Every finding on record at Quantum Homecare of New Mexico

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Mexico Health Care Authority. An unannounced on-site Recertification Survey at Grand View Health at Home (HHA) from 07/08/24 to 07/10/24 resulted in a finding of substantial compliance respective to the Emergency Preparedness Program Condition of Participation under 42 CRF 484.102.

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of New Mexico Health Care Authority. On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Grand View Health at Home Home Health Agency (HHA) on 07/10/2024 resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited:

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview, record review, and agency policy review, the agency failed to include pertinent diagnoses on the patients’ plans of care (POC-an individualized and comprehensive plan that includes diagnoses, medications, and interventions that guide the staff in providing patient care) for 1 (P (Patient) #7) of 7 patients reviewed. An agency policy titled, “Care Planning, Coordination of Services and Quality of Care,” dated 2019, revealed, “The individualized plan of care must include the following:” including “All pertinent diagnoses.” Patient #7’s “Home Health Certification and Plan of Care,” dated 05/17/2023, revealed a “Start of Care Date” of 05/17/2023 and a “Certification Period” of 05/17/2023 to 07/14/2023. According to the POC, Patient #7 had a medical history that included diagnoses of joint replacement (post operative care after surgical replacement of a joint), and the patient had an artificial knee joint. The POC revealed Patient #7’s medication list included mirtazapine (used to treat depression), duloxetine (used to treat depression and anxiety), lisinopril (used to treat hypertension [HTN, high blood pressure]), and buspirone (a medication used to treat anxiety) daily. Further review did not reveal any diagnoses related to depression, HTN, or anxiety. Patient #7’s “OASIS-E [Outcome Assessment Information Set Version E] Start of Care,” dated 05/17/2023, revealed Patient #7 had a past medical history (PMH) that included depression, HTN, and anxiety. During a concurrent record review and interview on 07/10/2024 at 12:00 PM, the Administrator stated the agency’s definition of pertinent diagnosis was any diagnosis pertinent to the care being provided for the patient and would include any cardiac history, PMH, and any underlying conditions the patient may have. The Administrator confirmed that Patient #7’s “OASIS-E Start of Care” dated 05/17/2023 indicated the patient had hypertension and depression, confirmed the diagnoses were not included on the patient’s POC, and acknowledged the agency was not following their policy.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview, record review, and agency policy review, the agency failed to provide services as ordered by a physician for 1 (Patient #2) of 7 patients reviewed. Specifically, the agency failed to contact the physician, per instructions listed on the patient’s plan of care (POC), when their diastolic blood pressure (DBP-a measure that represents the pressure in the arteries when the heart is resting between beats, filling with blood) was outside the established parameters. An agency policy titled, “Care Planning, Coordination of Services and Quality of Care,” dated 2019, revealed, “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.” Patient #2’s “Home Health Certification and Plan of Care,” dated 05/24/2024, revealed a “Start of Care Date” of 05/24/2024 and a “Certification Period” of 05/24/2024 to 07/22/2024. According to the POC, Patient #2 had a medical history that included diagnoses of aftercare following joint replacement (post operative care after surgical replacement of a joint), asthma, and depression. Further review of the POC revealed “Orders and Treatments” included instructions to notify Patient #2’s physician of a DBP higher than 90 millimeters of mercury (mmHg) or less than 55 mmHg. Patient #2’s “LPN/LVN [Licensed Practical Nurse/Licensed Vocational Nurse]-Skilled Nursing Visit,” dated 06/24/2024, revealed staff documented Patient #2’s DBP was 101 mmHg. Further review revealed no evidence that agency staff notified Patient #2’s physician. Patent #2’s clinical record revealed no evidence the agency notified Patient #2’s physician of the patient’s 06/24/2024 DBP. During an interview on 07/09/2024 at 1:25 PM, Physical Therapist (PT) #1 stated that if he received a high blood pressure reading for a patient, he would likely reassess the patient's blood pressure several times and if it continued to be elevated, he would contact the agency. During a concurrent record review and interview on 07/10/2024 at 12:00 PM, the Administrator (ADM) stated the agency expectation was clinicians to follow physician orders and interventions identified on the patients’ POCs. The ADM confirmed that on 06/24/2024, the agency staff documented Patient #2’s DBP as 101, and based on the orders, the staff should have immediately contacted the patient's physician to notify them of the reading being outside of the expected ranges. The ADM acknowledged the agency was not following their policy.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Grand View Home Health Agency (HHA) on 06/22/21 resulted in a finding of noncompliance with the Emergency Preparedness Program Condition for Coverage of Participation (CoP) under 42 CFR 484.102 with the following standard-level deficiencies cited.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview the facility failed to develop and maintain an Emergency Preparedness Plan to be utilized in case of an emergency situation. This failed practice can lead to breakdown in patient care in case of an emergency. The findings are: A. Record review of the Emergency Preparedness Plan Titled "Disaster Preparedness Toolkit" purchased from BBC Healthcare and Management Consultants Limited in 2017 (Outside business who sold the product "Emergency Preparedness Toolkit), revealed an Emergency Preparedness Plan that is not specific to this agency, has no risk assessment and emergency tabletop training with El Paso, TX. The Disaster Preparedness Toolkit does not contain any staff emergency information and does not include any patient information.. The plan has not been updated since 2017. B. On 06/22/21 at 10:00 am, during interview, S(Staff)#2 (Administrator) confirmed the Emergency Preparedness Plan has not been updated but it will be addressed immediately.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Grand View Home Health Agency (HHA) on 06/22/21 found that your facility resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited: A COVID-19 Focused Infection Control Survey was conducted by the New Mexico Department of Health, Division of Health Improvement on 06/22/21. The facility was found not 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.

Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient's legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This ELEMENT is not met as evidenced by: Based on record review and interview the facility failed to allow the patient or the patient's guardian the ability to complete their own form showing they received information during the initial evaluation by providing a form that has selections prefilled with a typed "X" for 7 (P#1 - P#7) of 7 patient records reviewed. This failed practice can lead to lack of information being provided to patient about their care. The findings are: A. Record review of 7 (P#1 - P#7) revealed the form titled "Release of Information & Assignment of Benefits" under the section labeled "Informed Consent" was prefilled with "X" typed in acknowledging received and understand the following documents: " Release of Information, Assignment of Benefits, Informed Consent, Financial Disclosure, Advanced Directives, Information about Abuse/Neglect/Exploitation Policy, Letter of Introduction, Home Care Information, Patient's Bill of Rights, Emergency Plan, OASIS Privacy Act Statement, Employee Drug Testing Policy, and HIPAA Privacy Practices." and prefilled "X" on statement "I have been given written materials about my right to accept or refuse medical treatment," prior to patient signature. B. On 06/21/21 at 3:30 pm during interview S#2 (Administrator) confirmed, "The form was prefilled for convenience and will be corrected immediately."

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on record review and interviews for chart audit of 7 patients (P1 - P7 patients), this facility failed to arrange a safe and appropriate transfer to another facility that is able to meet the needs of the patient that this facility could not meet for 1 (P2) out of 7 (1 - 7 patients) patients reviewed. This failed practice is likely to lead to rehospitalization of patients being discharged with no other home care in place. The findings are: A. On 6/22/21 record review of P2's chart revealed that the patient was discharged from care on 11/09/2020. Further investigation revealed that the reason for discharge was because the patient was exposed to a family member who had tested positive for COVID-19 (Infectious respiratory disease). No further arrangements or transfer to a different Home Health agency are documented. B. On 6/22/21 during an interview with S1 (Staff), (Facility Administrator), S1 stated "Rather than compromise staff safety, we decided to discharge the patient until a negative COVID-19 test (laboratory test to identify active COVID-19) could be supplied. We discharged confidently because the patient was close to being discharged soon anyway, and had already been discharged from the Physical Therapy component of services at that time." C. On 6/22/21 during interview with S2 (Owner/CEO), S2 stated "We didn't have all of the proper Personal Protective Equipment (PPE) on hand and didn't want to comprise the safety our employees."

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview the facility failed to conduct Inter-Disciplinary Team (IDT) meetings (meeting held with all branches of knowledge represented) for patients receiving treatment in the facility. This failed practice can lead to miscommunication and accidents in patient treatment. The findings are: A. Record review of IDT minutes requested, none provided. B. On 06/21/21 at 3:45 pm during interview, S (Staff) #2 (Administrator) confirmed, "No traditional IDT meetings are conducted. The staff communicates by phone, email, and text and information is documented in the Plan of Care, but it is not a formal process and is not documented in a formal meeting"

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation and record review, the facility failed to implement a daily COVID-19 screening tool (screening assessment to identify risk of infection with COVID-19, infectious respiratory disease) or contact tracing log (list of names and contact information to be utilized in order to notify in case of a potential exposure to COVID-19) for employees or visitors. This failed practice is likely to lead to the spread of COVID-19 between both staff and patients. Findings are: A. On 06/21/2021 at 1:00pm, observation of no COVID-19 screening utilized on surveyors from the New Mexico Department of Health. No contract tracing log identified B. On 06/22/2021 at 8:00 am, observation of no COVID-19 screening utilized on surveyors from the New Mexico Department of Health. No contact tracing log identified. C. On 06/22/2021 at 11:00am, observation of no contact tracing log identified for active staff members or visitors. D. On 6/22/21 at 10:45 am, during an interview with S1 (Facility Administrator), S1stated that "All staff are self-screening prior to entering a patient's home, however there is currently no documentation in place