Every finding on record at Matrix Home Care Services of New Mexico, LLC

A Recertification Survey was conducted by Healthcare Management Solutions, LLC, on behalf of the New Mexico Health Care Authority (HCA). An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 04/22/25 to 04/24/25 resulted in no deficiency citations respective to the Emergency Program Condition of Participation under 42 CFR 484.102.

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of New Mexico Health Care Authority (HCA). An unannounced on-site Recertification survey conducted at the above-named Home Health Agency (HHA) from 04/22/25-04/24/25 resulted in finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CRF 484 Subparts A through C and the following standard-level deficiencies listed below.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on record review and interview, the facility failed to ensure written policies were in place for influenza and pneumococcal vaccinations for patients who may or may not want to receive the vaccinations. This deficient practice could allow 153 of 153 patients to not receive the vaccinations or recognize an adverse reaction. Findings include: During review of the facility's policies and procedures for vaccinations, the facility failed to have any policy that described the steps that they would take to ensure patients were immunized. On 04/23/25 at 2:15 PM, the Assistant Director of Nursing (ADON) was asked how the influenza and pneumococcal vaccinations were provided if patients wanted to receive them. The ADON stated they referred to the Centers for Disease Control and Prevention (CDC) to guidance. The ADON stated, "If a patient wants to receive the vaccinations, then we will refer them to their physician or tell them to go to their pharmacy. Several of our patients are veterans and can receive those through the Veteran Administration (VA)." The ADON was asked where that policy was written. The ADON stated. "It could not be located." On 04/24/25 at 8:20 AM, the Vice President (VP) and acting Administrator was asked about the vaccination policy. The VP stated, "We will have to fix it."

E000 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 05/03/22 to 05/05/22 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

G000 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) from 05/03/22 to 05/05/22 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.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: G514 Based on medical record review, staff interview, and review of agency policy, the agency failed to ensure the Registered Nurse (RN) completed the initial assessment of patient needs within 48 hours of the referral date for one of seven medical records reviewed (Patient (P)2). Failure to assess the immediate care and support needs of patients while they wait for a complete and comprehensive assessment of needed services could cause a lapse in health and safety needs for all 87 patients receiving services from this agency, with possible negative outcomes. Findings include: Review of the undated "Intake Form," in the electronic medical record (EMR) of P2 revealed, "Referral date: 03/02/22." Review of the "OASIS [Outcome and Assessment Information Set/the standardized assessment tool used for home health agency admissions] SOC [Start of Care] in the EMR, dated 03/10/22, revealed, "Date of Physician-ordered Start of Care: NA - No specific SOC date ordered by physician," and the entry, "Date of Referral" indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA: 03/02/2022. During an interview with the Director of Nursing (DON) on 05/05/22 at 9:55 AM, the medical record of P2 was reviewed and verified as complete and accurate. The DON was unable to find documentation to explain the reason for the delay in the RN completing the initial assessment after the referral date. The DON agreed the initial assessment by the RN was not completed within 48 hours of the referral date and agreed there was no specific SOC date ordered by the physician to explain the delay. The DON stated, "We missed it in this case." The most current agency policy related to the need to complete the initial RN assessment in a timely manner was requested. Review of the undated agency policy titled, "Referral and Acceptance of Patient/Clients," revealed, "Upon receipt of a referral, an evaluation by a Registered Nurse and/or appropriate therapist will be made to determine that the care can be adequately and safely performed at home, to assess the patient/client care needs, and to ensure that the patient/client meets the admission criteria. Patients/clients will be evaluated by a nurse or appropriate staff member within 24-48 hours or referral or discharge from a facility whenever possible."

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: G682 Based on observation, staff interview, and review of agency policies and procedures, the agency failed to ensure the Skilled Nurse (SN) performed wound care with appropriate hand hygiene (washing hands with soap and water or alcohol-based hand rub/ABHR) after glove removal and failed to appropriately disinfect equipment for one of one observation of wound care (Patient (P) 4). Failure to maintain infection prevention techniques during wound care could lead to infections for all patients receiving wound care from this agency. Findings include: During a home visit to P4 on 05/04/22 from 1:10 PM to 2:00 PM, Licensed Practical Nurse (LPN) 3 was observed performing wound care on P4's suprapubic (above the pubic bone) area and to the right gluteal fold (skin fold below the right buttock). Starting with the suprapubic wound, LPN 3 cleansed the wound with multiple pieces of soaked gauze, then discarded each piece of gauze covered with dark reddish-brown drainage. After completing the procedure, LPN 3 removed his/her gloves and, without performing hand hygiene, used bare hands to remove clean supplies from the patient's supply bag. LPN 3 then donned new gloves and applied prescribed ointment to the wound edges, removed his/her gloves and, without performing hand hygiene, donned new gloves. LPN 3 then packed the wound with a gauze roll soaked with prescribed solution, applied a large sterile pad and tape on the wound before removing gloves and performing hand hygiene. LPN 3 then performed wound care on the second wound at the right gluteal fold. Using the same gloves, LPN 3 then assisted P4 to reposition in the bed. Using the same gloves, LPN 3 then collected and disposed of the trash on the bed, removed his/her gloves and, without performing hand hygiene, replaced the prescribed solution and ointment containers in the patient's storage box. While obtaining vital signs and performing a physical assessment with gloved hands, LPN 3 used his/her stethoscope on the patient's clothing and bare skin as needed, then placed the stethoscope around his/her neck. Using the same gloves, LPN3 then used a cell phone to document the visit notes, then wiped the phone. LPN 3 then had P4 sign his/her name using the phone's touch screen and, without again disinfecting the phone, LPN 3 placed the phone in his/her pocket. LPN 3 then removed the gloves, performed hand hygiene and, with bare hands, collected the barrier drape used under his/her bag from P4's bed and discarded it. LPN 3 did not disinfect the stethoscope prior to leaving the patient's home. During an interview with LPN 3 on 05/04/22 at 2:00 PM, the above observations were reviewed. LPN3 stated understanding of agency policy to always perform hand hygiene after glove removal and to disinfect all items used in a patient's home prior to leaving the home. LPN 3 agreed with all of the missed opportunities to perform hand hygiene noted above. LPN 3 agreed he/she should have disinfected the cell phone prior to placing it in his/her pocket and should have disinfected the stethoscope prior to leaving the patient's home. During an interview with the Facility Administrator and Director of Nursing (DON) on 05/04/22 at 2:35 PM, the above observations were reviewed. The DON confirmed it is agency policy and expectation for all staff to perform hand hygiene after glove removal and prior to handling clean items and to wear gloves when handling contaminated items or trash. The DON also confirmed that agency policy and expectation is for staff to disinfect all reusable equipment prior to leaving a patient's home. The most current policies and procedures related to these infection control procedures were requested. Review of the undated policy titled, "Hand Washing Policy," revealed, "All employees must wash their hands. This must be done whenever any of the following situations occur: After handling used dressings…even when gloves and protective clothing have been used; Before and after patient contact, even when gloves are used." Review of the undated policy titled, "Care of Reusable and Disposable Equipment," revealed, "Agency staff will wear disposable gloves or utility gloves when cleaning inanimate patient/client care items." Review of the undated policy titled, "Bag Technique," revealed, "When conditions warrant, wipe off equipment with alcohol after use. Example: scissors after removal of a dressing and bell of stethoscope."