Every finding on record at Rehoboth Mckinley Christian Home Care Services

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Rehoboth McKinley Christian Homecare Services, Home Health Agency (HHA) on 07/15/2021 resulted in noncompliance under 42 CFR 484.102 with the following standard-level deficiencies cited:

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on record review, the facility failed to develop a communication plan that includes contact information of needed personnel in the event of an emergency. This failed practice is likely to lead to poor communication in the event of an emergent situation. The findings are: A. Record Review of facility's "Emergency Preparedness Plan", undated, revealed: 1. No record of personnel contact log that is readily available in the event of an emergency. B. Record Review of facility's "Emergency Operations Plan", created 11/2010, revealed: 1. Notification of Personnel when Emergency Response measure are initiated: "The agency maintains a current callback list of all employees." 2. Backup Communication System: "The agency will provide alternate communication methods in the event of a failure."

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Rehoboth McKinley Christian Homecare Services, Home Health Agency (HHA) on 07/15/2021 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 07/15/2021. 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.

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 facility failed to ensure a Registered Nurse (RN) conducted an initial assessment to determine the immediate care and support within 48 hours from receiving a referral for home care services for 1 (P (patient) 6) out of 7 Patients sampled. This failed practice is likely to lead to ineffective plan of care development and delays in continuation of care. The findings are: A. Record Review of P6's Medical Records from 06/23/2021 to 07/15/2021 revealed: 1. Initial referral for home services was 06/23/2021. 2. Initial RN Assessment was completed on 06/30/2021. B. On 07/14/2021 at 10:0 am, during interview with S1 (Director of Home Health) confirmed that P6's initial assessment documentation indicated a delay from the expected 48 hour deadline.

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 record review and interview the agency failed to have a health certificate for all staff having contact with patient/clients stating that the employee is free from Tuberculosis (TB) (a serious infection, usually of the lungs caused by the bacteria Mycobacterium tuberculosis (species of bacteria) and is spread when you breathe in the air exhaled by a person infected with tuberculosis). There was no follow-up Tuberculosis (TB) education or screening done yearly for 6 (S3, S4, S5, S6, S8, S9) of 9 staff files reviewed. This deficient practice could result in the spread of communicable organisms (diseases) to patients and their family members. The findings are: A. Record review of 6 staff out of 9 staff records revealed no record of tuberculosis screening or tuberculosis education. 1. On 07/13/2021, record review of S3 (Physical Therapist) staff file revealed no record of annual tuberculosis screening or tuberculosis education. 2. On 07/13/2021 ,record review of S4 (Registered Nurse) staff file revealed no record of annual tuberculosis screening or tuberculosis education. 3. On 07/13/2021, record review of S5 (Home Health Aide) staff file revealed no record of annual tuberculosis screening or tuberculosis education. 4. On 07/13/2021, record review of S6 (Physical Therapist) staff file revealed no record of annual tuberculosis screening or tuberculosis education. 5. On 07/13/2021, record review of S8 (Registered Nurse) staff file revealed no record of annual tuberculosis screening or tuberculosis education. 6. On 07/13/2021, record review of S9 (Registered Nurse) staff file revealed no record of annual tuberculosis screening or tuberculosis education. B. On 07/14/21 at 4:15 pm, during interview with S1 (Director) confirmed the absence of Tuberculosis education and/or screening of staff.

Eligible training/competency evaluation orgs. CFR(s): 484.80(f) Standard: Eligible training and competency evaluation organizations. A home health aide training program and competency evaluation program may be offered by any organization except by an HHA that, within the previous 2 years: This STANDARD is not met as evidenced by: Based on record reviews and interview, the facility failed to ensure and retain orientation and training for 2 (S3, S4) out of 9 staff (s) reviewed (S1 through S9) providing care. This failed practice is likely to lead to gaps in training related to patient care and poor patient outcomes. The findings are: A. Record review of S3 (Physical Therapist) employee record revealed: 1. Date of hire 06/25/2020, no record of new hire required training upon hire. B. Record review of S4 (Registered Nurse) employee record revealed: 1. Date of hire 02/17/2020, no record of new hire required training upon hire. C. On 07/13/21 at 3:30 pm, during interview with S2 (Human Resources Manager) confirmed the orientation of the employees and agreed to the absence of documentation of orientation training in the personnel file.