Alto Mar New Mexico LLC

The agency failed to ensure staff performed hand hygiene before they put on gloves and after they removed their gloves.

The agency failed to safeguard personal health information (PHI) for 99 of 201 patients reviewed for protection of records.

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.

The facility failed to maintain and update the Emergency Preparedness manual (binder) with current annual Hazard Vulnerability Assessments, also known as a Hazard Vulnerability Analysis (HVA) (used to show hazards or risks that can impact a healthcare facility and the surrounding community), a…

The facility failed to maintain a program that must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care.

The facility failed to adequately screen (the process of identifying individuals concerning infectious disease) for COVID-19 (coronavirus, respiratory viral infection) and maintain a sanitary environment (an environment that is clean, and conducive to infection prevention), as boxes of medical…

The facility failed to ensure that items utilized for direct patient care are furnished appropriately by not using items past expiration dates and not identified as being under an extended use authorization by the United States Food and Drug Administration.

The facility failed to maintain a Governing Body (or designated persons functioning as the governing body) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all Home Health services, fiscal operations, review of the agency's…

The facility failed to advise patients of the State toll free Home Health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local Home Health Agencies for all patients treated.

The Condition of Participation is NOT met as evidenced by: Based on record review and staff interview, the agency failed to ensure the initial assessment was completed within 48 hours of the referral date to the Home Health agency for 3 patients (P#7, P#9 and #10) out of 10 (P #1 through #10)…

This condition of participation is NOT met as evidenced by: Based on record review and interview, the facility failed to 1) provide services as written in the patient's individualized Plan of Care (POC) and 2) notify physician of missed visits for 2 patients (P#5 and P#9) out of 10 (P#1 through…

The Condition of Participation is not met as evidenced by: Based on record review and interview, 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…

This Condition of Participation is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure staff followed accepted infection control practices during a home visit with 1 patient (P#2) out of 4 (P# 1 through Pt# 4) patients observed.

The facility failed to 1) provide services as written in the patient's individualized Plan of Care (POC) and 2) notify physician of missed visits for 2 patients (P#5 and P#9) out of 10 (P#1 through P#10).

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

The agency failed to ensure staff followed accepted infection control practices during a home visit with 1 patient (P#2) out of 4 (P# 1 through Pt# 4) patients observed.

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the Home Health Agency's quality assessment and performance improvement (QAPI) program.

The agency failed to ensure the initial assessment was completed within 48 hours of the referral date to the Home Health agency for 3 patients (P#7, P#9 and #10) out of 10 (P #1 through #10) sampled patients.

The agency failed to complete a comprehensive assessment within 5 calendar days after the Start of Care (SOC) date for 1 patient (P#7) out of 10 (P#1 through P#10) sampled patients.

The agency failed to reconcile medications for 3 patients (P#1, 2 and 4) out of 10 (P#1 through #10) sample patients.

The agency failed to ensure that the Plan of Care (POC) included 1) all known allergies for 3 patients (P#7, P#9 and P#10) out of 10 (P#1 through P#10) sampled patients and 2) documentation of environmental hazards present in the homes of 2 patients (P#2 and P#4) out of 4 (P#1 through P#4) patients…

The agency failed to have a doctor review and sign the Plan of Care (POC) to assure appropriate and necessary care is provided for 3 patients (P#1, P# 2 and P #9) out of 10 (P#1 through P#10) sampled patients.

The agency failed to acknowledge allergies to medications for 3 patients (P#7, #9, #10) out of 10 (P#1 through #10) sampled patients.