Initial Comment On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site recertification survey conducted at Enhabit Home Health Agency (HHA) on 04/07/22 resulted in findings of noncompliance under 42 CFR 484, Subpart A-C with the following standard level deficiencies cited.

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 Based on record review and interview the facility failed to document significant side effects, duplicate drug therapy, ineffective drug therapy, and adverse effects for 13 (P1-P13) of 13 patients sampled. This failed practice could lead to unwanted medication reactions, ineffective treatment, and failure to analyze and report medication compliance or significant side effects. Findings include: A. During record review with Staff S4 (Administrator) while navigating electronic charts for (P1-P13) under medications documentation the following was missing: significant side effects, ineffective drug therapy, duplicate drug therapy, and adverse effects. B. On 04/06/22 at 11:20am during interview with (S4) Administrator stated, “I guess we need to add those options in our system because they are just not here, or I can’t find it.”

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: G572 Based on record review and interview the facility failed to obtain a Doctor of Medicine or Osteopathy signature on current individualized plan of care for 2 (P2 and P5) of 13 patient charts reviewed. This failed practice could lead to individualized plan of care not being verified and approved by the physician. Findings include: A. On 04/06/22 during record review of (P5’s) electronic medical chart (S4) Administrator re-printed the individualized plan of care and reviewed the electronic chart but could not produce a signature of physician for individualized home plan of care. B. During record review electronic chart with (S4) for (P2) revealed the physician signature was missing from the individualized plan of care. (S4) stated “I’m sure there is a verbal order or something and I just can’t find it.” Surveyor asked (S4) what is the timeline for getting the home plan of care signed and (S4) replied “60 days usually, but we try for 30 days.” C. On 04/06/22 at 2:45pm during interview (S4) stated in reply to not finding signed individualized plan of care “I don’t know what happened, but I will look into it.”

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: G682 Based on observation and record review, the facility failed to prevent transmission of infection by not using standard precautions such as the Bag Technique (a technique that is used as a barrier to prevent cross contamination) during 2 (P1 and P4) of 5 patient home visits. This failed practice can lead to serious or life-threatening infections transmitted between staff and patients. Findings include: A. Article-Standard of care: place a disposable barrier under caregiver bag. …“always place a barrier under the bag, or hang it on a doorknob or on a hangar over a door” (McGoldrick, 2014). 1. McGoldrick M. Bag technique: preventing and controlling infections in home care and hospice. Home Health Nurse. 2014 Jan;32(1):39-45; quiz 45-7. Dol: 10.1097/NHH. 0000000000000003. PMID: 24326473. B. On 04/05/22 at 09:17 am during observation while on a home visit with staff for Patient (P1), Staff (S8) Physical Therapy Assistant (PTA) cleaned hands with hand sanitizer, placed gloves on, and placed (S8) bag directly on the TV tray without a barrier where P1’s breakfast was just removed by P1’s daughter. C. On 04/05/22 12:45 pm during observation while on a home visit with staff for patient (P1), (S7) Certified Occupational Therapy Assistant (COTA) came in and greeted (P1), sanitized hands, placed gloves on, and placed bag directly on top of kitchen table without a barrier. D. On 04/07/22 at 10:10 am during interview with (S3) Director, surveyor asked when your staff arrive to a patient’s home and place the bag down, should you place a barrier down first? (S3) replied, “Yes”. Surveyor asked (S3) have your staff been trained on proper bag handling technique, (S3) replied, “Yes”.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: G708 Based on record review and interview the facility failed to ensure patient participation including the documentation for the development and evaluation of the individualized plan of care for 3 (P3, P4 and P8) of 13 patient charts. This failed practice could lead to decreased patient participation, compliance, and accountability for patient individualized plan of care goals and outcomes. Findings include: A. During record review of the individualized plan of care for (P3), (P4) and (P8) with Staff (S4) Administrator, was unable to provide documentation of patient participation in development and evaluation of the individualized plan of care. B. On 04/06/22 at 3:50pm during interview of (S4), (S4) stated “I can’t find it the chart” while searching for patient participating in the development of the individualized plan of care. “I may need to get back to you on this.” C. On 04/07/22 at 9:55 am during interview with (S3) Director and (S4), surveyor inquired if they were able to locate participation in the development or evaluation of the individualized plan of care? (S3) replied “no.”

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: G948 Based on observation, interview, and record review the facility failed to provide identification (employee badges) to 3 (S2, S3 and S9) of 12 staff and enforce facility policy to wear identification while conducting agency business. This failed practice places all patients at risk for safety by allowing unidentified persons to enter the patients home. Findings include: A. Record review of policy dated 10/12/21, “Personal appearance … 2.0 Policy 2.1 All the Agency employees must wear the photo identification badge provided at all times while conducting Agency business.” B. On 04/05/22 at 3:12pm during observation, Staff (S9) Nurse arrived at (P5) home and gave her name and title stating, “my badge has not come in yet” and she started working for [facility] in “January of this year” [2022]. C. On 04/04/22 at 02:40pm during observation of entry to [facility] (S2) Staffing Coordinator/Licensed Practical Nurse was not wearing a badge. D. On 04/04/22 at 2:55pm during observation (S3) (Director) who was not wearing a badge came in and introduced herself. E. On 04/06/22 during interview with (S4) Administrator, stated (S1) (Human Resources Designee) knows to give new hires a temporary badge. (S4) shows a temporary badge to surveyor and states “we have 4 of these.” (S4) states (S3) is now aware of them and can make sure they are used in the future.” F. On 04/07/22 at 9:55am during interview with (S3) surveyor reviewed the badge policy that revealed, “All the agency employees must wear the photo identification badge provided at all times while conducting agency business.” Surveyor asked (S3) would (S3) consider working in the office and patient visits as agency business? (S3) replied “yes, and we are instructed to wear them while conducting agency business. I plan to provide education to staff and utilize temporary clinical badges.”