Every finding on record at Compassus Home Health Albuquerque Nm

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Compassus Home Health, Home Health Agency (HHA) on 08/20/2021 resulted in noncompliance under 42 CFR 484.102 with the following standard-level deficiency cited:

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 record review and interview, the facility failed to ensure the facility's Emergency Preparedness Plan (procedures utilized on what to do in the event of an emergency) for 6 (S (Staff) 3, S4, S5, S6, S7, S8) out of 10 (S2-S11) employee files reviewed. This included annual staff training and testing (conducting drills and/or exercises to test the emergency plan to identify gaps and areas for improvement) on the facility's Emergency Preparedness Plan. This failed practice is likely to have staff not being prepared during an emergency. The findings are: A. Record Review of the employees personnel files revealed that the files did not include annual staff training and testing on the facility's Emergency Preparedness Plan on 6 (S3, S4, S5, S6, S7, S8) out of 10 (S2-S11) employees sampled. 1. Record review of S3 (Registered Nurse) personnel file revealed, hired on 08/31/2015, no annual staff training and testing on the facility's Emergency Preparedness Plan since 2018. 2. Record review of S4 (Occupational Therapist) personnel file revealed, hired on 03/20/2020, no annual staff training and testing on the facility's Emergency Preparedness Plan upon hire. 3. Record review of S5 (Physical Therapy Assistant) personnel file revealed, hired on 02/25/2015, no annual staff training and testing on the facility's Emergency Preparedness Plan since 2017. 4. Record review of S6 (Occupational Therapy Assistant) personnel file revealed, hired on 08/20/2018, no annual staff training and testing on the facility's Emergency Preparedness Plan since hire. 5. Record review of S7 (Registered Nurse) personnel file revealed, hired on 11/12/2018, no annual staff training and testing on the facility's Emergency Preparedness Plan since hire. 6. Record review of S8 (Physical Therapist) personnel file revealed, hired on 06/15/2020, no annual staff training and testing on the facility's Emergency Preparedness Plan since hire. B. On 08/19/2021 at 1:30 pm, during interview with S1 (Executive Director) confirmed the absence of annual training of Emergency Preparedness Plan and drills and/or exercises to test the emergency plan to identify gaps and areas for improvement.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Compassus Home Health, Home Health Agency (HHA) on 08/20/2021 found that your facility was in substantial compliance with the participation requirements under 42 CFR 484, Subpart A through C.