Every finding on record at Mountain Home Health Care, Inc.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Mountain Home Health Care, INC, Home Health Agency (HHA) on 02/12/2025 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 Mountain Home Health Care, INC, Home Health Agency (HHA) on 02/12/2025 resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiency cited:

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 observations, interviews and record review, the facility failed to ensure infection prevention practices were followed during home health visits for 1 (Patient (P)10) of 4 (P7, P8, P9, and P10) patients observed receiving home healthcare visits. This deficient practice could likely result in patients receiving home health care that can expose the patients to potentially infectious pathogens (organisms that can lead to illness). The findings are: A. During an observation on 02/11/25 at 1:04 pm, S (Staff)1 clinical placed a portable medical equipment bag and stethoscope (a medical device used to listen to a person's heart, lungs and other parts of the body) on P10’s dining table without use of an infectious control barrier such as paper towels, newspapers, trash bags, etc. used as a protective barrier for bag placement in the patient/client’s home. B. During an observation on 02/11/25 at 1:14 pm, S1 performed wound care dressing change, then placed the soiled dressings on a paper cloth barrier, removed the contaminated exam gloves used for the dressing change and placed the gloves on top of the paper cloth following the completion of wound care. S1 used both bare hands to pick up the paper cloth barrier which held the soiled dressings, contaminated gloves and disposed of the contaminated items into a trash bag without performing hand washing or hand sanitation after contact with the contaminated items. C. During an interview with S1 on 02/11/25 at 1:59 pm, S1 was asked what the facility’s policy is on bag technique for prevention of cross-contamination in the patient’s homes. S1 replied “Oh shoot, I forgot to place a barrier under my bag and supplies. I did place one under P10’s foot, though. I forgot to do that for my bag.” When S1 was asked what the facility’s policy is regarding hand hygiene, S1 relied “I forgot to do that, too. Please don’t be hard on me. I messed up.” D. Record review of facility’s policy titled “Administrative Policy Manual Bag technique: with last review date of 11/01/2020 stated the following: “Purpose: To describe the procedure for maintaining a contaminate [sic] free home health bag and prevent cross-contamination. Policy: The principles in bag technique are developed and used to maximize the efficient use of the bag and to assure asepsis and the control of infection. Procedure: II. Bag Technique A. …In the patient/client home, a barrier (such as newspaper, paper towel, small trash bag, etc.) is to be placed under the bag. E. Paper towels, newspapers, trash bags, etc. used as a protective barrier for bag placement in the patient/client’s home will be disposed of properly. E. Record Review of the facility’s policy titled “Administrative Policy Manual, Hand Hygiene” with last review date of 01/14/23 stated the following: II. Hand hygiene with an alcohol-based rub Staff will apply product to the palm of on hand A. Staff will rub hands together covering all surfaces of hands and fingers, until hands are dry. This should take about 20 seconds. B. The manufacturer’s recommendations will be followed regarding the volume of the product use. C. Unless hands are visibly soiled, alcohol-based rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Staff may use alcohol-based rub for routinely decontaminating hands in the clinical situations described below: …2. Immediately before and after touching a patient …4. After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings and used supplies (PPE) if hands are not visibly soiled

E000 A recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of State of New Mexico Department of Health. An unannounced on-site recertification survey at the above-named Home Health Agency (HHA) from 03/08/22 to 03/10/22 resulted in a finding of standard level deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

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 policy review and interview, the home health agency (HHA) failed to develop a policy that addressed a system of medical documentation in the event of a disaster that prevented the use of the electronic medical record documentation system that preserved patient information, protected confidentiality of patient information, and secured and maintained availability of records. This deficient practice had the potential to affect all current patients of the agency and any future patient admitted for services. Findings include: Review of the HHA's "All-Hazards Emergency Operations Plan 2021" indicated no policy had been developed that addressed a system of medical documentation in the event of a disaster that addressed patient information, protected confidentiality of patient information, and secured and maintained availability of records. In an interview on 03/10/22 at 12:55 PM, Administrator stated the agency did not have a policy in its emergency preparedness plan that addressed the protocol to maintain confidentiality. of patient medical information during an emergency event.

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 policy review and interview, the home health agency (HHA) failed to develop a policy that addressed the means of providing information about the HHA's occupancy, needs, and its ability to assist during a disaster to the authority having authority. This deficient practice had the potential to affect all current patients of the agency and any future patient admitted for services. Findings include: Review of the HHA's "All-Hazards Emergency Operations Plan 2021" indicated no policy had been developed that addressed the means of providing information about the HHA's occupancy, needs, and its ability to assist during a disaster to the authority having authority. In an interview on 03/10/22 at 12:55 PM, Administrator stated the agency did not have a policy in its emergency preparedness communication plan that addressed the means of providing information about the HHA's occupancy, needs, and its ability to assist during a disaster to the authority having authority.

G000 A recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of State of New Mexico Department of Health. An unannounced on-site recertification survey conducted at the above-named Home Health Agency (HHA) from 03/08/22 to 03/10/22 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.

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 policy review, record review, and interviews, the home health agency (HHA) failed to ensure skilled professionals provided services as ordered by the physician for 8 (Patient (P) 1, P2, P3, P4, P6, P8, P9, P13) of 13 sampled records. This deficient practice had the potential to affect all patients receiving services of the HHA and any future patient admitted for HHA services. Findings include: During an interview on 03/08/22 at 12:30 PM, the Clinical Manager (CM) stated the agency staff have not notified the physician when visits were missed. The surveyor made a request to review the agency's policy regarding communication by staff with physicians related to missed visits. Review of the undated policy titled "Physician's Plan of Care/ Change Orders" indicated ". . . The physician's Plan of Care Home [sic] Health Certification and Plan of Treatment (CMS [Centers for Medicare and Medicaid Services] 485) is an individualized plan for care and treatment prepared by the client's physician with assistance from the nurse and/or Therapist who establishes the plan based upon the current assessment of the client . . . The Agency will provide care/services consistent with the Plan of Care. . . The physician shall be notified of any changes to the plan of care. . ." Review of the undated policy titled "Referral and Acceptance of Clients" indicated ". . . Referrals containing verbal orders must be given by the referring physician, or by others approved by law to prescribe . . . Upon receipt of a referral, an evaluation by a Registered Nurse and/or appropriate Therapist will be completed to determine that care can be adequately and safely performed in the client's residence, to assess the client care needs, and to ensure that the client meets the admission criteria . . ." 1. Review of P1's "Home Health Certification and Plan of Care," located under the "Medical Records" tab, for the certification period of 02/16/22 through 04/16/22 indicated the skilled nurse visit frequency was one time a week for eight weeks. Review of P1's visit notes, located under the "Medical Records" tab, indicated Registered Nurse (RN) 1 documented a nursing visit on visit on 02/28/22 and 03/03/22 (two visits the week of 02/27/22). In an interview on 03/08/22 at 12:45 PM, Clinical Manager (CM) stated P1's plan of care was not followed as ordered by the physician. 2. Review of P2's "Home Health Certification and Plan of Care," located under the "Medical Records" tab, for the certification period of 01/09/22 through 03/09/22 indicated the physical therapy (PT) frequency was one time a week for eight weeks. Review of P2's visit notes, located under the "Medical Records" tab, indicated Physical Therapy Assistant (PTA) 1 documented that a PT visit was not made on 02/03/22 (Thursday) and 02/24/22 (Thursday) due to weather conditions. There was no documentation that attempts were made later in the week to complete the ordered visits. In an interview on 03/08/22 at 1:30 PM, CM stated P2's plan of care was not followed as ordered by the physician. 3. Review of P3's "Home Health Certification and Plan of Care," located under the "Medical Records" tab, for the certification period of 12/29/21 through 02/26/21 indicated the speech therapy (ST) frequency was one time a week for nine weeks, and the occupational therapy (OT) frequency was one day (01/05/22) and then one time a week for six weeks. Review of P3's referral, located under the "Medical records" tab, dated 12/27/21 indicated ". . . Physical Therapist Referral . . . resume PT per previous referral situation . . . renewal of occupational and speech therapy as well as home care nursing as previously before discontinuation of therapy r/t [related to] safety issues. . ." Review of the plan of care and visit notes for P3 indicated no documentation that PT and nursing services were provided as ordered in the referral. Review of P3's documentation of visit notes, located under the "Medical Records" tab, indicated no ST visit was conducted the week of 02/20/22. Review of a "Quick Note," located under the Medical Records" tab, indicated Speech Language pathologist (SLP) 1 documented that the ST visit on 01/24/22 was cancelled due to SLP1 having "PTO" [paid time off]. Further review indicated there was no documentation of an OT visit the week of 02/13/22 as ordered in the plan of care (sixth week). Further review indicated OT1 documented an OT visit on 02/22/22, and there was no documentation of a physician's order for the visit. Review of documentation by Intake Coordinator (IC) on 03/10/22 indicated ". . . When the referral came in on 12/27/21, I was not expecting to see SN [skilled nursing] or PT. The wording indicates previously discontinued services, and SN had never been a service provided during the brief prior episode, so I did not schedule an SN evaluation. As far as PT goes, we are a small agency with limited resources and the patient is quite infirm. In my conversation with therapy dept [department] it was thought that it would be difficult for the patient to participate in PT and challenging for PT to show progress. I thought there had been discussions between therapy and [name of primary care provider], but I have no documentation of that. In an interview on 03/08/22 at 2:05 PM, CM stated the OT and ST visits were not conducted in accordance with P3's plan of care. CM stated nursing and PT services were not provided as requested in the referral. In an interview on 03/10/22 at 12:40 PM, IC confirmed he/she documented the above information related to P3's referral. IC stated he/she did not speak with P3's referring physician to clarify the referral request. 4. Review of P4's "Home Health Certification and Plan of Care," located under the "Medical Records" tab, for the certification period of 02/16/22 through 04/16/22 indicated a nursing frequency of one day a week for one week then two times a week for two weeks. Further review indicated OT1 evaluated P4 on 02/21/22 with a frequency of one time a week for eight weeks with two visits as needed for supervisory visits. Review of P4's visit notes, located under the "Medical Records" tab, indicated a second nursing visit was not conducted the week of 02/20/22 as ordered. Further review indicated an extra OT visit was performed the week of 02/20/22 (one visit was ordered; the second visit was not documented as an as needed supervisory visit) with no physician order for the visit. In an interview on 03/08/22 at 2:50 PM, CM stated review of P4's EMT indicated there was a missed nursing visit and an extra OT visit the week of 02/20/22. 5. Review of P6's physician orders for the certification period of 01/18/22 through 03/18/22, located under the "Medical Records" tab, indicated the following nursing orders: SN one day (01/18/22). SN one time a week for one week (01/19/22), then two times a week for eight weeks (01/23/22 to 03/18/22). SN change to one time a week for three weeks (02/21/22 to 03/12/22). Review of P6's nursing visit notes, located under the "Medical Records" tab, indicated one nursing visit was conducted the weeks of 02/06/22 and 02/13/22 rather than two visits as ordered. In an interview on 03/09/22 at 9:25 AM, CM stated the nursing frequency was not implemented according to P6's plan of care. 6. Review of P8's "Home Health Certification and Plan of Care," located under the "Medical Records" tab, for the certification period of 08/07/21 through 10/05/21 indicated the SN frequency was three times a week for nine weeks. Review of P8's SN visit notes, located under the "Medical Records" tab, indicated two SN visits were made the weeks of 08/08/21, 08/15/21, 08/29/21, and 09/05/21 rather than three visits each week as ordered. Further review indicated the list of SN visits, located under the "Medical Records" tab, indicated a SN visit was made by RN3 on 08/11/21 with no documentation of a SN visit note documented by RN3. Review of a "Quick Note," located under the "Medical Records" tab, documented by RN3 on 08/11/21 indicated "SN calls APS [adult protection service] at 1120a [11:20 AM] on 8/11/21 regarding [P8] and [his/her] fragile physical, mental, and emotional system and no support and ER [emergency room] visit for HTN [hypertensive] crisis. . ." In an interview on 03/10/22 at 9:00 AM, CM stated the nursing frequency for P8 was not implemented in accordance with P8's plan of care. In an interview on 03/10/22 at 10:33 AM, RN3 stated RN3 did not remember P8. RN3 stated in order to document a "Quick Note" stating that P8 was in hypertensive crisis, RN3 would expect that RN3 assessed P8's blood pressure, and if so, there should have been a nursing note for the visit made on 08/11/21. 7. Review of P9's "Home Health Certification and Plan of Care," located under the "Medical Records" tab, for the certification period of 05/22/01 through 07/20/21 indicated the PT frequency was one day for one day (05/22/21) then one time a week for five weeks. Review of P9's visit notes, located under the "Medical Records" tab, indicated PT did not make a visit the week of 06/20/21 as ordered and made an extra visit on 06/28/21 without having a physician's order for the visit. Review of P9's "Quick Note," located under the "Medical Records" tab, documented by PT1 on 06/29/21 at 9:18 AM indicated "Appointment for Jun [sic] 26, 2021 cancelled on Jun [sic] 29, 2021 . . . request to r/t [return] to mon [Monday] 06/28. . ." In an interview on 03/10/22 at 9:30 AM, CM stated PT1's note was documented after P9 was discharged. CM stated the PT visit made on 06/28/21 did not have a physician's order to conduct the visit. CM confirmed that P9's plan of care was not implemented as ordered. 8. Review of P13's "Home Health Certification and Plan of Care," located under the "Medical Records" tab, for the certification period of 02/17/22 through 04/17/22 indicated the SN frequency was one time a week times one week, then one to two times a week for one week, and then two times a week for three weeks. Further review indicated the OT frequency was two times a week for three weeks. Review of P13's visit notes, indicated one OT visit was missed 02/18/22 and the week of 02/20/22, and two OT visits were missed the week of 02/27/22. Review of P13's "Quick Notes," located under the "Medical records" tab, indicated OT1 documented that OT visits scheduled for 02/23/22, 03/01/22, and 03/03/22 were cancelled due to having no insurance authorization. There was no documentation that OT1 notified P13's physician of the missed visits that resulted in a change to P13's plan of care. Further review indicated RN1 documented that a SN visit was cancelled on 02/25/22 and 03/04/22 with no documentation that P13's physician was notified of the change in P13's plan of care. In an interview on 03/10/22 at 11:30 AM, CM confirmed that P13's EMR indicated P13's plan of care was not implemented as ordered. In an interview on 03/10/22 at 11:45 AM, CM stated the clinician should be notifying the physician of a frequency change and documenting the notification in the patient’s medical record. CM stated CM has not seen documentation in the visit notes reviewed with surveyor that the physician was notified of missed visits. CM stated there is a place in the visit note that allows the clinician to document communication with the physician and other agency clinicians. CM stated the “Quick Notes” that were documented for some of the patients reviewed with the surveyor did not include that the physician was notified of the missed visits. In an interview on 03/10/22 at 12:25 PM, Director of Rehabilitation (DReh) stated DReh noticed the policy stated they (agency staff) were supposed to notify the physician of missed visits, but they have not been doing it.

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 and interviews, the home health agency (HHA) failed to ensure the professional staff communicated with the physician and/or other agency professional staff involved in the patient's plan of care regarding a patient's report of a fall for two (Patient (P) 2, P12) of two patient records reviewed with reports of a fall from a sample of 13 patients. This deficient practice had the potential to affect all patients receiving services from the HHA as well as any future patient admitted for services. Findings include: A request was made to Clinical Manager (CM) on 03/08/22 at 12:30 PM and on 03/10/22 at 11:45 PM to review the HHA's policy regarding communication with the physician and amongst agency staff, such as between a COTA and an OT, regarding patient events, such as a fall. A request was made to Administrator on 03/10/22 at 12:55 PM to view a policy that addressed communication with the physician and amongst agency staff, such as between a COTA and an OT, regarding patient events, such as a fall. As of the time of exit on 03/10/22 at 2:05 PM, no policy had been presented regarding communication by staff with physicians and communication between agency staff related to the patients' plan of care, and the surveyor was not informed by Administrator or CM whether such a policy existed. 1. Review of P2's "Home Health Certification and Plan of Care" for 01/09/22 through 03/09/22, located under the "Medical Records" tab, indicated P2's primary diagnosis was "Facial weakness following cerebral infarction." Review of P2's "Narrative Note," located under the "Medical Records" tab, for a visit performed by COTA1 on 01/25/22 indicated ". . . Pt [patient] reported taking a fall on Saturday and using his L [left] elbow to break the fall. L elbow only injured area, and minor. Pt able to get up on his own. Pt attributes fall to loss of balance, was using cane and was alone at the time. . ." Review of the visit note indicated no documentation that COTA1 notified OT1 and P2's physician of the fall. In an interview on 03/08/22 at 1:30 PM, CM stated there was no documentation in COTA1's visit note on 01/25/22 and no "Quick Note" (tab in the electronic medical record (EMR) system under the "Medical Records" tab used by staff to document conversations with physicians and/or other clinical agency staff) in P2's EMR that COTA1 notified P2's physician and OT1 of P2's fall. In an interview on 03/08/22 at 2:17 PM, OT1 stated OT1 and COTA1 speak weekly to discuss patients seen by COTA1, but OT1 and COTA1 do not document the conferences. 2. Review of P12's skilled nursing notes for 02/17/22 and 02/18/22 documented by Licensed Practical Nurse (LPN) 1 indicated P12 reported two falls the night of 02/16/21 and two falls the morning of 02/18/22. LPN1 documented four skin tears to P12's left leg and foot from the fall on 02/16/22 that were cleaned and dressed. LPN1 documented bruising to P12's left flank and back and multiple skin tears to the left lower extremity that were cleaned and dressed. LPN1 documented that P12 was advised to go to the emergency room "ASAP" [as soon as possible] or to call emergency medical services. There was no documentation that LPN1 reported the falls to the Registered Nurse (RN) case manager and P12's physician. In an interview on 03/10/22 at 11:00 AM, CM confirmed that review of P12's EMR indicated there was no documentation that LPN1 reported P12's falls to the RN case manager and P12's physician. In an interview on 03/10/22 at 11:15 AM, CM stated LPN1 calls CM with questions or reports of patient incidents, but neither CM nor LPN1 documents the discussion or recommendations in the EMR.