Every finding on record at Presbyterian Healthcare Services

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Presbyterian Home Health Agency of Northern New Mexico (HHA) on 05/06/26 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 Presbyterian Home Health Agency (HHA) on 05/06/26 resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies 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 observation, interview and record reviews, the Agency failed to ensure infection control measures related to hand hygiene and care of patients with indwelling catheters were correctly performed for 1(P[patient] 9 out of 5 (P6, P9, P10, P11 and P12) patients observed. These failures could likely result in transfer of infectious agents from home to home, increase the likelihood of urinary tract infections for patients with catheters and generally cause a decline in health from infection for all patients served. A) During an observation of patient care for P(Patient) 9 on 05/05/26 at 8:30 AM, S(Staff) 3, clinical, entered the home and verified P9’s identity with P9 seated on the couch. -Without performing hand-hygiene or donning gloves, S3 picked up the catheter bag (a device that drains urine from the bladder continuously into a collection bag) holding it above P9’s waist level, allowing back flow of urine into the bladder. -S3 accompanied patient to the bathroom to shower and dress patient. At this time patient and staff member were unobserved as the patient requested privacy. -S3 then opened the door of the bathroom carrying catheter bag above P9’s waist with an ungloved hand and walked P9 to the couch. S3 then exited the home without performing hand hygiene. -After exiting home S3 pulled the electronic charting device (cell phone) from a pocket to document the visit, then placed the now contaminated device back into the pocket and departed for the next home visit. B) During an interview on 05/05/26 at 9:00 AM outside the home after the visit, S3 confirmed receiving annual trainings on hand hygiene and skin care. C) Record review of the document titled, Hand Hygiene Observations Tool, dated 04/01/26 for S3 revealed that S3 met the observation goal for performing hand gel before entering the patient’s home, before and after patient contact, before donning and doffing gloves, and before and after using a laptop or cell phone. D) Record review of document titled, CNA Competency Assessment Record, (CNA is a Certified Nursing Assistant) dated 05/07/25 documented S3 met the standards of skill observations related to infection control, hand hygiene, and urinary catheter care.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Presbyterian Home Healthcare of Northern New Mexico Home Health Agency (HHA) on 05/04/2023 resulted in a finding of noncompliance with Condition of Participation respective to applicable CoP under 42 CFR 484, Subpart A through C with the following 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 review and interview the agency failed to perform an initial assessment within 48 hours of the referral for 6 (P[patient] 6, P8, P9, P10, P11, P13) out of 17 (P1-P17) patients reviewed for being admitted to the agency. This deficient practice can lead to patients not receiving necessary care. The findings are: A. Record review of the agency policy titled, “Admission Criteria- Home Health” effective date 03/01/2023 on page 3 under “Home Health” it stated, “. . . 3. The initial visit must be performed either within 48 hours of the referral within 48 hours of the patient’s return home, or on the start of the care date ordered by the physician.” B. Record review of agency undated document titled, “Home Health Delay Start of Care Order” has the following reasons as “Reason for Delay”: “Patient requested start date, Patient agreed upon start date, Patient hospitalized prior to Start of Care, Patient has provider appointments for hospital follow-up, and Other”. C. Record review of P6’s medical record revealed: 1. Review of the “Referral” on page 4 the “Date Valid Referral Received” was listed as 04/12/2023. On page 2 under “Referral Notes” there was a note dated 04/14/2023 3:11 PM that stated, “Delay in SOC [start of care] for 04/18/2023 signed by agency staff and the authorizing provider.” 2. Review of the “Home Health Plan of Care” revealed a “Start of Care Date” listed as 04/18/2023. No evidence was found that an initial assessment was done prior to the start of care. 3. Review of document titled; “Home Health Delay in Start of Care” dated 04/14/23 under “Reason for Delay” there was a box marked “Patient agree upon start date.” No further evidence was found that indicated a valid reason for delay of care order noted. D. Record review of P8’s medical record revealed: 1. Review of the “Referral” on page 3, the “Date Valid Referral Received” was listed as 03/29/2023. 2. Review of the “Home Health Plan of Care” revealed a “Start of Care Date” listed as 04/03/2023. No evidence was found that an initial assessment was done prior to the start of care. E. Record review of P9’s medical record revealed: 1. Review of the “Referral” on page 4, the “Date Valid Referral Received” was listed as 07/03/2022. On page 2 under “Referral Notes” there was a note dated 06/30/2022 that stated, “SOC orders entered” and under “Diagnosis Description” it stated, “Delay of care order received on 6/30/22 from [Name of MD (Medical Doctor)] to admit on 7/3/22.” 2. Review of the “Home Health Plan of Care” revealed a “Start of Care Date” listed as 07/03/2022. No evidence was found that an initial assessment was done prior to the start of care. 3. No evidence was found that indicated a valid reason for delay of care order noted above. F. Record review of P10’s medical record revealed: 1. Review of the “Referral” on page 4, the “Date Valid Referral Received” was listed as 03/21/2023. On page 2 under “Referral Notes” there was a note dated 03/23/2023 that stated, “Orders entered.” 2. Review of the “Home Health Plan of Care” revealed a “Start of Care Date” listed as 03/27/2023. No evidence was found that an initial assessment was done prior to the start of care. 3. Review of a document titled; “Home Health Delay Start of Care Order” dated 03/23/2023 under “Reason for Delay” there was a box marked next to “Patient agreed upon start date.” No further evidence was found that indicated a valid reason for the delay of care order. G. Record review of P11’s medical record revealed: 1. Review of the “Referral” on page 4, the “Date Valid Referral Received” was listed as 02/16/2023. On page 2 under “Referral Notes” there was a note dated 02/16/2023 10:31 AM that stated, “Schedule SN [skilled nursing] SOC [start of care] on 02/21/23 with [name of staff], RN (Registered Nurse). . .”. The following note dated 02/16/2023 11:20 AM stated, “Will enter on 02/19 when pt [patient] is discharge from facility.” The following note dated 02/20/2023 8:19 AM stated “Orders entered for [initials of agency]” 2. Review of the “Home Health Plan of Care” revealed a “Start of Care Date” listed as 02/22/2023. No evidence was found that an initial assessment was done prior to the start of care. 3. No further evidence was found that indicated a valid reason for the further delay in starting care. I. Record review of P13’s medical record revealed: 1. Review of the “Referral” on page 4, the “Date Valid Referral Received” is listed as 09/28/2022. “Referral Notes” on page 2 & 3 revealed a note dated 09/21/2022 12:51 PM stated, “DIVERT unable to admit due to full staffing.” Another note dated 09/21/2022 1:03 PM, “UPDATE to SCHEDULING: Schedule SN SOC on 9/28/22 with [staff name], RN.” Under “Diagnosis Description” on page 2 it stated, “Delay of Care order approved via verbal order from [Name of referring facility] Case Management on 09/21/22 to admit on 09/28/22.” 2. Review of the “Admission Consent/Service Agreement” signed at start of care is dated 09/28/22.No evidence was found that an initial assessment was done prior to the start of care. 3. No further evidence was found that indicated a valid reason for the delay in starting care. J. During an interview on 05/03/2023 at 4:00 PM with S (staff)1, Director it was asked why the start of care was delayed for patients. S1 stated, “We will defer out if we can’t see them, but we do get patients who specifically request us or a certain provider. We aren’t doing a good job of documenting that.”

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure there was provider communication regarding medication concerns for 1 (P [patient ]17) out of 17 (P1-P17) patients reviewed for medication monitoring. This deficient practice can lead to poor outcomes related to poly-pharmacy [multiple medications with a combination of side effects] and lack of interdisciplinary communication. The findings are: A. Record Review of agency policy titled, “Medication Management HH [Home Health] and Hospice” dated 02/22/2023 on page 3 it stated, “14. The findings, conclusions, and recommendations or medication monitoring will be communicated to the providers, pharmacist, and other clinicians involved in the patient’s care. Updates will be made, if needed. 15. The information obtained through patient medication monitoring will be documented in the patient’s clinical record and, if applicable, in the pharmacy record.” B. Record review of documentation titled, “RN (Registered Nurse) Medication Review” for P17 dated 07/29/2022 revealed the following note under “Communication Details”, “*RN Medication Review: A complete medication review identified potential clinically significant medication issues. Issue noted: Drug-Drug. . . Different ordering providers. Provider notification needed based on findings. Please verify PCP has up to date medication list with potential issues noted. SOC [start of care] PT [Physical Therapist] notified via phone and Case Communication.” Details in this note such as “Contact person, Relationship to patient, Phone Number, Email, and Time” are all blank. The box titled “Follow-Up” is also blank. No evidence was found that the provider was notified of potential drug interactions. C. During an interview with S1, Director on 05/03/2023 at 4:00 PM when asked if there was documentation of providers response to medication concerns it was answered, “No, if there aren’t any new orders than we don’t pursue it further.”

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to communicate missed visits to patient’s providers for 8 out of (P [patient] 1, P7, P8, P9, P10, P11, P13, and P17) out of 17 (P1-P17) patients reviewed for compliance with plan of care. This deficient practice could lead to patients not receiving care as ordered and a communication breakdown between the agency and the responsible providers. The findings are: A. Record review of agency policy titled, “Missed Visits – HH [Home Health] and Hospice” effective date 08/31/2021 states on page 1, under “Purpose: To ensure that missed visits are documented and does not affect the quality of patient care. Missed visits will be communicated to the patient’s physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documents in the clinical record.” Under “Procedure” it states, “1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the physician of the missed visit and reason for missed visit. B. Document in the patient's clinical record the following information: 1. Reason for the missed visit. 2. Physician notification including date, time, physician name, method of notification and the staff reporting the information. 3. Other person(s) who were notified of the missed visit. 4. Description of any unmet needs and how the patient's needs were met. 5. Any other follow-up needed. . . . ” B. Record review of P1’s medical record revealed: 1. Scheduled visit on 04/20/2023 included the following note, “OT [Occupational Therapist] arrived at patient’s home, pt [patient] is scheduled for session later this afternoon, pt requests to re-schedule, OT evaluation scheduled w/ [with] pt. . .” No evidence was found that the provider was notified. C. Record review of P7’s medical record revealed: 1. Scheduled visit on 04/11/2023 included the following note, “PT [Physical Therapist] [name of employee] was called by wife of pt to relay to ST [Speech Therapist] that the patient is running late due to Dr [doctor] appt [appointment] and to cancel today’s appt. . .” No evidence was found that the provider was notified. D. Record review of P8’s medical record revealed: 1. Scheduled visit on 04/20/2023 included the following note, “Visit scheduled 4/26 per pt request due to scheduling conflicts.” No evidence was found that the provider was notified.. E. Record review of P9’s medical record revealed: 1. Scheduled visit on 09/28/2022 included the following note, “No visit on 09/28/22 as patient is attending wound clinic.” No evidence was found that the provider was notified. 2. Scheduled visit on 10/12/2022 included the following note, “Missed visit as pt was at wound clinic on this date.” No evidence was found that the provider was notified. 3. Scheduled visit on 10/19/2022 included the following note, “Missed visit due to patients appt with wound clinic.” No evidence was found that the provider was notified. 4. Scheduled visit on 10/26/2022 included the following note, “Patient did not require a visit on 10/2622 [sic] as she was in attendance at wound clinic. . .” No evidence was found that the provider was notified. 5. Scheduled visit on 03/15/2023 included the following note, “Patient does not need to be seen today as she is attending wound clinic.” No evidence was found that the provider was notified. 6. Scheduled visit on 04/01/2023 included the following note, “No visit indicated today as patient seen by wound clinic Wed 3/29, Nurse for HHC [Home health care?] on 3/31. Next appt due tomorrow on 4/2.” No evidence was found that the provider was notified. F. Record review of P10’s medical record revealed: 1. Scheduled visit on 04/20/2023 included the following communication note, “Hello, Discharge for [patient name] was scheduled for today, 4/20/23. Due to taxing effort yesterday from being in ED [Emergency Department] daughter [name] felt that patient would not be able to tolerate PT today. Patient generally has poor tolerance to activity and PT intervention so PT visit has been rescheduled for 4/27/23 with discharge planned at that time...” There is further communication between staff of agency but no evidence that the provider was notified. G. Record review of P11’s medical record revealed: 1. Scheduled visit on 02/28/2023 included the following note, “multiple attempts made to contact patient, no answer, left voice mails and text messages throughout the day. No return call. RN [Registered Nurse] later received notice from office manager that patient is currently hospitalized. transfer to be completed.” No evidence was found that the provider was notified. 2. Scheduled visit on 03/20/2023 included the following note, “Patient was texted in am to confirm appt [appointment] for today. Arrived at patient home with no answer at door. Patient was called from outside home with no answer. Received text later in the day that patient was at an MD [Medical Doctor] appt that she forgot about.” No evidence was found that the provider was notified. 3. Scheduled visit on 03/22/2023 included the following note, “PT out sick. PT visit cancelled.” No evidence was found that the provider was notified. 4. Scheduled visit on 03/28/2023 included the following note, “Arrived at patient home for scheduled PT visit. No answer at door. Text sent to patient. Attempted to call. No answer by phone. Later in day noted in chart review that patient went to ED with pneumonia [an infection in the lungs]. Note sent to HH office.” No evidence was found that the provider was notified. H. Record review of P13’s medical record revealed: 1. Scheduled visit on 10/25/2022 included the following note, “SN [Skilled Nursing] arrived for scheduled visit. No answer at door or on phone.” No evidence was found that the provider was notified. 2. Scheduled visit on 12/07/2022 included the following note, “Missed visit on week of 12/5/2022 2/2 [secondary to] clinician illness – unable to schedule 2nd visit in medicare week.” No evidence was found that provider was notified. 3. Scheduled visit on 12/27/2022 included the following note, “Pt mother as contacted and offered AM morning time but pt unable to do given appt this AM. Appt with ST would have started around 9 AM but he had conflicting appt at 930 [sic] so it would not work.” No evidence was found that the provider was notified. I. Record review of P17’s medical record revealed: 1. Scheduled visit on 10/14/2022 included the following note, “Spouse prefers to wait until MD pulls catheter for a trial void [process to be able to remove a catheter from the bladder that drains urine]. This was to happen on Thurs 10/13/2022 however MD is delaying removal by a week.” Documentation doesn’t not indicate what provider this was discussed with, when it was discussed or how it was discussed. 2. Scheduled visit on 10/21/2022 includes the following note, “Patient’s wife informs patient does not need SN [skilled nursing] due to not receiving cath [catheter].” No evidence was found that the provider was notified or discontinued home health services due to catheter being removed. J. During an interview on 05/02/2023 at 3:10 PM with S1, Director it was asked what the expectation was for documenting missed visits was and it was stated that it should be documented in the encounter notes. When asked if there should be communication with the providers regarding missed visits it was confirmed that there should always be communication with the provider.