Every finding on record at Esperanza Home Health Care/Hospice

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Esperanza Home Healthcare Home Health Agency (HHA) on 07/29/21 resulted in noncompliance under 42 CFR 484.102 with the following standard-level deficiencies cited:

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop 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: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the facility failed to establish a comprehensive emergency preparedness program. This failed practice is likely to lead to confusion and poor coordination of the facility's resources in the event of an emergency. The findings are: A. Record review of facility's emergency preparedness documents, undated, revealed: 1. No policies or procedures regarding facility specific emergency preparedness. 2. The given documents were templates from the Home Care Association of New York and the emergency order from the New Mexico Department of Health. B. On 07/30/2021 at 10:30 am, interview with S (staff) 2 (Administrator) confirmed that the facility does not have an updated or established emergency preparedness plan. S2 was unable to produce an outdated emergency preparedness plan in order to determine when they last had one. S2 reported that the emergency preparedness documents provided were going to be used as a guide so they facility can create their own.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Esperanza Home Healthcare Home Health Agency (HHA) on 07/29/21 resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited:

Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This ELEMENT is not met as evidenced by: Based on observation and interview the facility failed to ensure that items utilized for direct patient care are furnished appropriately by using items passed expiration dates and not identified as being under an extended use authorization by the United Stated Food and Drug Administration. This failed practice is likely to lead to insufficient treatment and delayed progression to goals. The findings are: A. On 07/29/2021 at 3:00 pm, observation of the following expired (exp) patient care items: 1. Triple Antibiotic (medication) 40 packets, exp 07/2021. 2. Cavilon No Sting Barrier Film (skin protectant), 50 packets, exp 02/2018. 3. Curity Plain Packing Strip (mesh gauze for wound packing), 6 bottles, exp 07/2018. 4. Ag Packing Strips (packing gauze with silver), 2 bottles, exp 12/2019. 5. Tegaderm film dressing (waterproof, sterile barrier), 30 dressings, exp 02/2019. 6. Tegaderm film dressing, 50 dressings, exp 08/2018. 7. Foley Catheters (flexible tube that a clinician passes through the urethra and into the bladder to drain urine) 2 sized 16 French (measurement of diameter), exp 12/2020, 1 sized 20 French, exp 07/2017, and 1 sized 18 French, exp 02/2018. 8. Foley catheter insert trays 2 exp 03/2018 and 6 exp 04/2021. 9. Adapitc Non-adhering Dressing (dressing that does not stick to the skin and allow fluid to leave the wound into a secondary dressing), 46 dressings, exp 03/2015. 10. Idoform packing strips ( medicated wound dressings are usually packaged in long strips) 5 bottles, exp 01/2020 and 2 bottles exp 03/2020. 11. Self-Adhering Foam Dressing (foam self-adhering dressing for patient comfort), 1 roll, exp 06/2012. 12. Providine-Iodine Swabs (antiseptic used for skin disinfection), 50 swabs, exp 05/2020. 13. Vacuette Purple Blood Tubes (blood sample tube used for blood counts), 10, 3milileter (mL) tubes, exp 05/2021 and 8, 5mL tubes, exp 04/2020. 14. Vacuette Gold Blood Tubes (blood sample tube with separator gel used for electrolyte results) 10, 5mL tubes exp 03/2020. 15. Vacutainer Blood Transfer Device (medical device to transfer blood into tubes), 20 devices, exp 06/2019. 16. Port Access Infusion Sets (utilized to access patient's implanted medication ports):10 sets exp 09/2016, 1 set exp on 02/2016, and 2 sets exp 03/2015. 17. 0.9% Sodium Chloride Injection Flush (medication, used to clean out intravenous lines after medication administration) 25 flushes, exp 06/2021. 18. Plastic Syringes without needle, 100, exp 09/2018. 19. Stoma powder (non-medicated powder that is designed to absorb moisture from raw or broken skin surrounding a stoma), 1 bottle, exp 01/2018. 20. Centerpointe lock skin barrier for stoma (stoma securement device prevents unintentional separation of the pouch from the skin barrier), 5 packages, exp 01/2018. 21. Male incontinence (loss of control of bladder) catheter, 30 catheters, exp 05/2017. 22. Coloplast speedicath kits (ready-to-use catheters patients can use by themselves), 200 kits exp 02/2020 and 180 kits, exp 07/2020. 23. Tegaderm Foam Adhesive Dressing (absorptive dressing), 40 dressings, exp 04/2015. B. On 07/29/2021 at 4:00 pm, interview with (Staff) S2 (Administrator) confirmed that the facility has not removed expired products "We wanted to have our nurse go through it but she hasn't in some time." S2 indicated that the facility will promptly address this issue.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review of patient medical charts and interview, the facility failed to update the Plan of Care after patient fell twice at home and suffered injuries. Plan of care was not updated to include new plans to address injuries or to reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcome and goals identified by the Home Health Agency(HHA) and patient in the plan of care for 1 (Patient 5) out 7 (P1-P7) charts reviewed. This failed practice is likely to lead to substandard care being provided and health issues not being addressed. The findings are as follows: A. On 7/29/2021 at 10:30 am, record review of P5's Plan of Care revealed the following: 1. For Patient 5 (P5), review of the most up-to-date treatment meeting on 06/30/2020 revealed that the patient fell twice at home. 2. Record review of P5's plan or care from 05/10/2020-07/30/2020 revealed that the patient's Plan of Care was never updated to reflect any changes or preventative fall measures. 3. Record review of P5's discharge summary reflect that P5 was discharged from care on 07/07/2020 due to deterioration of condition - worsening of health status rather than getting better, due to having fell twice. B. Confirmatory interview with Facility Administrator on 7/29/21 at 11:30 am revealed that no updates were made to the patient's Plan of Care.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview the facility failed to establish an ongoing Quality Assessment and Performance Improvement (QAPI) program by: 1. Failing to ensure that issues were addressed by the facility such as falls 2. Failing to conduct Quarterly QAPI meetings This failed practice is likely to lead to poor recognition of patterns, and residents are likely to not get the care and support needed to maintain their highest practicable level of well-being. The findings are: A. On 07/30/2021 at 10:00 am, interview with S (staff)2, (Administrator) indicated that the facility has not kept a consistent QAPI program due to lack of census to benchmark standards. (The number that is used as a point of reference against which one can measure or compare actual performance). S2 confirmed it is the expectation of the QAPI program to investigate adverse events, such as falls. B. Record Review of facility's Staff Meeting Minutes revealed: 1. On 03/24/2020 reflected the most recent meeting that included indicators of quality of care (unexpected safety events, length of stay, and plan of care progression) that would be addressed in a QAPI meeting. These minutes do not reflect that falls had been addressed. 2. On 06/05/2020, documentation indicates that P4 "Fell two times since last visit on 05/2020". There is no trending of adverse events (accounting, tracking, and pattern identifying for unexpected events during patient care". There is no documentation that indicates an investigation on cause of fall or that preventative methods had been addressed. C. Record Review of facility's "Quality Assurance and Improvement" (QAPI program) program policy dated 05/2018 revealed:: 1. "Adverse event outcome reports will be monitored monthly case by care case. In the event problematic care (facility issues, such as falls, unexpected safety events, et cetra.), it will be addressed through an improvement plan."

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review the facility failed to conduct interdisciplinary meetings (meetings that contain all levels and types of staff, such as social workers/doctors/nurses) beyond 9/22/2020. This deficient practice is likely to affect all residents in the facility if the facility is not aware of patients' current information, patients' overall status, patients' progress and/or changes in condition. The findings are: A) On 7/29/2021, record review of the facility's interdisciplinary meeting folder revealed that no meetings have occurred since 9/22/2020. B) Record review of the facility's policy on Coordination of Patient Services dated 05/2018 revealed: 1. "Care conferences by all licensed/certified staff, (RN, PT and Home Health Aide) will be held as necessary to establish interchange, reporting and coordinated evaluation of patient care." 2. "Monthly Meetings will be held with all licensed staff, will coordinate care to benefit the patient's specific needs or goals. Any changes will be discussed, and an action plan developed. This coordination will review the client's appropriateness of continuing services or client's discharge potential." 3. "The primary nurse will be responsible for updating the Plan of Care pertaining to any changes deemed necessary. The primary Nurse of Therapist, as appropriate, will be responsible for promptly communicating any changes to the physician and writing doctor's orders pertaining to the changes." 4. "The primary nurse and therapist, as appropriate, will educate and train the patient and caregiver on services and care necessary. Any changes to the patient's needs, due to change in patient's health status, will be communicated to the patient, caregiver or representative (if any) as this will result in a revision of the plan of care." 5. "The plan of care will be sent to the physician for review at least every sixty (60) days, from start of care date." 6. "Coordination with other agencies and institutions will be considered, if the need arises. Of services not able to be provided by Facility Name ." 7. "The patient and caregiver will be provided copies of: a. Frequency of discipline visits b. Current Medication List c. Agency contact info d. Any other pertinent instructions/information"

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview the facility failed to ensure the governing body members are included and are fully informed regarding the operation of the agency and it's services and performance improvement. This deficient practice is likely to cause a breakdown in communication affecting the agency's overall management and operation. The findings are: A. Record Review of facility's Staff Meeting Minutes (governing body minutes) revealed: 1. On 02/25/2020 discussion of new payer model (method of cost and fees associated with medical care) for insurance billing. 2. Most recent staff meeting 09/22/2020, redaction of discussion areas about policy and procedure and quality improvement. Meeting only discussed patients actively being cared for by facility. B. On 07/30/2021 at 10:15 am, interview with S (staff) 2 (Administrator) indicated that the staff meetings are the facility's governing body meetings. S2 further stated that staff meetings are being held by a Nurse and a Physical Therapist and they are not being recorded on paper and neither the Nurse or the Physical Therapist are part of the governing body.