Every finding on record at Socorro General Hospital Home Health Care

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Socorro General Hospital Home Health Care Home Health Agency (HHA) on 3/17/2026 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 Socorro General Hospital Home Health Care Home Health Agency (HHA) on 3/17/2026 resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited:

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure that patients were provided a copy of their medication list for 2 (P[patient]3 and P4) out of 3 (P3-P5) patients observed. This deficient practice could lead to medication errors, lack of patient understanding and poor coordination of care regarding the patient’s medication regimen. The findings are: A. During an observation on 3/17/2026 at 9:00 AM in the residence of P4 with S(Staff)1, clinical, and S4, clinical, it was observed that there was no medication list present in the home for the patient. B. During an interview with S4, clinical, on 3/17/2026 at 9:15 AM, S4 explained that medication lists should be provided to the patients and reviewed by the nurse. C. During an interview with P4 on 3/17/2026 at 9:35 AM, P4 explained that the nurse asked about any changes to the patient’s medications but did not provide a medication list. P4 confirmed there was no medication list in the home. D. During an observation on 3/17/2026 at 12:15 PM in the residence of P3 with S2, clinical, and S4, clinical, it was observed that there was no medication list in the home for the patient. E. During an interview on 03/15/2026 at 12:50 PM with P3, it was confirmed that there was no medication list available in the home.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of New Mexico Department of Health. An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 12/12/22 to 12/14/22 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of New Mexico Department of Health. An unannounced on-site Recertification Survey conducted at the above-named Home Health Agency (HHA) from 12/12/22 to 12/14/22 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level 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 medical record review, staff interview, and review of agency policy, the agency failed to ensure the Registered Nurse (RN) completed the initial assessment of patient needs within 48 hours of the referral date for three of seven medical records reviewed (Patient (P)1, P6, and P7). Failure to assess the immediate care and support needs of patients while they wait for a complete and comprehensive assessment of needed services could cause a lapse in health and safety needs for all 49 patients receiving services from this agency, with possible negative outcomes. Review of the "Referral Information," in the "Encounters" section in the electronic medical record (EMR) of P1 revealed, "Referral date: 04/11/22." Review of the "Home Health Plan of Care [POC] revealed the Start of Care [SOC] date was 04/14/22. Review of the "OASIS [Outcome and Assessment Information Set/the standardized assessment tool used for home health agency admissions], dated 04/14/22, revealed the entry, "Date of Physician-ordered Start of Care: NA - No specific SOC date ordered by physician." Review of the "Referral Information," in the "Encounters" section in the EMR of P6 revealed, "Referral date: 05/10/22." Review of the "Home Health Plan of Care revealed the Start of Care date was 05/17/22. Review of the "OASIS, dated 05/17/22, revealed the entry, "Date of Physician-ordered Start of Care: NA - No specific SOC date ordered by physician." Review of the "Referral Information," in the "Encounters" section in the EMR of P7 revealed, "Referral date: 01/09/22." Review of the "Home Health Plan of Care revealed the Start of Care date was 01/13/22. Review of the "OASIS, dated 01/13/22, revealed the entry, "Date of Physician-ordered Start of Care: NA - No specific SOC date ordered by physician." During an interview with the Clinical Manger (CM) on 12/14/22 at 10:40 AM, the EMR of P1, P6, and P7 were reviewed and verified as complete and accurate. The CM agreed that the entry in the OASIS, "No specific SOC date ordered by physician," indicated the SOC date was expected to follow agency policy and expectation for the RN to complete the initial visit within 48 hours of the referral in the absence of any other documentation to explain the delay. The CM was unable to find documentation to explain the reason for the delay for any of the records reviewed above, and stated, "We were not in compliance." The most current agency policy related to the need to complete the initial RN assessment in a timely manner was requested. Review of the agency policy titled, "Admission Criteria – HH [Home Health] and Hospice," current effective date 12/05/19, revealed, "For Home Health: 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 (or other authorized licensed independent practitioner)."

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, staff interview, and review of agency policies and procedures, the agency failed to ensure the Physical Therapist (PT) and Skilled Nurse (SN) used appropriate procedures for hand hygiene (washing hands with soap and water or alcohol-based hand rub/ABHR) and equipment disinfection during the care of two of three home visit observations (Patient (P)1 and P2). Failure to maintain infection prevention techniques during patient care could lead to infections for all patients receiving care from this agency. During a home visit to P1 on 12/12/22 from 9:50 AM to 10:40 AM, the PT was observed completing a skin assessment of P1's feet using bare hands. The visit was also observed by Quality 2 (QA2) as part of a routine oversight of staff technique for the agency. The PT was noted to complete the skin assessment and then, without performing hand hygiene, donned clean gloves used for the remainder of the visit, which included various exercises and manipulations of the patient's body. During an interview on 12/12/22 at 11:30 AM, QA2 agreed with the observation above and stated, "[He/she] should have performed hand hygiene prior to putting the new gloves on." During an interview with the Clinical Manager (CM) on 12/12/22 at 11:35 AM, the observation above was described. The CM agreed agency policy and expectation is for staff to perform hand prior to donning new gloves. The most current agency policy related to hand hygiene was requested. Review of the agency policy titled, "Hand Hygiene," dated 06/30/22, revealed, "Proper hand hygiene is performed…Before and after donning and doffing gloves and Personal Protective Equipment [PPE]." During a home visit to P2 on 12/13/22 from 1:15 PM to 2:00 PM, the SN was observed completing an assessment of P2's back, chest, and abdomen using a stethoscope. After completion of the assessment the SN draped the stethoscope around his/her neck. After completion of the home visit, the SN left the patient's home with the stethoscope still draped around his/her neck, and without disinfecting the stethoscope. During an interview on 12/13/22 at 2:05 PM, the SN agreed the stethoscope should have been disinfected along with all the other medical equipment used during the home visit, prior to leaving the patient's home. During a joint interview with the CM and Quality 1 (QA1) on 12/13/22 at 2:15 PM, the above observation was reviewed. The CM and QA1 agreed facility policy and expectation is for all reusable medical equipment used during a home visit to be disinfected at the end of the visit, then replaced the SN's clean bag. The most current policies and procedures related to equipment disinfection was requested. Review of the agency policy titled, "Bag Technique Home Health and Hospice," dated 05/08/20, revealed, "The bag may have the following contents, such as: Assessment equipment, such as a thermometer, stethoscope, blood pressure cuffs, and pulse oximetry unit [used to measure the oxygen content of a patient's blood]…When the visit is completed, noncritical multiuse equipment will be cleaned per the equipment cleaning grid [see grid] and placed on a clean barrier for drying. Hand hygiene will be performed, and equipment and supplies will be returned to the bag and bag will be zipped closed or secured with Velcro, whichever is relevant." Review of the undated, attached, "Cleaning and Disinfection of Non-critical Reusable Medical Equipment [RME], revealed, "Stethoscope, Approved Cleaning Agent/Method: Hydrogen Peroxide/Alcohol Wipe or 70% alcohol wipe; Contact Time: 1 min. [minute]; Frequency: After Each Patient, [and] When visibly soiled."