Every finding on record at Presbyterian Home Healthcare

The following deficiencies were cited during a Recertification Survey completed on 05/05/2021 for the requirements of 45CFR484 for the requirements of Home Health Agencies. A COVID-19 Focused Infection Control Survey was conducted by the New Mexico Department of Health, Division of Health Improvement on 05/05/2021 The facility was found to be in compliance with 42 CFR §484.70 Condition of participation: Infection prevention and control Regulations and Guidelines for Home Health Agencies and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. Definition: Advanced Directives (a legal document signed by a competent person to provide guidance for medical and health-care decisions (such as the termination of life support or organ donation) in the event the person becomes incompetent to make such decisions)

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record reviews and interviews, the facility failed to promptly alert relevant physician of changes to the plan of care for 1 (P8) out of 19 patients selected. This failed practice is likely to lead to fragmented care and miscommunication between patients and clinical providers. The findings are: A. Record review of P8's Home Health Certification (form used to determine eligibility for homecare services) and Plan of Care from 02/09/2021 for the certification period of 4/10/2021 to 06/08/2021 revealed: 1. Advanced care plan indicates that P8 has Advanced Directives and that P8 is to be a Full Code (Healthcare providers are to utilize all life saving measures) B. Record Review of P8's most recent Advanced Directive signed 02/05/2021 revealed: 1. P8 was ordered as a Full Code status C. Record Review of P8's Advanced Health Directive scanned into medical record on 04/12/2021 revealed: 1. Selection of the following under Stopping Life Prolonging Efforts: "If I reach a point where it is likely that I will not recover my ability to interact meaningfully with my family, friends, and environment, I want to stop or withhold all treatments, other than comfort care, that might be used to prolong my existence." 2. Selection of the following under Cardiopulmonary Resuscitation (CPR): "I do not want CPR if my heart stops, but rather, want to permit natural death." D. Record Review of P8's Clinical Notes from 04/12/2021 revealed: 1. Home health nursing note indicated that P8 was assisted in Advanced Directives. No documentation that P8 had changed advanced directives and made the decision not to be Full Code status. 2. No documentation from physician that P8 had changed Advanced Directives and made the decision not to be Full Code status. E. Record review of Home Health Admission Booklet undated revealed: 1. Advanced Directive revisions: If a patient gives oral directive to staff the staff will: document the specific information/request on the progress note, update this information in the clinical services record, and inform patient's physician of oral directives and document as a verbal order. F. On 05/05/2021 at 8:30am, interview with S1 (Facility Director) indicated that patients can revise their Advanced Directives electronically, but that the software does not automatically notify the clinical providers that a change has been made. S1 confirmed the expectation that nursing would notify the provider that a patient wished to change their advanced directives in to have the order changed to reflect the patient's wishes.