Santa Fe Home Care of New Mexico

The Home Health Agency (HHA) failed to meet the Condition of Participation for Skilled Professional Services and an investigation of Immediate Jeopardy (IJ) began on 07/10/24 at 10:24 AM when the HHA did not: 1) Coordinate services with members of the Interdisciplinary Team. 2) Provide teaching to…

The Home Health Agency (HHA) failed to review and update the EP plan every two years.

The Home Health Agency (HHA) failed to ensure that eight of eight agency staff reviewed received EP Plan training every two years.

The Home Health Agency (HHA) failed to conduct an exercise to test the EP Plan annually and failed to conduct a facility-based functional exercise every two years.

The Home Health Agency (HHA) failed to develop a Performance Improvement Project based on an analysis of Quality Assurance Policy Improvement (QAPI) data for 2023 and failed to start a Performance Improvement Project for 2024. This deficient practice had the potential to affect all 44 patients…

The Home Health Agency (HHA) failed to ensure the patient's medication lists matched the patients' medications in the home for two of three sampled patients (Patient (P) 6 and P7) and for P6 the HHA failed to ensure that a Registered Nurse (RN) reviewed the medication list after the patient was…

The Home Health Agency (HHA) failed to coordinate services with the Interdisciplinary Team including Registered Nurse (RN) 1, Licensed Practical Nurse (LPN) 1, Occupational Therapist (OT) 1, Physical Therapist (PT) 1, and the patient's attending physician for one of five active sampled patients…

The Home Health Agency (HHA) failed to provide colostomy care teaching to the patient's caregiver for one of five sampled patients (Patient (P) 7).

The Home Health Agency (HHA) failed to ensure communication was provided to the attending physician for one of five sampled patients (Patient (P) 7) to obtain wound treatment orders and to notify of a change in patient condition.

The Home Health Agency (HHA) failed to ensure a discharge summary was provided to the attending physician for two of two sampled patients (Patient (P) 3 and P4) reviewed for discharge.

The facility failed to meet the Condition of Participation (CoP) for Quality Assessment/performance Improvement by failing to have met with the inter-disciplinary team every four months (quarterly), and failed to develop an on-going quality improvement program that documents the quarterly…

The facility failed to have and maintain an updated Emergency Preparedness manual with complete annual Risk Assessments Analysis to identifying hazards or risks that are most likely to have an impact on a healthcare facility and the surrounding community and maintain a hard-copy (a printed version…

The facility failed to maintain an ongoing Quality Assessment Performance Improvement (QAPI) program to ensure adequate and effective operation in the areas of clinical care, operational activities, and provide quarterly (every four months) documentation of what was done to improve performance.

The facility's governing body failed to develop an on-going quality improvement program that documents quarterly activities and who is responsible for operating the QAPI (quality assessment and performance improvement) program which addresses, clinical care, operational activities, and quality…

The facility failed to have a Covid-19 (Infectious respiratory virus) screening process (process used for ensuring there are no signs or symptoms of illness) for all staff and visitors entering the facility, and did not use Clean Bag technique (process used in the Home Health realm to prevent…

The facility failed to maintain documentation of the governing body (professional advisory committee) engagement in oversight of daily operations.

The facility failed to maintain a process for Interdisciplinary Team Meeting/Minutes in order to coordinate patient treatment and care.

The facility failed to complete comprehensive assessments within 5 calendar days after the start of care (SOC) date.

The agency failed to provide documentation of physician's orders.

The home health agency failed to maintain an effective, ongoing, agency-wide, data-driven Quality Assessment Performance Improvement (QAPI) program that reflected the complexity of its organization and services, potentially resulting in patients receiving poor quality of care (See G0642).

The agency failed to 1) maintain agency-wide program for infection control and prevention that included a method of identifying infectious and communicable disease problems and a plan for implementation of appropriate actions, 2) provide current records of TB (tuberculosis) screening (HAI) for the…

The agency failed to maintain documentation of governing body engagement in the home health program and daily operation.

The agency failed to ensure that a system was in place to receive, record, investigate, and resolve patient grievances and complaints.

The agency failed to update and revise the comprehensive assessment for 1 (P#2) of 7 (P1# through P#7) sampled patients.

The agency failed to ensure Coordination of Care took place between disciplines (Skilled Nursing, Occupational/Physical/Speech therapy) for 4 (P#1, P#2, P#5 and P#6) of 7 (P #1 through#7) patient charts reviewed.

The home health agency failed to maintain an effective, ongoing, agency-wide, data-driven Quality Assessment Performance Improvement (QAPI) program that reflected the complexity of its organization and services, potentially resulting in patients receiving poor quality of care.

The facility failed to track and trend quality indicator data in the design of their Quality Assurance and Improvement Program (QAPI) derived from Outcome and Assessment Information Set (OASIS).

The facility's governing body failed to develop an on-going quality improvement program that documents quarterly activities which addresses, clinical care, operational activities, quality improvement action plans to ensure an adequate and effective program.

The agency failed to 1) maintain agency-wide program for infection control and prevention that included a method of identifying infectious and communicable disease problems and a plan for implementation of appropriate actions, 2) provide current records of TB (tuberculosis) screening for 3 of 8…

The agency failed to maintain an agency-wide program for infection control and integrate the infection control program into Quality Assessment Performance Improvement (QAPI). failed practice puts patients at risk of infections not being monitored and not preventing infections.

The agency failed to maintain documentation of governing body engagement in the home health program and daily operation.

The facility failed to complete comprehensive assessments within 5 calendar days after the start of care (SOC) date for 4 (P#2, P#3, P#5, and P#6) of 7 (P#1 through P#7) sampled patients.

The facility failed to ensure all medications, including over-the-counter medications, were reviewed and updated for possible interactions or adverse effects for 3 of 3 (P#1, P#6 and P#7) sampled patients with home visits.

The agency failed to provide documentation of physician's orders for 7 of 7 (P #1 through P#7) sample patients.

The facility failed to have a doctor review the Plan of Care (POC) and sign the POC to assure appropriate and necessary care is provided for 4 (P#4, P#5, P#6 and P#7) of 7 (P#1 through P#7) sampled patient.

The facility failed to coordinate care between patients, caregivers and other providers for 7 out of 7 (P#1 through P#7) sampled patients.

The agency failed to maintain documentation of governing body oversight of the home health program.

The agency failed to ensure employees were qualified to provide patient care.