Every finding on record at Angels Above Home Care

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 11/29/22 to 12/01/22 resulted in the following findings respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on review of the Home Health Agency’s (HHA) Emergency Plan and interviews, the HHA failed to develop a comprehensive Emergency Preparedness Plan in compliance with the Conditions of Participation (CoPs) for Emergency Preparedness (EP). The HHA failed to establish policies and procedures based on a facility and community Risk Assessment to develop a communication plan, establish 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, address subsistence needs for staff and patients during an emergency or disaster, address a means to shelter in place in the facility, establish policies and procedures to address preserving patient information, protecting confidentiality of patient information, and securing and maintaining availability of patient records in the event of an emergency, address the use of volunteers in an emergency, develop a communication plan that has a primary and alternate means for communicating with staff and emergency management agencies, develop a method for sharing information and medical documentation for patients under the facility's care. These failures had the potential to affect all staff and patients receiving care from the HHA. The facility failed to Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. Refer to tag E0009 The facility's failed to develop and implement emergency preparedness policies and procedures, based on a communication plan at E0013. The facility's failed to develop Individual plans for each patient as part of the comprehensive patient assessment. Refer to tag E0017. The facility's failed to develop procedures to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences at any time due to an emergency based on the patient’s medical and psychiatric condition and home environment. Refer to tag E0019. The facility's staff failed to develop procedures to follow up with on-duty staff and patients to determine services that are needed if there is an interruption in services during or due to an emergency. Refer to tag E0021. The facility's staff failed to establish policies and procedures to address a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. Refer to tag E0023. The facility's staff failed to establish policies and procedures for emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. Refer to tag E0024. The facility's staff failed to develop and maintain a written emergency communication plan. Refer to tag E0029. The facility's staff failed to develop a communication plan that includes names and contact information for staff, entities providing services under arrangement, Patients’, physicians, and volunteers. Refer to tag E0030. The facility's staff failed to develop a communication plan that includes contact information for Federal, State, tribal, regional, and local emergency preparedness staff, and other sources of assistance. Refer to tag E0031. The facility's staff failed to develop a communication plan that includes a primary and alternate means for communicating. Refer to tag E0032. The facility's staff failed to develop and maintain an emergency preparedness training and testing program. Refer to tag E0036. The facility's staff failed to develop policies and procedures for Initial training in emergency preparedness for all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. Refer to tag E0037.

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), §485.625(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 document review and interview, the agency failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. This deficient practice had the potential to negatively affect all home health agency staff and patients. A review of the HHA’s Emergency Preparedness Plan showed the agency failed to develop a policy that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency. In an interview on 11/30/22 at 3:45 PM, the Administrator confirmed the lack of a policy describing a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. The Administrator stated, “We recently discovered that this was a problem through another survey. We really didn’t understand what all we were responsible for to include in the EP Plan.”

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to develop and implement emergency preparedness policies and procedures, based on the emergency plans risk assessment, and the communication plan. This deficient practice had the potential to negatively affect all current home health agency (HHA) patients and staff. A review of the agency's Emergency Preparedness Plan showed the staff failed to develop and implement policies based on the emergency plans risk assessment, and the communication plan. In an interview on 11/30/22 at 3:45 PM, the Administrator confirmed the lack of policies based on the emergency plans risk assessment, and a communication plan. The Administrator stated, “We recently discovered that this was a problem through another survey. We really didn’t understand what all we were responsible for to include in our EP Plan.”

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on document review, medical record review, and interview, the agency failed to develop and implement policies and procedures for individualized emergency preparedness plans as a part of the patient's comprehensive assessment for seven of seven patients (Patient (P)1, P2, P3, P4, P5, P6, and P7). This deficient practice had the potential to negatively affect all home health agency (HHA) patients. A review of the HHA’s Emergency Preparedness Plan showed the agency failed to establish policies and procedures to ensure all patients had an individualized plan in the event of an emergency, and that individual plan was included as part of the patient’s comprehensive assessment. A review of seven patient medical records Patient (P) 1, P2, P3, P4, P5, P6, and P7 failed to include an individual emergency plan as part of the patient’s comprehensive assessment. A review of P1’s "OASIS [Outcome and Assessment Information Set] Assessment Details]" located in the "Comprehensive Assessment" tab in the medical record revealed there was no evidence of an individual emergency plan for P1. A review of P2’s "OASIS [Outcome and Assessment Information Set] Assessment Details]" located in the "Comprehensive Assessment" tab in the medical record revealed there was no evidence of an individual emergency plan for P2. A review of P3’s "OASIS [Outcome and Assessment Information Set] Assessment Details]" located in the "Comprehensive Assessment" tab in the medical record revealed there was no evidence of an individual emergency plan for P3. A review of P4’s "OASIS [Outcome and Assessment Information Set] Assessment Details]" located in the "Comprehensive Assessment" tab in the medical record revealed there was no evidence of an individual emergency plan for P4. A review of P5’s "OASIS [Outcome and Assessment Information Set] Assessment Details]" located in the "Comprehensive Assessment" tab in the medical record revealed there was no evidence of an individual emergency plan for P5. A review of P6’s "OASIS [Outcome and Assessment Information Set] Assessment Details]" located in the "Comprehensive Assessment" tab in the medical record revealed there was no evidence of an individual emergency plan for P6. A review of P7’s "OASIS [Outcome and Assessment Information Set] Assessment Details]" located in the "Comprehensive Assessment" tab in the medical record revealed there was no evidence of an individual emergency plan for P7. In an interview on 12/01/22 at 4:00 PM, Registered Nurse (RN) 2 confirmed the lack of individual emergency preparedness plans in P1 through P7’s comprehensive assessments. RN 2 explained they were unclear on the requirement for individual EP plans. In an interview on 12/01/22 at 4:00 PM, RN 1 stated he/she is in the process of contacting each HHA patient to develop individual EP plans, educating the patients and incorporating their plans into the patient’s individual comprehensive assessments.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to develop and implement policies and procedures to inform State and local emergency preparedness officials about home health agency (HHA) patients in need of evacuation from their residences during an emergency. This deficient practice had the potential to negatively affect all HHA staff and patients. A review of the HHA’s Emergency Preparedness Plan, showed the staff failed to develop and implement policies and procedures to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences during an emergency, based on the patient’s medical and psychiatric condition and home environment. There was no process to inform emergency personnel if the patient is mobile, what type of life-saving equipment the patient may require, if their life-saving equipment is able to be transported, is it battery operated, transportable, the condition of equipment, etc. The was no procedure defined to inform emergency responders if the patients have special needs, such as, communication challenges, language barriers, intellectual disabilities, special dietary needs, etc. In an interview on 11/30/22 at 3:45 PM, the Administrator confirmed the lack of a policies and procedures to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences during an emergency, based on the patient’s medical and psychiatric condition and home environment. The Administrator stated, “We recently discovered that this was a problem through another survey. We really didn’t understand what all we were responsible for to include in our EP Plan.”

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to develop and implement policies and procedures to follow up with on-duty staff and patients to determine services that are needed when there is an interruption in services due to an emergency, and additionally, inform State and local officials of any on-duty staff or patients the agency is unable to contact. This deficient practice had the potential to negatively affect all home health agency (HHA) staff and patients. A review of the HHA’s Emergency Preparedness Plan showed the staff failed to develop and implement policies and procedures to clearly outline what surrounding facilities, such as a hospital or a nursing home, they have a transfer arrangement with. Additionally, there was no process to outline timelines for transferring patients, under what conditions patients would need to move, a priority for when the moves need to occur, and for how long. Also, the HHAs’ policies and procedures did not address what actions would be required due to the inability to contact staff or patients and report capabilities to the local and State emergency officials. In an interview on 11/30/22 at 3:45 PM, the Administrator confirmed the lack of a policies and procedures to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences during an emergency, based on the patient’s medical and psychiatric condition and home environment. The Administrator stated, “We recently discovered that this was a problem through another survey. We really didn’t understand what all we were responsible for to include in our EP Plan.”

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to develop and implement policies and procedures describing a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. This deficient practice had the potential to negatively affect all home health agencies (HHA) patients. A review of the HHA’s Emergency Preparedness Plan, showed the agency failed to develop and implement policies and procedures to preserve patient information, protect confidentiality of patient information, and secure and maintain availability of patient records during an emergency when routine procedures are not available. In an interview on 11/30/22 at 3:45 PM, the Administrator confirmed the lack of policies and procedures to preserve patient information, protect confidentiality, and secure and maintain availability of patient records during an emergency. The Administrator stated, “We recently discovered that this was a problem through another survey. We really didn’t understand what all we were responsible for to include in our EP Plan.”

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to develop and implement policies and procedures for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This deficient practice had the potential to negatively affect all the home health agency (HHA) patients. A review of the HHA’s Emergency Preparedness Plan showed the agency failed to develop and implement policies and procedures to use volunteers in an emergency or develop other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. In an interview on 11/30/22 at 3:45 PM, the Administrator confirmed the lack of a policies and procedures for using volunteers during an emergency or a process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. The Administrator stated, “We recently discovered that this was a problem through another survey. We really didn’t understand what all we were responsible for to include in our EP Plan.”

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to develop a written emergency communication plan that contains how the facility coordinates patient care within the facility, across healthcare providers, and with state and local public health departments. This deficient practice had the potential to negatively affect all of the home health agency (HHA) patients and staff. A review of the HHA’s Emergency Preparedness Plan showed the staff failed to develop a written emergency communication plan that included how the facility coordinates patient care within the facility, across healthcare providers, and with state and local public health departments. Additionally, there was no written process for how the facility would interact and coordinate with emergency management agencies and systems to protect patient health and safety or support the coordination of care in the event of a disaster. In an interview on 11/30/22 at 3:45 PM, the Administrator confirmed the lack of a written emergency communication plan. The Administrator stated, “We recently discovered that this was a problem through another survey. We really didn’t understand what all we were responsible for to include in our EP Plan.”

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to develop a written emergency communication plan that included names and contact information required in the event of an emergency. This deficient practice had the potential to negatively affect all of the current home health agency (HHA) patients and staff. A review of the HHA’s Emergency Preparedness Plan showed the agency failed to develop a written emergency communication plan that included names and contact information for staff, entities providing services under arrangement, patients, physicians, and volunteers. In an interview on 11/30/22 at 3:45 PM, the Administrator confirmed the lack of a written emergency communication plan that contained names and contact information for staff, entities providing services under arrangement, patients, physicians, and volunteers. The Administrator stated, “We recently discovered that this was a problem through another survey. We really didn’t understand what all we were responsible for to include in our EP Plan.”

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to develop a written emergency communication plan that included all required sources of assistance. This deficient practice had the potential to negatively affect all home health agency (HHA) patients and staff. A review of the HHA’s Emergency Preparedness Plan showed the staff failed to develop a written emergency communication plan that included contact information for Federal, State, tribal, regional, and local emergency preparedness staff, and other sources of assistance. In an interview on 11/30/22 at 3:45 PM, the Administrator confirmed the lack of a written emergency communication plan that included contact information for Federal, State, tribal, regional, and local emergency preparedness staff, and other sources of assistance. The Administrator stated, “We recently discovered that this was a problem through another survey. We really didn’t understand what all we were responsible for to include in our EP Plan.”

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to develop a written emergency communication plan that included a primary and alternate means of communication. This deficient practice had the potential to negatively affect all home health agency (HHA) patients and staff. A review of the HHA’s Emergency Preparedness Plan showed the agency failed to develop a written emergency communication plan that included a primary and alternate means of communication for facility staff, Federal, State, tribal, regional, and local emergency management agencies. In an interview on 11/30/22 at 3:45 PM, the Administrator confirmed the lack of a written emergency communication plan that includes a primary and alternate means of communication. The Administrator stated, “We recently discovered that this was a problem through another survey. We really didn’t understand what all we were responsible for to include in our EP Plan.”

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to develop and maintain an emergency preparedness training and testing program that was based on the emergency plan. This deficient practice had the potential to negatively affect all home health agency (HHA) patients and staff. A review of the HHA’s Emergency Preparedness Plan showed the staff failed to develop a training and testing program to test their emergency plan, and review and update their emergency plan at least annually. In an interview on 11/30/22 at 3:45 PM, the Administrator confirmed the lack of a training and testing program that tests their emergency plan that is reviewed and updated at least annually. The Administrator stated, “We recently discovered that this was a problem through another survey. We really didn’t understand what all we were responsible for to include in our EP Plan.”

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to develop and maintain an emergency preparedness training and testing program for all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. This had the potential to impact the agency's ability to respond in an emergency and could affect all the home health agency (HHA) patients and staff. A review of the HHA’s Emergency Preparedness Plan showed the agency failed to develop an emergency preparedness training and testing program that included an initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. The HHA did not have documentation of training provided at least annually. In an interview on 11/30/22 at 3:45 PM, the Administrator confirmed the lack of documentation supporting an initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, or that it is reviewed and updated at least annually. The Administrator stated, “We recently discovered that this was a problem through another survey. We really didn’t understand what all we were responsible for to include in our EP Plan.”

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) facility from 11/29/22 to 12/01/22 resulted in a finding of substantial compliance respective to the applicable CoP under 42 CFR 484 Subparts A through C with the following standard-level deficiencies listed below.

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 develop a procedure to identify infections, communicable diseases, or risks of infections and diseases among patients, as part of a coordinated agency-wide program for surveillance, identification, prevention, control, and investigation, specific to care and services provided in the home setting. This failure had the potential to affect the current 40 patients and any future patients receiving home health services from the agency at risk for infections and/or infectious diseases. A review of the agencies undated Infection Control manual revealed the home health agency (HHA) failed to develop a process to observe or evaluate their services to identify sources or causative factors of infection, track patterns and trends of infections, establish corrective plans for infection control, and monitor the effectiveness of the corrective plans implemented. A review of the agency policies revealed the HHA failed to develop a policy and procedure to identify infections, communicable diseases, or risks of infections and diseases among patients, as part of a coordinated agency-wide program for surveillance, identification, prevention, control, and investigation, specific to care and services provided in the home setting. In an interview on 12/01/22 at 2:00 PM, the Administrator confirmed that the HHA has no process for identifying or tracking infections or infectious diseases for patients. The Administrator stated he/she was not aware that they needed to have a process to identify infections or infectious diseases in their patients. In an interview on 12/01/22 at 2:00 PM, RN2 confirmed that they do not have any quality measures related to patient infections or infectious diseases. RN2 stated he/she was not aware this was required.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on document review and interview, the agency's Governing Board and the Administrator failed to establish and approve in advance a pre-designated person in writing, who is qualified and would be responsible for fulfilling the role of the administrator in his/her absence. This failure had the potential to leave the agency employees, 40 patients, and any future patients with unqualified leadership and mismanaged care. A document review for information about the Governing Board showed an organizational chart, and a statement, no title, and no date, describing the HHA, the Governing Body, and the Scope of services. The statement failed to identify a pre-designated person who is qualified and would be responsible for fulfilling the role of the administrator in the administrator's absence. In an interview on 11/29/22 at 12:35 PM, the Administrator confirmed that they do not have documentation outlining the designation of a substitute Administrator in his/her absence. He/she stated, “Because we are so small, we really didn’t think that we needed this.” The Administrator explained that the Chief Executive Officer (CEO) or Registered Nurse (RN)2 would probably assume those responsibilities but confirmed that there is no person pre-designated in writing who is qualified and would be responsible for fulfilling the administrator’s role in his/her absence.