Every finding on record at Santa Fe Home Health Care Inc

During the recertification survey conducted on 02/14/2022 to 02/16/2022 at Santa Fe Home Health Care Inc., a Home Health Agency, Emergency Preparedness was reviewed. Santa Fe Home Health Care Inc. is in compliance with Emergency Preparedness per Code of Federal (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies.

A recertification survey was conducted on 02/14/2022 to 02/16/2022 at Santa Fe Home Health Care Inc. The home health agency was in non-compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to demonstrate it had obtained the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities for 1 out of 10 Sampled Patients (SP). SP#8 Findings include: Clinical record review conducted on 02/15/22 of SP#8 revealed a start of care date 01/19/22 with the Client Service Agreement signed and dated 01/19/22. Further review of the clinical record contained a Plan of Care that revealed the patient lives at an assisted living and retirement facility (ALF). During an interview conducted with the Administrator on 02/15/22 at 1:14 PM, the Administrator confirmed that the signature on the service agreement form is one of the caregiver’s at the ALF facility and not the patient's legal representative (the patient's daughter). Telephone interview was conducted by the Administrator and SP#8’s daughter on 02/15/22 at 1:07 PM. The Administrator informed SP#8’s daughter that agency had obtained signature on consent agreement for service by the ALF staff, adding that the consent cannot be signed by a staff and must be signed by the patient's legal representative. The Administrator informed SP#8’s daughter that the agreement will be emailed to her for her to sign and return to agency for compliance.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to demonstrate that 7 out of 10 (Staff A, B, C, E, F, H, and J) active staff received annual in-service on infection control. Findings include: Record review revealed that the provider conducted an annual infection control education in-service on 02/15/21 and 07/15/21. Further review revealed no documentation to show that Staff A, B, C, E, F, H, and J participated in an annual in-service infection control for the year 2021. On 02/16/22 at 10:13 AM, the Administrator reviewed the signature sign in sheet and confirmed that Staff A, C, E, and F are not on the list. The Administrator added that Staff B, H, and J did not receive training due to being hired after the training was conducted for 2021.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health staff failed to prepare and record clinical notes for 2 out of 10 Sampled Patients (SP). SP#5 and SP#7 Findings include: Clinical record review conducted on 02/14/22 to 02/15/22 of SP#5 and SP#7 revealed the patients have been serviced by the Registered Nurse. Review of the date(s) range 12/12/21 to 02/12/22 showed that the Registered Nurse did not complete the service notes as follow: -SP#5 (active record) scheduled visit dates 01/24/22, 01/26/22, 01/28/22, 01/31/22, 02/02/22, and 02/04/22. -SP#7 (active record) scheduled visit dates 01/24/22, 01/26/22, 01/28/22, 01/31/22, 02/02/22, and 02/04/22. Interview was conducted on 02/16/22 at 12:20 PM with the Administrator, who stated of no specific policy but that for standard practices the staff should be submitting at least every 2 weeks their notes.

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to maintain documentation which demonstrates that an individual may furnish home health services on behalf of the Home Health Agency only after that individual has successfully completed a competency evaluation program for 1 out of 5 personnel file review. (Staff J) Findings include: Personnel file review conducted on 02/15/22 to 02/16/22 revealed Staff J is a Home Health Aides and has a date of hire of 05/26/20. The Staff J personnel file omitted documentation of an initial evaluation to show successful completion of a competency evaluation program. Further review of the personnel file contained competency evaluations dated 02/15/21 and 05/28/21. Interview conducted with the Administrator on 02/16/22 at 12:36 PM stated that competency evaluation has been completed for Staff J but at time of survey the provider is not able to demonstrate the documentation, only the evaluations dated 02/15/21 and 05/28/21 are in the file.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to maintain the content of clinical record that includes notation of all interventions, including medication administration, treatments, and services, and responses to those interventions rendered by the home health agency staff for 1 out of 10 Sampled Patients (SP). SP#9 Findings include: Closed clinical record review conducted on 02/14/22 to 02/15/22 of SP#9 revealed the patient had been serviced by Licensed Practical Nurse (Staff C). Review of the date(s) range 12/12/21 to 01/14/22 showed that Staff C did not complete the service notes for SP#9 (closed record) scheduled visit dates from 01/02/22 to 01/07/22 and 01/3/22 to 01/14/22. Interview was conducted on 02/15/22 at 10:52 AM with the Administrator. The Administrator reviewed SP#9’s clinical record and confirmed last note in chart is dated 01/01/22, adding that nurse (Staff C) needs to bring the rest of the notes. The Administrator stated that SP#9 was last serviced by Staff C on 01/14/22. Interview was conducted on 02/16/22 at 12:20 PM with the Administrator, who stated of no specific policy but that for standard practices the staff should be submitting at least every 2 weeks their notes.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency is unable to demonstrate a completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the Home Health Agency for 2 out 10 Sampled Patients (SP). (SP#9 and SP#10); and the provider failed to ensure the clinical record included a completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the Home Health Agency (HHA) becomes aware of the transfer for 1 out 10 Sample Patients. (SP#9) Findings include: Closed record review of SP#9 and SP#10 were conducted on 02/14/22 and 02/15/22. The SP#9 and SP#10 records contained a discharge summary from agency with that all omitted details on the summary of care/outcomes in meeting the goals in the plan of care, clinical summary, patient and/or family post discharge instructions. An interview was conducted with the Administrator on 02/14/22 at 3:54 PM. The Administrator acknowledged that the discharge summary for SP#9 and SP#10 are incomplete, omitting the required information as stated above. Closed record review of SP#9 revealed that on 01/07/22 and 01/14/22 a transfer to an inpatient facility were completed. The documentation revealed the patient was admitted to hospital [hospital name], further review of the clinical record revealed no documentation of a transfer summary completed for 01/07/22 and 01/14/22 and sent to the receiving facility to inform of patient's current course of illness and treatment to ensure the safe and effective transition of care. Interview conducted with the Administrator on 02/14/22 at 3:54 PM confirmed that no transfer summary was completed and sent to the last receiving facility, admission to hospital on 01/14/22. The Administrator added that patient lived in an assisted living facility and upon being sent to the hospital, a copy of medication sheet and plan of care was sent with the patient.