Every finding on record at Nm Cuidado Casero Home Health, LLC

A Recertification Survey was conducted by Healthcare Management Solutions, LLC, on behalf of the New Mexico Health Care Authority (HCA). An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 06/10/25 to 06/12/25 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 Health Care Authority (HCA). An unannounced on-site Recertification survey conducted at the above-named Home Health Agency (HHA) from 06/10/25 to 06/12/25 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CRF 484 Subparts A through C with the following standard-level deficiencies listed below.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on document review, staff interview, and policy review, the Home Health Agency (HHA) failed to ensure comprehensive assessments accurately reflect the patient's medical status for one of seven sampled patients (Patient (P) 7). This deficient practice has the potential to allow patients to receive improper, and/or insufficient care, leading to worsening health conditions, and could affect all patients. Findings include: Review of the agency's policy titled, "Admission/Scope of Service," updated December 2024, revealed under "Comprehensive Assessment" paragraph "15. The clinician conducts an analysis and evaluation of data collected to draw conclusion and in consultation with physician subsequently formulate interventions directed toward improving or maintaining health status …" Review of P7's electronic medical record (EMR) under the "Plan of Care" tab indicated P7 was admitted to the facility on 02/10/25, with the primary diagnosis of "nonrheumatic aortic valve stenosis." The hospital "DME [durable medical equipment]/Oxygen/Resp Home Health Order," dated 02/10/25, indicated P7 was referred with a diagnosis of "heart valve replacement" performed on 02/06/25. The "Wound Addendum" to the comprehensive assessment indicated P7 had a 24 centimeter (cm) by 1-cm, closed, surgical wound, to the sternum. Section "12. Surgical Procedure" was blank. Section "21. Orders for Discipline and Treatment," lacked orders for wound care, and monitoring the surgical site. During an interview on 06/11/25 at 2:00 PM, the Administrator indicated that P7's plan of care should have had a primary diagnosis of encounter for surgical aftercare following surgery on the circulatory system, and there should have been physician orders for interventions related to that diagnosis.

Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient's clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This STANDARD is not met as evidenced by: Based on policy review, and staff interview, the Home Health Agency (HHA) failed to ensure clinical records (whether hard copy or electronic form) were made available to a patient, free of charge, thereby creating barriers to patient access, and disproportionately affecting low-income individuals. This has the potential to affect all patients. Findings include: Review of the agency's policy titled, "Maintenance of the Clinical Record," dated December 2020, located in the agency's "Survey Binder" under tab "M. Maintenance Policy," indicated under "Clinical Record Security: 9. A fee of $1.00 per page is charged for copying of active clinical records done at the request of the client, a duly authorized legal representative, or a third party. A fee of $3.00 per page is charge [sic] for copying of closed clinical records stored at an archival record storage department." During an interview on 06/12/25 at 10:15 AM, the Administrator indicated that it had been past practice by the facility not to charge for copies of the medical record. The Administrator stated, "Since I've been here there have only been two cases when patients have requested their medical records, and we didn't charge them for it."