Every finding on record at Las Cruces Home Care

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted Las Cruces Home Care, Home Health Agency (HHA) on 07/22/2021, 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 maintain and update the Emergency Preparedness manual with complete annual Hazard Vulnerability Assessments also known as a Hazard Vulnerability Analysis (HVA) (Systematic approaches to identifying hazards or risks that are most likely to have an impact on a healthcare facility and the surrounding community) and maintain a current patient list and a current staff list. This deficient practice can likely delay the ability to provide continued patient care by not evaluating the damage that could be caused by a potential disaster, the severity of the impact, and the availability of medical resources during a disaster and to know which patients are receiving care and contacting current staff 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 3. No current copy of a dated Staff list. B. Record review of policy Hazard Vulnerability Analysis (HVA), Reference #1002, dated 06/1/2013, revealed, on page 2 of 2 under Policy section, bullet item five, "The Hazard Vulnerability Analysis (HVA) shall be revised annually by the Administration, and whenever a new threat emerges." C. Record review of policy Natural Disaster Management Plan, Reference #1014, dated 06/01/2013, revealed, on page 1 of 5 under Procedure section, bullet item one, "Staff information is kept current and updated on an ongoing basis and includes contact numbers in the event of an emergency." On bullet item three, "Active patient demographic and clinical data is updated on an ongoing basis." D. On 07/22/2021 at 10:00 am during interview, Staff (S)#2 (Director of Nursing) confirmed there was not a current Hazard Vulnerability Analysis (HVA) in the Emergency Preparedness manual. S#13 (Administrative Assistant) and S#2 acknowledged the patient list and staff list was not current in the Emergency Preparedness manual.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Las Cruces Home Care, Home Health Agency (HHA) on 07/22/2021 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 07/22/2021. The facility was found not to be in noncompliance with 42 CFR §484.70 Condition of participation: Infection prevention and control Regulations and Guidelines for Home Health Agencies and has not implemented the CMS and Centers for Disease Control and Prevention (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 using items that are not 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 07/22/2021 at 9:30 pm, observation of supply room revealed the following expired (exp) products used in direct patient care: 1. Three (3) Adapt (product name) paste tubes, (used to fill or caulk uneven skin contours to create a flatter surface.): exp (2) 11/2019 and (1) 3/2021. 2. Dynarex Skincote Protective Dressing Applicators (provide a protective coating to the skin, helping to guard against irritations caused by adhesives, appliances and other medical devices) four boxes: exp 11/2020. 3. Sixty-nine (69) red cap Vacuette blood collection tubes (clear glass tube used to collect blood): exp 06/13/2021. 4. PleurX Vacuum Bottle (a drain catheter and active vacuum bottles for collecting fluid. The catheter gets inserted into either the chest or the abdomen) seven (7) bottles: exp: (4) 06/09/2021, (2) 07/06/2021, and (1) 05/2/2021. B. On 07/22/2021 at 9:45 am during interview, Staff (S)#13 (Administrative Assistant) and S#2 (Director of Nursing) acknowledged the expired products in the supply room. S#13 reported there is not a set log to ensure that all product is up to date, "I check the supply room once a week or every other week to make sure there's nothing expired being used."

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 (environment that is hygienic, clean, and conducive to infection prevention) as boxes of medical supplies were on the floor in the supply room. This deficient practice is likely to lead to contamination and potential infection control issues. The findings are: A. On 07/21/2021 at 3:45 pm, during observation of the supply room inspection revealed the following: 1. Cardboard boxes with medical supplies stored on the floor (cardboard boxes must be stored off the ground due to their potential to grow and perpetuate bacteria, mold, or insects.) 2. An open bag of Priority Pet Care (brand name) of cat litter (absorbent clay used for lining a box in which a cat can eliminate waste) next to an uncovered box of (20) Suction Catheters (a medical device used to extract bodily secretions, such as mucus or saliva from the upper airway.) B. On 07/22/2021 at 9:30 am, during an interview with Staff (S)#13 (Administrative Assistant), confirmed the boxes on the floor, and stated, "Had just gotten the supplies in and should have put them on the shelf instead of on the floor." C. On 07/22/2021 at 9:35 am, during an interview with S#13 and S#2 (Director of Nursing) both confirmed the open bag of cat litter next to the box of suction catheters.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation and interview the facility failed to adhere to Federal Regulatory Infection Control guidelines regarding the critical elements of mitigating COVID-19 (coronavirus, respiratory infection) transmission by not following the screening process (process used for ensuring there are no signs and symptoms of illness) for staff and visitors entering the facility, sinage of mandatory mask wearing for all individuals and failed to adhere to established infection control policies for 3 (P (patient) 7, P10, & P11) out of 4 patients sampled and establish a clean work area during the observational home visits (visits conducted by the New Mexico Department of Health focused on the quality of services) provided. This failed practice is likely to lead to potential infectious disease spread through asymptomatic (spreading the infectious agent without showing signs of infection) or symptomatic transmission and failure to identify potentially exposed parties. The findings are: A. On 07/21/2021 at 1:05 pm, during observation, no temperature check or COVID symptom screening (set of questions for COVID symptoms) was done by facility for visiting surveyors from the New Mexico Department of Health, Division of Health Improvement. There were no signage notifying the visitors of potential signs or symptoms of COVID-19 (cough, fever, or shortness of breath) should not enter facility. No signage indicating that face mask wearing is mandatory for unvaccinated visitors. B. On 07/22/2021 at 12:15 pm, interview with S (staff) 1 (Office Manager/Owner) stated, "I thought that we did not have to do that anymore. I was informed at the round table that was held at the hospital. I will fix that now." Evidence Regarding infection control policies for direct patient contact. C. On 07/22/2021 at 10:00 am, during home visit, observation of care provided to P11 by S (staff) 11 (Physical Therapist) revealed: 1. S11 placed their treatment bag directly on P11's floor, failing to use any barrier. 2. S11 sanitized blood pressure cuff with a disinfecting wipe and placed the used wipe back into the bag. 3. S11 performed exercises with P11 and then retrieved pulse oximeter (device to measure heart rate and oxygen percentage) without performing hand hygiene. 4. S11 picked up used disinfecting wipes from P11's floor without performing hand hygiene. D. On 07/22/2021 at 11:00 am, during home visit observation of care provided to P7 by S11 revealed: 1. S11 disposed of a disinfecting wipe by placing it in P7's trash can and retrieved pulse oximeter from bag without performing hand hygiene prior. E. On 07/22/2021 at 12:00 pm, during home visit observation of care provided to P10 by S12 (Licensed Practical Nurse) revealed: 1. S12 placed bag directly onto P10's table without any use of barrier. 2. S12 removed P10's dressing and began providing wound care over the patient's left leg. S12's hair was passed shoulder length and appear to come into direct contact with the wound bed. F. On 07/22/2021 at 3:00 pm, interview with S2 (Director of Nursing) indicated that the expectation for clinical staff regarding bag technique is to employ the use of a barrier, such as a pad or newspaper, between the staff member's bag and the patient's residence. S2 confirmed that it is the expectation that the bag's interior is to remain clean and this is ensured through performing hand hygiene prior to retrieving or placing items inside it. When asked about wound care, S2 confirmed that long hair must be kept up in order to prevent cross-contamination or infection. G. Record Review of facility's "Nursing Bag Technique" policy, effective 06/01/2013, revealed: 1. "The bag shall not be placed down on the floor at a patient's home or in a patient room/care area." 2. "Hands shall be cleansed prior to returning clean equipment and supplies to the bag" 3. A protective barrier shall be used for bag placement in the patient's home. H. Record review of facility's "Wound Care Policy-Wound Care Team" Policy, effective since 06/01/2014, revealed: 1. "All wound care, unless otherwise ordered, is done using clean technique following standard precautions (infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin)"