Every finding on record at Del & Associates Nursing Service

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 08/23/23 to 08/24/23 resulted in a finding of standard level deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA's) "Emergency Plan," and interview, the HHA failed to include a risk assessment in its Emergency Plan. Failure to complete a risk assessment had the potential to impact the HHA's response during an actual emergency. Review of the agency's "Emergency Plan" dated January 2023 revealed it lacked a risk assessment. During an interview on 08/24/23 at 11:45 AM, the Administrator confirmed the "Emergency Plan" dated January 2023 did not include a risk assessment.

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 review of the Home Health Agency's (HHA's) "Emergency Plan," and staff interview, the HHA failed to develop a comprehensive emergency preparedness plan including policies and procedures to inform State and local emergency preparedness officials about patient's needing evacuation. This had the potential to delay moving patients out of harm's way during a community disaster. Review of the agency's "Emergency Plan" dated January 2023 revealed it failed to include a process to notify officials of homebound patients in the case for the need of evacuation. During an interview on 08/24/23 at 11:45 AM, the Administrator confirmed the "Emergency Plan" dated January 2023 did not include a process to notify officials in case of the need for an evacuation for homebound patients.

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 08/23/23 to 08/24/23 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.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review, interview, and agency policy review, the agency failed to document medication instructions for seven of seven patients (Patient (P)1, P2, P3, P4, P5, P6, and P7) on the medication profile in plain language that could be understood by the patient and caregiver. Failure to complete the patient medication profile in plan language that does not include medical terminology could result in the patient or caregiver making medication errors. Review of P1, P2, P3, P4, P5, P6, and P7's "Medication Profile" located in the medication tab in the medical record binder revealed the Registered Nurse (RN) who completed the admission for home health services documented the patients medications using medical terms including PO (by mouth), BID (twice a day), QD (daily), QHS (at bedtime), QAM (in the morning), TID (three times a day, and Q8h PRN (every eight hours as needed). During an interview on 08/24/23 at 11:45 AM, the Administrator stated that the "Medication Profile" included an attached carbon that is left in the patients home by the RN who completed the admission. The Administrator stated the "Medication Profile" is left in the home for the patient and caregivers use and for the RN to use for medication teaching. The Administrator confirmed that the "Medication Profile" was not written in terms the patient and/or caregiver could easily understand. Review of the undated agency policy titled, "Medication Administration" revealed, "A medication profile will be completed for each patient at the time of admission … The profile may also serve as a tool for the purpose of patient/caregiver education." The agency policy failed to address the documentation of medications in a manner easily understood by the patient and/or caregiver.