Every finding on record at New Mexico Healthcare Services, LLC

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Interim Healthcare Home Health Agency (HHA) on 12/05/2024 found that your facility was in substantial compliance with the Conditions of Participation (CoPs) under 42 CFR 484.102.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Interim Healthcare Home Health Agency (HHA) on 12/05/2024 resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited:

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on record review and interview the facility failed to provide contact information for other agencies on elective transfer from agency for 1 (P[patient]14) out of 2 (P14, and P15) patients reviewed for filing complaints with the agency. This deficient practice could lead to patients not receiving home care services after requesting to end services with this agency. The findings are: A. Record review of the agency’s policy titled, “Discharges, Transfers, and Discharge Planning” dated 12/2023 stated, “X. The patient will be discharged or transferred from any discipline/service when, on consultation with the patient or his family and the physician/practitioner, it is determined that. . . D. The patient refuses services or elects to be transferred or discharged . . . iii. The agency will provide the patient and representative (if any) with contact information for other agencies or providers who may be able to provide care. . .” B. Record review of a complaint report dated 04/14/2024 for P14 revealed that the interventions in response to the patient’s complaint were, “Transfer/discharge from agency.” Patient was discharged from the agency on 04/16/2024. C. Record review of P14’s record did not reveal any evidence that patient was provided with contact information for home care agencies that could provide the services patient needed. D. During an interview on 12/5/2024 at 8:27 AM with S(staff), non-clinical, it was confirmed that there was no contact information provided to the patient.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure that verbal orders received for services were entered in the system for 1 (P[patient]13) out of 13 (P1-P13) patients reviewed for order accuracy. This deficient practice could lead to services being completed without an active order from a physician. The findings are: A. Record review of the agency’s policy titled, “Plan of Care” dated 12/2023 number 5 under, “Procedure” stated “Verbal orders received from the physician/allowed practitioner shall be accepted by personnel authorized to do so by applicable state and federal laws and regulations as well as agency policies. A. All verbal orders shall have the signature, date and time of the authorized personnel receiving the order. B. Verbal orders shall be authenticated and dated by the physician/allowed practitioner in accordance with agency policies and applicable state law and regulations.” B. Record review of P13’s referral received 11/26/2024 under, “Type of Service Requested” it was marked that the only service being requested was physical therapy. C. Record review of P13’s start of care note dated 11/27/2024 revealed that the visit was completed by skilled nursing and revealed that patient was to be scheduled for future skilled nursing visits. D. There was no evidence of an order for skilled nursing services in P13’s record. E. During an interview on 12/4/2024 at 2:50 PM with S(staff)1, non-clinical, it was explained that the order for skilled nursing services was a verbal that had not been entered in the system.

327191_20211221_E000 A Recertification Survey and COVID-19 Focused Infection Control Survey were conducted by Healthcare Management Solutions, LLC on behalf of the New Mexico Department of Health. An unannounced on-site Recertification Survey and COVID-19 Focused Infection Control Survey at the above-named Home Health Agency (HHA) from 12/20/21 to 12/21/21 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

327191_20211221_G000 A Recertification and Focused Infection Control Survey were conducted by Healthcare Management Solutions, LLC on behalf of the New Mexico Department of Health. An unannounced on-site Recertification and Focused Infection Control Survey conducted at the above-named Home Health Agency (HHA) facility from 12/20/21 to 12/21/21 resulted in a finding of substantial compliance respective to the applicable Conditions 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: 327191_20211221_G514 Based on medical record review, policy review, and interview, the home health agency (HHA) failed to conduct the initial assessment visit within 48 hours of the referral, or the patients return home from an inpatient hospital stay, or on a physician or practitioner ordered start of care (SOC) date for two of ten patients (Patient (P) 4, P6). The failure to complete an initial assessment to determine that patient's immediate care needs had the potential to increase the patient's risk for emergent care or rehospitalization. Findings include: 1.Review of P4's electronic medical record (EMR) with Registered Nurse (RN)3 navigating revealed the HHA received a referral for skilled nursing services with a hospital discharge date identified as 10/10/21. Diagnosis identified on the "Home Health Certification and Plan of Care" included chronic kidney disease with heart failure, anemia (lack of healthy red blood cells), acute kidney failure, chronic obstructive pulmonary disease (COPD-lung disease that block airflow making it difficult to breathe), and chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). Review of the "OASIS (Outcome and Assessment Information Set) Start of Care Assessment" in the "Visits" tab in the EMR revealed the initial visit assessment date of 10/14/21. Review of the "Physician Orders" tab in the EMR failed to reveal a specific physician ordered SOC date. At the time of P4's EMR review, RN3 confirmed that the initial assessment visit was not completed within 48 hours of the referral, or the patients return home from a hospital stay, or on a physician ordered SOC date. 2.Review P6's EMR with RN3 navigating revealed a referral from a physician office for physical therapy services dated 11/02/21. Diagnosis on the referral information included osteoarthritis, hypertension, type 2 diabetes, and age-related physical debility. Review of the "OASIS Start of Care Assessment" in the "Visits" tab in the EMR revealed the initial visit assessment was dated 11/08/21. Review of the "Physician Orders" tab in the EMR failed to reveal a specific physician ordered SOC date. Review of the EMR revealed P6 did not have a hospital stay. At the time of P6's EMR review, RN3 confirmed that the initial assessment visit was not completed within 48 hours of the referral or on a physician ordered SOC date. Review of the agency policy titled, "Initial Comprehensive Assessment," dated 04/02/21, revealed, "An initial comprehensive assessment of an individual is conducted a) within 48 hours of referral for home care/service(s), or b) within 48 hours of the individual's return home, or c) on the physician or allowed practitioners' (e.g., NP, PA, CNS) ordered start of care date." During an interview on 12/21/21 at 1:45 PM, the Administrator confirmed P4 and P6 were admitted more than 48 hours after the referral or hospital discharge date, and that neither patient's EMR included a physician or practitioner specified SOC date.