Every finding on record at Ambercare Home Health

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Ambercare Las Cruces Home Health Agency (HHA) on 06/22/2021 resulted in noncompliance under 42 CFR 484.102 with the following standard-level deficiencies 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 with complete annual Hazard Vulnerability Assessments also known as a Hazard Vulnerability Analysis (HVA) (Systematic approaches to identifying hazards or risks that are most likely to have an impact on a healthcare facility and the surrounding community), and maintain a hard-copy (a printed version on paper of data held in a computer) of a current patient list including contact information and categories identified for each patient. This deficient practice can delay the ability to provide continued patient care by not evaluating the damage that could be caused by a potential disaster, the severity of the impact, and the availability of medical resources during a disaster. The findings are: A. Record review of the Emergency Preparedness manual revealed of copy of the Hazard Vulnerability Assessment for the Las Cruces location was last completed on 5/01/2017. No other Hazard Vulnerability Assessments provided. B. Record review of [name of facility] Risk Management: Infection and Safety Control, Emergency Management Plan, Policy No. 5-037.2, revised June 2021, revealed: 1. Under Procedure, Planning Process - Before an Emergency section, "Organization leadership will conduct a Hazard Vulnerability Analysis (HVA) to identify potential emergencies (risks) that could impact the need for services or the ability to provide care to patients. Item #1. The HVA is evaluated annually to reflect changes in organization, risk conditions, patient information and changes in staff." 2. Record review of [name of facility] Risk Management: Infection and Safety Control, Emergency Management Plan, Policy No. 5-037.3, revised June 2021, revealed: 1. Under Procedure, Planning Process - Before an Emergency section, Item #12. "The agency maintains a hard-copy of a current patient list including contact information and categories identified for each patient in the event there is a power failure." C. On 06/22/2021 at 3:00 pm during an interview, Staff (S)#1 (Administrator) confirmed the Hazard Vulnerability Assessments had not been completed since 05/01/2017 and there was not a hard-copy of a current patient list including contact information and categories identified for each patient in the Emergency Preparedness manual.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Ambercare Las Cruces Home Health Agency (HHA) on 06/22/2021 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 06/22/2021 resulted in noncompliance under 42 CFR 484.70 with standard-level deficiencies cited.

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that a system was in place to receive, record, investigate, and resolve patient grievances and complaints. This deficient practice prevents the facility the ability to effectively track and investigate complaints and grievances from patients and their family, this leaves no assurance that grievances and complaints are getting resolved and that patients are are free from mistreatment and getting the required care and treatment. The findings are: A. Record review of a binder (a cover for holding loose sheets of paper), called QAPI (Quality Assurance and Performance Improvement) revealed the following: 1. Copies of the Home Health QAPI Meeting Agenda for 06/01/2020 through 02/08/2021 no other Home Health QAPI Meeting Agendas were provided for 02/09/2021 through 06/21/2021. B. On 06/21/2021 at 2:20 pm during an interview, Staff (S) #1 (Area Vice President) confirmed the missing Home Health QAPI Meeting Agendas in the binder from 02/09/2021 to present date. C. Record review of Home Health QAPI Meeting Agenda, complaints section, Reviewed complaints for South region for skilled care (Home Health.), dated 10/05/2020, revealed the following: 1. On 10/01/2020 "Patient (P) #20: Complaint received by Staff (S) #20 (Physical Therapist) and S #21 (Director of Nursing.) Patient's wife expressed wanting to submit a grievance in writing. Resolution still pending." 2. Section: Addendums (an addition to), "P #20. Resolution still pending as of 10/08/2020." D. Record review of Home Health QAPI Meeting Agenda, complaints section, reviewed complaints for South Region for skilled care (Home Health.), dated 01/25/2021, revealed the following: 1. On 01/22/2021 South office: "P #21, Complaint received by S #22 (Executive Director) from S #23 (SOC (start of care) Nurse.) Resolution pending." 2. On 01/22/2021 Main office: "P #22. Complaint received by S #21 (Director of Nursing) from patient. PT (patient) admit with dx (diagnosis) COVID-19 upset PT (physical therapist) showed 2 weeks ago and she hasn't heard anything since. Resolution pending." E. On 06/21/2021 at 2:35 pm during an interview, S #4 (State Executive Director) confirmed after further research the complaints listed on the Home Health QAPI Meeting Agenda dated 10/05/2020 and 01/25/2021, were resolved but were not updated on the agenda.

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 maintain a sanitary environment (environment that is hygienic, clean, and conducive to infection prevention) as boxes of personal protective equipment (PPE) were on the floor of the training room. This deficient practice is likely to lead to contamination and potential infection control issues. A. On 06/21/2021 at 3:45 pm, during observation of supply room inspection revealed the following: Cardboard boxes with PPE stored on the floor in training room. Cardboard boxes must be stored off the ground due to their potential to grow and perpetuate bacteria, mold, or insects. B. On 06/21/2021 at 3:47 pm, during an interview with S1 (Office Manager), revealed that when asked about the boxes on the floor, S1 acknowledged the boxes on the floor and stated, "We will take care of this."