Every finding on record at Alpha Nurses

The following deficiencies were cited during a recertification survey completed 04/14/2021 for the federal requirements of 42 CFR 484.102 for Emergency Preparedness for Home Health Agencies.

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), §485.625(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 record review and interview the facility failed to develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. This deficient practice increases the likelihood of failed patient care in the event of an emergency. The findings are: A. Record review of Facility Emergency Preparedness Plan was requested and document provided contained 1) a hierarchy of the facility in the community and 2)information on Corona Virus. B. On 4/14/2021 at 2:00pm S#1 confirmed, "The facility has only the documents provided, the facility has no emergency preparedness plan".

The following deficiencies were cited as a result of a recertification survey completed on 04/14/2021 for the requirements of 42 CFR 11.02 Federal Requirements for Home Health Agencies. A COVID-19 Focused Infection Control Survey was conducted by the New Mexico Department of Health Division of Health Improvement on 04/14/2021. The facility was 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.

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 record review and interview the facility failed to provide an ongoing program for quality improvement and patient safety that shows quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and shows that all improvement actions are evaluated for effectiveness and show clear expectations for patient safety are established, implemented, and maintained in the facility. This failed practice increases the likelihood of continued issues of poor quality and lack of performance improvement in the facility. The findings are: A. Record review for Quality Assurance and Performance Improvement (QAPI) documents requested from the facility were declined due to the facility not maintaining these documents. B. On 4/14/2021 at 11:00 am during interview S#1 (Administrator) confirmed, "we are not conducting any QAPI at this time in this facility.".

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review and interview the facility failed to provide ongoing interdisciplinary assessment of the patient for 6 (P#1-P#6) of 6 patients reviewed. This failed practice increases the likelihood of errors in patient treatment due to lack of interdisciplinary communication, The findings are: A. Record review of Interdisciplinary Team / Care Coordination meetings were requested, and facility is not conducting this type of meeting. B. On 4/14/2021 at 11:30 am during interview S#1 (Administrator) confirmed, "The team meets to discuss the patients, but it is not formal, and it is not documented anywhere".