Home Kare Inc. of Dona Ana

“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 interview, review of a list of new staff recently hired, and policy review, the agency failed to ensure six new staff (Authorization Department (AD)7, AD6, AD8, Certified Occupational Therapy Assistant (COTA)5, Physical Therapist (PT)4, and Licensed Practical Nurse (LPN)3) had received Emergency Preparedness (EP) training at orientation as a new hire. This deficient practice had the potential for an emergency to occur and staff not be able to respond appropriately. Review of the undated agency’s policy titled, “Emergency Preparedness Plan,” revealed, “Policy: [name of agency] to provide a plan that will ensure continuity of care for all patients during severe weather, disaster/emergency conditions and staff shortages, or dissolution of services . . . The Goals of the Emergency Operations Plan include the following. . . Provide education to staff on the elements of the Emergency Operations Plan during orientation. . .” Review of the staff list provided by the agency revealed the following new staff and their hire dates. There was no evidence found or provided by the agency to show the six employees had received EP training at orientation or at hire. 1.AD7 hired on 03/01/24; 2.COTA5 hired on 04/23/24; 3. AD6 hired on 05/28/24; 4.AD8 hired on 05/28/24; 5.PT4 hired on 06/16/24; 6.LPN3 hired on 07/16/24. During an interview on 07/25/24 at 12:45 PM, the Administrator1 stated, “Training should happen when new staff are hired, I don’t think we have been doing that. I don’t know when the last training was.””

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review, policy review, and interview, the Home Health Agency failed to ensure that the Home Health Aide (HHA) reported missed aide visits to the Registered Nurse (RN) and the patient’s physician for one of 17 (Patient (P)4) sampled patients. This deficient practice had the potential to affect 240 patients receiving services from the HHA. Review of P4’s Electronic Medical Record (EMR), under the “Visit Note Calendar” tab revealed missed HHA visits on 02/02/24, 03/08/24, 06/07/24 and 05/29/24. There was no documentation indicating that the HHA notified the RN or the physician regarding the missed visits. During an interview on 07/25/24 at 12:30 PM, the Administrator 1 confirmed that the HHA failed to inform the RN or the physician that the aide visits were missed. Review of the agency’s undated policy titled “Medical Records and Documentation” indicated “Missed visits are documented on the Missed visit form with reasons for missed visit and Follow-up as required. The physician will be notified of the Missed visit and the date and time of notification will be documented on the form.””

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on personnel file review, policy review, and interview, the Home Health Agency failed to ensure that three of three sampled (Home Health Aides (HHAs 1, HHA2, and HHA3) received at least 12 hours of annual training. This deficient practice had the potential to affect 240 patients receiving services from the Home Health Agency. Review of HHA1, HHA2, and HHA3’s personnel files revealed that throughout the past 12 months, the HHAs received some training; however, there was no documentation indicating how many hours the training consisted of and if the training totaled 12 hours annually. During an interview on 07/25/24 at 9:30 AM, the Administrator 1 stated “I don’t make the HHA’s keep track of the amount of time they spend on the training. I didn’t know I had to do that.” Review of the agency’s undated policy titled “Home Health Aide” revealed “Position Qualifications - Attends twelve (12) hours of Aide orientation in-services per year.””

“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, policy review, observation, and interviews, the Home Health Agency (HHA) failed to ensure the patient’s medication lists matched the patients’ medications in the home for one of four (Patient (P)14) observed patients. This deficient practice had the potential to affect 240 patients receiving services from the HHA. Review of P14’s “Medication” list dated 12/15/23, found in P14’s Electronic Medical Record (EMR) under the “Home Health Certification and Plan of Care” tab, indicated the patient was taking Nifedipine (for high blood pressure) ER 60 milligrams (mg.) tablets. During an observation on 07/25/24 at 9:30 AM in P14’s home revealed Nifedipine ER tablets were not found in the patient’s home. Magnesium 500 mg tablets, vitamin D3 50 microgram (mcg) tablets, vitamin C 500 mg tablets, and Xarelto (blood thinner) 20 mg tablets were found in the P14’s home but were not found on the patient’s medication list. During an interview on 07/25/24 at 10:10 AM, P14 stated he/she was, “no longer taking Nifedipine” and indicated the medication was stopped in 02/2024. P14 confirmed that he/she was ordered by the physician on 06/24/24 to take Xarelto and confirmed that he/she had been taking magnesium, vitamin D3, and vitamin c “for a long time.” During an interview on 07/25/24 at 12:00 PM, the Administrator 1 confirmed that the medications should have been correctly reconciled during the nursing visits. Review of the agency’s undated policy titled “Medication Worksheet & Schedule” revealed “All patients receiving nursing services will have a current and accurate Medication Sheet to follow in their place of residence. PROCEDURE: 1. Medication Sheets are established at the time of admission and updated as the physician alters the patient’s medication regimen. 2. Agency nursing staff shall assess each patient’s medication regimen for possible ineffective drug therapy and discuss any problems with the patient’s physician.””