Every finding on record at Access Home Health, LLC

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 06/21/23 to 06/23/23 resulted in a finding of standard level deficiencies citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on review of the emergency preparedness (EP) plan and interview, the agency failed to ensure the EP plan was reviewed and updated at least every two years. Failure to update the EP plan had the potential to impact the agency response in the event of an emergency which could affect patient and staff safety. Review of an agency document titled, "Emergency Preparedness Plan," revealed it was dated 01/01/19. There was no evidence the EP plan was reviewed or updated since the date identified on the document. During an interview on 06/21/23 at 3:15 PM, the Administrator confirmed the date of the EP plan and stated there was no additional information to show the EP plan had been reviewed or updated since that time.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to ensure the emergency preparedness (EP) plan included the names and contact information of agency staff and patients' physicians. Failure to include this information in its communication plan had the potential to limit the agency's response during an emergency. Review of an agency's document titled, "Emergency Preparedness Plan," dated 01/01/19, revealed it did not include contact information for agency staff or patients' physicians. During an interview on 06/21/23 at 3:15 PM, the Administrator confirmed the EP plan did not include documentation of staff or patients' physicians contact information.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to complete an exercise of its choice to test of the emergency preparedness (EP) plan. The failure to complete an exercise to evaluate the agency's ability to respond to an emergency could impact its response in an actual emergency. Review of an agency's document titled, "Emergency Preparedness Plan," dated 01/01/19, revealed, "The EPP [emergency preparedness plan] will be tested at least once each year … For testing purposes, a tabletop drill is acceptable for meeting this portion of the exercise … The purpose of this evaluation is to identify opportunities for improvement, and thus modify the EPP accordingly." Review of the EP program documentation located in a binder provided by the Administrator revealed the agency had not completed any type of exercise to test its ability to respond in an emergency since 2019. During an interview on 06/21/23 at 3:15 PM, the Administrator confirmed there was no documentation of the agency completing any test of the EP plan.

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 06/21/23 to 06/23/23 resulted in noncompliance with the Quality Assessment and Performance Improvement Condition of Participation §484.65 respective to applicable CoP under 42 CFR 484 Subparts A through C and the following standard-level deficiencies 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 observation, record review, policy review, and interview, the agency failed to ensure that patient care was provided as written in the plan of care for one of seven patients (Patient (P) 3) whose blood sugar readings were not reviewed or reported to the physician. Failure to provide patient care as written in the plan of care had the potential to affect the care and safety of all patients receiving services. Review of P3's "Home Health Care Certification and Plan of Care (POC)" located in the "Plan of Care" section of the electronic medical record (EMR) revealed a start of care (SOC) date of 03/31/22 and a current certification period of 05/25/23 to 07/23/23. The POC showed P3 had a diagnosis of type 2 diabetes with long term use of insulin and was being seen by skilled nursing (SN) twice a week for wound care following a surgical amputation of the left foot great toe. P3's POC revealed SN interventions included, "Assess blood sugar monitoring and results. Notify MD as indicated." The POC did not include blood sugar parameters. During a home visit observation on 06/22/23 at 9:30 AM, Licensed Practical Nurse (LPN)1 asked P3 "How have your blood sugars been? Last time it was 180. Is it still around that?" P3 said that it was. LPN1 did not ask any other questions about P3's blood sugar. The surveyor asked P3 where his/her glucometer was located and if the surveyor could look at it. Review of the glucometer showed P3's blood sugar readings were averaging over 200 with one reading of 309. During an interview on 06/22/23 at 10:10 AM, LPN1 confirmed that he/she had never checked P3's glucometer to confirm recent blood sugars. Review of P3's EMR failed to show that a physician was notified of P3's blood sugar ranges. Review of an undated agency policy titled, "Care Plan" revealed, "The individualized plan of care must specify the care and services necessary to meet the patient/client specific needs as identified in the comprehensive assessment, including the identification of the responsible discipline(s), and the measurable outcomes that the agency anticipate will occur … Include on the 485 [Center for Medicare and Medicaid Services (CMS) form number for POC] the physician's parameters for vital signs, and fasting blood sugar. If the physician does not specify the parameters to be reported the following parameters will be used by the Agency … Fasting blood sugar less than 60 or greater than 250" During an interview on 06/23/23 at 1:45 PM, the Administrator confirmed that it would be a usual nursing standard of practice to check the blood sugars of diabetic patients for whom they are providing care. The Administrator confirmed the POC for P3 identified that the physician should be contacted "as indicated" but that the POC did not contain parameters identifying when to contact the physician.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on review of quality assessment performance improvement documentation and interview the home health agency (HHA) failed to develop, implement, and maintain an ongoing quality assessment and performance improvement (QAPI) program to improve patient safety, health outcomes or quality of care since 03/26/21. This had the potential to affect the safety of services and quality of care for the 50 current home health patients. Adverse event and infection surveillance data was not analyzed and there was no identification of trends (See the findings in G642). Data collected was not used to identify opportunities to improve patient care and there was no evidence that the governing body had approved the data collected by the agency (See the findings in G644). The agency's governing body failed to ensure an ongoing QAPI program was maintained (See the findings in G660).

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to analyze patient adverse events and infection surveillance data that was collected or review this information as a component of a quality assessment and performance improvement (QAPI) program. Failure to analyze the information collected and review the findings as a part of a QAPI program could affect the agency's ability to implement interventions that could improve patient outcomes. Review of two binders identified as containing documentation of the agency's QAPI program revealed the last QAPI meeting was held on 03/26/21. There was no indication of an active QAPI program since that time. Review of a binder labelled "Incident Binder" revealed this binder was separated by monthly tabs and there has been ongoing tracking of patient incidents including patient falls and rehospitalization. The binder did not include evidence of an analysis of the data that was tracked or review of the data as a part of QAPI. Review of a binder labelled "Infection Control" revealed it included individual patient "Infection Report Forms" completed by staff when a patient was identified as having an infection and a monthly "Infection Control log" form completed which tracked infections by name, site of infection, and antibiotic prescribed. The binder did not include evidence of an analysis of the data that was tracked, identification of trends, or review of the data as a part of QAPI. During an interview on 06/23/23 at 12:00 PM, the Administrator confirmed that patient infections and adverse patient events are the only information that the agency had tracked. The Administrator confirmed the agency did not have documentation of trending or analysis of infection data or adverse event data and that there had not been an active QAPI program or meetings held 03/26/21. A copy of the agency's QAPI policy and procedures was requested but none was provided prior to exit.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to (1) use data indicators to identify opportunities for improvement of patient services, and (2) ensure the governing body approved the data collected by the agency. Failure to ensure an active quality assessment performance improvement (QAPI) program that includes data indicators had the potential to miss opportunities to improve the safety and quality of services being provided to all the home health agency patients. Review of two binders provided as evidence of the agency's QAPI program revealed the agency had been engaged in regular QAPI meeting until 03/26/21. The binders failed to reveal evidence of QAPI documentation since that time including evidence that the governing body approved the data the agency should collect. During an interview on 06/23/23 at 12:00 PM, the Administrator confirmed since 03/26/21 there have been no QAPI meetings, review of data indicators, to identify opportunities for improvement or discussion of QAPI during meetings of the governing body. A copy of the agency's QAPI policy and procedures was requested but none was provided prior to exit.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on document review, policy review, and interview, the governing body failed to ensure a quality assessment performance improvement (QAPI) program was implemented and maintained on an ongoing basis. Failure to ensure an ongoing QAPI program had the potential to impact the quality of patient care and the safety of all home health patients. Review of two binders presented as the agencies QAPI program revealed the agency had not documented QAPI information or meetings since 03/26/21. A document located in a binder identified by the Administrator as being the QAPI Program 2021 revealed that on 10/05/2018 the governing body reviewed and approved QAPI. Neither of the binders reviewed had documentation of the governing body review and approval of QAPI since that time. The most recent review of the QAPI program by the governing body was requested but no further documentation was provided. Review of a document titled, "Access Home Health Governing Body Meeting," dated 12/19/22 revealed, "[name of a staff person] was unavailable to present the QAPI report due to being out of town." During an interview on 06/21/23at 3:15 PM, the Administrator was asked about the staff person identified as being responsible for QAPI and the Administrator stated the person was contracted by the agency but had not been in contact with the agency since before his/her appointment as the administrator in 2022. Review of an undated policy titled, "Governance," revealed, "Responsibilities of the Governing Body include the following: … Monitor Agency organizational efforts to identify and address patient/community concerns … Evaluate organizational performance … Allocate resources for the implementation of an Agency wide Quality Assessment and Performance Improvement Program, receive reports and approve the data collection." During an interview on 06/23/23 at 12:00 PM, the Administrator confirmed there was no other documentation to show the governing body's oversight of the agency's QAPI program.

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, policy review, and interview, the agency failed to ensure staff completed hand hygiene in between glove changes and cleaned equipment during one of three patient (Patient (P) 3) observations. The failure to follow standard precaution principles and complete hand hygiene during patient care had the potential to increase the risk of transmission of infections and communicable diseases for all patients receiving services from the home health agency. A home visit observation of Licensed Practical Nurse (LPN)1 on 06/22/23 at 9:30 AM, revealed the following: LPN1 completed hand washing after entering P3's home. LPN1 checked P3's temperature, blood pressure, and used the stethoscope to listen to heart sounds. LPN1 then put the equipment used to check P3's vital signs into his/her equipment bag without cleaning the equipment. LPN1 put on gloves and removed the dressing from P3's left foot. LPN1 removed the gloves and put on new gloves without completing hand hygiene. LPN1 then reached into the supply bag with the clean gloves on and removed a packaged medical cotton swab. LPN1 opened the package, removed the swab, and held it up against the wound, touching the wound with the tip of the swab, then use the package ruler marks to determine the length of the wound. The swab touched the outer aspect of the package in the process. LPN1 then held the swab against the wound again to measure the width of the wound, then held the tip of the swab into the wound to determine the depth of the wound and held it up against the paper package to determine the measurement. LPN1 set the swab down on the barrier he/she had placed and removed the gloves. LPN1 did not complete hand hygiene after removing the gloves. LPN1 put on new gloves and removed 4x4 (4-inch by 4-inch size) gauze from an opened package that had been sitting on a fireplace shelf with other patient supplies, sprayed the gauze with wound cleanser, and proceeded to clean the wound. LPN1 removed the gloves after cleaning the wound and did not complete hand hygiene after removing the gloves. LPN1 put on new gloves, picked up a package of Opticell (a type of wound dressing) that was located with the other patient supplies, opened the package, and using a scissors that was sitting on the fireplace shelf cut a small piece of the wound dressing and placed it in the wound on P3's left foot. LPN1 then covered the wound with soft roll dressing and put the scissors back by the fireplace without cleaning it. LPN1 removed the gloves and without completing hand hygiene collected and disposed of used materials by placing them in a bag, before washing his/her hands. During an interview on 06/22/23 at 10:10 AM, LPN1 was asked if he/she had completed hand hygiene and standard precaution training at the agency and if that included completing hand hygiene after removing gloves or before putting on gloves. LPN1 stated, "I guess I forgot to do that." LPN1 confirmed he/she had put the equipment used to check P3's vital signs back in the supply bag without cleaning it. Review of an undated agency policy titled, "Hand Washing Policy - In Patient's Homes," revealed, "Use of alcohol-based hand sanitizer is preferred … After removing gloves." Review of an undated agency policy titled, "Standard Precautions for All Health Care Workers," revealed, "Hands must be washed before and after contact with each patient, if hands become soiled with body fluids, before the donning (putting on) of gloves, after the removal of all gloves, after contact with non-intact skin and wound dressings and if moving from a contaminated area to a clean area. This is completed following the Agency handwashing policy." Review of an undated agency policy titled, "Bag Technique," revealed, " All equipment is cleansed with disinfectant after use and before returning to the bag." During an interview on 06/22/23 at 4:00 PM, the Administrator confirmed that it is the agency's expectation that staff complete hand hygiene after removing gloves and before putting on clean gloves and confirmed that equipment is to be cleaned with disinfectant wipes after use and before putting into the staff person's bag.

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 document review and interview, the agency failed to ensure infection surveillance data was investigated, analyzed, or reviewed as a part of an agency quality assessment and performance improvement (QAPI) program. Failure to maintain a QAPI program that included an analysis of infection surveillance data had the potential to miss opportunities to identify gaps in infection prevention and allow for the spread of infections. Review of the agency's infection surveillance data revealed monthly documentation was present that included the name of the patient, the site of the infection, and the antibiotic prescribed. The documentation did not include an investigation or analysis of infection data or trends. Documentation of the agency's QAPI program revealed that the agency has not had a functional QAPI program since 03/26/21. During an interview on 06/23/23 at 12:00 PM, the Administrator confirmed the agency has not had any QAPI meetings since 03/26/21 and that infection surveillance data has not been reviewed to determine if any trends exist.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to complete a discharge summary for two of two discharged patients (Patient (P)1 and P2). Failure to complete and send a discharge summary to the physician or other health care provider who will be continuing care for the patient could affect the continuity of care after discharge from the agency. Review of the P1's plan of care (POC) revealed an admit date of 01/06/23 and a discharge date of 03/18/23. Review of the entire medical record failed to reveal a discharge summary was completed and sent to the patient's primary care physician. Review of P2's POC revealed an admit date of 02/16/23 and a discharge date of 03/18/23. Review of the entire medical record failed to reveal a discharge summary was completed and sent to the patient's primary care physician. Review of an undated agency policy titled, "Discharge/Transfer Policy," revealed, "A written discharge summary will be sent to the physician within 5 business days of discharge with a copy maintained in the clinical record. The discharge summary will include: a. The reason for the discharge. b. The patient's physical and psychosocial status at the time of discharge. c. A summary of the care and services provided. d. Patient progress toward desired goals. e. Instructions and referrals provided to the patient." During an interview on 06/22/23 at 4:00 PM, the Administrator confirmed the discharge summaries were not completed for P1 or P2. The Administrator stated a few months ago the agency changed to a new web-based electronic medical record (EMR) system and was still in the process of learning the program. The Administrator stated that the prior program created a summary upon discharge and the agency realized today that it had not been completing discharge summaries since using the new web based EMR.