Every finding on record at Alamogordo Home Health Care & Hospice, Inc

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 06/26/23 to 06/28/23 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation 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 06/26/23 to 06/28/23 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with 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 record review, policy review, and interview, the agency failed to conduct an initial assessment visit within 48 hours of the referral, the patients' return home from an inpatient setting, or on the physicians' ordered start of care date for three of 13 patients (Patient (P) 6, P7, and P13). Failure to complete an initial assessment within 48 hours had the potential for a patient's immediate care needs to not be addressed and could impact the patient's safety and well-being. Review of an agency policy titled, "Initial Patient/Client Comprehensive Assessment," dated 12/10/21, revealed, "The initial visit will be conducted within 48 hours of referral, or within 48 hours of the patient's/client's return home, or on the physician and/or non-physician practitioner ordered start of care date. ln instances where the patient/client requests a delay in the start of care date, the Agency will contact the physician and/or non-physician practitioner to request a change in the start of care date and such change will be documented in the medical record." Review of the "Documents" section of P6's EMR revealed a referral for home health services dated 06/09/23. Review of P6's POC initial SOC assessment revealed it was dated 06/12/23 which is greater than 48 hours after the referral. Review of the "Documents" section of P7's EMR revealed a referral for home health services dated 05/10/23. Review of P7's initial SOC assessment revealed it was dated 05/15/23 which is greater than 48 hours after the referral. Review of the "Documents" section of P13's EMR revealed a referral for home health services dated 06/01/23. Review of P13's initial SOC assessment revealed it was dated 06/07/23 which is greater than 48 hours after the referral. During an interview on 06/27/23 at 10:30 AM, the Chief Executive Officer (CEO) confirmed the initial assessment visit for the above patients was greater than 48 hours after the referral or discharge from the hospital and that there was no documentation that the patient, the patient's caregiver, or the patient's physician requested the delay.

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 medical record review, policy review, and interview, the agency failed to ensure that visits were completed as indicated on the plan of care or that the primary care provider was notified of missed visits for three of 13 patients (Patient (P) 5, P7, and P10). Failure to complete visits as order by the primary care provider in the patient plan of care had the potential to affect the safety and well-being of all patients receiving home health services. Review of an agency policy titled, "Implementing Care and Treatment," dated 08/01/20, revealed "When the provision of care and treatment cannot be implemented as established on the care planning document(s), the patient's/client's physician and/or non-physician practitioner will be notified." Review of P5's plan of care (POC) in the electronic medical record (EMR) revealed home health aide (HHA) visits were ordered once a week for nine weeks. Review of the HHA visit documentation revealed a missed visit on 05/17/23 which stated the reason for the missed visit was "I [the HHA] was out of town." There is no indication in the EMR that the agency sent a different HHA or notified the primary care provider (PCP) of the missed visit. Review of P7's POC in the EMR revealed a start of care (SOC) date of 05/15/23. SN frequency on the POC was two times a week for nine weeks. Review of the skilled nursing (SN) visit notes revealed that SN began seeing P7 once a week starting the third week. The EMR did not contain any missed visit notes, an order to decrease the frequency, or evidence the PCP was notified of the missed visits or change of SN visit frequency. Review of P10's POC in the EMR revealed a SOC date of 06/06/23. SN frequency on the POC was two times a week for one week and then one time a week for five weeks. Review of the SN visit notes revealed a second visit was not completed during the first week of home health services. There was no evidence in the medical record that the PCP was notified. During an interview on 06/27/23 at 10:30 AM, the Chief Executive Officer (CEO) confirmed that it is the agency policy to notify the primary care provider (PCP) of missed visits. The CEO also confirmed that a visit should not be missed because the aide was "out of town" and another staff person should have been assigned.

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 document review, observation, policy review, and interview, the agency failed to provide a written visit schedule to four of four patients (Patient (P) 6, P7, P9, and P10) seen for home visit observations. Failure to provide a written visit schedule to patients had the potential to result in missed visits which could impact the safety and well-being of all patients receiving home care services. Review of the home health agency admission documentation provided to patients at the start of care revealed it included blank calendars on which staff could indicate the anticipated visit frequency during each week. 1. Review of P6's plan of care (POC) in the electronic medical record (EMR) revealed a start of care (SOC) date of 06/12/23. Skilled nursing (SN) frequency was indicated as once a week for nine weeks. Review of a missed SN visit note, dated 06/23/23, revealed the reason for the missed visit as "SN called client to schedule visit and client was on their way to El Paso for radiation treatments." During a home visit observation on 06/26/23 at 2:00 PM, review of the admission booklet provided to P6 showed that physical therapy (PT) and occupational therapy (OT) had documented on the calendar the days of the week they could be anticipated to visit. There was no written information of a visit schedule or frequency for SN. 2. Review of P7's POC in the EMR revealed a SOC date of 05/15/23. A review of P7's POC revealed home health services were ordered due to the need for wound care, colostomy care, suprapubic catheter care, and PT due to a crushing injury to abdomen, lower back, and pelvis following an accident involving a semi-truck trailer. The POC indicated SN frequency as two times a week for 9 weeks, PT two times a week, and occupational therapy (OT) two times a week. Review of three SN missed visit notes located in the EMR revealed the following: 05/22/23-"SN called client to schedule visit and client stated [he/she] was seeing new PCP today so SN will attempt to see client on next schedule visit date." 05/25/23-"SN called client and schedule [sic] a time to do visit and upon arrival client spouse stated the client was sleeping due to not feeling well and did not want to be seen." 06/21/23-"Multiple attempts made to reach client via phone without success." During a home visit observation on 06/26/23 at 3:30 PM, P7 stated staff usually call in the morning to say they are coming. P7 was not aware of receiving a written schedule of when to anticipate visits. 3. Review of P9's POC in the EMR revealed a SOC date of 06/22/23 and SN frequency of one time a week for nine weeks. During a home visit observation on 06/27/23 at 2:00 PM, review of the admission booklet provided to the patient showed the calendar was blank. During an interview on 06/27/23 at 2:30 PM, Registered Nurse (RN)1 stated he/she usually calls a patient the night before a visit and then again in the morning to confirm the time of the visit. 4. Review of P10's POC in the EMR revealed a SOC date of 06/06/23. The POC indicated SN visits were to occur one time a week and PT were to occur one time a week for one week and two times a week for five weeks. During a home visit observation on 06/27/23 at 3:30 PM, P10 stated he/she was not aware of having received a written visit schedule. P10 stated staff "just call and ask if it is ok to come over." Review of an agency policy titled, "Implementing Care and Treatment," dated 08/01/20, revealed "The Agency [sic] must provide the patient/client, and caregiver, with a copy of written instructions outlining: 1. The visit schedule, including frequency of visits by agency personnel and personnel acting on behalf of the Agency [sic]." During an interview on 06/28/23 at 2:00 PM, the Administrator confirmed that per policy the staff should be providing the patient with a written visit schedule and that there were blank calendars in the admission booklet provided to patients.

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 observation, document review, policy review, and interview, the agency failed to provide four of four patients (Patient (P) 6, P7, P9, and P10) seen for home visit observations with a medication list. Failure to provide a list of medication written in plain language without medical abbreviations had the potential to lead to medication errors. Review of the agency policy titled, "Implementing Care and Treatment," dated 08/01/20, revealed, "The Agency [sic] must provide the patient/client, and caregiver, with a copy of written instructions outlining: … Patient/client medication schedule/instructions, including medication name, dosage, time of medication administration, frequency … " 1. Review of P6's plan of care (POC) in the electronic medical record (EMR) revealed a start of care (SOC) date of 06/12/23. A visit to P6's home with the Occupational Therapist (OT) on 06/26/23 at 2:00 PM failed to show evidence that the patient had been given a medication list. 2. Review of P7's POC in the EMR revealed an SOC date of 05/15/23. A visit to P7's home with the Doctorate Physical Therapist (DPT) 06/26/23 at 3:30 PM failed to show evidence that the patient had been given a medication list. 3. Review of P9's POC in the EMR revealed an SOC date of 06/22/23. A visit to P9's home with Registered Nurse (RN)1 on 06/27/23 at 2:00 PM failed to show evidence that the patient had been given a medication list. 4. Review of P10's POC in the EMR revealed an SOC date of 06/06/23. A visit to P10's home with RN2 on 06/27/23 at 3:30 PM failed to show evidence that the patient had been given a medication list. Prior to the scheduled home visits a printed list of medications for P6, P7, P9, and P10 was reviewed. The medication lists provided were not written in plain language. All four medication lists reviewed prior to the home visit included medical abbreviations. During an interview on 06/28/23 at 2:00 PM, the Administrator confirmed that the medication list provided for review would be the same as what should be printed and provided to the patient after admission. The Administrator confirmed that the medication list is not written in plain language.

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, policy review, and interview, the agency failed to track and analyze adverse patient events and include the information in its quality assessment performance improvement program (QAPI). Failure to track adverse events and analyze the data had the potential to impact patient outcomes. Review of the agency policy titled, "Quality Assessment Performance Improvement Program," dated 01/13/18 revealed, "The QAPI Plan will be developed based on … Program scope … Measure, analyze, and track quality indicators, including adverse patient /client events, and other aspects of performance … Criteria in setting priorities will include: … Track adverse patient/client events, analyze their causes, and implement preventive actions … Review of a binder titled, "Adverse Events," revealed it included individual patient "Incident Log" forms with dates ranging between 12/01/22 and 05/01/22. There was a total of seven incidents involving either falls, emergent care, or medication issues. Review of the agency's QAPI documentation with the Chief Executive Officer (CEO) on 06/28/23 at 3:00 PM revealed the QAPI program included information from the Outcome and Assessment Information Set (OASIS) but did not include the agency adverse event tracking or analysis. During an interview on 06/28/23 at 2:00 PM, the Administrator confirmed that patient adverse events including falls, emergent care, or medication issues identified on the "Incident Log" forms were not tracked or analyzed to determine potential trends or causes. During an interview an interview with the CEO on 06/28/23 at 3:00 PM the CEO confirmed that patient falls, emergent care, or medication issues identified during review of "Incident Log" forms were not included in QAPI.

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, policy review, and interview, the agency failed to maintain an infection surveillance program that included ongoing tracking and investigation of infections and include its findings as a part of the agencies quality assessment and performance improvement (QAPI) program. Failure to maintain and analyze infection surveillance data had the potential to miss the opportunity to identify causative factors of infections or establish corrective plans for infection control which could affect all patients receiving home care services. Review of an agency policy titled, "Infection Control Program," dated 07/01/20, revealed "The Agency's Infection Control Program will be based on the following criteria: … Current scientific methods of surveillance and prevention or control of adverse outcomes related to infections … The infection Control Program will include: … surveillance for the occurrence of an infection … identification of the occurrence … review of the data collected to evaluate for trends, patterns, etc." Review of an undated agency policy titled, "Infection Control" revealed, "The Agency will maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. Reports will be made available as part of the agency's quality assessment and performance improvement program." Review of an undated binder titled, "Home Health Infection Log," provided by agency staff, showed no ongoing systematic collection, tracking, or analysis of infection data. During an interview on 06/28/23 at 1:45 PM, the Administrator confirmed that the agency had not maintained an infection control surveillance program and that no further information was available. Review of QAPI documentation presented by the Chief Executive Officer (CEO) on 06/28/23 at 3:15 PM showed no information on infection tracking. During an interview while reviewing the QAPI data, the CEO confirmed QAPI did not include infection trends or analysis.