Every finding on record at Heritage Home Care - Las Cruces Inc.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Good Samaritan Society Home Care Home Health Agency (HHA) on 07/25/2024 found that your facility was in substantial compliance with the Conditions of Participation (CoPs) under 42 CFR 484.102.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Good Samaritan Society Home Care Home Health Agency (HHA) on 07/25/2024 resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited:

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, interview, and observation the agency failed to update the plan of care to include a verbal wound care order for 1(P(patient) 4 out of 10 (P1-P10) patients reviewed. This deficient practice could lead to inappropriate treatment of patients in need of wound care. The findings are: A. Record review of agency policy titled, “Care Planning and Care Coordination, Home Health, and Therapy -Enterprise” dated 05/02/2024, stated under number 6, “The POC [Plan of Care] must be reviewed and revised by the provider and the team as frequently as the patient’s condition requires, but no less frequently than once every 60 days, beginning with the Start of Care (SOC).” B. Record review of P4’s Plan of Care revealed an order dated 06/03/2024 for skilled nursing wound care for a surgical wound, under “Interventions” it stated, “Surgical Wound Care [three times a week] to midline abd [abdomen]: cleanse with NS [normal saline], spray flonase OTC [medication used to decrease inflammation] spray to rash below wound, cover with ABD pad [thick padded dressing]. Apply HFB transfer [type of specialized dressing] to wound bed, ABD pad, gauze, soft cloth surgical tape.” C. During an observation on 07/24/2024 at 11:00 am of P4’s wound care, S(staff)5 clinical, removed a dressing from the midline abdomen that had a Mepilex dressing (padded cover dressing tan in color) and a piece of foam from the wound. S5 then cleaned the wound with NS and applied a piece of foam and covered the foam with a padded cover dressing. D. During an interview with S5 on 07/24/2024 at 11:45AM with S5 it was asked why that dressing orders were not followed. S5 explained that the dressing order was changed by the wound care clinic and they had not yet supplied the agency with a new written order. E. During an interview on 07/24/2024 at 3:40 PM with S1, non-clinical, it was asked if there should have been a verbal order placed in P4’s chart if the nurse knew the order was changed. S1 stated, “Yes, there should have been a written verbal order and placed on the plan of care.”

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 record review, interview and observation the agency failed to ensure supplies were not expired in the supply closet. This deficient practice could lead to an increased risk for infection as the quality of the supplies cannot be guaranteed past the expiration date. The findings are: A. Record review of agency policy titled, “Supply Procurement Storage and Inventory Controls-Home Health” dated 02/08/2022 under, “Purpose” stated, “To maintain a usable inventory of supplies to meet the needs of the Home Health agency client census.” Under bullet 5 it stated, “Supplies should be rotated and used by age of the product, with the oldest supplies used first.” B. During an observation of the agency’s supply room on 07/24/2024 at 10:00 am there were expired supplies found to include packing strip iodoform strips (medication-soaked strips used to pack a wound) unopened bottled with expiration date of 09/2023, Duoderm 4x4 CGF Border (specialized dressing) with an expiration date 01/01/2024. C. During an interview with S(staff) 1, non-clinical, it was confirmed that these supplies were expired.

Supervise skilled professional assistants CFR(s): 484.75(c) Standard: Supervision of skilled professional assistants. This STANDARD is not met as evidenced by: Based on record review, interview, and observations the facility failed to provide supervision for the Physical Therapy Aide (PTA) by the Physical Therapist (PT) for 1 (P(patient) 9 out of 10 (P1-P10) patients reviewed. This deficient practice could lead to unsafe care for all patients receiving physical therapy services with the agency. The findings are: A. Record review of the agency’s policy titled, “Therapy Service, Home Health and Therapy [and] Rehab-Enterprise” dated 02/22/2024 under “Purpose” stated, “To ensure that Home Health patient is served by professional employees and is receiving quality rehabilitation services.” Under “Procedures” stated, “. . . 4. Therapists may utilize and supervise therapy assistants such as PTA’s [physical therapy assistants] or Certified OTA’s (COTA) [Certified Occupational Therapy Assistant] as outlined by federal and state requirements. 5. The qualified therapist will: . . . Assist with the development and revision of the POC [plan of care], including specific procedures including the amount, frequency and duration of each - Prepare and submit clinical progress notes - Advise and consult with the family and agency staff. . . - Collaborate with the team in case conferences for coordination of care - Set up specific instructions for therapy assistants based on treatment prescribed in the POC [plan of care], patient evaluation, and acceptable standards of professional practice. - Document therapy assistant information in the EMR: delegation of duties, communication between team members, and the existence of supervision. . .” B. During observation on 07/24/2024 at 2:00 PM, S (Staff)7, PTA (physical therapy assistant), asked P9 if the therapist came to see the patient, P9 stated, “Yes, he did.” S7 then asked where the exercise plan and the band were that he left, P9 stated, “He didn’t leave anything”. The PTA stated, “Ok, well then let’s do some exercises.” There was no evidence during this observation that the PTA was left with specific instructions based on the POC. C. During an interview on 07/24/2024 at 2:30 PM with S7 when asked if the therapist will leave a plan and a band for the exercises she stated, “Yes, the PT will usually leave a program and band for the exercise plan”. D. During an interview on 07/24/2024 at 3:45 PM with S4, PT (Physical Therapist), he confirmed that there was not a program or band left at P9’s home and he did not have any conversation with S7 about the plan of care for P7. E. During an interview on 07/24/2024 at 4:28 PM with S1, non-clinical, it was explained that the therapist will go evaluate the patient, create the care plan and communicate with the aide regarding the patient’s needs.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Complaint survey conducted at Good Samaritan Society Home Health Agency (HHA) on 10/25/2023 resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited: A deficiency was related to Intake 67616.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review, observation, and interview the facility failed to provide patients with a written schedule of visits for 3 (P [patient] 8, P9, P10) of 3 (P8-10) patients reviewed for care provided by homecare staff. This deficient practice can lead to patients being unaware of when the home health agency staff will be coming to provide care in the patient’s home. The findings are: A. Record review of agency policy titled, “Admissions Process, Home Health-Enterprise” dated 07/19/2023 on page 4, number 16 it stated, “The following documents should be provided to the patient/caregiver/representative no later than the next visit after the POC [plan of care] has been approved by the provider. The written information should be updated as the POC [plan of care] changes: - Visit schedule, including frequency, from all members of the team. . .-Any treatments to be administered by employees and contract staff. . .” B. Record review of agency documents titled, “Home Health Admission Packet”, undated, revealed a blank calendar to be taken to the patient’s home. C. Record review of P8’s admission packet in the home revealed that the calendar was not filled out by staff for planned visits. No written schedule was revealed in the patient’s home. D. Record review of P9’s admission packet in the home revealed that the calendar was not filled out by staff for planned visits. No written schedule was revealed in the patient’s home. E. Record review of P10’s admission packet in the home revealed that the calendar was not filled out by staff for planned visits. No written schedule was revealed in the patient’s home. F. During an observation on 10/25/2023 at 9:05 AM, S4, RN (Registered Nurse) Case Manager completed a home visit for P10 and did not update the calendar in the patient’s home with the next scheduled visits. G. During an observation on 10/25/2023 at 10:43 AM, S5, LPN (Licensed Practical Nurse) completed a home visit for P10 and did not update the calendar in the patient’s home with next scheduled visits. H. During an interview on 10/25/2023 at 10:55 AM, P10 was asked if staff provided the schedule in writing for the patient, it was confirmed that the staff goes over the schedule verbally but does not maintain a written schedule. I. During an interview on 10/25/2023 at 2:05 PM, S1, RN Administrator confirmed that the expectation was that staff fill out the calendar in the admissions packet for patients.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Good Samaritan Society Home Care, Home Health Agency (HHA) on 08/10/2021 resulted in noncompliance under 42 CFR §418.102 with the following standard-level deficiency 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 maintain and update the Emergency Preparedness manual (binder) with current annual Hazard Vulnerability Assessments, also known as a Hazard Vulnerability Analysis (HVA) (used to show hazards or risks that can impact a healthcare facility and the surrounding community), and a current patient list. This deficient practice can delay the ability to offer continued patient care by not evaluating the damage and severity of impact a disaster could potentially cause, and knowing which patients are receiving care in an emergent (unpredictable or unforeseen) situation. The findings are: A. Record review of the Emergency/Disaster Manual, undated, revealed the following: 1. No current copy of a dated Hazard Vulnerability Assessment 2. No current copy of a dated Patient list. B. Record review of [name of facility] Home and Community Based Services Emergency Management Plan dated 04/06/2021, revealed the following: 1. On page 2, under I. Hazard Analysis section, no information of the Hazard and Vulnerability Assessments needing to be completed on annual basis 2. On page 2, under Services Provided section, Home- and Community-Based Services and under Number of Clients section, variable. C. On 08/10/2021 at 3:15 pm during an interview, Staff (S)#1 (Administrator) confirmed there was not a current Hazard Vulnerability Analysis (HVA), and a current patient list in the Emergency Preparedness manual.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Good Samaritan Society Home Care, Home Health Agency (HHA) on 08/10/2021 resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited: A COVID-19 Focused Infection Control Survey was conducted by the New Mexico Department of Health, Division of Health Improvement on 08/10/2021. The facility was found to be in compliance with 42 CFR §484.70 Condition of Participation: Infection Control Regulations and Guidelines for Home Health Facilities and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. The standard-level Infection Control deficiencies cited are in relation to expired medical supplies, sanitary environment, and personnel files and not CDC recommended practices to prepare for COVID-19.

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 not using items passed expiration dates and not identified as being under an extended use authorization by the United States Food and Drug Administration. This failed practice is likely to lead to insufficient treatment and delayed progression to goals. The findings are: A. On 08/09/2021 at 3:30 pm, observation of the medical supply room revealed the following expired (exp) products used in direct patient care: 1. One McKesson (product name) Calcium Alginate (composed of sodium and calcium fibers which are derived from seaweed) Dressing (alginate dressing mold themselves to the shape of the wound so that the wound drainage is properly absorbed.): exp 07-2019 2. Two (2) Assure Dose (product name) Control Solution (a solution used to verify the glucose (a type of sugar from foods that the body uses for energy) monitoring system (meter and test strips) is working correctly and giving accurate results. A drop of the glucose control solution to a test strip and run a standard glucose test.): exp (2) 5-31-2019 B. On 08/10/2021 at 3:45 pm during an interview, Staff (S)#3 (Office Manager) acknowledged the expired products in the supply room. S#1 (Administrator) reported there is not a set log to ensure that all product(s) is up to date. S#3 stated, "I check the supply room once a week or every other week to make sure there's nothing expired being used."

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to make sure a consistent method is in place to provide samples of complaints and grievances which shows how the facility handled ongoing complaints received, investigated, and resolved. This deficient practice prevents the facility the ability to provide proof and track which complaints and grievances from patients and family have been resolved and that residents are free from mistreatment. The findings are: A. Record review of a binder (a cover for holding loose sheets of paper), titled Situations/Complaints & Incidents revealed the following: 1. Copies of Complaints and Incidents the facility received for dates 08/01/2020- 07/31/2021 (no log (report) to indicate what steps the facility completed to resolve the complaints.) B. On 08/10/21 at 2:20 pm during interview, Staff (S)#1 (Administrator) confirmed does not have a complaint/grievance log to reference any complaints or grievances in a binder to indicate what steps the facility completed to resolve the complaints.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview the facility failed to provide ongoing interdisciplinary assessment (assessment of patient attended by all disciplines involved in treatment) of the 34 patients reviewed. This failed practice increases the likelihood of errors in patient treatment due to lack of interdisciplinary communication. The findings are: A. Record review of Interdisciplinary (IDT) Team Meeting minutes dated 08/03/21 reveals: 1. Vague and limited entries for all 34 currently registered patients, entries include but not limited to "Pt (patient) picked up for short-term" (no explanation why or for how long), "D/C (discharge) Pt by this week" (no reason for discharge given), "ROC (resume of care)" (no explanation), "PT ongoing" (no progress or lack of progress), "SN (Skilled Nursing)-ongoing w/wound care" (no progress or lack of progress), "SN issues" (no explanation), "fall on 8/1" (no explanation or detail). 2. All attendee signatures written in by the same person, many entered by first name only and do not clarify the team members discipline. 3. Education noted by title only "LOD (undefined) -masks & goggles, unvaccinated-N95, vaccinated-face-shield, goggles", no time of education, no duration of education, no instructor or method of learning, making it unclear what education was provided." B. On 08/10/21 at 4:15 pm during interview, S(Staff)1 (Administrator) confirmed, "The changes I need to make to the IDT minutes make sense to me, they need to be more detailed."

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 maintain an ongoing program to inform the Governing Body (professional advisory committee) of issues within the Quality Assurance and Performance Improvement (QAPI) to make sure adequate and effective operation in the areas of clinical care and to discuss concerns that will improve the quality of care and patient safety. This deficient practice increases the likelihood of the facility not having a process for improving the quality and performance of patient care practices. The findings are: A. Record review of Quality Assurance and Performance Improvement (QAPI) documents dated 08/01/2020 through 07/15/2021, did not show patient falls and patient infection (wound care) monitoring discussed with the governing body to implement resolutions to minimize the risk of patient falls and patient infection (wound care) monitoring to include patient or staff education. B. On 8/10/2021 at 11:00 am during an interview, Staff (S)#1 (RN, Administrator) confirmed, in the governing body meeting agenda, there is a section for QAPI, and it does not indicate on the governing body minutes new issues discussed or what are the resolutions. S#1 confirmed the QAPI committee does identify problems and develop solutions but does not track and trend indicators or outcomes. C. Record review of governing body meeting agenda meetings dated 08/01/2020 through 07/15/2021 revealed, under the section for QAPI, no discussion of tracking and trending of patient falls and patient infection (wound care) monitoring or possible resolutions. D. On 8/10/2021 at 11:00 am during an interview, Staff (S)#1 (Administrator) confirmed, in the governing body meeting agenda there is a section for QAPI, and it does not show on the governing body minutes new issues discussed or what steps were taken to resolve any concerns. S#1 confirmed the QAPI committee does identify problems and develop solutions but does not track and trend indicators or outcomes.

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 and interview, the facility failed to maintain a sanitary environment (an environment that is hygienic, clean, and conducive to infection prevention) as boxes of medical supplies were on the training room floor. This deficient practice is likely to lead to contamination and potential infection control issues. The findings are: A. On 08/09/2021 at 3:45 pm, during observation of the supply room, revealed the following: 1. Cardboard boxes with medical supplies stored on the floor (should store cardboard boxes off the ground due to their potential to grow and perpetuate bacteria, mold, or insects.) B. On 08/09/2021 at 3:50 pm during an interview, Staff (S)#3 (Office Manager) confirmed the boxes on the floor and understood that there shouldn't be any boxes on the floor.