Every finding on record at Alto Mar New Mexico LLC

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Alto Mar New Mexico Home Health Agency (HHA) on 10/11/2024 found that your facility was in substantial compliance with the Conditions of Participation (CoPs) under 42 CFR 484.102.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Alto Mar New Mexico Home Health Agency (HHA) on 10/11/2024 resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited:

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on interview, record review, agency document review, and agency policy review, the agency failed to ensure staff provided care as directed by a patient’s plan of care for 1 (Patient #2) of 17 sampled patients. An agency document titled, “Job Description/Qualifications,” for the position of home care aide with a review date of 05/2009, indicated, “Position summary: Responsible for the provision of personal care and related assigned services to agency patients in accordance with an established physician plan of care, under the supervision of a registered nurse.” Patient #2’s “Home Health Certification and Plan of Care,” for the certification period 07/07/2024 to 09/04/2024, revealed an order for a home health aide (HHA) 40 hours weekly for nine weeks beginning on 07/07/2024. Patient #2’s care calendar hours, confirmed by the Alternate Administrator (AA), indicated the following: - for the week of 08/18/2024, 39 HHA hours were provided. - for the week of 08/25/2024, 37 HHA hours were provided. - for the week of 09/01/2024, 38 HHA hours were provided. Patient #2’s “Home Health Certification and Plan of Care,” for the certification period 09/05/2024 to 11/03/2024, revealed an order for a HHA 40 hours weekly for nine weeks beginning on 09/05/2024. Patient #2’s care calendar hours, confirmed by the Alternate Administrator (AA), indicated the following: - for the week of 09/08/2024, 37 HHA hours were provided. - for the week of 09/15/2024, 37 HHA hours were provided. - for the week of 09/22/2024, 33 HHA hours were provided. - for the week of 09/29/2024, 37 HHA hours were provided. During an interview on 10/10/2024 at 3:00 PM, the AA stated Patient #2 did not receive the amount of HHA services ordered by the physician in the patient’s plan of care.

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, interview, agency document review, and agency policy review, the agency failed to ensure staff performed hand hygiene before they put on gloves and after they removed their gloves. The agency further failed to ensure staff placed a barrier before they placed their bag down in a patient’s home. These deficient practices affected 2 (Patient #2 and Patient #3) of 7 sampled patients observed during home visits. An undated agency policy titled, “Hand Washing Policy,” revealed, “Hands must be washed before and after patient contact, during patient care (if hands become soiled), immediately following contact with body areas containing blood or other potentially infectious materials and immediately after removing gloves. (Wearing gloves does not eliminate the necessity for hand washing). Hands must be washed with soap and water. If soap and water are not available, antiseptic hand cleaner or towelette [towelettes] may be used then wash hands with soap and water as soon as possible.” 1. During a concurrent observation and interview on 10/07/2024 at 2:00 PM, in Patient #3’s home, Licensed Vocational Nurse (LVN) #2 provided wound care to the patient. During the observation, LVN #2 did not wash her hands after she removed a pair of gloves and before she put on a new pair of gloves. LVN #2 stated she was unsure of any agency policy regarding hand hygiene and the need to perform hand hygiene between glove changes. 2. An undated document, provided with the agency, titled, “Healthcare Bag Technique,” revealed, “8. Spread an impervious barrier on the surface before setting the bag down.” During a concurrent observation and interview on 10/07/2024 at 3:15 PM, in Patient #2’s home, Registered Nurse (RN) #4 entered the patient’s home and placed his bag on the patient’s bed, without a first setting a barrier to place his bag on. RN #4 put on gloves, checked the patient’s vital signs, and removed the gloves. RN #4 did not perform hand hygiene before he put on gloves or after he removed his gloves. RN #4 stated staff were expected to place a barrier under their bags while in a patient’s home and confirmed that he failed to do so during the home visit. RN #4 stated he performed hand hygiene in his vehicle before he went into the patient’s home. During an interview on 10/10/2024 at 4:18 PM, the Alternate Administrator stated the agency expected staff to perform hand hygiene after they removed their gloves and place a barrier down prior to setting their bags down in a patient’s home.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on interview, document review, and agency policy review, the agency failed to safeguard personal health information (PHI) for 99 of 201 patients reviewed for protection of records. Specifically, the agency conducted interdisciplinary team (IDT) care coordination meetings with patient PHI through unsecured text messaging. An agency policy titled, “Individual Responsibilities for Safeguarding PHI Policy,” updated 11/01/2020, “5. Do not send PHI via text message.” Case conference notes revealed the case conferences were conducted via text messages on 09/09/2024, 09/16/2024, 09/23/2024, 09/30/2024, and 10/07/2024. The records revealed the conference notes began with a screenshot of patient names and were sorted by the clinician who provided the care. The records revealed, in addition to patient names, details of the patient’s health care were discussed including hospitalization, the need for an indwelling catheter, weekly changes, those patients who were discharged to other care settings, and those patients who needed wound care. During an interview on 10/07/2024 at 12:30 PM, Physical Therapist (PT) #13 stated weekly IDT care coordination meetings were conducted via text message every Monday. PT #13 stated during the care coordination meetings each patient was reviewed and all the disciplines could see the responses of the other disciplines. PT #13 stated those texts were not sent through a secure application or documented in the patients’ medical records, but instead were sent to the clinicians’ personal cell phones. During an interview on 10/07/2024 at 2:00 PM, Licensed Vocational Nurse (LVN) #2 stated weekly IDT meetings were conducted via text messaging to the staff members’ personal cell phones. LVN #2 stated the company did not utilize a secure messaging platform for the messages, and the company did not provide cell phone for staff to use for these communications. During an interview on 10/07/2024 at 3:15 PM, Registered Nurse (RN) #4 stated IDT meetings were done monthly via text to their personal phones. RN #4 stated there was no secure platform used by the company for these texts. During an interview on 10/08/2024 at 10:05 AM, LVN #14 stated case conferences were done via group text. During an interview on 10/09/2024 at 11:20 AM, the Quality Assurance Patient Coordinator (QAPC) confirmed that all case conferences were conducted via group text. The QAPC stated during these care team meetings, the care team discussed recertifications, discharges, and any needed changes to the patient’s plan of care. The QAPC stated that the text messages for care conferences were done via regular texting platforms, not a secure application. During an interview on 10/10/2024 at 4:27 PM, the Alternate Administrator (AA) stated case conferences were conducted via text messaging. The AA stated the case conferences included PHI, and the agency policy was to not send PHI via text messaging. The AA further confirmed that the text messages were not sent via a secure messaging platform, and the current case conference system of reviewing patient cases via text messaging was not an approved way to protect patient PHI.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Altomar New Mexico, Home Health Agency (HHA) facility on 09/17/2021 resulted in noncompliance under 42 CFR 484.102 with the following standard-level deficiency cited:

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 maintain and update the Emergency Preparedness manual (binder) with current annual Hazard Vulnerability Assessments, also known as a Hazard Vulnerability Analysis (HVA) (used to show hazards or risks that can impact a healthcare facility and the surrounding community), a current patient list, a current staff list, and a current emergency resource list. This deficient practice can delay the ability to offer continued patient care by not evaluating the damage and severity of impact a disaster could potentially cause, and knowing which patients are receiving care in, contact currently employed staff and other emergency resources an emergent (unpredictable or unforeseen) situation. The findings are: A. Record review of the Emergency/Disaster Manual, undated, revealed the following: 1. No current copy of a dated Hazard Vulnerability Assessment 2. No current copy of a dated Patient list 3. No current copy of a dated Staff list 4. No current copy of a dated in case of emergency resource list to include Fire Dept, Police Dept, or Emergency Medical Transport, etc. B. On 09/15/2021 at 3:15 pm during an interview, Staff (S)#1 (Administrator) confirmed there was not a current Hazard Vulnerability Analysis (HVA), a current patient list, a current staff list, and a current emergency resource list in the Emergency Preparedness manual.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Altomar New Mexico, Home Health Agency (HHA) facility on 09/17/2021 resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited: A COVID-19 Focused Infection Control Survey was conducted by the New Mexico Department of Health, Division of Health Improvement on 09/17/2021. The facility was found not to be in noncompliance with 42 CFR §484.70 Condition of participation: Infection prevention and control Regulations and Guidelines for Home Health Agencies and has not implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and interview the facility failed to advise patients of the State toll free Home Health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local Home Health Agencies for all patients treated. This failed practice can lead to patients not being informed of their options for reporting complaints. The findings are: A. Record review of facility admission packet information, undated, Section Titled, "Statement of Patient Rights and Responsibilities" reveals, "For any complaints with our service please call, Facility Name at (575)874-2211 . . . . .write or call Texas Department of Human Services, 701 West 51st Street, P.O. Box 149030, Austin TX 78714-9030, Hotline Number 1-800-458-9858." B. Record review of facility admission packet information, undated, Section Titled, "Admission Consent Form" reveals in the last paragraph, "I can also contact the NM Department of Human Services, Hotline Number 1-800-228-4802." This is the incorrect contact information for complaints. The facility has a poster in the front lobby that contains the correct contact information. C. On 09/15/21 at 11:55 am during interview with S3 (Assistant Director) who confirmed, "This facility has branches in New Mexico and Texas, we have been trying to get all the forms to reflect the appropriate states, it is a work in process and we will have the appropriate information reflected on the document as soon as possible"

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 record review and interview the facility failed to maintain a program that 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. This failed practice can cause the facility to continue problems in patient treatment that have not been identified, tracked or trended. The findings are: A. Record review of QAPI (Quality Assessment Performance Improvement) binder provided by the facility reveals no QAPI meeting minutes have been conducted and review of QAPI indicators are as follows: Last information gathered on identified indicators: For SOC (Start of Care) indicator - July 2020 For DC (Discharge) indicator - May 2020 For ROC (Resumption of Care) indicator - April 2020 For HHA CP/SUP Audits (Home Health Aide/Supervisory Audits) indicator - April 2019 For Infection Control indicator - no information For Criminal History Check indicator - no information For Medication Administration indicator - no information For Satisfaction Survey indicator - no information For Adverse Occurrence indicator - no information B. On 09/15/21 at 2:30 pm during interview with S1 (Administrator), who confirms, "we started to collect data and there is no reason why it has not been continued"

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 observations and interviews, the facility failed to adequately screen (the process of identifying individuals concerning infectious disease) for COVID-19 (coronavirus, respiratory viral infection) and maintain a sanitary environment (an environment that is clean, and conducive to infection prevention), as boxes of medical supplies were on the floor; and general cleaning supplies near medical supply boxes in the medical supply room. This failed practice is likely to poorly identify individuals with possible COVID-19 diseases and increase the risk of transmission, and also lead to contamination and potential infection control issues. The findings are: A. On 09/15/2021 at 10:00 am, upon arrival at the facility, observed no temperature or screening for COVID-19 symptoms (cough, fever, shortness of breath) check done on visiting DHI/POB Surveyors. B. On 09/15/2021 at 3:45 pm, during observation of the medical supply room, revealed the following: 1. Cardboard boxes with medical supplies stored on the floor (should keep cardboard boxes off the ground due to their potential to grow and perpetuate bacteria, mold, or insects.) 2. A plastic bucket filled with general cleaning supplies (cloth rags, a spray bottle of disinfectant to sterilize hard surfaces, and a glass cleaner) on a shelf next to medical supplies used in patient care. C. On 09/15/2021 at 11:15 am during an interview, Staff (S)#1 (Administrator) confirmed has not been screening for COVID-19 symptoms since July 2021 and understood the importance of continuing to screen for COVID-19. D. On 09/15/2021 at 3:50 pm during an interview, S#4 (Licensed Vocational Nurse) confirmed the boxes on the floor and the bucket filled with general cleaning supplies and understood the importance of those items not being where they were in the medical supply room.

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 observation and interview, the facility failed to ensure that items utilized for direct patient care are furnished appropriately by not using items past expiration dates and not identified as being under an extended use authorization by the United States Food and Drug Administration. Certain expired medications are at risk of bacterial growth and antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. This failed practice is likely to lead to poor treatment and delayed progression to goals and bacterial growth due to using expired medical supplies. The findings are: A. On 09/15/2021 at 3:30 pm, observation of the medical supply room revealed the following expired (exp) products used in direct patient care: 1. One (1) Hartmann (product name) Sorbalgon Ag Silver Calcium Alginate (composed of sodium and calcium fibers from seaweed) Dressing (alginate dressing mold themselves to the shape of the wound so that the wound drainage is appropriately absorbed.): exp 09-2020 2. Ten (10) McKesson (product name) Hypodermic Needle 20G (size) x 1 (inch) (a small syringe used with a hollow needle for injection of material into or beneath the skin.): exp (10) 06-2021 3. Six (6) Coloplast (product name) SpeediCath urinary catheter (a tube placed in the body to drain and collect urine (a watery, typically yellowish fluid) from the bladder (which urine is collected to pass from the body.): exp (2) 01-23-2020 and (4) 09-16-2019 4. Three (3) Braun (product name) Extension Set Luer Lock Connector and Spin-Lock Connector (designed to prevent moving of the IV (in the vein) catheter (tubing).): exp (2) 05-2020 and (1) 08-05-2020 5. Two (2) Braun (product name) Ultrasite Injection Site (designed to prevent blood setbacks when injecting (inserting) fluids and medications.): exp 01-2021 B. On 09/15/2021 at 3:45 pm during an interview, Staff (S)#4 (Licensed Vocational Nurse) acknowledged the expired products in the medical supply room. S#4 reported there is no set log to ensure that all product(s) are up to date. S#4 stated, "reviews medical supplies once a week to make sure nothing is expired."

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview the facility failed to maintain a Governing Body (or designated persons functioning as the governing body) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all Home Health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program for the Home Health Agency. This failed practice can cause a breakdown in patient care due to lack of communication between the Governing Body and the facility. The findings are: A. Record review of Governing Body Minutes last meeting 7/17/2020, (3 months late for 2020) and no meeting minutes for 2021, None of the meeting minutes contain no reference to QAPI or Complaints/Grievance/Incidents. Other meetings were held on 9/16/19, 3/28/19, 1/18/19. B. On 09/15/21 at 2:30 pm Interview with S1 (Administrator) who confirms, "we started to collect data for Governing Body and there is no reason why it has not been continued"