Santa Fe Health Care Inc.

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on record review and interview, the Agency’s written emergency preparedness and response plan (ERP) failed to include a continuity of operations business plan that addressed essential functions for patient services, critical personnel and how to return to normal operations as quickly as possible for 3 of (2022, 20234, and 2024) of 3 years reviewed. This failure could place the Agency’s active clients at risk of harm from employees that are unfamiliar with their job responsibilities during a natural or man-made disaster or emergency. The findings included: Record review of the Agency’s Emergency preparedness and response binder included a completed “Ready Business, Business Emergency Plan…Business Continuity and Disaster Preparedness Plan” not signed or dated, that addressed the Agency’s “Plan to stay in Business…” Record review of the Agency’s “Business Emergency Plan” not signed or dated, revealed the following sections were left blank, “Evacuation plan for…. If we must leave the workplace quickly [section left blank] …1. Warming system [section left blank] …2 Assembly site [section left blank] …3. Assembly site manager and alternate [section left blank] …Responsibilities include [section left blank] … 4. Shut down manager and alternate [section left blank] …Responsibilities include… 5. [section left blank] is responsible for issuing all clear… Shelter in place…3. Seal the room Shelter Location [section left blank] …4. Shelter Location & Alternate [section left blank]…Responsibilities include [section left blank]….5 Shut Down Manager & Alternate [section left blank]…Responsibilities include [section left blank]… 6 [section left blank] is responsible for issuing all clear…Records back up….If our accounting and payroll records are destroyed, we will provide for continuity in the following ways…[section left blank]…Annual review…We will review and update this business continuity and disaster plan in [section left blank]….” Record review of the Agency’s “Business Emergency Plan” not signed or dated, revealed the following sections were left blank, “Evacuation plan for…. If we must leave the workplace quickly [section left blank] …1. Warming system [section left blank] …2 Assembly site [section left blank] …3. Assembly site manager and alternate [section left blank] …Responsibilities include [section left blank] … 4. Shut down manager and alternate [section left blank] …Responsibilities include… 5. [section left blank] is responsible for issuing all clear… Shelter in place…3. Seal the room Shelter Location [section left blank] …4. Shelter Location & Alternate [section left blank]…Responsibilities include [section left blank]….5 Shut Down Manager & Alternate [section left blank]…Responsibilities include [section left blank]… 6 [section left blank] is responsible for issuing all clear…Records back up….If our accounting and payroll records are destroyed, we will provide for continuity in the following ways…[section left blank]…Annual review…We will review and update this business continuity and disaster plan in [section left blank]….” Record review of the Agency’s “Business Emergency Plan” not signed or dated, failed to document the actions and responsibilities of Agency staff in each phase of emergency planning, including mitigation, preparedness response and recovery. In a simultaneous record review of the Agency’s “Emergency Preparedness and Response Plan” binder and interview on 03/27/25 at 11:00 a.m., the DON identified herself as the Disaster Coordinator. The DON identified the Office Mgr. as the Alt Disaster Coordinator. At 11:10 a.m. the DON called the Office Mgr. for assistance in reviewing the ERP binder and identifying the Business Continuity Plan. The DON stated the plan just “tells you what to do during the disaster” but not how to return to normal operations. The DON stated they had been doing this [DON/Disaster Coordinator] for so long “over 20 years” and new how to run the ERP. The DON stated they could run the ERP based on their experience. The DON stated the plan was not accurate and could understand how someone could have a problem with the ERP because she could not find anything in the “book” [ERP binder]. In a simultaneous record review of the Agency’s “Emergency Preparedness and Response Plan” binder and interview on 03/27/25 at 11:10 a.m. the Office Mgr. identified herself as the Alt Disaster Coordinator. The Office Mgr. identified the Ready Business, Business Emergency Plan…Business Continuity and Disaster Preparedness Plan as the Agency’s Business Continuity Plan. The Office Mgr. stated the Agency’s ERP did not document the actions and responsibilities of each staff during each phase of emergency planning or how the Agency would be returning to normal operations in a natural or man-made disaster. The Office Mgr. stated, “it might be in the Agency’s policy, but it has to be in the Plan” The Office Mgr. stated the ERP did not have the actions or responsibilities for each staff during each phase of the ERP including mitigation, preparedness, response, and recovery. The Office Mgr. stated we “need to make it easier”. The Office Mgr. stated, “we do not have it [documentation on how to return to normal operations]”. The Office Mgr. stated the Agency’s plan was accurate for the Agency, but she could understand how someone else could have a problem with it. The Office Mgr. stated the ERP was not complete and that it could potentially be disastrous to active clients because the Agency would not be able to carry out emergency procedures immediately. In an interview on 03/27/25 at 03:20 p.m., the Adm stated the DON and Office Mgr. were the Disaster Coordinator and Alternate Disaster Coordinator for the Agency. The Adm stated the Agency had been using the same forms for Emergency preparedness in previous surveys and have not had any issues. In a follow up interview on 04/01/25 at 11:30 a.m., the Office Mgr. confirmed the ERP was reviewed annually and that the form “Ready Business, Business Emergency Plan…Business Continuity and Disaster Preparedness Plan” was updated annually. The Office Mgr. stated the form from the previous year was then pushed further back in the binder as newer forms were added to the binder. The Office Mgr. stated the Agency was following the consultant’s recommendations for the Agency’s Emergency Preparedness and Response Plan. The Office Mgr. stated the Agency did not double check to ensure the Agency was following state/federal regulations for compliance. In a simultaneous interview on 04/01/25 at 11:45 a.m., the Office Mgr. and the DON stated the Agency was not able to provide documentation of the forms from previous years. The Office Mgr. and DON confirmed the “Ready Business, Business Emergency Plan…Business Continuity and Disaster Preparedness Plan” that listed the current DON and Office Mgr. as the Disaster Coordinator and Alternate Disaster Coordinator was used for 2023,2024, and 2025. The Office Mgr. stated the “Ready Business, Business Emergency Plan…Business Continuity and Disaster Preparedness Plan” that listed the previous employees was used prior to 2021. The Office Mgr. stated the Agency was recommended they use those forms as their ERP but did not ensure it had all the components needed. The Office Mgr. confirmed the “Ready Business, Business Emergency Plan…Business Continuity and Disaster Preparedness Plan” did not document the essential functions for patient services, critical personnel, or how to return to normal operations. Record review of the Agency’s policy titled “EC.8 Emergency Preparedness Policy and Plan”, with a revised date 07/11/23, quoted in part, “I. Agency will develop a Business and Continuity and Disaster Preparedness Plan to ensure needs of agency staff and patients are met… 6. Agency leaders will develop the Business and Continuity and Disaster Preparedness Plan which will be maintained in the Emergency Preparedness and Response Plan Manual to address the following. This document will be maintained separately from this policy, as it addresses the specific details of the agency’s information that may change on an ongoing basis, while this policy and procedure for implementation does not change depending on the agency’s physical address and other demographic information… c. essential functions for patient services…. d. critical personnel, roles, and responsibilities…h. how to return to normal operations as quickly as possible…””

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to transmit completed OASIS (Outcome and Assessment Information Set) assessments within 30 days of completions for 1,056 of 4,617 assessments submitted between 03/01/24 through 03/20/25. This failure prevented the patient’s data from being made available to the Center’s for Medicare and Medicaid (CMS) for analysis to identify Agency performance levels in the provision of patient care. Findings included: Record review of the IQIES (Internet Quality Improvement and Evaluation System) “Home Health Error by Summary Agency” report generated from the CMS national data system during presurvey preparation on 03/19/25 revealed the Agency had submitted and processed 4,587 assessments. The report indicated the Agency had 22.91% of assessments with -3330 error that indicated the assessments were submitted after the 30th date of the M0090 (last date that information used to complete the comprehensive assessment and determine OASIS coding was gathered by the assessing clinician and documentation of the specific responses completed). date. Record review of the Agency OASIS final validation reports dated 03/01/25 through 03/20/25 revealed 4,617 assessments were processed by the Agency. Further review of the Agency OASIS final validation reports 1,056 of the 4,617 had error -3330 indicating those record were submitted after the 30th date of the M0090 date. In an interview on 03/27/25 at 02:25 p.m., the DON stated QA (Quality Assurance) department performed exporting OASIS assessments for both the parent Agency and the branch. The DON stated the Agency’s policy for exporting and submitting OASIS assessments to CMS was 30 days. The DON stated the RN performed an assessment and submitted the assessment to the Agency’s QA department. The DON stated that the QA department would then revise it and send it to the nurse for corrections or submit it to CMS, but if it was sent to the nurse the nurse would then have to return it to the QA department with corrections before it was sent to CMS. The DON stated there were only 2 LVNs in the QA department responsible for revising assessments and exporting all the Agency’s assessments to CMS. The DON stated the Agency had a process in place where the nurse would see “OASIS in their box” and they “don’t start seeing patients until the OASIS has been completed”. The DON stated this was completed on a “daily basis, ever morning”. In an interview on 03/27/25 at 02:35 p.m., LVN K stated she was responsible for the exporting of OASIS assessments in the QA department and had been doing that for over 19 years. LVN K stated the Agency’s policy for exporting and submitting OASIS assessments to CMS should be done within 30 days. LVN K stated the Agency had been having some “issues” with previous nurses who had been “let go” because they were not submitting their assessments in a timely manner. LVN K stated the Agency has had improvement in submitting OASIS assessments and not had “as many late” OASIS assessments submissions. LVN K stated she tried to export every Friday and sometimes exported every day. LVN K stated on occasion the assessments had been sent but because the assessments needed corrections, they had to retrieve the already submitted OASIS assessment and when they tried to re-submit the assessment again, it would then be late. LVN K stated once the QA department receives the OASIS assessments, they revise them and submit the plan of correction for signature and return the assessment to the nurse for corrections if needed. LVN K stated the assessments should have very minimal corrections and if they do go back to the nurse for corrections, the QA department attempted to “get them back or contact the nurse immediately” so they could return the assessment to the QA department. LVN K stated submitting the OASIS assessments to CMS has also improved because the system gives the Agency the “report right then and there”. LVN K stated the report gave the Agency all errors immediately, so the Agency knew if there were any late submissions, and they did not have to wait an “hour or more” for those reports. LVN K stated those changes had been implemented since “December, very recent”. In an interview on 03/27/25 at 02:45 p.m., the Office Mgr. stated she did not know what the policy for exporting OASIS assessments to CMS was. The Office Mgr. stated the DON, and the QA department were responsible for ensuring the assessments were submitted. In an interview on 03/27/25 at 03:20 p.m., the Adm stated Agency policy for submitting OASIS assessments were 30 days. The Adm stated the DON and QA department was responsible for ensuring the assessments were submitted to CMS. Record review of Agency policies titled, “IM.9 Timelines” with a revised date 07/01/21, quoted in part, “To establish timeframes for completions and incorporation of paperwork and OASIS into the clinical record…A. Agency will ensure timely provision of care and services to meet the patient’s needs in compliance with all federal and state laws and regulations and standards of practice…17. Encoding and transmission of OASIS data to CMS (Centers for Medicare and Medicaid) is performed at least monthly and prior to billing. The OASIS is required to be transmitted to CMS within 30 days of date of assessment is completed (M0090) …” Record review of Agency policies titled, “IM.10 OASIS Collecting, Encoding and Transmitting” with a revised date 01/01/21, quoted in part, “Timepoints for completing OASIS include…The Agency must encode and electronically transmit each completed OASIS assessment to the CMS system, for each beneficiary with respect to which information is required to be transmitted within 30 days of completing the assessment of the beneficiary…””