Every finding on record at American Healthcare Systems LLC

An unannounced, onsite recertification survey was conducted 5/27/25-5/29/25. No deficiencies were identified to the Emergency Preparedness Plan.

An unannounced, onsite recertiification survey was conducted 5/27/25-5/29/25. Standard level deficiencies were identified to the Medicare CoP.

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 agency policy, direct observation, and staff interviews, the skilled nurse failed to perform proper hand hygiene and infection control practices when completing wound care for 2 of 2 patients with home visits who required wound care (#6 and #9). Findings included: 2. Patient # 9 had a Start of Care date of 3/4/25 with an admitting diagnosis of type 2 diabetes mellitus with foot ulcer. Review of the Plan of Care [POC] for the certification period 5/3/25-7/1/25 included orders for SN [skilled nursing] 2 times a week for 8 weeks, 1 time a week for 1 week and “SN or patient/caregiver to perform wound care daily to bi [bilateral] feet, clean with dermal cleanser, pat dry, apply nick thick santyl to wound bed, cover with maxorb AG, paint periwound with betadine, cover with foam dressing...” On 5/27/25 at approximately 9 am a joint visit was made with RN # 5. During the visit wound care was performed by RN # 5. RN # 5 removed the soiled dressings from the top of each foot. The areas were cleaned in accordance with the plan of care. RN # 5 applied santyl to the wound bed on each foot using the same cotton tipped swab. The RN was then noted to use the same betadine swab to paint around the periwound on the top of each foot. During an interview with employee # 2 on 5/21/25 at approximately 11:30 am, employee # 2 confirmed RN # 5 failed to complete proper wound care by cross contamination of the wounds. Policy HH IC-006 Bag Technique (reviewed 5/21/25), received on 5/29/2025 at 10:25 am from the agency director stated: “Staff will practice proper bag technique procedures while providing care in the home…to establish guidelines for use/care of visiting staff’s supply bag to decrease the potential for cross-contamination…all equipment will be cleaned prior to returning it to the bag”. Policy Aseptic Wound care (reviewed 5/21/25), received on 5/29/2025 at 10:24 am from the agency director stated: “To provide standard of practice for aseptic (aim to prevent contamination) wound care in order to promote healing and prevent wound infection…all wound care will be performed using aseptic technique and standard precautions will be observed…assemble the following equipment on a clean work surface…clean gauze…perform hand hygiene and don (put on) non-sterile gloves…remove soiled dressing…doff (take off) gloves and place in plastic bag…perform hand hygiene and don non-sterile gloves…perform wound care…perform hand hygiene.” Policy OW-IP-001 Hand Hygiene (reviewed 3/5/2024), received on 5/29/2025 at 10:24 from the agency director stated: “…perform proper hand hygiene techniques at the appropriate times and indications…to protect…from potential disease-causing microorganisms…5 moments of hand hygiene: before patient contact, before clean/aseptic procedure, after body fluid exposure risk, after touching a patient, after touching patient surroundings”. The policy also stated “glove use is not a substitute for hand hygiene, clean hands prior to putting on gloves, wear gloves when contact with blood or other infectious materials, mucous membranes or non-intact skin could occur, change gloves during patient care if moving from a contaminated body site to a clean body site, clean hands after taking off gloves and before putting on new gloves, clean hands after removing gloves”. 1.Patient #6 was admitted on 05/02/2025 with a primary diagnosis of varicose veins (bulging, enlarged veins) of left lower extremity with ulcers (persistent sores, usually caused by poor blood circulation) on other part of lower leg. Review of the Plan of Care for the certification period of 5/2/25-5/27/25 included orders for SN (skilled nursing) 1 time a day for 1 day, 2 times a week for 8 weeks and “Skilled nurse to perform wound care to left lower leg, right lower leg: cleanse wound with wound cleaner, apply medihoney, xeroform, and alginate, wrap with kerlix and secure with coban. Change twice weekly”. A joint home visit was conducted with RN #1 on 5/27/2025 at approximately 1:15 pm. RN #1 cleaned her hands with hand sanitizer and applied clean gloves. RN #1 then removed saturated wound dressings from patient #6’s right leg using bandage scissors. RN #1 dropped the bandage scissors onto patient’s floor and then picked them up and put them on patient’s chair without a barrier. RN #1 then removed saturated wound dressings from patient #6’s left leg using a different pair of scissors. After using all the gauze pads she had on the barrier, RN #1 was observed reaching gloved hand into bulk 4x4 gauze pack while cleaning left leg. The only hand hygiene RN#1completed was prior to moving from right leg wound to left leg wound. Hand hygiene was not performed until the dressing change to the left leg was completed. RN #_ was observed picking up scissors that were used to cut saturated dressings off right leg and putting them back in nursing bag without cleaning them. An interview was conducted on 5/29/2025 at approximately 12:20 pm with the agency director and the clinical manager present. The director and clinical manager were asked what their expectations were in this situation and they confirmed that RN #1 should have performed hand hygiene and changed gloves after removing dressings from left leg, before wrapping leg with clean bandages, and before reaching into multi-use bulk gauze package. They also confirmed that nurse #1 should have cleaned bandage scissors prior to putting back in her travel bag.

An onsite recertification survey was conducted 06/06/22-06/07/22. No deficiencies to the Emergency Preparedness Program were identified. ABH

An onsite recertification survey was conducted 06/06/22-06/07/22. Deficiencies to the Medicare Conditions of Participation were identified. ABH

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy and procedure, observation, clinical record review, and patient/caregiver interview the agency failed to review all current medications for 4 of 7 patients that received a virtual home visit (#2, 15, 11, and 14). Findings included: 3. Patient # 11 had a Start of Care (SOC) of 05/12/2022. The diagnoses on the Plan of Care (POC) for the certification period 05/12/2022 to 07/10/2022 included Type 2 Diabetes mellitus with foot ulcer; Non- pressure chronic ulcer of other part of right foot and Non- pressure chronic ulcer of right heel and midfoot. The POC had orders for Skilled nursing (SN) for 1 time a week for 1 week with 4 PRN (as needed) for wound care, PICC (Peripheral inserted central catheter) line, and Intravenous antibiotics. The following visits were scheduled as alternating number of visits per week, 4 times per week alternated by 3 times per week. A virtual home visit was conducted on 06/06/2022 at 1:25 pm with SN #5 A review of the current medication list which was provided by the agency director on 06/06/2022 at 11:34 am, showed the following discrepancies: Colace 100 mg (milligram) capsule by mouth daily for stool softener was listed on the medication profile. During the visit, the patient confirmed he had taken as needed, not daily. Sertraline HCL 50 mg tablet, take 1 tablet daily which had a start date of 05/12/2022, the patient stated he “had not started it because he wasn’t sure what it was for.” Omeprazole 40 mg take 1 capsule daily for acid reflux was on the current medication profile. During the visit the patient stated he “stopped taking approximately 3 weeks ago.” 4. Patient # 14 had a Start of Care (SOC) of 04/17/2022. The diagnoses on the Plan of Care (POC) for the certification period 04/17/2022 to 06/15/2022 included Age- related osteoporosis with current pathological fracture, left Humerus, subsequent encounter for fracture with routine healing; Parkinson’s disease. The POC had orders for Skilled nurse for 1 time per week for 1 week; 1 time per week for 4 weeks and with 4 PRN (as needed) for lab work, change in patient condition, wound care; Physical therapy 1 time every 30 days; then changed on 04/21/2022 to 1 time per week for 1 week; 2 times per week for 3 weeks; 1 time per week for 4 weeks. Occupational therapy scheduled for 1 time every 30 days. A virtual home visit was conducted on 06/07/2022 at 11:00 am with Occupational therapist #4. A review of the current medication list revealed duplication of Acetaminophen 500 mg (milligram) 1 to 2 tablets every 8 hours as needed for pain, not to exceed 6 tablets in 24 hours and Tylenol 325 mg tablet take 2 tablets every 6 hours as needed for pain. During the visit, the patient’s spouse confirmed the patient “had been taking Acetaminophen 500 mg tablets for pain if needed and not the Tylenol 325 mg tablets.” Review of policy “Medication Reconciliation and Medication Profile”, was revised on 12/03/2020 was received from the agency director on 06/07/22 at 4:19 p.m. The policy stated, “…with each home visit the clinician will review and update the EMR (electronic medical record) and patient’s home medication profiles…” 1.Patient #2 was admitted on 05/18/22 with diagnoses of age related osteoporosis, unspecified atrial fibrillation, heart failure, and history of falling. The plan of care for 05/18/22 to 07/16/22 included the following orders: skilled nursing 1 every 30 days; physical therapy 1 time a week for 1 week, 2 times a week for 3 weeks, and 1 time a week for 5 weeks. A virtual home visit was conducted on 06/07/22 at 10:20 a.m. with the physical therapist assistant. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancy: Tylenol 500 mg (milligram) 1 tablet by mouth once a day as needed for headaches and shoulder pain. Per interview with the patient, “I’ve been taking this medicine for a long time’. 2. Patient #15 was admitted on 04/25/22 with diagnoses of other pneumonia, acute respiratory failure, hypertensive heart and chronic kidney disease, and long term use of antiplatelet(prevents blood clots). The plan of care for 04/25/22 to 06/23/22 included the following orders: skilled nursing 1 time a week for 1 week, 2 times a week for 3 weeks, and 1 time a week for 5 weeks. A virtual home visit was conducted on 06/07/22 at 1:07 p.m. with licensed practical nurse. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancy: Eliquis 5mg 1 table twice a day by mouth for atrial fibrillation. Per interview with the patient caregiver “she has always been taking 2.5mg of Eliquis by mouth daily she has never taken 5mg”.

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 policy review, client record review, direct observation and staff interview the agency staff failed to use proper hand hygiene for 1 of 3 virtual physical therapy visits (#12) and use aseptic technique during wound care for 1 of 3 nursing visits (#13). Findings included: The agency policy provided by the Agency Director (AD) on 6/7/2022 at 10:40 am titled, “Nursing Skill- Changing Composite Wound Dressings, Procedural Steps” stated … “Protect the work area with an absorbent linen- saver pad to collect discharge or drainage…follow appropriate aseptic technique when removing the soiled CWD (composite wound dressing) … remove and dispose of soiled gloves… perform hand hygiene… Follow appropriate aseptic technique to apply new dressing…” Patient # 13 was admitted with a Start of Care of 01/14/2022. The diagnoses for the Plan of Care (POC) for the Certification period of 05/14/2022 to 07/12/2022 included, Encounter for change or removal of nonsurgical wound dressing; Peripheral vascular disease, unspecified; Type 2 Diabetes Mellitus with diabetic polyneuropathy. The POC had orders for Skilled nurse (SN) 1 time per week for 9 weeks with 2 PRN (as needed) visits for changes in patient’s condition, PRN labs, medication changes. A virtual home- visit was conducted on 06/07/2022 at 9:30 am with SN #3. The following observations were made, the nurse did not place a protective pad under the patients’ foot prior to removing the dressing. Once the nurse removed the old dressing, she placed the soiled material onto the floor. It was also observed during the cleansing of the wound the nurse re-entered the gauze bag without changing gloves. An interview with the agency director on 06/07/2022 at 10:00 am, confirmed the nurse did not follow the agency’s infection prevention standards during wound care. Review of policy “Hand Hygiene”, revised 04/02/21 was received from the agency director on 06/07/22 at 9:43 a.m. The policy stated,”…glove use is not a substitute for hand hygiene…do not wash gloves between uses”. Review of an undated policy” Applying Aseptic Technique” was received from the agency director on 06/07/22 at 10:50 a.m. The policy stated” remember these strategies when working with patient in their homes…perform hand hygiene before opening clinical bag to retrieve supplies, before direct patient contact, and after direct patient contact, and after contact with objects in patients home…” Patient #12 was admitted was admitted on 04/11/22 with diagnoses of hypertensive chronic kidney disease, type 2 diabetes, chronic kidney disease stage 4, and hyperlipidemia (high cholesterol). The plan of care for 04/11/22 to 06/09/22 had orders for physical therapy 1 time a week for 1 week, 2 times a week for 3 weeks, and 1 time a week for 5 weeks. A virtual visit was conducted on 06/07/22 at 8:43 a.m. with the physical therapist. Employee #2 was observed using hand sanitizer on gloved hands during the visit with bag technique (before and after cleaning equipment), and during the visit while obtaining vital signs. Employee #2 did not remove the gloves during my observation time of the visit. Interview with the agency director on 6/7/22 at 9:11 a.m. “that’s not our policy to use hand sanitizer with gloves”. Interview with Employee #2 on 06/07/22 at 10:50 a.m., revealed “ I just got nervous and forgot to take the gloves off”. I normally take them off and sanitize my hands”.