Alto Mar New Mexico LLC

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, agency document review, and agency policy review, the agency failed to ensure staff performed hand hygiene before they put on gloves and after they removed their gloves. The agency further failed to ensure staff placed a barrier before they placed their bag down in a patient’s home. These deficient practices affected 2 (Patient #2 and Patient #3) of 7 sampled patients observed during home visits. An undated agency policy titled, “Hand Washing Policy,” revealed, “Hands must be washed before and after patient contact, during patient care (if hands become soiled), immediately following contact with body areas containing blood or other potentially infectious materials and immediately after removing gloves. (Wearing gloves does not eliminate the necessity for hand washing). Hands must be washed with soap and water. If soap and water are not available, antiseptic hand cleaner or towelette [towelettes] may be used then wash hands with soap and water as soon as possible.” 1. During a concurrent observation and interview on 10/07/2024 at 2:00 PM, in Patient #3’s home, Licensed Vocational Nurse (LVN) #2 provided wound care to the patient. During the observation, LVN #2 did not wash her hands after she removed a pair of gloves and before she put on a new pair of gloves. LVN #2 stated she was unsure of any agency policy regarding hand hygiene and the need to perform hand hygiene between glove changes. 2. An undated document, provided with the agency, titled, “Healthcare Bag Technique,” revealed, “8. Spread an impervious barrier on the surface before setting the bag down.” During a concurrent observation and interview on 10/07/2024 at 3:15 PM, in Patient #2’s home, Registered Nurse (RN) #4 entered the patient’s home and placed his bag on the patient’s bed, without a first setting a barrier to place his bag on. RN #4 put on gloves, checked the patient’s vital signs, and removed the gloves. RN #4 did not perform hand hygiene before he put on gloves or after he removed his gloves. RN #4 stated staff were expected to place a barrier under their bags while in a patient’s home and confirmed that he failed to do so during the home visit. RN #4 stated he performed hand hygiene in his vehicle before he went into the patient’s home. During an interview on 10/10/2024 at 4:18 PM, the Alternate Administrator stated the agency expected staff to perform hand hygiene after they removed their gloves and place a barrier down prior to setting their bags down in a patient’s home.”

“Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This Standard is not met as evidenced by: Based on interview, document review, and agency policy review, the agency failed to safeguard personal health information (PHI) for 99 of 201 patients reviewed for protection of records. Specifically, the agency conducted interdisciplinary team (IDT) care coordination meetings with patient PHI through unsecured text messaging. An agency policy titled, “Individual Responsibilities for Safeguarding PHI Policy,” updated 11/01/2020, “5. Do not send PHI via text message.” Case conference notes revealed the case conferences were conducted via text messages on 09/09/2024, 09/16/2024, 09/23/2024, 09/30/2024, and 10/07/2024. The records revealed the conference notes began with a screenshot of patient names and were sorted by the clinician who provided the care. The records revealed, in addition to patient names, details of the patient’s health care were discussed including hospitalization, the need for an indwelling catheter, weekly changes, those patients who were discharged to other care settings, and those patients who needed wound care. During an interview on 10/07/2024 at 12:30 PM, Physical Therapist (PT) #13 stated weekly IDT care coordination meetings were conducted via text message every Monday. PT #13 stated during the care coordination meetings each patient was reviewed and all the disciplines could see the responses of the other disciplines. PT #13 stated those texts were not sent through a secure application or documented in the patients’ medical records, but instead were sent to the clinicians’ personal cell phones. During an interview on 10/07/2024 at 2:00 PM, Licensed Vocational Nurse (LVN) #2 stated weekly IDT meetings were conducted via text messaging to the staff members’ personal cell phones. LVN #2 stated the company did not utilize a secure messaging platform for the messages, and the company did not provide cell phone for staff to use for these communications. During an interview on 10/07/2024 at 3:15 PM, Registered Nurse (RN) #4 stated IDT meetings were done monthly via text to their personal phones. RN #4 stated there was no secure platform used by the company for these texts. During an interview on 10/08/2024 at 10:05 AM, LVN #14 stated case conferences were done via group text. During an interview on 10/09/2024 at 11:20 AM, the Quality Assurance Patient Coordinator (QAPC) confirmed that all case conferences were conducted via group text. The QAPC stated during these care team meetings, the care team discussed recertifications, discharges, and any needed changes to the patient’s plan of care. The QAPC stated that the text messages for care conferences were done via regular texting platforms, not a secure application. During an interview on 10/10/2024 at 4:27 PM, the Alternate Administrator (AA) stated case conferences were conducted via text messaging. The AA stated the case conferences included PHI, and the agency policy was to not send PHI via text messaging. The AA further confirmed that the text messages were not sent via a secure messaging platform, and the current case conference system of reviewing patient cases via text messaging was not an approved way to protect patient PHI.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on interview, record review, agency document review, and agency policy review, the agency failed to ensure staff provided care as directed by a patient’s plan of care for 1 (Patient #2) of 17 sampled patients. An agency document titled, “Job Description/Qualifications,” for the position of home care aide with a review date of 05/2009, indicated, “Position summary: Responsible for the provision of personal care and related assigned services to agency patients in accordance with an established physician plan of care, under the supervision of a registered nurse.” Patient #2’s “Home Health Certification and Plan of Care,” for the certification period 07/07/2024 to 09/04/2024, revealed an order for a home health aide (HHA) 40 hours weekly for nine weeks beginning on 07/07/2024. Patient #2’s care calendar hours, confirmed by the Alternate Administrator (AA), indicated the following: - for the week of 08/18/2024, 39 HHA hours were provided. - for the week of 08/25/2024, 37 HHA hours were provided. - for the week of 09/01/2024, 38 HHA hours were provided. Patient #2’s “Home Health Certification and Plan of Care,” for the certification period 09/05/2024 to 11/03/2024, revealed an order for a HHA 40 hours weekly for nine weeks beginning on 09/05/2024. Patient #2’s care calendar hours, confirmed by the Alternate Administrator (AA), indicated the following: - for the week of 09/08/2024, 37 HHA hours were provided. - for the week of 09/15/2024, 37 HHA hours were provided. - for the week of 09/22/2024, 33 HHA hours were provided. - for the week of 09/29/2024, 37 HHA hours were provided. During an interview on 10/10/2024 at 3:00 PM, the AA stated Patient #2 did not receive the amount of HHA services ordered by the physician in the patient’s plan of care.”