Every finding on record at Tucumcari Home Health

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 10/12/22 to 10/14/22 resulted in a finding of a standard level deficiency respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

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: Based on observation, interview, document review, and review of the agency's policy, the home health agency (HHA) failed to ensure a written, individualized emergency plan was provided to the patient for three of three patients interviewed during home visits (Patient (P)1, P4 and P5). Failure to develop specific plans for patients had the potential for patients to remain unprepared in the event of an emergency. This had the potential to affect all 33 patients receiving services from the agency. Review of the agency policy titled, "Disaster Preparedness for Patients," effective 08/10/21 indicated, "Purpose: Patients and families/caregivers will receive information on an emergency management plan during the initial visit." "Procedure: 3. The patient and family/caregiver will be assessed and instructed regarding the components of an emergency preparedness/natural disaster plan that will include…A. Emergency phone access, including ambulance, police, fire, gas, electricity and water. B. Emergency supplies, including food, water, heat, light, day-to-day necessities, medications. C. Disaster follow up, including battery-powered access to local radio stations. D. Procedures to follow if care is disrupted by a natural disaster. G. Evacuation plans for the home. 4. Detailed, written information will be provided to the patient and family/caregiver in the Admission Booklet and reviewed, based on patient and family/caregiver knowledge, skills, and identified needs." 1. During an interview outside of P1's home prior to entering for a home visit on 10/12/22 at 10:55 AM, the Registered Nurse (RN) was asked how P1 had been educated/prepared for emergency situations. The RN replied, "I tell them to keep the floor uncluttered so they can get out of the house." RN did not describe any further preparation for the patient. During an interview with P1 on 10/12/22 at 11:00 AM, P1 reported a start of care (SOC) of January 2022. When P1 was asked to describe the Emergency Preparedness teaching/preparation he/she had received from agency staff during and following admission, he/she stated there was no teaching done. Review of P1's admission packet during the home visit revealed a document titled, "Presbyterian Healthcare at Home." It was noted the form was blank. During a brief interview with RN on 10/12/22 at 11:30 AM, RN verified that the document was used by the agency to develop a patient's individual plan for emergencies. RN agreed the document was designed to define important contact names and phone numbers of friends, family members and utility companies. RN agreed the document was blank and had at the bottom, the section, "I have reviewed the above information with my Nurse/Therapist and understand the information and the importance of having and following an emergency plan," which was unchecked, with the section for the Nurse/Therapist to sign also blank. During an interview with the Clinical Manager (CM) on 10/13/22 at12:00 PM, the above document was reviewed. The CM stated facility policy and expectation is for that form, or a newer admission booklet currently being used by the agency, to be filled out and left in the patient's home. A copy of the new admission booklet, titled, "Home Health Admission Booklet," which contained a place on the back cover for "Important Phone Numbers." The most recent agency Emergency Preparedness policy was requested. 2. Review of the Electronic Medical Record (EMR) for Patient (P) 4 revealed a Comprehensive Assessment dated 10/03/22. The Comprehensive assessment indicated emergency preparedness information such as local fire department number, local non-emergency call center, electric company, power company, and oxygen vendor phone. During an interview on 10/13/22 at 11:00 AM with the Physical Therapist (PT) regarding Emergency Preparedness, the PT stated, "I have not done any emergency preparedness training with this patient (referring to P4). Not me personally. No. I think the nurse does that on the start of care, but I have not done anything." During a Home Health visit with P4 on 10/13/22 at 11:30 AM, regarding Emergency Preparedness, P4 stated that he could not remember if someone from the Home Health Agency had gone over any emergency preparedness information or important phone numbers to call in case of an emergency or what to do or where to go in the event of an emergency. P4 stated, "I don't remember if they did or not. I guess I would just call 911." Review of an orange folder with the name of the home health agency listed provided by Family Member (F)2 on 10/13/22 at 11:30 AM, revealed no specific individualized emergency preparedness evacuation plan with information to include local emergency officials. Further review of the contents of the orange folder revealed no specific written individualized emergency preparedness evacuation plan and phone number of who to contact in the event of an emergency. During an interview with Family Member (F)2 of P4 specifically regarding Emergency preparedness on 10/13/22 at 11:35 AM, stated that they were given the number to the Home Health Agency to call, and an after-hours phone number, but nothing more specific as far as an individualized evacuation plan in the event of an emergency. F2 stated, "Nothing has really been discussed as far as what to do, or where to go in case of an emergency. I guess we would go to the Recreation center which used to be the National Guard Armory. We just know they have a basement from living here but nothing was discussed as far as a specific plan. No." During an interview with Family Member (F)1 of P4 specifically regarding Emergency Preparedness on 10/13/22 at 11:37 AM, F1 stated, "I'm not aware of any specific evacuations plans or numbers related to Emergency Preparedness. I guess I would call the Ambulance." During an interview with the Clinical Manager (CM) on 10/14/22 at 3:00 PM, the CM stated that P4 should have received an Admission booklet with the emergency phone numbers to call like fire department, power company and oxygen vendor. The CM then stated, "I do not see evidence of any documentation in the admission folder of numbers to call such as fire department, power company or additional emergency officials. 3. During an interview 10/13/22 at 1:00 PM with the Home Health Aide (HHA) regarding emergency preparedness for P5, the HHA stated, "I have not provided any information/education on emergency preparedness with this patient. I'm hoping the nurse has gone over that with him and his family." During a Home Health visit with P5 and interview on 10/13/22 at 1:15 PM with Family Member (F)3 of P5 regarding emergency preparedness, F3 stated, "No-one really has gone over emergency preparedness, or what to do in case of an emergency. If there was a tornado, I guess I would try to get him inside the closet. There is no other place to go. I guess I would call 911. I never even thought of those things if I needed to leave the house." When F3 was asked if she or P5 has been given information on who to call, or if the Home Health Agency has given information or discussed an Emergency Evacuation Plan, F3 stated, "No, nothing. No-one has gone over anything like that." At this time, F3 provided an Admission Booklet that she received from the Home Health Agency. Review of the Admission Booklet revealed no specific individualized emergency evacuation plan with contact information of emergency officials or what to do in the event of an emergency. During an interview with the Clinical Manager (CM) on 10/14/22 at 9:30 AM, regarding an Emergency Plan for P5, the CM stated, "We are supposed to review what to do in case of an emergency, and those important phone numbers would be put on the back of the patient's admission packets." The CM them stated, "Whoever is doing the admission, would be going over the phone numbers." The CM then confirmed emergency officials' information was not indicated on the admission packet.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Mexico Department of Health. An unannounced on-site recertification conducted at the above-named Home Health Agency (HHA) from 10/12/22 to 10/14/22 resulted in a finding a 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. Survey Dates: 10/12/22 to 10/14/22 Survey Census: 33 Sample Size: 7

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 two of seven patients (Patient (P)3 and P4). 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 33 patients receiving services from this agency, with possible negative outcomes. Review, in the presence of the Clinical Manager (CM), of the undated "Intake Form," in the electronic medical record (EMR) of P3 revealed, "Referral date: 11/23/21." Review of the "OASIS [Outcome and Assessment Information Set/the standardized assessment tool used for home health agency admissions] SOC [Start of Care] in the EMR, dated 11/26/22, revealed, "Date of Physician-ordered Start of Care: NA - No specific SOC date ordered by physician," During an interview with the CM on 10/13/22 at 1:15 PM, the CM agreed the SOC date was not within 48 hours of the referral date, adding, "We are not compliant here." The most recent policy was requested. (Rachel has additional findings for P4) Review of the agency policy titled, "Admission Criteria – HH [Home Health] and Hospice," effective date 12/05/19, revealed, "The Clinical Supervisor will assign clinical organization personnel to conduct assessments of eligibility for services within 24-48 hours of acceptance of referral information and/or discharge from a referring facility, or as ordered by the physician. 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 care date ordered by the physician (or other authorized licensed independent practitioner)." 1. Review, in the presence of the Clinical Manager (CM), of the undated "Intake Form," in the electronic medical record (EMR) of P3 revealed, "Referral date: 11/23/21." Review of the "OASIS [Outcome and Assessment Information Set/the standardized assessment tool used for home health agency admissions] SOC [Start of Care] in the EMR, dated 11/26/22, revealed, "Date of Physician-ordered Start of Care: NA - No specific SOC date ordered by physician," During an interview with the CM on 10/13/22 at 1:15 PM, the CM agreed the SOC date was not within 48 hours of the referral date, adding, "We are not compliant here." 2. Review of the Electronic Medical Record (EMR) for Patient (P) 4 with the Clinical Manager (CM) on 10/13/22 at 3:00 PM was conducted. Review of the EMR "Face Sheet" indicated a referral date of 09/30/22. Review of an "Encounter Note" dated 10/03/22, indicated, the "Date of Referral"-the date that the written or verbal referral for initiation or resumption of care was received by the Home Health Agency was 09/30/22. Review of a "Communication Note" dated 10/01/22, indicated, "SN [Skilled Nursing] called P4 to schedule a HH [Home Health] evaluation. Patient states he/she is still out of town and might be home on Monday but not sure…" Further review of the Communication Note revealed no communication to the physician to inform the physician the initial assessment would not be completed as ordered. Review of an "Encounter Note" dated 10/03/22 indicated, "SN-Initial Visit Home Health" was initially conducted on 10/03/22 (3 days later from referral date on 09/30/22). Further review of the Encounter Note indicated the "Start of Care" began on 10/03/22. The Encounter Note indicated the initial nursing assessment was completed on 10/03/22 (3 days later) from the original referral date of 09/30/22. The initial nursing assessment indicated no communication to the physician about a resumption of care being delayed from 09/30/22 until 10/03/22. During an interview on 10/13/22 at 3:10 PM, the CM stated that the initial referral date for P4 to receive Home Health Services was on 09/30/22. The CM then stated that although the nurse did call P4 on 10/01/22 (the next day after the referral date) to schedule a home health evaluation, P4 stated he was out of town. The CM stated, "I see no evidence that the Dr. was notified that there would need to be a new start of care." The CM stated, "The process for timely initiation of care is that if the nurse is not able to get out to the home to do the initial home health evaluation within that 24–48-hour timeframe, then we need to be contacting the physician to see if we can have updated orders. The nurse should have notified the physician requesting an order for an updated start of care." During an interview on 10/14/22 at 10:30 AM, the Administrator stated that her expectation regarding timely initiation of care within 48 hours, is "We comply with the 48-hour requirement. That would be my expectation and if we are not doing that, we would need to put an action plan in place to comply with the requirements."