Every finding on record at Dale County Health Care Authority

A recertification survey was conducted on 12/29/25 to 12/30/25, and Dale Medical Center Home Health was found to be In substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted at Dale Medical Center Home Health on 12/29/25 to 12/30/25. Standard level deficiencies were cited and will require a plan of correction.

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 observations, medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure an accurate medication list was maintained for each patient. This affected two of three home visit (HV) patients, including HV # 1 and HV # 3, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Medication Reconciliation Policy Number: 8.15.1 Purpose: To define the medication reconciliation process. Procedure: ...2. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. 1. HV # 1 was admitted to the agency on 11/7/25 with a diagnosis of Pressure Ulcer of Left Heel, Stage 3. A HV was conducted on 12/29/25 at 1:01 PM to observe care provided by Employee Identifier (EI) # 3, Licensed Practical Nurse. During the HV, EI # 3 reviewed the medications with HV # 1 and compared the medications with the agency medication list. The following is a list of discrepancies: Docusate Sodium 100 milligrams (mg) take one capsule by mouth daily as needed for constipation, was listed on the medication list. HV # 1 stated he/she stopped taking about a month ago. Tylenol Extra Strength Rapid Release 500 mg two tablets by mouth every six hours as needed for pain, was listed on the medication list. HV # 1 stated he/she currently takes one tablet every morning and one tablet every evening. An interview was conducted on 12/30/25 at 4:10 PM with EI # 6, Director, who confirmed the medications were not reconciled per agency policy and procedure. 2. HV # 3 was admitted to the agency on 12/3/25 with a diagnosis of Urinary Tract Infection, site not specified. A HV was conducted on 12/30/25 at 10:55 AM to observe care provided by EI # 2, Certified Nursing Assistant. During the HV, the surveyor reviewed the medications with HV # 3 and compared the medications with the agency medication list. The following is a list of discrepancies: Gabapentin 100 mg one capsule by mouth three times daily, was listed on the medication list. HV # 3 stated he/she was no longer taking and "...stopped taking a couple of months ago." Omeprazole 20 mg one capsule by mouth as needed for acid reflux. HV # 3 stated he/she was no longer taking, but wasn't quite sure when he/she stopped. An interview was conducted on 12/30/25 at 4:10 PM with EI # 6, Director, who confirmed the medications were not reconciled per agency policy and procedure.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on a review of the agency reference manual, medical record (MR), and interviews with staff, it was determined the agency failed to measure Peripherally Inserted Central Catheter (PICC) line catheter with each dressing change. This deficient practice affected one out of one MR reviewed with a PICC line, including MR # 6, and had the potential to affect all patients served by the agency. Findings Include: Agency Reference Manual: The Visiting Nurse Associations of America VNAA Clinical Procedure Manual 18th Edition. Section: 08.07 Last revised: 9/12 Title: Infusion Therapy - Central Line Type: PICC Considerations: 6. Site Care ...D. Dressing Change Equipment:... …Procedure:… …13. Verify the external catheter length visible outside corresponds to initial placement measurement. If it does not, notify physician before continuing use. 1. MR # 6 was admitted to the agency on 11/21/25 with a primary diagnosis of Type 2 Diabetes Mellitus with Foot Ulcer. Review of the MR demonstrated a certification period of 11/21/25 to 1/19/26. Further review of the MR demonstrated a PICC line was placed on 12/1/25. Review of the MR on 12/30/25 demonstrated no record of the PICC line external catheter length measurements being obtained with the ordered weekly PICC line dressing change. An interview was conducted with EI # 6, Director, on 12/30/25 at 4:05 PM who confirmed there was no documentation to support the PICC line external catheter length was measured with the PICC line dressing changes.

A recertification survey was conducted at Dale Medical Center Home Health on 1/5/23 and the agency was found to be in substantial compliance with the Conditions of Participations for Emergency Preparedness.

A recertification survey was conducted at Dale Medical Center Home Health from 1/3/23 to 1/5/23, Standard Level deficiencies were cited.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, and interviews with the staff it was determined the agency failed to ensure the staff documented all physician orders in the medical record. This affected two of ten MR's reviewed and did affect MR # 4, MR # 6, and had the potential to negatively affect all patients served by the agency. Findings include: Agency policy: Plan of Care and Physician Orders Policy Number: 9.10.1 Revised Date: March 2018 Policy: ...Each Plan of Care must be signed and dated by the physician. Procedure: 5. All patient care orders, including verbal orders, must be recorded in the plan of care... 7. The physician who establishes the Plan of Care must sign and date the recertification. 22. Verbal orders are put in writing, signed, timed and dated with the date of receipt by an RN (Registered Nurse)... 1. MR # 4 was admitted to the agency on 2/19/22 with admitting diagnoses of Fracture Unspecified Part of Neck of Right Femur Subsequent For Closed Fracture With Routine Healing and Urinary Tract Infection. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 2/19/22 revealed the skilled nurse (SN) was to visit one time a week for one week, two times a week for one week then one time a week for seven weeks. Further review of the HHC and POC revealed the following wound care orders: Wound # 2 Right Hip cleanse wound with NS (Normal Saline), pat dry with sterile gauze, cover with Medipore pad. Review of the SN visit note dated 3/10/22 revealed the following documentation under the wound section of the note: Wound # 2 Right Hip, cleansed with NS, patted dry with sterile gauze and left open to air. Review of the physician orders in the MR revealed no documentation of an order in the MR to leave wound Wound # 2 open to air. An interview was conducted on 1/5/23 at 2:00 PM with Employee Identifier (EI) # 2, Director, who confirmed the SN failed to document an order to leave wound open to air. 2. MR # 6 was admitted to the agency on 4/6/22 with admitting diagnoses of Obstructive Sleep Apnea and Type 2 Diabetes Mellitus. Review of the HHC and POC dated 4/6/22 revealed the SN to visit two times a week for one week then one time a week for eight weeks. Review of the SN visit note dated 4/8/22 revealed the SN documented under labs: UA (Urinalysis), Clean Catch, Specimen transported to DMC (Dale Medical Center) Lab. Further review of the SN visit note dated 4/8/22 revealed the SN documented in the narrative section of the note SN was able to obtain UA specimen W/O (without) straight cath (catherization). Review of all the physician orders within the MR revealed no documentation an order was written for the UA. An interview was conducted on 1/5/22 at 2:04 PM with EI # 2, who confirmed the staff failed to document an order for the UA.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on Medical Record (MR) review, agency policy, and interviews it was determined the agency failed to ensure visit frequency and wound care orders were followed. This deficient practice affected three of ten MR reviewed including MR # 4, MR # 5, MR # 1, MR # 2 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Physician Orders Policy number: 9.10.1 Revised: March 2018 Policy Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient's diagnosis and assessment... 26. The physician orders may authorize a specific range in the frequency of visits for each service... The agency alerts the physician to any changes that suggests a need to alter the plan of care. If the Agency provides fewer visits than the physician orders, it has altered the plan of care and the physician must be notified. The Agency must maintain documentation in the clinical record indicating the physician was notified and aware of the missed visit... Best Practices for Home Care: Date Revised: October 2021 Wounds: Wound measurements obtained minimum of weekly 2. Any changes in an aspect of the wound will be reported to MD (Medical Doctor) 3. Wound care should be performed by skilled nurse as ordered. 3. MR # 1 was admitted on 12/2/22 with diagnoses including Unspecified Open Wound, Left Lower Leg and Cellulitis of Left Lower Limb. Review of the Home Health Supplemental Order dated 12/7/22 revealed orders for Physical Therapy (PT) two visits a week x two weeks then one visit a week x one week beginning the week of 12/12/22. Review of the PT visits notes revealed only one PT visit was completed the week of 12/12/22. There was no documentation the physician was notified and no documentation of attempts to reschedule the visit. In an interview conducted on 1/5/23 at 2:27 PM, EI # 2 confirmed the PT visits were not completed as ordered and there was no documentation the physician was notified. 4. MR # 2 was admitted on 12/2/22 with diagnoses including Type 2 Diabetes Mellitus with Hypoglycemia and Unspecified Dementia. Review of the HHC and POC dated 12/2/22 revealed orders for MSS (Master of Social Services) one visit x one week to begin 12/5/23. Review of the MR revealed no MSS visits were completed the week of 12/5/22 and the first MSS visit was not completed until 12/15/22. There was no documentation the physician had been notified of the missed visit for the week of 12/5/22. In an interview conducted on 1/5/23 at 2:47 PM, EI # 2 confirmed the MSS visit was not completed as ordered and the physician had not been notified of the missed visit. 1. MR # 4 was admitted to the agency on 2/19/22 with admitting diagnoses of Fracture Unspecified Part of Neck of Right Femur Subsequent For Closed Fracture With Routine Healing and Urinary Tract Infection. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 2/19/22 to 4/19/22 revealed the skilled nurse (SN) was to visit one time a week for one week, two times a week for one week then one time a week for seven weeks. Further review of the HHC and POC revealed the following wound care orders: Wound # 2 Right Hip cleanse wound with NS, pat dry with sterile gauze, cover with Medipore pad. Review of the SN visit note dated 3/10/22 revealed the following documentation under the wound section of the note: Wound # 2 Right Hip, cleansed with NS, patted dry with sterile gauze and left open to air. The SN failed to follow the physician order for wound care and cover wound # 2 with Medipore pad. An interview was conducted on 1/5/23 at 2:00 PM with Employee Identifier (EI) # 2, Director, who confirmed the SN failed to follow the physician orders for wound care. 2. MR # 5 was admitted to the agency on 4/1/22 with admitting diagnoses of Essential Hemorrhagic Thrombocythemia and Rash and Other Non-specified Skin Eruption. Review of the HHC and POC dated 4/1/22 revealed the SN was to visit one time a week for one week then two times a week for one week, then one time a week for seven weeks. Further review of the HHC and POC dated 4/1/22 revealed the following physician order: Assess shingles to upper back, Cleanse with NS or soap and water, leave open to air. Review of the SN visit note dated 4/1/22 revealed the SN documented under the wound section of the note wound cleansed/irrigated with: NS or soap and water and pat dry left open to air. The SN failed to document if he/she cleaned the wound with NS or if the wound was cleaned with soap and water. An interview was conducted on 1/5/23 at 2:10 PM with EI # 2 who stated the nurse failed to follow physicians orders and document he/she cleaned the wound with either NS or soap and water.

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 observations, agency policy and procedure, and interviews it was determined the agency failed to ensure the staff folllowed agency policy for hand hygiene. This deficient practice affected two of four Home Visit (HV) patients including HV # 2, HV # 3, and had the potential to affect all patients under the agency's care. Findings include: Agency Policy: Hand Hygiene Policy Number: 07.05 Last Updated: 9/2012 ...7. Hand hygiene must be performed: b. Before and after touching patients' intact skin... d. After removing gloves... f. Before and after performing a procedure...wound care... h. Before moving from a contaminated body site to a clean body site... i. After contact with body fluids, excretions, mucous membranes or non-intact skin... 1. HV # 2 was admitted on 12/3/22 with diagnoses including Dehiscence of Amputation Stump and Infection of Amputation Stump, Left Lower Extremity. Review of the Home Health Certification and Plan of Care (HHC and POC) dated 12/3/22 to 1/31/23 revealed orders including Skilled Nurse (SN) two times a week x two weeks then one time a week x seven weeks to perform wound care to the left lower extremity. A HV was conducted on 1/4/23 to observe wound care provided by Employee Identifier (EI) # 6, Registered Nurse (RN). After obtaining vital signs, EI # 6 performed hand hygiene, donned gloves, then cleaned the reusable items with disinfecting wipes. EI # 6 then removed gloves and donned clean gloves. EI # 6 failed to perform hand hygiene after removing gloves. EI # 6 then set up dressing supplies, performed hand hygiene with gloves still on, then removed the gloves and donned new gloves. EI # 6 failed to perform hand hygiene after removing gloves. EI # 6 obtained wound measurements from the wound to medial stump, removed the gloves and donned new gloves. EI # 6 failed to perform hand hygiene after removing gloves. EI # 6 then obtained wound measurements from the wound to the lateral stump, removed the gloves and donned new gloves. EI # 6 failed to perform hand hygiene after removing gloves. In an interview conducted on 1/5/23 at 2:34 PM, EI # 2, Director, confirmed the staff failed to perform hand hygiene per agency policy. 2. HV # 3 was admitted on 12/21/22 with diagnoses including Age Related Osteoporosis with Current Pathological Fracture of Vertebra and Other Intervertebral Disc Degeneration. Review of the HHC and POC dated 12/21/22 to 2/18/23 revealed orders for Home Health Aide (HHA) two times a week x three weeks then one time a week x 5 weeks beginning the week of 12/26/22 A HV was conducted on 1/4/23 to observe care provided by EI # 5, HHA. EI # 5 donned gloves and cleaned the rectal area of HV # 3 then turned the patient and cleaned the upper back of HV # 3. EI # 5 failed to removed gloves and perform hand hygiene after moving from a contaminated body site to a clean body site. EI # 5 then turned HV # 3 to his/her back, provided perineal care, then removed gloves. EI # 5 failed to perform hand hygiene after removing gloves. In an interview conducted on 1/5/23 at 2:10 PM, EI # 5 confirmed the staff failed to perform hand hygiene per agency policy.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on agency policy and procedure, Medical Record (MR) review, and interviews it was determined the agency failed to ensure wound assessments including wound measurements were obtained and documented weekly per agency policy. This deficient practice affected 2 of 6 MR reveiwed of patients with wounds including MR # 3, MR # 1, and had the potential to affect all patients with wounds. Findings include: Agency Policy: Best Practices for Home Care Policy Number: none listed Policy date: 10/2021 ...Wound Care Wound measurements obtained minimum of weekly. Any changes in a aspect of the wound will be reported to the MD... 1. MR # 3 was admitted on 11/17/22 with diagnoses including Hemiplegia Following Cerebral Infarction and Dysarthria Following Cerebral Infarction. Review of the Home Health Supplemental Order dated 11/28/22 revealed orders including SN (Skilled Nurse) one time per week one the two times per week x two weeks beginning 12/5/22 Review of the SN Visit Note dated 12/16/22 revealed an assessment of a new wound to the right great toe. There was no documentation of wound measurements. In an interview conducted on 1/5/23 at 2:05 PM, Employee Identifier (EI) # 2, Director, confirmed the staff failed to obtain and document the wound measurements for the week of 12/16/22 per agency policy. 2. MR # 1 was admitted on 12/2/22 with diagnoses including Unspecified Open Wound, Left Lower Leg and Cellulitis of Left Lower Limb. Review of the Home Health Certification and Plan of Care (HHC and POC) dated 12/2/22 to 1/30/23 revealed orders including SN one time a week times one week, three times a week times one week, two times a week times two weeks, then one time a week times five weeks to assess and measure the wound and record every week. Review of the SN Visit Note dated 12/27/22 revealed a new wound to the left lower extremity. There was no documentation wound measurements were obtained for the new wound. In an interview conducted on 1/5/23, EI # 2 confirmed the wound measurements had not been obtained and documented per agency policy.