Every finding on record at New Mexico Healthcare Services LLC

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 at the above-named Home Health Agency (HHA) from 10/31/22 to 11/02/22 resulted in a 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 New Mexico Department of Health. An unannounced on-site recertification survey conducted at the above-named Home Health Agency (HHA) from 10/31/22 to 11/02/22 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record reviews, policy review, and interviews, the home health agency (HHA) failed to ensure staff performed the initial assessment within 48 hours of the referral or discharge from the hospital for six (Patient (P) 1, P3, P4, P5, P6, P7) of 10 patient records reviewed. This deficient practice had the potential to affect any patient admitted to the HHA for home health services. Review of the policy titled "Initial Comprehensive Assessment," dated 04/02/21, indicated "Policy 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's or allowed practitioner's . . . ordered start of care date. . . If the initial comprehensive assessment cannot be conducted within the time frame agreed upon at referral . . . the ordering physician or allowed practitioner . . . is contacted for an order for an alternate date. 1. Review of P1's electronic medical record (EMR) indicated a referral (located under the "Patient Attachments" tab that was located under the "Attachments" tab) was signed by the physician on 09/27/22 for a physical therapy (PT) and occupational therapy (OT) evaluation. Review of P1's "Home Health Certification and Plan of Care" (located under the "Orders" tab) for the certification period of 09/30/22 to 11/28/22 indicated P1's start of care (SOC) date was 09/30/22, 72 hours after receipt of P1's referral. There was no documentation that P1's physician was notified of the delay in providing services, and there was no physician order for P1's admission to be done greater than 48 hours after receipt of the referral. In an interview on 11/01/22 at 12:01 PM, Administrator confirmed P1's initial assessment was conducted greater than 48 hours after the referral was received. Administrator confirmed there was no documentation P1's physician was notified of the delay, and no physician order was received for an alternate date for the assessment to be done. 2. Review of P3's EMR indicated a referral was signed by the physician on 09/01/22 for skilled nursing, PT, OT, and home health aide and received by fax by the HHA on 09/05/22. Review of P3's "Home Health Certification and Plan of Care" for the certification period of 09/14/22 to 11/12/22 indicated P3's SOC date was 09/14/22, nine days after the HHA received the referral. There was no documentation that P3's physician was notified of the delay in providing services, and there was no physician order for P3's admission to be done greater than 48 hours after receipt of the referral. In an interview on 11/01/22 at 12:06 PM, the Administrator confirmed P3's initial assessment was conducted more than 48 hours after the referral was received. The Administrator confirmed there was no documentation that P3's physician was notified of the delay, and no physician order was received for an alternate date for the assessment to be done. 3. Review of P4's EMR indicated a referral was signed by the physician on 09/21/22 for skilled nursing, PT, and OT. Review of P4's "Home Health Certification and Plan of Care" for the certification period of 09/28/22 to 11/26/22 indicated P4's SOC date was 09/28/22, seven days after the HHA received the referral. There was no documentation that P4's physician was notified of the delay in providing services, and there was no physician order for P4's admission to be done greater than 48 hours after receipt of the referral. In an interview on 11/01/22 at 11:58 AM, Administrator confirmed P4's initial assessment was conducted greater than 48 hours after the referral was received. The Administrator confirmed there was no documentation that P4's physician was notified of the delay, and no physician order was received for an alternate date for the assessment to be done. 4. Review of P5's EMR indicated a referral was signed by the physician on 08/30/22 for skilled nursing and PT. Further review indicated P5 was being discharged from the hospital on 08/31/22. Review of P5's "Home Health Certification and Plan of Care" for the certification period of 09/04/22 to 11/02/22 indicated P5's SOC date was 09/04/22, four days after P5 was discharged from the hospital. There was no documentation that P5's physician was notified of the delay in providing services, and there was no physician order for P5's admission to be done greater than 48 hours after discharge from the hospital. In an interview on 10/31/22 at 12:20 PM, Administrator confirmed P5's initial assessment was conducted greater than 48 hours after P5 was discharged from the hospital. Administrator confirmed there was no documentation P5's physician was notified of the delay, and no physician order was received for an alternate date for the assessment to be done. 5. Review of P6's EMR indicated a referral was signed by the physician on 08/23/22 for PT and OT and received by fax by the HHA on 08/24/22. Further review indicated P6 was discharged from the hospital on 08/25/22. Review of P6's "Home Health Certification and Plan of Care" for the certification period of 09/08/22 to 11/06/22 indicated P6's SOC date was 09/08/22, 14 days after P6 was discharged from the hospital. There was no documentation that P6's physician was notified of the delay in providing services, and there was no physician order for P6's admission to be done greater than 48 hours after discharge from the hospital. In an interview on 11/01/22 at 12:03 PM, Administrator confirmed P6's initial assessment was conducted greater than 48 hours after P6 was discharged from the hospital. The Administrator confirmed there was no documentation P6's physician was notified of the delay, and no physician order was received for an alternate date for the assessment to be done. 6. Review of P7's EMR indicated a referral was signed by the physician on 07/19/22 for PT and skilled nursing. Review of P7's "Home Health Certification and Plan of Care" for the certification period of 09/23/22 to 11/21/22 indicated P7's SOC date was 07/25/22, six days after the referral was made. There was no documentation that P7's physician was notified of the delay in providing services, and there was no physician order for P7's admission to be done greater than 48 hours after receipt of the referral by the HHA. In an interview on 11/02/22 at 8:55 AM, Administrator confirmed P7's initial assessment was conducted greater than 48 hours after P7's referral was received. Administrator confirmed there was no documentation P7's physician was notified of the delay, and no physician order was received for an alternate date for the assessment to be done.

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: Based on policy review, record reviews, observations, and interviews, the home health agency (HHA) failed to ensure a copy of each patient's medication profile was in the home and kept current with the medications the patient was taking as observed during three of three patient (Patient (P) 4, P2, P1) home visits conducted from a sample of 10 patients. This deficient practice had the potential to affect the current 155 patients and any future patient admitted to the HHA for home health services. Review of the policy titled "Medications," dated 12/21/21, indicated ". . . 1. The designated qualified nurse provides the patient/caregiver with medication instructions that include at a minimum: . . . b) Name and description of the medication; c) Dosage, route of administration, and duration of drug therapy; d) Special directions and precautions for preparation, self-administration as appropriate. . . ensures: a) Orders for administration of medications are complete, including: patient name, name of medication, dosage or amount, frequency and duration, method or route of administration. . ." Review of the policy titled "Contents of the Patient/Client Record – continued," dated 04/02/21, indicated ". . . The following standardized paper forms or their equivalent are found in the in-home presentation Pocket Folder. . . h) Medication Profile. . ." Review of the policy titled "Coordination of Care Services," dated 04/02/21, indicated ". . . The designated Clinical Manager ensures the patient/client/caregiver is provided written instructions outlining: . . . b) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by the agency. . ." The policy did not address the process for keeping the medication profile updated as medication changes, additions, and/or discontinuation of medications occur. 1. Observation on 11/01/22 at 9:00 AM during a home visit with P4 revealed a copy of P4's medication profile was not in the home. Review of P4's medication profile, copied from the electronic medical record (EMR) and presented by Administrator, for the certification period of 09/28/22 to 11/26/22 indicated the following medications listed on the medication profile. The medications listed had no specific instruction for use which included the frequency the medication was to be taken or a dosage listed: a. Hydrocodone (used to relieve acute pain severe enough to require opioid treatment) 5 mg (milligrams)-Acetaminophen 325 mg tablet, take one tablet by mouth every eight hours as needed. The medication bottle had instructions to take every four hours as needed for pain. b. Metoprolol Succinate ER (extended release) (used to treat chest pain and high blood pressure) 50 mg tablet "per instructions." The bottle had instructions to take one and a half tablet daily. c. Omeprazole (used to treat certain conditions where there is too much acid in the stomach) 20 mg capsule, delayed release "per instructions." The bottle had instructions to take one capsule twice a day. d. Pravastatin (medicine to treat high cholesterol) 40 mg tablet "per instructions." The bottle had instructions to take one tablet daily. e. Spironolactone (used in combination with other medicines to treat high blood pressure and heart failure) 25 mg tablet "per instructions." The bottle had instructions to take one tablet daily. f. Cyclobenzaprine (used with rest, physical therapy, and other measures to relax muscles and relieve pain and discomfort) 10 mg tablet, one tablet every eight hours. The bottle had instructions to take one tablet twice daily as needed for muscle spasm. g. Ergocalciferol (Vitamin D2) (works by helping the body to use more of the calcium found in foods) 1250 mcg (micrograms) capsule "per instructions." The bottle had instructions to take one capsule weekly. Further review of the medication profile indicated the following medications were not listed but were being taken by P4: a. Feosol (iron supplement used to treat or prevent low blood levels of iron) one tablet every day. b. Aspirin (used to reduce the risk of serious problems like heart attacks and strokes) 81 mg, one orally per day. c. Lisinopril (used to treat high blood pressure) 20 mg, take one daily. d. Biotin (often recommended for strengthening hair and nails)10,000 mcg one orally daily. e. Gabapentin (treats seizures, also nerve pain) 100 mg one orally three times a day. In an interview on 11/01/22 at 9:50 AM, Registered Nurse (RN) 1 confirmed a copy of P4's medication profile was not in the file. RN1 confirmed the medication profile in P4's EMR did not include specific instructions for the frequency the medications were to be taken and did not include all medications being taken by P4. 2. Observation on 11/01/22 at 10:58 AM during a home visit with P2 revealed a copy of P2's medication profile was not in the home. Review of P2's medication profile, copied from the EMR and presented by Administrator, for the certification period of 09/04/22 to 11/02/22 indicated the following discrepancy from the medication in the home compared to the medication listed on the medication profile: a. Amitriptyline (used to treat symptoms of depression) 25 mg tablet with directions to take two tablets at bedtime (listed on the medication profile). The directions on the bottle in the home dated 10/14/22 indicated one tablet was to be taken at bedtime for one month then two tablets were to be taken at bedtime thereafter. b. Atorvastatin (used together with a proper diet to lower cholesterol and fat levels in the blood) 20 mg tablet, one tablet at bedtime was listed on the profile but was not with P2's medications. At the time of the observation and review, P2 stated P2 no longer took Atorvastatin. c. Oxybutynin Chloride (used to treat certain bladder and urinary conditions such as overactive bladder) 5 mg tablet, take one tablet daily. The bottle dated 10/21/22 had directions to take 10 mg orally every day. Observation on 11/01/22 at 10:58 AM revealed a bottle of Rosuvastatin (used to treat high cholesterol) 10 mg dated 08/02/22 with directions to take one tablet every day. This medication was not listed on P2's medication profile. In an interview on 11/01/22 at 11:10 AM, P2's spouse stated P2 did not have a copy of P2's medication profile in the home. In an interview on 11/01/22 at 11:30 AM, Occupational Therapist (OT) 1 stated he/she does not review P2's medications on P2's visit. OT1 stated the nurse does the medication review. When OT1 was informed that only OT and the physical therapist were providing services in the home, OT1 stated the physical therapist reviewed the medications when only OT and physical therapy provided services. 3. Observation on 11/01/22 at 1:00 PM during a home visit with P1 revealed a copy of P1's medication profile was not in the home. Review of P1's medication profile, copied from the EMR and presented by Administrator, for the certification period of 09/30/22 to 11/28/22 indicated the following discrepancy from the medication in the home compared to the medication listed on the medication profile: a. Metoprolol tartrate (used to treat chest pain and high blood pressure) 25 mg tablet, take one tablet daily. The bottle in P1's home had directions to take one-half tablet daily. b. Tamsulosin (used to treat the symptoms of an enlarged prostate) 0.4 mg, take one daily. The bottle had directions to take one-half daily. Observation on 11/01/22 at 1:00 PM revealed a bottle of Losartan (used to treat high blood pressure and heart failure) 25 mg dated 09/12/22 with directions to take one tablet every day. This medication was not listed on P1's medication profile. In an interview on 11/01/22 at 1:50 PM, Physical Therapist (PT) 1 stated PT1 "usually asks the patient if there's any change in medications if there's a caregiver present, if not I check the medications with medications bottles." PT1 confirmed there was no medication profile in P1's home. PT1 confirmed the discrepancies of medications in P1's home and what was listed on the medication profile.

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 policy review, observations, and interviews, the home health agency (HHA) failed to ensure staff practiced hand hygiene in accordance with policy as observed during two (Patient (P) 4, P2) of three home visits conducted on 11/01/22. This deficient practice had the potential to affect the current 155 patients and any future patient admitted for home health services. Review of the policy titled "Engineering Controls and Work Practices," dated 06/24/11, indicated ". . . Employees who come in contact with patients/clients or regulated biohazardous waste practice the following good hand-washing behaviors to reduce exposure and prevent the spread of bloodborne pathogens and other infections. Employees wash their hands: a) Prior to patient/client care or interventions. . . b) Immediately after patient/client care or contact with objects in the immediate vicinity of the patient/client; c) Immediately before using gloves and immediately after removal of gloves and other personal protective equipment; d) Moving from a contaminated body site to a clean body site during patient care; e) Immediately after handling or contact with any contaminated material. . . h) When leaving the assignment. . . Equipment/Supply Bag technique. . . Employees' [sic] clean equipment carried in their equipment/supply bag with a disinfectant. . . after each use and before returning to the equipment/supply bag to prevent the spread of bloodborne pathogens. . . Hands must always be cleansed after removing gloves or if they have inadvertently been contaminated. F) Clean used equipment and wash hands before replacing equipment in the bag. . ." 1. Observation during a home visit on 11/01/22 at 9:08 AM revealed Registered Nurse (RN) 1 donned gloves to assess P4's vital signs. RN1, while wearing the gloves used to touch P4's skin and clothing to assess vital signs, opened a container of "Micro-Kill Germicidal Bleach Wipes" (used for disinfection of patient care equipment), held the roll of wipes in RN1's contaminated gloved hands, removed a wipe to disinfect patient care equipment, and returned the contaminated roll of wipes to the container. RN1 then disinfected the blood pressure cuff and pulse oximeter (equipment used to measure oxygen level) with RN1's contaminated gloved hands. RN1 then touched inside RN1's supply bag to return the patient care equipment while wearing the same contaminated gloves. RN1 then documented on RN1's tablet while wearing contaminated gloves. While wearing the same gloves, RN1 took RN1's cell phone from RN1's pocket to call P4's physician at 9:40 AM and touched P4's medication bottle. RN1 then removed RN1's gloves and performed hand hygiene. In an interview on 11/01/22 at 9:50 AM, RN1 confirmed the above observations were breaches in the agency's hand hygiene policy. 2. Observation during a home visit on 11/01/22 at 11:28 AM revealed Occupational Therapist (OT) 1 performed hand hygiene and donned gloves to assess P2's vital signs and assist P2 in performing exercises. Continuous observation revealed OT1 used "Micro-Kill Germicidal Bleach Wipes" to wipe OT's hands. OT1 then wiped all patient care equipment used during the visit with "Micro-Kill Germicidal Bleach Wipes" while wearing the same contaminated gloves used to provide patient care. In an interview on 11/01/22 at 11:30 AM, OT1 confirmed OT1 wiped his/her gloved hands with the "Micro-Kill Germicidal Bleach Wipes" and disinfected the patient care equipment with contaminated gloved hands.

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: Based on policy review, "Quality, Safety & Oversight (QSO) memo 22-09”, and interview, the home health agency (HHA) failed to ensure the agency's COVID-19 vaccination policy contained all the required content. This deficient practice had the potential to affect the current 155 patients, all current staff, any future patient admitted to the HHA for home health services, and any future staff employed or contracted to provide home health services. 1.Review of the agency policy titled, "COVID-19 Vaccination Policy," effective 11/18/21, indicated ". . . All employees are required to receive vaccinations as determined by the CMS [Centers for Medicare and Medicaid Services] Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule, unless a reasonable accommodation is approved. Employees not in compliance with this policy will be placed on unpaid leave until their employment status is determined by the human resources department . . ." The agency policy, "COVID-19 Vaccination Policy" did not include the following content required by "QSO-22-09-ALL Guidance for the Interim Final Rule - Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination": a. 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 b. A process for tracking and securely documenting the COVID-19 vaccination status of all staff c. 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 d. 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 e. 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 (1) 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 (2) 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 f. 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 g. Contingency plans for staff who are not fully vaccinated for COVID-19. In an interview on 11/01/22 at 3:10 PM, Administrator confirmed the HHA's policy did not include the processes for COVID-19 vaccination as required by "QSO-22-09-ALL Guidance for the Interim Final Rule - Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination."

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: Based on policy review, medical record review, and interviews, the home health agency (HHA) failed to ensure services were provided as ordered by the physician in the patient's plan of care (POC) for four (Patient (P) 1, P4, P8, P9) of ten sampled patients. This deficient practice had the potential to affect the 155 current home health patients and any future patient admitted for services. Review of the policy titled "Developing a Plan to Meet Patient/Client Needs," dated 04/02/21, indicated "Policy An individualized Plan of Care/Service Plan is developed for each patient receiving care/service to specify the care and services necessary to meet the patient's specific needs and goals as identified in the comprehensive assessment. . . The provision of care/service is in accordance [sic] a physician or allowed practitioner . . . orders that are: . . . Complete including at least discipline, frequency, duration and detailed intervention. . ." Review of the agency policy titled "Variances from the Plan of Care/Service Plan," dated 04/02/21, indicated ". . . If the office is unable to fill the visit/shift/hour requirement of a patient/client, then the [office designee] a) Contacts the patient/client/caregiver to reschedule the visit/shift to comply with the physician's or allowed practitioner's. . . orders or service plan as established. I) If rescheduling is not an option, the designated employee identified the patient's/client's needs and the potential for clinical impact upon the patient, during this unfilled visit/shift or reduced hours. ii) The designated employee identified alternative measures/means to ensure the patient's/client's needs are met . . . b) If alternative means can be engaged to fulfill the patient's/client's needs, that does not have a potential for clinical impact upon the patient, the communication and alternative means of care/service is documented. c) If alternative means cannot be identified and the visit/shift/hours are not filled but the missed care/services do not put the patient/client at risk and does not have a potential for clinical impact upon the patient, the communication is documented such. D) If the alternative means cannot be identified and the patient/client will be put at risk by not filling the visit/shift/hour requirement, then the . . . designee notifies all parties including any ordering physician or allowed practitioner. . . i) The physician or allowed practitioner. . . decides whether the patient visit may be skipped, or additional intervention is required by the Office due to the impact on the patient. . . for care/services. . ." The policy did not require the physician to be notified and an order obtained for the change to the POC when alternative means cannot be identified, and the visit/shift/hours are not filled, but the missed care/services do not put the patient/client at risk and does not have a potential for clinical impact upon the patient. 1. Review of P1's electronic medical record (EMR) indicated P1's "Home Health Certification and Plan of Care" for 09/30/22 to 11/28/22, located under the "Orders" tab, included a physical therapy (PT) frequency of one time a week for one week then two times a week for three weeks, effective 10/02/22. Review of P1's PT visits, located under the "Visits" tab, indicated a PT visit was missed the week of 10/09/22. Review of P1's "Missed Visit Report," located under the "Coordination Notes" tab, indicated a PT was missed on 10/13/22 with the reason documented as "duplicated visit." There was no documentation that P1's physician was notified of the change in P1's POC. In an interview on 10/31/22 at 1:50 PM, Administrator stated a duplicated visit should not be the reason for the missed visit, because P1's visit was scheduled, and the frequency was for two times a week. Administrator confirmed the visit was missed, and there was no documentation that P1's physician was notified of the missed visit. 2. Review of P4's EMR indicated P4's "Home Health Certification and Plan of Care" for 09/28/22 to 11/26/22, located under the "Orders" tab, included a PT frequency of two times a week for four weeks effective 10/02/22. Review of P4's "Client Coordination Note Report," located under the "Coordination Notes" tab, indicated a PT visit was missed on 10/07/22 with the reason missed documented as "clinician COVID positive, reschedule for next week" with documentation that P4's physician was notified. Review of P4's "Missed Visit Report," located under the "Coordination Notes," indicated a PT visit was missed on 10/14/22 with the reason documented as "duplicated visit." There was no documentation P4's physician was notified of the missed visit on 10/14/22. In an interview on 10/31/22 at 1:05 PM, Administrator stated a physical therapy assistant (PTA) should have been scheduled to make the PT visit when the PT was out with COVID. Administrator stated a missed visit note was documented for 10/14/22 stating it was a "duplicated visit," but a visit should have been made according to the physician orders. 3. Review of P8's EMR indicated P8's "Home Health Certification and Plan of Care" for 07/21/22 to 09/18/22, located under the "Orders" tab, included a skilled nurse frequency of one time a week for one week then two times a week for eight weeks. Review of a physician's order, located under the "Orders" tab dated 08/05/22, indicated the skilled nursing frequency was changed to three times a week for two weeks then two times a week for four weeks effective 08/07/22. Review of P8's "Client Coordination Note Report" located under the "Coordination Notes" tab indicated a nursing visit was missed 08/08/22 with the reason being "auth [authorization] approved 2x [two visits] visits a week." There was no documentation of a physician order to change the nursing frequency in P8's POC. In an interview on 11/02/22 at 9:49 AM, Administrator stated there was no physician order obtained to change the frequency to two times a week when authorization didn't approve the skilled nursing visits to be done three times a week as ordered. 4. Review of P9's EMR indicated P9's "Home Health Certification and Plan of Care" for 08/24/22 to 10/22/22, located under the "Orders" tab, included a PT frequency of one time a week for one week. Review of a physician's order dated 08/26/22 indicated the PT frequency was one time a week for one week then two times a week for four weeks effective 08/24/22. Review of P9's EMR indicated only one PT visit was made the week of 08/28/22 (two visits were ordered). In an interview on 11/02/22 at 10:18 AM, Administrator confirmed a missed visit note for the visit missed the week of 08/28/22 was not documented, and there was no documentation that P9's physician was notified of the missed visit. Administrator stated a physician's order should have been obtained for the change to P9's POC when the visit was missed.

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: Based on policy review, medical record review, and interviews, the home health agency (HHA) failed to ensure the physician was notified of missed visits for three (Patient (P) 1, P4, P9) of 10 sampled patients. This deficient practice had the potential to affect the current 155 patients and any future patient admitted for services. Review of the policy titled "Variances from the Plan of Care/Service Plan," dated 04/02/21, indicated ". . . If the office is unable to fill the visit/shift/hour requirement of a patient/client, then the [office designee] a) Contacts the patient/client/caregiver to reschedule the visit/shift to comply with the physician's or allowed practitioner's. . . orders or service plan as established. I) If rescheduling is not an option, the designated employee identified the patient's/client's needs and the potential for clinical impact upon the patient, during this unfilled visit/shift or reduced hours. ii) The designated employee identified alternative measures/means to ensure the patient's/client's needs are met . . . b) If alternative means can be engaged to fulfill the patient's/client's needs, that does not have a potential for clinical impact upon the patient, the communication and alternative means of care/service is documented. c) If alternative means cannot be identified and the visit/shift/hours are not filled but the missed care/services do not put the patient/client at risk and does not have a potential for clinical impact upon the patient, the communication is documented such. D) If the alternative means cannot be identified and the patient/client will be put at risk by not filling the visit/shift/hour requirement, then the . . . designee notifies all parties including any ordering physician or allowed practitioner. . . i) The physician or allowed practitioner. . . decides whether the patient visit may be skipped, or additional intervention is required by the Office due to the impact on the patient. . . for care/services. . ." The policy did not require the physician to be notified and an order obtained for the change to the POC when alternative means cannot be identified, and the visit/shift/hours are not filled, but the missed care/services do not put the patient/client at risk and does not have a potential for clinical impact upon the patient. 1. Review of P1's electronic medical record (EMR) indicated P1's "Home Health Certification and Plan of Care" for 09/30/22 to 11/28/22, located under the "Orders" tab, included a physical therapy (PT) frequency of one time a week for one week then two times a week for three weeks, effective 10/02/22. Review of P1's PT visits, located under the "Visits" tab, indicated a PT visit was missed the week of 10/09/22. Review of P1's "Missed Visit Report," located under the "Coordination Notes" tab, indicated a PT was missed on 10/13/22 with the reason documented as "duplicated visit." There was no documentation that P1's physician was notified of the change in P1's POC. In an interview on 10/31/22 at 1:50 PM, Administrator stated a duplicated visit should not be the reason for the missed visit, because P1's visit was scheduled, and the frequency was for two times a week. Administrator confirmed the visit was missed, and there was no documentation that P1's physician was notified of the missed visit. 2. Review of P4's EMR indicated P4's "Home Health Certification and Plan of Care" for 09/28/22 to 11/26/22, located under the "Orders" tab, included a PT frequency of two times a week for four weeks effective 10/02/22. Review of P4's "Missed Visit Report," located under the "Coordination Notes," indicated a PT visit was missed on 10/14/22 with the reason documented as "duplicated visit." There was no documentation P4's physician was notified of the missed visit on 10/14/22. In an interview on 10/31/22 at 1:05 PM, Administrator stated a missed visit note was documented for 10/14/22 stating it was a "duplicated visit," but a visit should have been made according to the physician orders. Administrator confirmed there was no documentation that P4's physician was notified of the missed visit. 3. Review of P9's EMR indicated P9's "Home Health Certification and Plan of Care" for 08/24/22 to 10/22/22, located under the "Orders" tab, included a PT frequency of one time a week for one week. Review of a physician's order dated 08/26/22 indicated the PT frequency was one time a week for one week then two times a week for four weeks effective 08/24/22. Review of P9's EMR indicated only one PT visit was made the week of 08/28/22 (two visits were ordered). In an interview on 11/02/22 at 10:18 AM, Administrator confirmed a missed visit note for the visit missed the week of 08/28/22 was not documented, and there was no documentation that P9's physician was notified of the missed visit.