Every finding on record at Southwestern Home Health Care, Inc.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site recertification survey conducted at Southwestern Home Health Inc. Home Health Agency (HHA) on 07/09/2025 resulted in noncompliance under 42 CFR 484.102 with the following standard-level deficiencies:

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview the facility failed to provide initial and subsequent annual emergency preparedness training for new and existing staff for 3 (S[Staff] 5, S6, and S7) out of 4 (S5-S8) staff files reviewed. This deficient practice could lead to a failure in continuity of care possibly resulting in poor outcomes for the patient during an emergency. The findings are: A. Record review of the facility’s policy titled “Emergency Operations Plan” dated 02/18/2025, under the heading “Staff” it stated the facility would instruct staff on the agency’s Emergency Preparedness (EP) plan at orientation and establish a training schedule; instruct and assist staff to develop personal/family emergency plan. B. Record review of personnel files showed the personnel files did not contain any documentation of emergency preparedness training. C. During an interview with S6, clinical, on 07/08/2025 at 10:05 AM, S6 stated she had not received EP training by the facility and has not discussed EP with the patient or caregivers. D. During an interview with S5, clinical, on 07/08/2025 at 2:00 PM, S5 stated he had not received any training on EP by the facility and had not discussed EP with the patient or their caregiver. E. During an interview with S7, clinical, on 07/09/2025 at 9:00 AM, S7 stated she had not received any EP training by the facility and had not discussed EP with the patient or their caregiver. F. During an interview with S1, clinical, on 07/09/2025 at 11:50 AM, S1 stated her facility did not provide initial or subsequent annual emergency preparedness training or maintain documentation of emergency preparedness training.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the facility failed to conduct testing of the emergency preparedness program annually. This deficient practice could lead to the facility being unprepared for emergencies that occur and a delay or failure to meet the needs of patients who rely on the agency. The findings are: A. Record review of “After-Action Report/Improvement Plan” (an after action report is a process used to analyze the outcomes of a emergency preparedness drill or exercise) dated 11/10/2023 was the most recent emergency preparedness exercise. No emergency preparedness exercise for 2024 was performed. B. During an interview with S (staff)1, clinical, on 07/09/25 at 11:50 AM, S1 stated her facility did not participate in an annual emergency preparedness exercise in 2024.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Southwestern Home Health Care Inc. Home Health Agency (HHA) on 07/09/2025 resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited:

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to notify patient and the provider of the planned discharge prior to completion of treatment for 1 (P[patient]7) out of 2 (P6, and P7) patients reviewed for discharge from the agency. This deficient practice could lead to the patient not having an opportunity to receive instruction regarding medication changes and not receiving the necessary treatment plan. The findings are: A. Record review of agency’s policy titled, “Discharge Planning, Summary [and] OASIS [Outcome and Assessment Information Set]” dated 01/2025 stated, “…Prior to discharge the patient’s attending physician will be notified…a discharge order is only required if the treatment plan cannot be completed as prescribed.” B. Record review of P7’s discharge summary revealed that the patient was discharged as of 04/12/2024. Review of the narrative notes dated 04/12/2024 revealed that the patient was being discharged from home health agency due to non-compliance. Prior to discharge on 04/12/2024 there was no discussion with patient or the patient’s physician regarding the planned discharge from home health for non-compliance. There was no discharge order prior to patient being discharged from the home health agency. C. During an interview on 07/09/2025 at 1:00 PM with S1, clinical, it was confirmed that the patient was not notified of discharge because they could not get a hold of the patient. It was explained that the provider was sent the discharge summary but was not notified prior to discharge.

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 agency failed to complete the discharge summary for 2 (P[patient] 6 and P7) out of 2 (P6 and P7) patients reviewed for discharge from the agency. This deficient practice could lead to patients’ physicians not being provided with all necessary information to continue care. The findings are: A. Record review of the agency’s policy titled, “Discharge Planning, Summary [and] OASIS [Outcome and Assessment Information Set]” dated 01/2025 stated, “The discharge summary will include but not limited to: - Reason for discharge – Status of problems throughout the course of care – A narrative summary of the care/services provided – The progress or lack of toward established goals – The patient’s overall status – Any continuing care needs, instructions, or referral regarding the needs.” B. Record review of P6’s discharge summary for certification period 01/08/2025 through 01/30/2025 revealed the boxes titled, “Reason for Admission”, “Discharge Condition”, and “Patient/Family Discharge Instructions” were blank. C. Record review of P7’s discharge summary for certification period 03/15/2024 through 04/12/2024 revealed a box titled, “Reason for Admission” was blank. D. During an interview on 07/09/2025 at 1:00 PM with S (Staff)1, clinical, it was confirmed there were components missing from the discharge summary.

E000 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 03/21/22 to 03/23/22 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

G000 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 03/21/22 to 03/23/22 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.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: G714 Based on record review, policy review, and interview, the home health agency (HHA) failed to ensure the registered nurse (RN) provided patient and caregiver education related to the performance of wound care for one (Patient (P) 5) of one patient record reviewed with wound care ordered from a sample of seven patients. This deficient practice had the potential to affect all current patients receiving wound care and any future patient admitted that required wound care provided by family. Findings include: Review of the agency policy titled, "Standards of Nursing Practice," revised July 2018, indicated ". . . Standard IV The nurse will prioritize nursing interventions needed to achieve the goals derived from the nursing diagnosis. Rationale Nursing actions are planned to promote, maintain and restore the patient's wellbeing . . . 3. Teaching-learning principles are incorporated into the plan of care. . . Standard VI The nursing staff will assist the patient to maximize his health capabilities. . . Nursing Actions . . . Employ teaching-learning opportunities of the patient. . . Standard VII The nurse will collect date [sic] continuously as evidence by documentation in the patient's record. . . Documentation is to include: . . . The patient's response to medical orders, treatments, and nursing interventions. . . Education patient/family/significant other received and indications of their understanding of instructions." Review of P5's "Home health Care Certification and Plan of Care," provided in hard paper copy by Director of Nursing (DON), indicated the certification period was 01/31/22 to 03/31/22, and the primary diagnosis was urinary tract infection. Further review indicated the frequency of nurse visits was one time a week for eight weeks. Review of P5's physician orders, located under the "Orders" tab, indicated an order on 02/10/22 to perform "wound care/dressing change" to the buttocks and left heel "twice a week or PRN [as needed] if breakthrough drainage occurs. SN [skilled nurse] to change each visit. Family to change on other days. . ." Review of P5's "Skilled Nursing Visit Note," located under the "Visit Management" tab, indicated on 02/10/22 RN1 documented ". . . Patient has a pressure wound noted to his left heel (four centimeters long by two centimeters wide with a depth of 0.2 centimeters) and pressure sore to his buttocks (2.5 centimeters long by 2.5 centimeters wide with no depth). SN [skilled nurse] changed dressing as charted. No s/s [signs and symptoms] of infection noted. Patient daughter was in the home. SN instructed patient daughter to keep wound covered with bandage." Review of P5's "Skilled Nursing Visit Note" documented by RN1 for 02/10/22, 02/15/22, 02/23/22, 03/02/22, and 03/07/22 indicated no documentation that P5's daughter was instructed on performing wound care once a week when the RN didn't visit and if breakthrough drainage occurred. There was no documentation of RN5 observing P5's daughter performing wound care to determine that P5's daughter was compliant and knowledgeable of performing the ordered wound care. In an interview on 03/22/22 at 2:00 PM, RN1 sated he/she did teach P5's daughter wound care that was ordered on 02/10/22 and observed a return demonstration, but RN1 did not document it in P5's medical record. RN1 stated he/she could not document an addendum to the note, because RN1 could not remember when RN1 did the teaching. RN1 confirmed he/she documented on 02/10/22 that RN1 instructed P5's daughter to keep the wound covered. In an interview on 03/23/22 at 8:30 AM, DON stated RN1's nurse notes for P5 did not have documentation that RN1 instructed P5's daughter on wound care and observed a return demonstration to assure compliance. DON stated the teaching and return demonstration should be documented as well as P5's daughter's understanding of the wound care orders.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: G804 Based on record review, policy review, and interview, the home health agency (HHA) failed to ensure the home health aide reported a patient's missed visit to the registered nurse (RN) for one (Patient (P) 6) of two patient records reviewed with home health aide services provided from a sample of seven patients. This deficient practice had the potential to affect all current patients receiving home health aide services and any future patient admitted that required home health services. Findings include: Review of the agency policy titled, "Standards of Nursing Practice," revised July 2018, indicated ". . . Documentation of missed visit. A. If nursing staff misses visits or services with patient and the visit cannot be rescheduled within the week as required by the plan of care, it must notify the responsible physician of the missed visit if there is any potential for clinical impact upon the patient. . ." There was no documentation that the policy addressed when the aide needed to report to the nurse or therapist regarding missed aide visits. Review of P6's "Home Health Care certification and Plan of care," presented in hard paper copy by Director of Nursing (DON), indicated the certification period was 07/13/21 to 09/10/21, and the primary diagnosis was displaced intertrochanteric fracture of the left femur. Further review indicated the home health aide frequency of visits was once a week for one week, then two times a week for eight weeks. Review of P6's "Aide Visit Note," located under the "Communication" tab, documented by Certified Nursing Assistant (CNA) 1 on 07/30/21 indicated ". . . Patient is going out with family. Patient stated that her daughter will shower Thursday night. Patient will be a miss visit." In an interview on 03/23/22 at 8:30 AM, DON stated CNA1 did not document that CNA1 notified the RN of the missed aide visit on 07/30/21. DON stated CNA1 should have notified the RN of the missed visit. DON confirmed the policy did not address that the aide needed to report to the nurse or therapist regarding missed aide visits.