Every finding on record at Amercare Home Health Care Corporation

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 08/07/23 to 08/09/23 resulted in a finding of a standard level deficiency citation respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on policy review, "Emergency Preparedness Plan" document review, and interviews, the Home Health Agency (HHA) failed to develop a process for collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. This deficient practice has the potential to affect all 245 patients receiving services from the HHA. Review of the agency's "Emergency Preparedness Plan", developed on 08/20/22, located in the "Emergency Preparedness" binder, revealed no documentation indicating that a process was developed for collaboration with local, tribal, regional, State, and Federal emergency preparedness officials to maintain a coordinated response during an emergency or a disaster. During an interview on 08/08/23 at 3:00 PM, the Clinical Services Manager confirmed that there was no process developed for the HHA to collaborate with local, tribal, regional, State, and Federal officials. Review of the agency's undated policy number 5-037.1 titled "Emergency Management Plan" indicated " … 2. Staff will work with regional or county emergency management planning agencies, where available, in: A. Establishing priorities among the potential emergencies identified in the hazard vulnerability analysis B. Defining organization's role in relation to the community-wide emergency management program, use of volunteers, other emergency staff, including state or federally designated health care professionals to address the organization's surge needs 3. Specific procedures that describe mitigation, preparedness, response and recovery strategies, actions, and responsibilities will be developed for each priority emergency. 4. Based on the hazard vulnerability analysis and community planning activities, the organization's general emergency plan may be enhanced or revised according to identified potential emergencies and planning activities …"

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 conducted at the above-named Home Health Agency (HHA) from 08/07/23 to 08/09/23 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on medical record review, policy review, and interview, the Home Health Agency's (HHA's) staff failed 1.) notify the physician of the patient's increased pain level; 2.) obtain the patient's pain goal (the desired level of pain that will allow the patient to improve functionality and quality of life); and 3.) assess the patient's use of pain medications including the dosage and times taken for one (Patient (P) 1) of five medical records reviewed. This deficient practice has the potential to affect patient's experiencing pain receiving services from the HHA. Review of P1's "Visit Note Report"[s], located under the "Visit Note" section in the patient's Electronic Medical Record (EMR), from 02/13/23 to 08/07/23 indicated the following: a. During the RN's visit on 07/17/23, the RN documented that P1's pain level was a four on a pain scale of zero to 10. Zero indicates no pain, and 10 indicates the highest intensity of pain. The RN documented that "medications" relieve P1's pain; however, the RN failed to determine how often P1 was taking the pain medications, failed to obtain a pain goal, failed to provide additional education on pain relieving measures, and failed to notify the physician of the patient's pain. The "Patient's Goal" was documented as "pain control". b. During the RN's visit on 03/16/23, the RN documented that P1's pain level was a seven on a pain scale of zero to 10, and that "medications" relieve the patient's pain. The RN failed to determine how often P1 was taking the pain medications, failed to obtain a pain goal, failed to provide additional education on pain relieving measures, and failed to notify the physician of the patient's pain. The "Patient's Goal" was documented as "pain control". c. During the Physical Therapist's (PT's) visit on 02/28/23, the PT documented that P1's pain level was an eight on a pain scale of zero to 10. The PT failed to report the patient's pain level to the patient's RN or physician. The "Patient's Goal" was documented as "pain control". d. During the PT's visit on 02/21/23, the PT documented that P1's pain level was an eight on a pain scale of zero to 10. The PT failed to report the patient's pain level to the patient's RN or physician. The "Patient's Goal" was documented as "pain control". e. During the PT's visit performed on 02/14/23, the PT documented that P1's pain level was an eight on a pain scale of zero to 10. The PT documented in the "Narrative" section of the "Visit Note" that "[P1] reports eight out of 10 pain to left LE, radiating down into left foot. [P1] reports [he/she] has struggled with left leg pain before, though it has been worse the past two days". The PT failed to report the increased patient's pain level to the patient's RN or physician. The "Patient's Goal" was documented as "pain control". f. During the Occupational Therapist's (OT's) visit on 02/14/23, the OT documented that P1's pain level was a five on a pain scale of zero to 10. The OT failed to report the patient's pain level to the patient's RN or physician. The "Patient's Goal" was documented as "pain control". g. During the RN's visit on 02/13/23, the RN documented that P1's pain level was a six on a pain scale of zero to 10, and that "medications" relieve the patient's pain. The RN documented in the "Narrative" section of the "Visit Note" "PRN Tylenol continues to be given to patient." The RN failed to determine how often P1 was taking the pain medications, failed to obtain a pain goal, failed to provide additional education on pain relieving measures, and failed to notify the physician of the patient's pain. The "Patient's Goal" was documented as "pain control". During an interview on 08/09/23 at 10:25 AM, the Clinical Service Manager and Area Vice President confirmed that the agency needs to develop a procedure to obtain patient's pain goals and confirmed that the physician was not notified of P1's increased pain level. Review of the agency's undated policy number 3-023.1 titled "Pain Assessment" revealed " … When pain is identified, a more comprehensive pain assessment will be completed when warranted by the patient's condition. Pain assessments will be age-appropriate and will be documented to facilitate regular reassessment and follow up by clinicians. When the patient or the clinician identifies pain, the following in-depth pain assessment information should be obtained whenever possible: … G. Pain management history to include a medication history, presence of common barriers to reporting pain and using analgesics, past interventions and response, and manner of expressing pain … l. The patient's pain goal, including pain intensity and goals related to function, activities, and quality of life … Pain assessments will be documented in the clinical record, and information will be communicated to other caregivers …"

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on personnel file review, policy review, and interview, the Home Health Agency failed to ensure that for one of one Home Health Aide (HHA) (HHA1) personnel file reviewed that the competency evaluations were performed by the HHA's Registered Nurse (RN) prior to the aide providing patient care. This deficient practice has the potential to affect all 245 patients receiving aide services from the agency. Review of HHA1's personnel file revealed HHA1 confirmed the document titled "Competency Assessment Skills Checklist – Hospice Aide" dated 03/20/22 and signed by HHA1 and a RN not associated with this agency. There was no competency evaluation performed by HHA1 and a RN with oversight to Home Health Agency competency evaluation. During an interview on 08/09/23 at 10:30 AM, the Clinical Service Manager confirmed that the competency evaluation performed by HHA1 and signed off by a RN who was employed by the Hospice branch, and not this Home Health Agency's RN responsible for the oversight and competency evaluations of this Home Health Agency. Review of agency's undated policy number 3-007.1 titled "Orientation of Assigned Home Health Aide" indicated " … B. A home health aide assignment sheet is completed, reviewed with the home health aide, and signed by either the nurse or therapist and the home health aide. Return demonstration will be requested, as appropriate …"

Documentation of inservice training CFR(s): 484.80(d)(2) The HHA must maintain documentation that demonstrates the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on interview and personnel file and policy review, the Home Health Agency failed to ensure that one of one Home Health Aide (HHA) (HHA1) personnel file reviewed maintained documentation to demonstrate compliance with required annual in-service training. This deficient practice has the potential to affect all 245 patients receiving aide services from the agency. Review of HHA1's personnel file revealed the aide was not employed by this Home Health Agency but was employed by the Hospice branch and provided patient care as an aide between the Hospice and the Home Health Agency. There was no documentation of the required annual 12-hour in-service and training for this Home Health Agency. During an interview on 08/09/23 at 10:30 AM, the Clinical Service Manager confirmed that HHA1 was employed by the hospice branch but provided patient care as an aide at this Home Health Agency. The Clinical Service Manager confirmed this Home Health Agency did not maintain a file on HHA1. The Clinical Manager confirmed he/she was not able to provide documentation of HHA1's in-service training. The Clinical Service Manager confirmed the agency did not have a policy regarding HHA training and in-service. Review of the agency's undated policies titled "Orientation Assigned Home Health Aides" policy number 3-007.1, and "Home Health Aide Plan of Care" policy number 3-006.1, revealed the policies did not address the HHA's training and in-service requirements.