Every finding on record at El Mirador Home Health Agency

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site complaint survey conducted at El Mirador Home Health Agency (HHA) on November 9, 2022, resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited: A deficiency was related to intake ID NM62484. The complaint ID NM62484 was substantiated.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on interview and record review the facility failed to provide written rights and responsibilities in a language that patients could understand for 4 (P(patient)1, P3, P4, P5) out of 7 patients reviewed. This deficient practice is likely to lead to patients not being able to understand what information is being given to them regarding their care. The findings are: A. Record review of facility’s form titled “Patient’s Bill of Rights/Responsibilities and Transfer/Discharge Criteria” revised March 2020 on page 2, the last bullet reads, “[Patients have the right] To be informed of the patient’s rights in a language and manner the individual understands. The Agency must protect and promote the exercise of these rights. The Agency will provide verbal notice of the patient’s rights and responsibilities in the individual’s primary or preferred language and in a manner the individual understands, free of charge, with the use of a competent interpreter, if necessary, no later than the completion of the second visit from a skilled professional.” Continuing onto page 3, the next bullet point reads, “[Patients have the right to] The following information during the initial evaluation visit, in advance of furnishing care to the patient: - Written notice of the patent’s rights and responsibilities and Agency’s transfer and discharge policies. Written notice will be understandable to persons who have limited English proficiency and accessible to individuals with disabilities.” B. Record review of “Patient Profile” found in P1’s Electronic Medical Record (EMR) indicated the patient’s primary language is Russian. Review of P1’s “Oasis Start of Care” found under “Visit Narrative” it is noted by staff that patient speaks Romanian exclusively. C. Record review of document titled “Your Rights & [and] Responsibilities as a Home Health Care Patient” found in P1’s EMR dated 02/07/2022 shows an English form signed on the line that states “Client Signature.” D. Record review of “Patient Profile” found in P3’s EMR indicated Spanish is patient’s primary language. E. Record Review of document titled “Oasis Start of Care” found in P3’s EMR dated 10/25/2022 in the section titled “Visit Interventions” under “Legal” it states “Patient Received Written Patient Rights and Responsibilities: Patient selected representative received written patient rights and responsibilities in the primary or preferred language of the patient or representative, and in a manner that the individual can understand, during the initial evaluation visit, and in advance of care being furnished by the HHA. This included policies on discharge, transfer, abuse and exploitation, emergency preparedness, OASIS and HIPAA Privacy Statements. Signature(s) received for written notices per requirements.” F. Record review of document titled “Your Rights & Responsibilities as a Home Health Care Patient” for P3 dated 10/25/2022 an English form signed on the line that states “Client Signature”. G. Record review of form titled “Patient’s Responsibilities” for P3 the line for “Representative Signature/Date” is blank. H. Record review of “Patient Profile” found in P4’s EMR indicated Spanish is patient’s primary language. I. Record review of document titled “Your Rights & Responsibilities as a Home Health Care Patient” for P4 dated 11/07/2022 shows an English form signed on the line for “Client Signature”. J. Record review of document titled “Oasis Start of Care” for P5 dated 10/22/2022 on page 16 under the section titled “Visit Narrative” it states, “Daughter and husband present for interpretation dt [due to] patient primary language Spanish.” K. Record Review of document titled “Oasis Start of Care” for P5 dated 10/22/2022 on page 15 under “Visit Interventions” under “Legal:” it states “Patient Received Written Patient Rights and Responsibilities: Patient, patient-selected representative, legal representative received written patient rights and responsibilities in the primary or preferred language of the patient or representative, and in a manner that the individual can understand, during the initial evaluation visit, and in advance of care being furnished by the HHA. This included policies on discharge, transfer, abuse and exploitation, emergency preparedness, OASIS and HIPAA Privacy Statements. Signature(s) received for written notices per requirements.” L. Record review of undated document titled “Your Rights & Responsibilities as a Home Health Care Patient” for P5 shows an English form signed on the line for “Client Signature”. M. Record review of undated document for P5 titled “Patient’s Responsibilities” the line for “Representative Signature/Date” is blank. N. Interview with staff (S)3 (Director of Nursing) on 11/09/2022 at 1:00 PM confirmed that the Rights and Responsibilities presented to the patients is only available in English.

Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to- (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations.Standard: Accessibility Information must be provided to patients in plain language and in a manner that is accessible and timely to- This STANDARD is not met as evidenced by: Based on interview and record review the facility failed to provide a competent interpreter for patients that had limited English proficiency for 4 (P(patient)1, P3, P4, P5) out of 4 patients reviewed. This deficiency is likely to lead to poor outcomes for all patients that receive care and cannot properly communicate any needs or concerns. The findings are: A. Refer to Tag G412 for additional supporting evidence. B. Record review of “Patient Profile” found in P1’s Electronic Medical Record (EMR) indicated the patient’s primary language is Russian. Review of P1’s “Oasis Start of Care” found under “Visit Narrative” it is noted by staff that patient speaks Romanian exclusively. C. Record review of P1’s signed “Patient Agreement Form”, “Consent for Medical Photography”, and “Consent to Treat” dated 02/07/22 found in EMR (Electronic Medical Record) shows that all forms are in English and signed on the line for client signature. Review of these documents revealed no evidence of the use of an interpreter or patient representative. D. Record review of a “Visit Narrative” found in the “Oasis Start of Care” for P1 dated 02/07/2022 it is charted that “RN (Registered Nurse) called daughter at end of visit to explain consent forms, daughter states she will go over them with pt, pt signed consents using phone app to translate as best as possible.” E. Record review of “Patient Profile” found in P3’s EMR indicated Spanish is patient’s primary language. F. Record review of P3’s signed “Financial Policy”, “Patient Agreement Form”, and “Consent to Treat” dated 10/25/22 shows that all forms are in English and signed on the line for client signature. Review of these documents revealed no evidence of the use of an interpreter or patient representative. G. Record review of P3’s signed “Consent for Medical Photography” dated 10/25/22 shows the form is in English and is signed in space indicating “Signature of patient”, “son” is written on the line for “Guardian/relative” and under “Reason patient why is not signing consent?” it is written “no ability to use hands”. H. Record review of “Patient Profile” found in P4’s EMR indicated Spanish is patient’s primary language. I. Record review of P4’s signed “Financial Policy”, “Patient Agreement Form”, “Consent for Medical Photography” and “Consent to Treat” dated 11/07/22 shows that all forms are in English and signed on the line for client signature. The consent for medical photography also has illegible writing on the line for “Guardian/relative”, the line for “reason patient why is not signing consent” is blank. Review of these documents revealed no evidence of the use of an interpreter or patient representative. J. Record review of document titled “Oasis Start of Care” for P5 dated 10/22/2022 on page 16 under the section titled “Visit Narrative” it states, “Daughter and husband present for interpretation dt [due to] patient primary language Spanish.” K. Record review of P5’s signed “Financial Policy”, “Patient Agreement Form”, “Consent for Medical Photography”, and “Consent to Treat” shows that all forms are in English and signed on the line for client signature. Review of these documents revealed no evidence of the use of an interpreter or patient representative. L. Interview with S(staff)3 (Director of Nursing) on 11/09/2022 at 11:00 AM it was asked where staff chart that they used an interpreter for patients with limited English proficiency. It was stated that staff should use the narrative to document use of an interpreter. M. Interview with S1 (Compliance Manager), S2 (Director of Operations) and S3 (Director of Nursing) on 11/09/2022 at 12:35 PM, it was asked if they require staff that translate for patients to be certified in medical translation? S3 (Director of Nursing) stated they do not require that right now, but they would like to see that happen. S1 (Compliance Manager) indicated that this was the reason they are looking into utilizing a different language service. N. Interview with S1 (Compliance Manager), S2 (Director of Operations) and S3 (Director of Nursing) on 11/09/2022 at 12:35 PM it was asked what the facility’s process is to ensure patients receive information in a language they understand. They stated that they utilize their Spanish speaking staff and if they need to for a basic assessment, they use a translation app like Google translate. O. Interview with S7 (Registered Nurse) on 11/09/2022 at 3:35 PM it was asked if a patient doesn’t speak English and they need to sign consent forms would you use Google translate? They stated, “No, that’s too complicated, I wouldn’t feel comfortable having them sign for that. We use Google translate for informal conversations.”