Santa Fe Home Health Care Inc

The provider failed to demonstrate that 7 out of 10 (Staff A, B, C, E, F, H, and J) active staff received annual in-service on infection control.

The provider failed to demonstrate it had obtained the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities for 1 out of 10 Sampled Patients (SP).

The home health staff failed to prepare and record clinical notes for 2 out of 10 Sampled Patients (SP).

The provider failed to maintain documentation which demonstrates that an individual may furnish home health services on behalf of the Home Health Agency only after that individual has successfully completed a competency evaluation program for 1 out of 5 personnel file review.

The provider failed to maintain the content of clinical record that includes notation of all interventions, including medication administration, treatments, and services, and responses to those interventions rendered by the home health agency staff for 1 out of 10 Sampled Patients (SP).

(SP#9 and SP#10); and the provider failed to ensure the clinical record included a completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the Home Health Agency…

The provider failed to develop, establish and maintain a comprehensive emergency preparedness plan that must be reviewed and updated at least annually.

The provider failed to develop an emergency preparedness plan that include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including…

The provider failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws that includes Names and Contact information for the Staff; Entities providing services under arrangement; Patients' physicians; Other [facilities] and Volunteers.

The provider failed to ensure that all new and existing staff that participated in the initial emergency preparedness training, demonstrated knowledge of the Home Health Agency's emergency procedures and of their expected roles.

The provider failed to demonstrate tabletop exercise(s) that included a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan, analyze the…

The provider failed to have staff follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases for 1 out of 3 Sampled Patients(SP) with home visits made.

The home health agency failed to provide the patient with proper written notice, in advance of a specific service being furnished, if the Home Health Agency (HHA) believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care for 2 out of 8 Sampled…

The provider failed to ensure that a review of all medications the patient is taking in 1 out of 3 Sampled Patients (SP) with home visits.

The provider failed to include in the individualized plan of care the following: a description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors; and information related to any advanced directives…

The provider failed to document the orders in the patient's clinical record, and sign, date, and time the orders in 2 out of 7 Sampled Patients (SP).

The provider failed to maintain documentation which demonstrates that an individual may furnish home health services on behalf of an Home Health Agency only after that individual has successfully completed a competency evaluation program for 1 out of 5 personnel file review.

The provider failed to ensure that an onsite visit to the patient's home no less frequently than every 14 days is conducted for supervision of the Home Health Aide (HHA) by a Registered Nurse or other appropriate skilled professional in 1 out of 7 Sampled Patients (SP).

The provider failed to make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care for 3 out of 5 employee records reviewed.

The provider failed to document in the home health aide supervision the following elements: maintaining an open communication process with the patient, representative (if any), caregivers, and family; demonstrating competency with assigned tasks in 2 out of 7 Sampled Patients (SP).