Every finding on record at Basin Home Health, Inc

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 09/11/23 to 09/13/23 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

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 09/11/23 to 09/13/23 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.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and review of agency policy, the agency failed to ensure the Registered Nurse (RN) completed the initial assessment of patient needs within 48 hours of the referral date for two of thirteen medical records reviewed (Patient (P)1, and P8). Failure to assess the immediate care and support needs of patients while they wait for a complete and comprehensive assessment of needed services could cause a lapse in health and safety needs for all 55 patients receiving services from this agency, with possible negative outcomes. 1.Review of P1's electronic medical record (EMR) "Visit Notes" section revealed the "SOC (Start of Care) OASIS (Outcome and Assessment Information Set/a standardized, systematic collection of assessment information)" visit was dated 06/26/21. Review of the entry, "Date of Referral," showed, "referral date: 06/23/21." Review of the entry, "Date of Physician-ordered start of care," showed, "No specific SOC date ordered by physician." During an interview with the Clinical Director (CD) on 09/11/23 at 12:50 PM, the above documentation was reviewed. The CD stated that because the physician did not order a specific SOC date, the agency was obligated to complete the SOC visit within 48 hours of the referral date. The CD was unable to locate any other documentation to show the rationale for the late SOC visit and agreed that the 48-hour obligation was not met in the case of P1's SOC. 2.Review of P8's EMR "Visit Notes" section revealed the "SOC OASIS" visit was dated 08/14/23. Review of the entry, "Date of Referral," showed, "referral date: 07/18/23,". Review of the entry, "Date of Physician-ordered start of care," showed, "No specific SOC date ordered by physician." During an interview with the CD on 09/13/23 at 9:00 AM, the above documentation was reviewed. The CD stated that because the physician did not order a specific SOC date, the agency was obligated to complete the SOC visit within 48 hours of the referral date. The CD stated his/her recollection was that P8 had requested the delay in SOC, but was unable to locate any notes, physician orders, or other documentation to show the rationale for the late SOC visit. The CD agreed that the 48-hour obligation was not met in the case of P8's SOC. The most current related agency policy was requested. Review of the agency policy titled, "Admission Criteria and Process," last revised 11/2022, revealed, "The initial visit must be performed either within 48 hours of the referral, within 48 hours of the patient's return home, or on the start of care date ordered by the physician (or other authorized licensed independent practitioner."

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, staff interview and review of agency policies and procedures, the agency failed to ensure the Skilled Nurse (SN) performed wound care with appropriate hand hygiene (washing hands with soap and water or alcohol-based hand rub/ABHR) after glove removal during one of two observations of wound care (Patient (P) 5). Failure to maintain infection prevention techniques during wound care could lead to infections for all patients receiving wound care from this agency. During a home visit to P5 on 09/11/23 from 2:35 PM to 3:55 PM, Registered Nurse (RN)1 used gloved hands to elevate the right foot of P5 and remove P5's sock in preparation for wound care. RN1 then removed the old dressing along with the attached old tubing from the wound vacuum device (in place to suction and remove drainage from the healing wound). RN1 disposed of the dressing and tubing, removed the soiled gloves and, without performing hand hygiene, donned (put on) new gloves. RN1 then handled and removed multiple clean items from P5's supply box in preparation for cleansing the wound and applying the new dressing. RN1, wearing the same gloves, then opened the new vacuum tubing kit and manipulated the sterile supplies in the kit. RN1 then removed the gloves and, after documenting wound measurements on his/her assigned tablet, performed hand hygiene, and donned new gloves. RN1 then cleansed the wound with spray solution and gauze pads, removed his/her left glove and, without performing hand hygiene, donned a new glove on the left hand and continued with the rest of the wound care procedures. During an interview with RN1 on 09/11/23 at 3:55 PM, the above observation was reviewed. RN1 correctly stated the agency policy to perform hand hygiene after removal of gloves and was unaware of his/her failure to perform hand hygiene between glove changes during the observation. During a joint interview with the Administrator, the Vice President of Operations (VP), and the Clinical Director (CD) on 09/11/23 at 4:05 PM, the above observation was reviewed. The Administrator, VP, and CD agreed agency expectation and policy was for staff to perform hand hygiene after glove removal in order to prevent transmission of pathogens. The most current related policy was requested. Review of the agency policy titled, "Hand Hygiene," last revised 11/2022, revealed, "Hand decontamination using an alcohol-based hand rub should be performed: G. After removing gloves."