Every finding on record at Medisource Home Health Services

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

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 conducted at the above-named Home Health Agency (HHA) facility from 4/22/2025-4/24/2025 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.

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, interview, policy review, and training aide review, the facility failed to ensure that one of two staff (Physical Therapist (PT) 1) observed during home visits performed hand hygiene in a manner to prevent cross contamination. This had the potential to affect nine of nine patients Physical Therapist (PT 1) regularly visited. Findings include: Review of the undated agency policy titled, "Safety/Infection Control Hand washing," revealed, "All personnel will wash their hands: Upon arrival to work, before and after each contact with a client . . . When leaving work. Procedure A. Hand washing with water 1. Turn on the water. 2. Adjust temperature to warm. Avoid hot water as it increases the risk for dermatitis. 3. Wet hands. 4. Apply the soap and work into a heavy lather using vigorous friction, covering the entire hands, top and bottom, front and back, between the fingers and back of the hands. 5. Pay special attention to the nails and between the fingers and back of hands. 6. Wash hands for at least 20 seconds. 7. Rinse hands thoroughly with running water while holding them downwards and allowing the water to run off. 8. Dry hands with a paper towel or clean unused cloth towel. 9. Use a towel to turn off faucet." During observation of Patient (P) 2's home visit on 04/22/24 at 5:00 PM, PT1 went into P2’s kitchen, turned on the faucet with his/her hands, washed both hands with soap and water, and then with his/her clean hands, turned off the same faucet, potentially contaminating his/her hands. After the visit was completed, PT1 went back into P2’s kitchen, turned on the faucet with his/her hands, washed his/her hands with soap and water, and then using clean his/her hands, turned off the faucet, potentially contaminating PT1’s hands. During an interview immediately following the observation, PT1 confirmed he/she did not use a barrier to turn the faucet off and therefore possibly contaminated his/her hands. During an interview on 04/23/2025 at 8:25 AM, the Administrator informed the surveyor that PT1 had telephoned the Administrator the evening of 04/22/2025 to report that he/she forgot to get his/her paper towels out of his/her vehicle and verified turning off the potentially contaminated faucet with clean hands. The Administrator reported that he/she did hand hygiene teaching with PT1 via an email on the evening of 04/23/2025. Review of the copy of the handwashing training document the Administrator sent to PT 1 via email on 04/23/2025, showed pictures of turning off faucets with a paper towel after cleansing hands.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, interview, and policy review, the Home Health Agency (HHA) failed to ensure that supplies kept in the supply storage room in the agency’s office for patient use were not expired. This had the potential to negatively affect 23 of 23 patients receiving services. Expired products may not perform as intended, leading to ineffective treatment, and/or increase the risk of infection. Findings include: Review of the undated facility document titled, "Medical Supplies and Equipment" revealed, "No supplies will be issued that are damaged or expired. They will be disposed of per manufacture recommendations." During an observation on 04/24/25 at 2:15 PM, the surveyor and Administrator toured the agency's supply room. The following expired supplies were noted: Three containers labeled "Adapt Stoma Powder" with an expiration date of 10/2022. Four "COVID" test kits with the expiration date of 09/08/22. Three bags labeled "Biohazard Specimen" that expired on 07/26/23. Four "COVID" test kits with the expiration date of 09/08/22. Three bags labeled "Biohazard Specimen" that expired on 07/26/23. Three bottles labeled "Iodoform Packing Strips" that expired on 10/15/24. The Administrator confirmed the supplies were past their expiration date and removed the items.

E0000 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 04/27/22 to 04/29/22 resulted in a finding of standard level deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: E0009 Based on document review and interview, the home health agency (HHA) failed to develop a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. This deficiency had the potential to affect the 12 current patients and any future patient admitted for home health services. Findings include: Review of the undated document titled, "Emergency Preparedness Plan," contained in the Emergency Preparedness Binder presented by Administrator, indicated there was no process developed that addressed how cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials would be maintained. In an interview on 04/27/22 at 12:57 PM, Administrator confirmed the agency's emergency preparedness plan did not address a process for cooperating and collaborating with local, tribal, regional, State, and Federal emergency preparedness officials.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: E0023 Based on record review and interview, the home health agency (HHA) failed to develop a policy that addressed a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records needed during a disaster or emergency. This deficiency had the potential to affect the ability of the agency to ensure needed information is communicated timely and efficiently to emergency personal and resources in for the 12 current patients and any future patient admitted for home health services. Findings include: Review of the undated "Emergency Preparedness Plan," contained in the Emergency Preparedness Binder presented by Administrator, indicated the policy did not address preserving patient information, protecting confidentiality, and maintaining the availability of medical records needed during a disaster. In an interview on 04/27/22 at 12:57 PM, Administrator confirmed the agency's emergency preparedness plan did not address maintaining the confidentiality of patient information or a mechanism for releasing patient documentation in the event of a disaster.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: E0031 Based on document review and interview, the home health agency (HHA) failed to ensure the communication plan included contact information for State, tribal, regional, and local emergency preparedness staff. This deficiency had the potential to affect the 12 current patients and any future patient admitted for home health services. Findings include: Review of the undated document titled, "Emergency Preparedness Plan," contained in the Emergency Preparedness Binder presented by Administrator, indicated there was no documentation of contact information for the State, tribal, regional, and local emergency preparedness staff. In an interview on 04/27/22 at 12:57 PM, Administrator confirmed the agency's emergency preparedness plan did not include contact information for the State, tribal, regional, and local emergency preparedness staff.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: E0033 Based on document review and interview, the home health agency (HHA) failed to ensure the communication plan included the method to be used for sharing information and medical documentation for patients with other health providers to maintain continuity of care. This deficiency had the potential to affect the 12 current patients and any future patient admitted for home health services. Findings Include: Review of the undated document titled, "Emergency Preparedness Plan," contained in the Emergency Preparedness Binder presented by Administrator, indicated there was no documentation of a method for sharing information and medical documentation for patients with other health providers to maintain continuity of care. In an interview on 04/27/22 at 12:57 PM, Administrator confirmed the agency's emergency preparedness plan did not include a method to be used for sharing information and medical documentation for patients with other health providers to maintain continuity of care.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: E0034 Based on document review and interview, the home health agency (HHA) failed to ensure the communication plan included how the agency would provide information about the agency's occupancy, needs, and the agency's ability to assist the authority having jurisdiction. This deficiency had the potential to affect the 12 current patients and any future patient admitted for home health services. Findings include: Review of the undated document titled, "Emergency Preparedness Plan," contained in the Emergency Preparedness Binder presented by Administrator, indicated there was no documentation of a method for sharing information about the agency's occupancy, needs, and ability to assist the authority having jurisdiction. In an interview on 04/27/22 at 12:57 PM, Administrator confirmed the agency's emergency preparedness plan did not include a method for sharing information about the agency's occupancy, needs, and ability to assist the authority having jurisdiction.

G0000 A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Mexico Department of Health. An unannounced on-site Recertification Survey conducted at the above-named Home Health Agency (HHA) from 04/27/22 to 04/29/22 resulted in noncompliance with §484.70 Condition of Participation: Infection Prevention and Control, respective to applicable CoP under 42 CFR 484 Subparts A through C and the following standard-level deficiencies listed below. The HHA census is 12.

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 record review, policy review, and interview, the home health agency (HHA) failed to ensure an initial assessment was conducted within 48 hours of the referral for one (Patient (P) 5) of seven sampled patients. This deficient practice had the potential to affect any future patient admitted to the HHA for home health services. Findings include: Review of the undated policy titled "Admission Criteria" indicated ". . . Upon referral, the decision regarding acceptance of and initiation of service by licensed staff will be made within 48 hours of the referral or within 48 hours of the patients [sic] return home or knowledge of return home or on the physicians [sic] ordered start of care date. . ." Review of P5's "Home Health Certification and Plan of Care," located under the "Physician Tasks" tab in the EMR, for the certification period of 02/19/21 to 04/19/21 indicated the start of care date was 02/19/21. Review of P5's physician's referral form, located under the "Referral" tab in the paper copy of the chart, dated 02/08/21 indicated the reason for referral was "Visiting Nurse Evaluation" and an appointment date of 02/12/21 with a hand-written note of "2/8/21 Patients daughter will be in town visiting so she wants to wait until Friday" (02/12/21) with the signature of the first name of Administrator. There was no documentation in the medical record that P5's physician was notified that the initial assessment was requested to be done later than 02/08/21 and that the initial assessment was done one week after the patient's requested day. In an interview on 04/28/22 at 11:30 AM, Administrator confirmed there was no documentation in P5's medical record that P5's physician was notified of the delay in performing the initial assessment and the reason why the assessment was not done on 02/12/21as requested by P5 and P5's daughter.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: G548 Based on record review, policy review, and interview, the home health agency (HHA) failed to ensure the resumption of care (ROC) visit was performed within 48 hours of the patient's return from the hospital for one (Patient (P) 1) of seven patient records reviewed for a ROC visit. This deficient practice had the potential to affect the 12 current patients and any future patient admitted for home health services who may be hospitalized and require a ROC visit. Findings include: Review of the undated policy titled "Admission Criteria" indicated ". . . Upon referral, the decision regarding acceptance and initiation of service by licensed staff will be made within 48 hours of the referral or within 48 hours of the patients [sic] return home or knowledge of return home or on the physicians [sic] ordered start of care date. Review of P1's "Home Health Care Request Resumption of Care Form," located under the "Authorization/Insurance" tab in the hard copy chart and dated 04/11/22, indicated P1 was discharged from the hospital on 04/12/22 with the date of ROC to be 04/13/22. Review of the dates of visits, located under the "Scheduling" tab in the electronic medical record (EMR), indicated P1's ROC visit was conducted by Administrator on 04/15/22, three days (72 hours) after P1 returned from the hospital. There was no documentation that P1's physician was notified of the delay in resuming P1's care. In an interview on 0428/22 at 10:50 AM, Administrator stated there was a delay in P1 returning to P1's own home after discharge from the hospital that caused the delay in resuming care. Administrator confirmed P1's EMR had no documentation that P1's physician was notified that the ROC visit would not be conducted within 48 hours of P1's discharge from the hospital.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: G616 Based on record review, policy review, observation, and interviews, the home health agency (HHA) failed to ensure written information was provided to the patient regarding the patient's medication regimen as based on the medication review for two (Patient (P) 2, P3) of two patients observed during home visits on 04/28/22 from a sample of seven patients. This deficient practice had the potential to affect the 12 current patients and any future patient admitted for home health services. Findings include: Review of the undated policy titled "Medication Profile" indicated ". . . The clinician will verbally review all medications with the patient (or person responsible) to ensure knowledge of the medication purpose, route, amount, and frequency and compare to the written labels on the medication bottles. The clinician can document on the paper medication sheet enclosed in the admission packet and return it to the office along with other signed admission documentation. . . The medication profile will be updated at least every 60 days or more often as needed. All new medications will be added to the Medication profile and checked for interaction risks by the case manager. . . Medication Profile will be updated when the patient's medications change. A change is any/or all of the following related to routine and as needed medications: Change in dosage Change in frequency Addition of medication Deletion/discontinuance of medication Change in medication directions . . ." There was no documentation in the policy that addressed providing the patient with written information regarding the patient's medication regimen. 1. Observation during a home visit to P2 on 04/28/22 at 1:05 PM revealed there was no Medication Profile contained in the HHA binder in P2's home. Further observation revealed the following medications were present and were not listed on P2's "Home Health Certification and Plan of Care" for the certification period of 03/01/22 to 04/29/22: Gabapentin (used with other medications to prevent and control seizures and is also used to relieve nerve pain following shingles) 300 milligrams (mg) one twice a day orally, bottle dated 01/04/22 Losartan (used to treat high blood pressure and to help protect the kidneys from damage due to diabetes; also used to lower the risk of strokes in patients with high blood pressure and an enlarged heart) 100 mg one daily orally, bottled dated 01/16/22 Ferrous Sulfate (used in the treatment of iron deficiency) 325 mg one twice a day orally, bottle dated 04/12/22 Hydralazine (used with or without other medications to treat high blood pressure) 100 mg, take one-half tablet orally three times a day, bottle dated 04/12/22 Eliquis (used to prevent serious blood clots from forming due to a certain irregular heartbeat) 5 mg one twice a day orally, bottle dated 04/24/22 Oxybutynin (used to treat an overactive bladder) 5 mg one three times a day orally, bottle dated 03/29/22 Valproic Acid (used to treat seizure disorders, mental/mood conditions (such as manic phase of bipolar disorder), and to prevent migraine headaches) 250 mg one twice a day orally, bottle dated 04/12/22. Further observation revealed there was no Zyrtec (antihistamine used to relieve allergy symptoms such as watery eyes, runny nose, itching eyes/nose, sneezing, hives, and itching) present. Zyrtec 10 mg one time a day orally was listed to be taken on P2's POC. In an interview on 04/28/22 at 1:05 PM, P2 stated he/she took the medications listed above that were in the plastic bin on the kitchen table. In an interview on 04/28/22 at 1:33 PM, Physical Therapist (PT) 1 stated PT1 performed a PT visit with P2 on 04/25/22 (after the date on P2's medication bottles). PT1 confirmed there was no medication profile in P2's home health binder. In an interview on 04/28/22 at 1:55 PM, PT1 stated he/she doesn't check patient medications during the PT visit. 2. Observation during a home visit with P3 on 04/28/22 at 2:05 PM revealed Ambien (used to treat a certain sleep problem (insomnia) in adults) 10 mg tablets and Lasix (used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease) 20 mg tablets were not present with P3's medications stored in the medication cabinet in P3's bathroom. Review of the list of current medications for P3, provided by Administrator, listed Ambien 10 mg tablet, take one tablet by mouth at bedtime, and Lasix 20 mg tablet, take one tablet by mouth once daily. In an interview on 04/28/22 at 2:28 PM, P3 stated if the medication bottle isn't in the medication cabinet, P3 doesn't take the medication. P3 stated P3 does take Ambien but offered no explanation why the medication wasn't in the medication cabinet. In an interview on 04/28/22 at 3:40 PM, Administrator stated the PT is required to ask the patient on each visit if there any changes to their medications, and if so, the PT had to update the medication profile.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: G680-CONDITION Based on policy review, record review, observation, and interviews, the home health agency (HHA) failed to meet the requirements of the Condition of Participation of Infection Prevention and Control. 1. The HHA failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. Three (Registered Nurse (RN) 1, Occupational Therapist (OT) 1, Physical Therapy Assistant (PTA) 1) of 12 total staff having direct patient contact or presence in the HHA agency failed to be fully vaccinated. This deficient practice had the potential to cause serious harm to the 12 current HHA patients and any future patient admitted for home health services. (see findings in tag G687) 2. The HHA failed to ensure accepted standards of practice, including the use of standard precautions, were followed to prevent the transmission of infections and communicable diseases. Observation during one of two (Patient (P) 2) home visits made on 04/28/22 at 1:40 PM revealed a breach in the use of personal protective equipment (PPE), specifically glove use. This deficient practice had the potential to affect the 12 current HHA patients and any future patient admitted for home health services. (see findings in tag G682) G680-CONDITION Based on policy review, record review, observation, and interviews, the home health agency (HHA) failed to meet the requirements of the Condition of Participation of Infection Prevention and Control. 1. The HHA failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. Three (Registered Nurse (RN) 1, Occupational Therapist (OT) 1, Physical Therapy Assistant (PTA) 1) of 12 total staff having direct patient contact or presence in the HHA agency failed to be fully vaccinated. This deficient practice had the potential to cause serious harm to the 12 current HHA patients and any future patient admitted for home health services. (see findings in tag G687) 2. The HHA failed to ensure accepted standards of practice, including the use of standard precautions, were followed to prevent the transmission of infections and communicable diseases. Observation during one of two (Patient (P) 2) home visits made on 04/28/22 at 1:40 PM revealed a breach in the use of personal protective equipment (PPE), specifically glove use. This deficient practice had the potential to affect the 12 current HHA patients and any future patient admitted for home health services. (see findings in tag G682)

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 policy review, observation, and interview, the home health agency (HHA) failed to ensure accepted standards of practice, including the use of standard precautions, were followed to prevent the transmission of infections and communicable diseases. Observation during one of two (Patient (P) 2) home visits revealed a breach in the use of personal protective equipment (PPE), specifically glove use. This deficient practice had the potential to affect the 12 current HHA patients and any future patient admitted for home health services. Findings include: Review of the undated policy titled "Personal Protective Equipment" indicated ". . . Gloves will be worn when it can be reasonable anticipated that personnel may have contact with blood or other potentially infectious materials, when performing vascular access procedures; and when handling or touching contaminated items or surfaces. . . Disposable gloves will be removed and discarded after contact with each person, fluid item, surface, if torn or punctured, or when their ability to function as a barrier is compromised. Hands will be washed immediately or as soon as feasible after removal of gloves or any other personal protective equipment. A new set of gloves will be used for contact with each person. . ." Observation on 04/28/22 at 1:40 PM during a home visit revealed Physical Therapist (PT) 1 assessed P2's vital signs (temperature, pulse, blood pressure, oxygen saturation) while wearing gloves. PT1 wore the same gloves used to touch P2 to clean the equipment (blood pressure cuff, thermometer, pulse oximeter probe) used before returning the equipment to PT1's personal bag. PT1 then removed PT1's gloves and re-donned gloves without performing hand hygiene. In an interview on 04/27/22 at 1:55 PM, PT1 stated he/she wore the same gloves that worn to assess P2's vital signs to clean the equipment used and changed gloves without performing hand hygiene before applying the new gloves. PT1 stated he/she should have changed gloves between patient contact and cleaning equipment and performed hand hygiene before applying a second set of gloves.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: G687 Based on record review, policy review, and interview, the home health agency (HHA) failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated as required in QSO-22-07-All for COVID-19. Three (Registered Nurse (RN) 1, Occupational Therapist (OT) 1, Physical Therapy Assistant (PTA) 1) of 12 total staff having direct patient contact or presence in the HHA agency failed to be fully vaccinated. This deficient practice had the potential to cause serious harm to the 12 current HHA patients and any future patient admitted for home health services. Findings include: Review of the undated agency policy titled "Covid Vaccination" indicated ". . . all current staff that has not received the Covid 19 vaccination will be encouraged to receive the vaccination, and provided with information of locations offering the Covid vaccination. . . . This agency will notify the staff that the Covid vaccination is not required but is recommended and that the agency goal is 100 percent compliance. . . Staff that accept or decline the Covid vaccination will have their decision recorded for the purpose of monitoring the agency goal of 100 percent compliance. 6. The periodic recommended boosters will also be encouraged." There was no documentation that the following was addressed in the policy in accordance with the federal regulation for home health agencies as outline in QSO-22-07-All: 1. A process for ensuring that all staff (except for those staff who have pending requests for, or who have been granted, exemptions or those for whom vaccination must be temporarily delayed) have received , at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; 2. A process for ensuring that all staff, except for those staff who have pending requests for, or who have been granted, exemptions or those for whom vaccination must be temporarily delayed, are fully vaccinated. 3. A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated. 4. A process for tracking and securely documenting the COVID-19 status of all staff; 5. A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC (Centers for Disease Control and Prevention); 6. A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; 7. A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements. 8. A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions, has been signed and dated by a licensed practitioner who is acting within their respective scope of practice and for further ensuring that such documentation contains (a) all information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindication, and (b) a statement by the authenticating practitioner recommending that the staff member be exempted based on the recognized clinical contraindications; 9. A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed due to clinical precautions and consideration as recommended by the CDC; and 10. Contingency plans for staff who are not fully vaccinated for COVID-19. Review of documentation of the COVID-19 vaccination of staff, presented in a folder by Administrator, indicated RN1, OT1, and PTA1 had not received a COVID-19 vaccination. In an interview on 04/28/22 at 12:17 PM, Administrator stated "for a while there was a requirement that COVID vaccination was mandatory, but it was held up by the courts." Administrator stated [he/she] wasn't aware that anything had changed." In an interview on 04/28/22 at 3:40 PM, Administrator stated RN1 is testing weekly, because RN1 refuses to get the vaccine. Administrator stated he/she did not have a copy of OT1's vaccination dates, and PTA1 did not receive the vaccination. Administrator confirmed the agency's policy did not require staff to be fully vaccinated and did not include the processes listed above.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: G710 Based on record review, policy review, and interviews, the home health agency (HHA) failed to ensure home health services were provided as ordered by the physician as indicated in the patient's plan of care (POC) for six (Patient (P) 1, P2, P4, P5, P6, P7) of seven sampled patients. This deficient practice had the potential to affect the 12 current patients and any future patient admitted for home health services. Findings include: Review of the undated policy titled "Physician Orders/Plan of Care" indicated ". . . The physician sets up a plan of care, which includes . . . frequency and type of service, . . . an order for each service . . . to be provided by the Agency. . . Orders for all disciplines shall include amount, frequency, and duration. . . Drugs and treatments shall be administered by agency staff only as ordered by the physician . . . The Agency's professional staff will review the clinical records on a continuous basis to ensure that each POC is specific to the patient and that additional orders for services are present in the clinical record. . ." 1. Review of P1's "Home Health Certification and Plan of Care," located under the "Physician Tasks" tab in the electronic medical record (EMR), for the certification period of 03/22/22 to 05/20/22 indicated the skilled nurse (SN) frequency was two times a week for four weeks then one time a week for four weeks. Review of P1's SN visit notes, located under the "Scheduling" tab in the EMR, indicated one SN visit was made the week of 03/27/22, rather two visits as ordered in the POC. In an interview on 04/28/22 at 11:14 AM, Administrator confirmed a SN visit was missed the week of 03/27/22, and there was no documentation that P1's physician was notified. 2. Review of P2's "Home Health Certification and Plan of Care," located under the "Physician Tasks" tab in the EMR, for the certification period of 03/01/22 to 04/29/22 indicated the SN frequency ordered was one time a week for one week. Review of P2's "Physical Therapy Eval [evaluation] & [and] Physician's Certification," performed on 03/22/22 and located under the "Scheduling" tab in the EMR, indicated the PT frequency was two times a week for eight weeks. Review of P2's SN visit notes, located under the "Scheduling" tab in the EMR, indicated there was no SN visit made from 03/01/22 to 03/05/22 (the first week of the certification period). Review of P2's PT visit notes, located under the "Scheduling" tab in the EMR, indicated an extra PT visit was made the weeks of 04/03/22, 04/10/22, and 04/17/22. In an interview on 04/27/22 at 4:22 PM, Administrator stated the SN recertification visit was made at the end of the previous certification, and there was no SN visit made from 03/01/22 to 03/05/22. Administrator confirmed there were extra PT visits made the weeks of 04/03/22, 04/10/22, and 04/17/22. Administrator stated P2's physician was not notified that P2 did not have a SN visit as ordered and that extra PT visits were made without a physician's order. 3. Review of P4's "Home Health Certification and Plan of Care," located under the "Physician Tasks" tab in the EMR, for the certification period of 03/12/22 to 05/10/22 indicated the SN frequency ordered was one time a week for eight weeks. Review of P4's SN visit notes, located under the "Scheduling" tab in the EMR, indicated two SN visits were made the week of 03/13/22 rather than one SN visit as ordered. In an interview on 04/28/22 at 11:20 AM, Administrator stated he/she wanted to recheck P4's leg. Administrator stated he/she spoke with P4's physician but failed to document a verbal order for the extra SN visit. 4. Review of P5's "Home Health Certification and Plan of Care," located under the "Physician Tasks" tab in the EMR, for the certification period of 02/14/22 to 04/14/22 indicated the SN frequency ordered was one time a week for eight weeks. Review of the SN visits performed, located under the "Scheduling" tab in the EMR, indicated a SN visit was performed by Administrator on 04/14/22 without an order for the visit. In an interview on 04/28/22 at 11:40 AM, Administrator confirmed the SN visit made on 04/14/22 did not have a physician's order to perform the visit. Administrator offered no explanation for performing a SN visit without a physician's order. 5. Review of P6's "Physical Therapy Eval & Physician's Certification," performed on 01/22/22 and located under the "Scheduling" tab in the EMR, indicated the PT ordered frequency was two times a week for eight weeks. Review of P6's PT visit notes, located under the "Scheduling" tab in the EMR, indicated one PT visit was made the week of 03/13/22, rather than two visits as ordered. In an interview on 04/28/22 at 11:50 AM, Administrator confirmed a PT visit was missed the week of 03/13/22. 6. Review of P7's "Physical Therapy Eval & Physician's Certification," performed on 01/28/22 and located under the "Scheduling" tab in the EMR, indicated the PT ordered frequency was two times a week for eight weeks. Review of P7's PT visit notes, located under the "Scheduling" tab in the EMR, indicated a PT visit was made on 01/18/22, 02/16/22, and 03/04/22. There was no documentation of missed visit notes, an explanation for the missed visits, or that P7's physician was notified of the change to the POC. In an interview on 04/28/22 at 11:55 AM, Administrator stated the PT visits were made as approved by P7's insurance. Administrator confirmed P7's physician was not notified that the insurance didn't approve the ordered PT visits and the change to P7's POC.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: G718 Based on record review, policy review, and interviews, the home health agency (HHA) failed to communicate with the physician in accordance with agency policy for missed visits and/or extra visits for five (Patient (P) 1, P2, P4, P6, P7) of seven sampled patients. This deficient practice had the potential to affect the 12 current patients and any future patient admitted for home health services. Findings include: Review of the undated policy titled "Physician Orders/Plan of Care indicated ". . . The Agency provides written and oral reports to the physician regarding the patient's plan of treatment and appropriateness of the continuation of care. . ." Review of the undated policy titled "Staffing Issues/Scheduling" indicated ". . . Whenever agency staff is unable to complete a visit either due to the patient not being at home, at the scheduled time or refusing staff admittance; [sic] the staff member will notify the case manager and document the occurrence. If the visit cannot be rescheduled during the same Medicare week a missed visit note will be sent to the physician explaining the circumstances. . ." Review of the undated policy titled "Timeliness and Accuracy of Entries in the Clinical Record" indicated ". . . Any care or visits not provided as ordered must be reported to the physician within 3 days. A written missed visit report is completed, faxed to the physician and kept in patients [sic] chart. The administrator is also notified." 1. Review of P1's "Home Health Certification and Plan of Care," located under the "Physician Tasks" tab in the electronic medical record (EMR), for the certification period of 03/22/22 to 05/20/22 indicated the skilled nurse (SN) frequency was two times a week for four weeks then one time a week for four weeks. Review of P1's SN visit notes, located under the "Scheduling" tab in the EMR, indicated one SN visit was made the week of 03/27/22, rather two visits as ordered in the POC. In an interview on 04/28/22 at 11:14 AM, Administrator confirmed a SN visit was missed the week of 03/27/22, and there was no documentation of a missed visit note and that P1's physician was notified. 2. Review of P2's "Home Health Certification and Plan of Care," located under the "Physician Tasks" tab in the EMR, for the certification period of 03/01/22 to 04/29/22 indicated the SN frequency ordered was one time a week for one week. Review of P2's "Physical Therapy Eval [evaluation] & [and] Physician's Certification," performed on 03/22/22 and located under the "Scheduling" tab in the EMR, indicated the PT frequency was two times a week for eight weeks. Review of P2's SN visit notes, located under the "Scheduling" tab in the EMR, indicated there was no SN visit made from 03/01/22 to 03/05/22 (the first week of the certification period). Review of P2's PT visit notes, located under the "Scheduling" tab in the EMR, indicated an extra PT visit was made the weeks of 04/03/22, 04/10/22, and 04/17/22. In an interview on 04/27/22 at 4:22 PM, Administrator stated the SN recertification visit was made at the end of the previous certification, and there was no SN visit made from 03/01/22 to 03/05/22. Administrator confirmed there were extra PT visits made the weeks of 04/03/22, 04/10/22, and 04/17/22. Administrator stated missed visit notes were not documented. Administrator stated P2's physician was not notified that P2 did not have a SN visit as ordered and that extra PT visits were made without a physician's order. 3. Review of P4's "Home Health Certification and Plan of Care," located under the "Physician Tasks" tab in the EMR, for the certification period of 03/12/22 to 05/10/22 indicated the SN frequency ordered was one time a week for eight weeks. Review of P4's SN visit notes, located under the "Scheduling" tab in the EMR, indicated two SN visits were made the week of 03/13/22 rather than one SN visit as ordered. In an interview on 04/28/22 at 11:20 AM, Administrator stated he/she wanted to recheck P4's leg. Administrator stated he/she spoke with P4's physician but failed to document the report and to document a verbal order for the extra SN visit. 4. Review of P6's "Physical Therapy Eval & Physician's Certification," performed on 01/22/22 and located under the "Scheduling" tab in the EMR, indicated the PT ordered frequency was two times a week for eight weeks. Review of P6's PT visit notes, located under the "Scheduling" tab in the EMR, indicated one PT visit was made the week of 03/13/22, rather than two visits as ordered. In an interview on 04/28/22 at 11:50 AM, Administrator confirmed a PT visit was missed the week of 03/13/22. Administrator stated a missed visit note was not documented, and there was no documentation that P6's physician was notified of the missed visit. 5. Review of P7's "Physical Therapy Eval & Physician's Certification," performed on 01/28/22 and located under the "Scheduling" tab in the EMR, indicated the PT ordered frequency was two times a week for eight weeks. Review of P7's PT visit notes, located under the "Scheduling" tab in the EMR, indicated a PT visit was made on 01/18/22, 02/16/22, and 03/04/22. There was no documentation of missed visit notes, an explanation for the missed visits, or that P7's physician was notified of the change to the POC. In an interview on 04/28/22 at 11:55 AM, Administrator stated the PT visits were made as approved by P7's insurance. Administrator confirmed P7's physician was not notified that the insurance didn't approve the ordered PT visits and of the change to P7's POC.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: G1028 Based on policy review, observation, and interviews, the home health agency (HHA) failed to monitor, manage, and maintain the equipment used to access the web-based medical record system. This had the potential to result in unauthorized access to patient information for the current 12 patients, any discharged patient, and any future patient receiving care from the HHA. Findings include: Review of the undated policy titled "Security of Clinical Information" indicated "Security standards are established to ensure that patient-identifiable information remains confidential and protected from unauthorized disclosure, alteration, or destruction. The Health Insurance and Portability Act of 1996 mandates the adoption of security standards for all healthcare facilities. Security includes the physical and electronic protection of the integrity, availability, and confidentiality of computer based information and the resources used to enter patient information. The security of the records includes the storing, processing and communication of all patient identifiable data. . . The Agency is required by law to maintain the privacy of protected health information and to provide patients with notice of its legal duties and privacy practices with respect to protected health information. . .Protect written communication regarding patients from being viewed by unauthorized individuals, such as phone messages, communication boards, computer entered data . . . All records will be maintained in a lockable storage area or interior locked room and maintained together. . ." Review of the undated policy titled "Cyber Security" indicated ". . . When employees use their digital devices to access company emails or accounts, they introduce security risk to our data. We advise employees to keep both their personal and company-issued computer, tablet and cell phone secure. Keep all devices password protected. . ." Review of the undated policy titled "Protected Health Information Applications Username/Password" indicated ". . . These computer systems and networks must also require that all users change their passwords at least every 180 days and verify that the change has taken place. Users are allowed and encouraged by [name of HHA] to change their passwords at more frequent intervals than the 180-day mandatory period. . ." Review of the above agency policies indicated oversight of staff-owned computers and cell phones used for HHA documentation was not addressed. Observation on 04/28/22 during two home visits from 1:05 PM to 3:00 PM revealed Physical Therapist (PT) 1 used PT1's personal computer to document each visit and PT1 had his/her personal cell phone available if PT1 needed to communicate with office staff or physicians during the visits. In an interview on 04/27/22 at 4:00 PM, Administrator stated staff use their personal computer for documentation and personal cell phones for communication. Administrator stated the staff have to enter a password to access the web-based system, "On Demand." Administrator confirmed HHA staff were not issued agency-provided computers, tablets, or cell phones. In an interview on 04/28/22 at 10:40 AM, Administrator stated the agency doesn't have a policy developed related to staff use of personal computers and cell phones that addresses oversight, security, and maintenance of patients' protected health information. In a telephone interview on 04/29/22 at 8:34 AM, PT1 stated the computer used during the two home visits observed on 04/28/22 was PT1's personal computer. PT1 stated PT1 uses PT1's personal cell phone for HHA needs. PT1 stated PT1 has to enter a password selected by PT1 each time PT1 enters the web-based documentation system, and PT1 has to change the password every 30 days.