Every finding on record at Star Care Home Health

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey was conducted at Starcare Home Health Agency (HHA) on 02/13/2024 resulted in noncompliance under 42 CFR 484.102 with the following standard-level deficiencies cited:

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a process of emergency preparedness collaboration with the local emergency preparedness (EP) agency to confirm it is aware of the agency’s needs in the event of an emergency. This deficient practice could lead to delays in meeting the agency’s needs in an emergency, which could impact on all patients receiving care at this agency. The findings are: A. Record review of the agency’s Emergency Preparedness (EP), undated, revealed that no documented communication was noted between local, tribal, regional, state and federal EP officials. B. During an interview with S(Staff) 1, nonclinical, confirmed that there is no evidence of communication with local, tribal, regional, state and federal EP officials at least annually.

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), §485.542(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 and interview, the agency failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and Local laws and must be reviewed and updated at least annually. This deficient practice could lead to delays in contacting Emergency Preparedness (EP) services, which could negatively impact all patients receiving care at this agency in an emergency. The findings are: A. Record review of the agency’s EP, undated, revealed contact information for staff, patients, and local EP have not been updated in the past two years. B. During an interview on 02/13/2025 at 9:38AM, S(Staff)1, nonclinical, confirmed that this agency’s EP communication plan was not updated in the past two years.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness plan that complies with Federal, State, and local laws and must be reviewed and updated at least annually. The communication plan must include all of the following: Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. This deficient practice could lead to communication breakdown between emergency preparedness agencies and this agency and could also negatively impact the health and safety of all patients who receive services at this agency if an emergency were to occur. The findings are: A. Record review of the agency's Emergency Preparedness Plan (EP), undated, the plan did not contain a policy or procedure in place regarding communication planning that would comply with federal, state and local laws. B. During an interview on 02/13/2025 at 9:38AM, S(Staff)1, nonclinical, confirmed that there was no alternate communication methods are used, and who uses them in place at this agency.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey was conducted at Star Care Home Health Agency (HHA) on 02/13/2025 resulting in findings of non-compliance with Condition of Participation under 42 CFR 484, subpart A through C with the following standard-level deficiencies listed below.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to advise patients of their right to report complaints to the state toll free home health hotline for 2 (P (Patients) 1 and P4 of 7 (P1-P7) patients reviewed for understanding of how to report concerns to the state. This deficient practice could possibly result in patient rights' concerns about their care or complaints not being addressed. The findings are: A. An interview on 02/11/2025 at 12:04 PM, P 1 confirmed that he was not aware of how to report concerns to the state, nor that there is a state hotline. B. Record review of P4’s agency admission packet (a folder of information given by the agency to each patient at the start of care. This folder including important numbers, at-home emergency preparedness, and individualized health information regarding plan of care and medications), undated, revealed the state hotline’s number was not listed.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review and interview the facility failed to meet the Condition of Participation to ensure that the patients medications were updated during the comprehensive assessment. The findings are: A. The agency failed to update patient's medications. Refer to Tag 536.

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 interview and record review, the agency failed to ensure that a registered nurse completed an initial assessment within 48 hours of receiving a referral from a provider for 3 (P (Patients) 1, P2, and P6) of 7 (P1-P7) patients reviewed for accurate and timely care. This deficient practice could result in patients not receiving physician ordered treatment and services in a timely manner. The findings are: A. Record review of P1’s medical record revealed a referral was received by the agency on 08/13/2024. The start of care document stated the first assessment was performed on 08/16/2024, which exceeds 48 hours from referral to first assessment. B. Record review of P2’s medical record revealed a referral was received by the agency on 09/08/2023. The start of care document stated the first assessment was performed on 09/12/2023, which exceeds 48 hours from referral to first assessment. C. Record review of P6’s medical record revealed a referral was received by the agency on 06/21/2024. The start of care document stated the first assessment was performed on 06/26/2024, which exceeds 48 hours from referral to first assessment. D. During an interview on 02/12/2025 at 3:39 PM with S (Staff)1, non-clinical, confirmed P1, P2 and P6s first assessments were not performed within 48 hours of receiving the referral.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review, observation and interviews, the agency failed to maintain a current and accurate list of all prescribed and over the counter medications for 2 (P [Patients] 1 and P4) out of 7 (P1-P7) patients reviewed. This deficient practice could lead to polypharmacy and harm to all the patients admitted to the agency. The findings are: A. Record review of the facility’s Policy titled "Medication List and Monitoring" with the last review date of 05/02/2024, stated "The agency will maintain a current, accurate list of all prescriptions and over the counter (OTC) medications taken by the patients". B. Record review of P1's plan of care with the Certification Dates 12/14/2024 through 02/11/2025, under medications revealed CoQ10 (Vitamin) and Cranberry capsules were not documented on the list of medications and Lasix (medication to remove excess fluid from body) 20 mg (milligrams) oral tablets 1 tab every day by mouth was ordered. C. During an observation on 02/11/2025 at 11:30 am in the home of P1, S [Staff] 3 (clinical) was reconciling the patient’s medications and found the Lasix bottle had a different prescription order that read, Lasix 40 mg, 1 tablet by mouth daily, this was ordered on 08/26/2024. D. During an interview with P1 on 02/11/2025 at 2:15 pm, P1 confirmed the Lasix dose did get increased to 40 mg on 08/26/2024 because swelling in P1’s legs. E. During an interview on 02/11/2025 at 2:46 pm with S3, it was confirmed that P1's Lasix dosage was changed on 08/26/2024 to 40 mg and the new order should have been placed on the prior recertification. F. Record review of P4's plan of care with the certification period dated 01/13/2025 through 03/13/2025, revealed under the section Medication, an order for Fluoxetine HCL (antidepressant) 40 mg by mouth every day, Remeron (antidepressant) 15 mg oral tablet 1 tab by mouth at night, Hydroxyzine HCL (antianxiety) 10 mg 1- 2 tablets every 6 hours as needed by mouth. G. Record review of P4's Medical Profile dated 01/13/2025 through 03/13/2025, revealed the order for Fluoxetine HCL oral capsule 40 mg once a day by mouth with the start date 09/11/2024, Remeron was discontinued on 09/11/204 and that hydroxyzine was discontinued on 09/25/2023. H. During an observation on 02/12/2025 at 10:15 am in the home of P4 the Fluoxetine prescription bottle stated Fluoxetine 30 mg every day by mouth and there was no prescription bottle for Remeron or Hydroxyzine. I. During an interview on 02/12/2025 at 10:16 am with P4 it was confirmed that the medications Fluoxetine dose was changed to 30 mg, and Remeron was stopped on 09/11/2024 and "I haven't taken Hydroxyzine in over a year". J. During an interview on 02/12/2025 at 10:30 am with S4, it was confirmed that the medications should be reconciled with every visit by the nurse and the plan of care medication list should be updated with every recertification.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview the facility failed to meet the Condition of Participation to ensure the plan of care was individualized and revised based on changes in the patient needs and condition. The Findings are: A. The facility failed to revise and individualize the plan of care as needed. Refer to Tag G592.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, interviews and observations, the facility failed to have an updated plan of care to include all changes throughout the certification period for 1 (P[Patients]4) of 7 (P1-P7) patients. This deficient practice could lead to the staff not being able to appropriately care for the patients and could cause the patient harm The findings are: A. Refer to Tag 536 for medication updates related to P4 not being updated in the plan of care. B. Record review of P4's plan of care for the certification period dated 01/13/2025 through 03/13/2025 under principal diagnosis stated, "Acute Bronchitis" (a short-term inflammation of the lungs). Under SN (skilled nursing) orders stated, " SN to perform complete physical assessment each visit with emphasis on Hypertensive heart disease with heart failure [heart failure related to high blood pressure]" also "SN to minimize/eliminate risk for hospitalization due to high-risk principal diagnosis HTN; multiple comorbidities [having more than one medical condition] COPD (chronic obstructive pulmonary disease), Lupus (autoimmune disease), anticoagulant syndrome (bleeding disorder), Fibromyalgia (autoimmune disease that causes pain throughout the body), Hypothyroidism (decrease function of the thyroid), Depressive disorders and Hyperlipidemia ( high fat level in the blood), There was no monitoring or mentioning of the principal diagnosis Acute Bronchitis. C. During an interview with S4, clinical, on 02/12/2025 at 10:50 am, it was confirmed the medications should be reconciled with every visit by the nurse and the medication plan of care updated. D. During an interview with S1, clinical, on 02/12/2025 at 4:30 pm, it was confirmed that P4's plan of care was not individualized for the patient and the plan of care, and the medication list had not been updated with the last 2 recertifications.

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 record review, observation, and interview, the agency failed to meet standard infection control requirements by not having a proper medical supply inventory management and monitoring system. This deficient practice could potentially result in using expired medical supplies, which can compromise patient safety and lead to negative health outcomes for all patients who require these supplies. The findings are: A. Record review of the agency’s document titled “Infection Control Program,” dated 01/01/2025, under Policy stated “II. The infection control Program will include: . . . 3. Implementing appropriate preventative measures. . . III. Coordinated activities: . . .C. Prevention and Control Activities 1. The agency will follow accepted standards of practice, including the use of standard precautions and as needed, transmission-based precautions with standard precautions, to prevent the transmission of infections and communicable diseases.” B. Observation on 02/11/2025 at 12:15 PM of S (Staff)3’s, clinical, supplies revealed a laboratory blood tube (a tube to collect and store blood for testing) with an expiration date of 10/31/2024. C. Observations on 02/11/2025 at 2:30 PM of the agency’s general supply room, revealed expired supplies. These expired supplies include two foley catheters (tube that goes through the urethra and ends in the bladder and drains urine) expired on 09/26/2023 and 10/28/2022; seven blood collecting tubes expired on 07/31/2024, 08/31/2024, and 10/31/2024; and 20 heparin filled syringes (a high-risk blood thinning medication) expiration years ranged from 2022 to 2024. D. Observation on 02/11/2025 at 2:30 PM of the agency’s general supply room, a carboard box full of supplies (like syringes, gauze, and other wound care supplies), labeled with a discharged patient's personal health sensitive information, was placed on the counter next to other equipment for general use. Items released to a patient must remain with a patient and cannot be used for other patients. E. During an interview on 02/11/2025 at 2:45 PM with S (Staff)2, clinical, confirmed that it is not appropriate to have expired supplies, nor can the agency store patient’s personally issued supplies in the general supply room.

E000 A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Mexico Department of Health. An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 03/14/22 to 03/16/22 resulted in a finding of standard level deficiencies citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: E0017 Based on observation, record review, staff interview and review of the agency's policy, the agency failed to ensure an individualized emergency plan was included in the patient's comprehensive assessment for seven (Patient (P)1, P2, P3, P4, P5, P6, and P7) of seven patient charts reviewed. Failure to assess the specific emergency needs for patients had the potential for unmet patient needs in the event of an emergency. This had the potential to affect all 61 patients in the agency census. Finding include: 1. Review of the closed electronic medical record (EMR) for P1 revealed a start of care (SOC) date of 12/23/20. Review of the OASIS assessment (Outcome and Assessment Information Set, a comprehensive assessment designed to collect information on nearly 100 items used to develop a patient's plan of care), located under the "Nursing" tab, dated 12/23/20, at the SOC, revealed no individualized emergency preparedness needs were assessed. Review of the OASIS recertification assessment, located under the "Nursing" tab, completed 08/16/21, for the most current recertification period reviewed, revealed no individualized emergency preparedness needs were assessed. 2. Review of the closed EMR of P2 revealed a SOC date of 11/16/21. Review of the OASIS assessment located under the "Nursing" tab, dated 11/16/21, revealed no individualized emergency preparedness needs were assessed. Review of the OASIS recertification assessment located under the "Nursing" tab, for the most recent certification period reviewed, 01/15/22 through 03/15/22, revealed no individualized emergency preparedness needs were assessed. 3. Review of the EMR of P3 revealed a SOC date of 02/22/22. Review of the OASIS assessment located under the "Nursing" tab, dated 02/22/22, revealed no individualized emergency preparedness needs were assessed. During a home visit made to P3 on 03/14/22 at 2:00 PM, P3's admission packet was examined and found to contain pre-printed emergency preparedness information only, with no evidence of an individualized plan. 4. Review of the EMR of P4 revealed a SOC date of 11/06/20. Review of the OASIS assessment, located under the "Nursing" tab, dated 11/06/20, revealed no individualized emergency preparedness needs were assessed. Review of the OASIS recertification assessment, located under the "Nursing" tab, for the most recent certification period, 03/01/22 through 04/29/22, revealed no individualized emergency preparedness needs were assessed. During a home visit made to P4 on 03/15/22 at 9:30 AM, P4's admission packet was examined and found to contain the identical pre-printed emergency preparedness information as found in P3's packet, with no evidence of an individualized plan. 5. Review of the active EMR of P5 revealed a SOC date of 09/18/21. Review of the OASIS assessment located under the "Nursing" tab, dated 09/18/21, revealed no individualized emergency preparedness needs were assessed. Review of the OASIS recertification assessment, located under the "Nursing" tab, for the most recent certification period reviewed, 01/16/22 through 03/16/22, revealed no individualized emergency preparedness needs were assessed. During a home visit made to P5 on 03/15/22 at 1:00 PM, P5's admission packet was examined and found to contain the identical pre-printed emergency preparedness information as found in P3's and P4's packet, with no evidence of an individualized plan. 6. Review of the active EMR of P6 revealed a SOC date of 01/28/22. Review of the OASIS, located under the "Nursing" tab, dated 01/28/22, revealed no individualized emergency preparedness needs were assessed. 7. Review of the active EMR of P7 revealed a SOC date of 10/21/21. Review of the OASIS assessment, located under the "Nursing" tab, dated 10/21/21, revealed no individualized emergency preparedness needs were assessed. Review of the OASIS recertification assessment, located under the "Nursing" tab, for the most recent certification period reviewed, 02/18/22 through 04/18/22, revealed no individualized emergency preparedness needs were assessed. During a joint interview with the Program Manager (PM) and Director of Nursing (DON) on 03/16/22 at 10:35 AM, the above documentation was reviewed and found to be complete. Both the PM and DON agreed there was no individualized emergency preparedness assessment found in the patients' OASIS comprehensive assessments and would not be found in any other portion of the patient's medical records, either the EMR or the paper records. Both the PM and DON agreed the emergency preparedness information provided to patients in their admission packets are the same for all patients receiving services from the Home Health Agency (HHA). The PM stated, "We need to improve that," and the DON provided a blank sample of a document titled, "Individualized Emergency Plan," which he/she stated the HHA was, "…planning to use." Review of the agency's policy titled, "Emergency Preparedness and Response Plan," last revised 07/01/20, revealed, "If the Agency identifies a patient/client who may need evacuation assistance, personnel may provide the patient/client with the amount of assistance the patient/client requests to complete the registration process for evacuation assistance. The home health agency must document in the patient’s/client’s file if the patient/client plans to evacuate or remain at home. The Agency will assist with the completion of individual emergency plans for each patient/client that will be included as part of their comprehensive patient/client assessment."

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: E0024 Based on staff interview and document review, the agency failed to ensure it developed policies and procedures for managing a staffing shortage during an emergency. Failure to develop strategies to maintain adequate staffing levels could lead to negative patient outcomes due to missed and/or shortened home visits for all 61 patients currently receiving services from this agency. Findings Include: Review of the HHA's documents titled, "Emergency Preparedness Plan," last reviewed and approved by the Governing Body for the 2020 plan year, revealed no documented policy, procedure, or other plan for managing the agency during a staffing shortage. During an interview with the agency Program Manager (PM) on 03/16/22 at 2:22 PM, the PM stated he/she was unable to locate any documentation of a policy or plan for managing patient care during a staffing shortage, either in the Emergency Preparedness Plan or elsewhere in the agency. Review of the agency policy titled, "Emergency Preparedness and Response Plan," last revised 07/01/20, revealed, "Administration will ensure adequate staffing is provided, and back-up staffing plans are in place."

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), §485.625(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, "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: E0037 Based on document review and staff interview, the Home Health Agency (HHA) failed to maintain a training and testing program for employees related to the Emergency Preparedness (EP) Plan. Failure to ensure staff are fully trained to respond to emergencies could cause a delayed or inappropriate response, placing all 61 patients receiving services at this agency at risk of harm. Findings include: Review of the HHA's documents titled, "Emergency Preparedness Plan," last reviewed and approved by the Governing Body for the 2020 plan year, revealed the most recent staff training was conducted on 04/03/19. During an interview with the agency Program Manager (PM) on 03/16/22 at 12:35 PM, the PM stated no new trainings had taken place with agency staff since the date documented above. The PM stated he/she was aware of the requirement for staff training and testing every two years. Review of the agency policy titled, "Emergency Preparedness and Response Plan," last revised 07/01/20, revealed, "The Agency will provide initial training and at least every two (2) years thereafter, on emergency preparedness policies and procedures to all new and existing staff, contract staff, and volunteers (consistent with their expected role). The Agency will also provide training to all staff when new or updated policies and/or procedures are issued. The Agency will maintain documentation of the training."

G000 A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of New Mexico Department of Health. An unannounced on-site Recertification Survey conducted at the above-named Home Health Agency (HHA) facility from 03/14/22 to 03/16/22 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C. Survey Dates: 03/14/22 – 03/16/22 Survey Census: 61 Sample Size: 7