Every finding on record at East Alabama Medical Center Homecare, LLC

A recertification survey was conducted on 4/1/25 to 4/3/25, and Homecare of East Alabama Medical Center was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted at Homecare of East Alabama Medical Center on 4/1/25 to 4/3/25. Standard level deficiencies were cited and will require a Plan of Correction.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) 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. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, review of medical records (MR), agency policy and procedure, and interviews, it was determined the agency failed to ensure: A. A plan of care was developed for a patient with a Percutaneous Endoscopic Gastrostomy (PEG) Tube. B. A plan of care was developed for the education of a patient/caregiver with a Non Invasive Ventilator (NIV). This deficient practice affected two of 17 MR reviewed including MR # 10, and MR # 12, and had the potential to negatively affect all patients served by the agency. Findings include: Agency policy: Plan Of Care Policy number: 2.1.007 Revised date: 09/01/24 Purpose: To assure an appropriate POC is developed...for each patient... Policy: Each patient has an individualized POC developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. Procedure: ...2. The POC includes: ...Patient specific interventions... 2. MR #12 was admitted to the agency on 3/6/25 with the primary diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. A review of the discharge paperwork from the hospital dated 2/26/25 revealed the patient was discharged with a NIV with orders to use at bedtime daily. A review of the HHC and POC dated 3/6/25 revealed no documentation of interventions and goals related to the NIV. A review of the SN Visit Note Report dated 3/12/25 revealed the nurse documented education given to the patient and caregiver regarding the NIV. An interview was conducted on 4/3/25 at 10:38 AM with EI # 1, who confirmed there were no specific orders and goals in the HHC and POC for the NIV. 1. MR # 10 was admitted to the agency on 3/9/25 with diagnoses of Pressure Ulcer of Sacral Region, Stage 4 and Pressure Ulcer Left Heel, Stage 2. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/9/25 revealed documentation of Nutritional Requirements: Jevity Peg Tube Feeding. There was no other documentation in the POC for care of the patient's PEG tube. An interview was conducted on 4/3/25 at 10:48 AM with Employee Identifier (EI) # 1, Interim Executive Director, who confirmed there was no documentation in the POC for care of the patient's PEG tube.

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 review of agency policies and procedures, observations and staff interviews, it was determined the agency failed to ensure staff: A. Followed infection control policies. B. Maintained sterility throughout PICC (peripherally inserted central catheter) line dressing change. This deficient practice did affect two of seven home visits (HV) including HV # 1 and HV # 5 and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Hand Hygiene Policy Number: 8.004 Revised Date: 05/01/19 Purpose: To help prevent the spread of microorganisms and infection by cross-contamination ant to provide practice guidelines. Policy: Staff are required to perform hand hygiene (HH) prior to, at specified time points during, and following patient contact… Procedure: 1. Staff performs HH by…using an alcohol-based hand sanitizer: a. Before direct contact with patients. b. Before performing an aseptic task (ergo, insertion of invasive devices, wound care). c. After contact with blood, …, non-intact skin, wound dressings, or contaminated surfaces. d. If moving from a contaminated body site to a clean body site during patient care. e. After contact with inanimate objects (including medical equipment…) … f. Before and after removal of personal protective equipment (PPE). g. At the conclusion of the visit after contact with a patient’s intact skin. 8. Other aspects of HH: a. Wear gloves when contact with blood or other potentially infectious materials…and non-intact skin could occur… c. Change gloves during patient care if moving from a contaminated body site to a clean body site. Agency Policy: Dressing Change Procedure for Central Venous, Midline, and Peripherally Inserted Central Catheters Policy Number: 10.027 Revised Date: 10/01/16 Purpose: To keep insertion sites clean, stabilize catheters and minimize the risk of infection. Policy: …Sterility will be maintained throughout this procedure… Agency Policy: Standard Precautions Chapter: Infection Prevention and Control Policy Number: 8.005 Revised Date: 12/01/21 Purpose: To prevent spread of disease and infections between and among patients and staff. To provide the minimum level of precautions used for all patients receiving care, regardless of their diagnosis or presumed infection status. Policy: Staff will follow guidelines for protection from infectious disease based on Occupational Safety and Health Administration (OSHA) and Centers for Disease Control (CDC) for standard precautions... Procedure: ...d. Patient-Care Equipment... ii. Ensure that reusable equipment is not used for the care of another person until it has been cleaned appropriately... 2. HV # 5 was admitted to the agency on 10/31/24 and recertified for continued care from 2/28/25 to 4/28/25 with a primary diagnosis of Type Two Diabetes Mellitus with Foot Ulcer. A HV was conducted on 4/2/2025 at 9:58 AM with EI # 5, Licensed Practical Nurse(LPN) to observe wound care. EI # 5, failed to maintain a clean barrier for supplies during the HV. An interview was conducted on 4/2/25 at 11:27 AM with EI # 3, Patient Care Manager, who confirmed the staff failed to maintain a clean barrier for supplies during the HV. HV # 1 was admitted to the agency on 3/22/25 with diagnoses including Pneumonia Due to Pseudomonas and Type Two Diabetes Mellitus Without Complications.A HV was conducted on 4/1/25 at 12:52 PM with Employee Identifier (EI) # 4, RN (Registered Nurse), to observe care provided. EI # 4 performed HH and donned gloves to remove the old PICC line dressing. The gloves were removed and without performing HH, the supplies were gathered and opened to replace the PICC line dressing. Without performing HH, sterile gloves were donned and EI # 4 moved HV # 1's t-shirt to further expose the PICC line site for insertion, contaminating the sterile gloves. Without performing HH and donning sterile gloves, EI # 4 continued with the dressing change. EI # 4 opened two saline syringes to flush the ports, and without performing HH, donned gloves. Staff failed to perform HH and maintain sterility throughout the PICC line dressing change. An interview was conducted on 4/3/25 at 10:53 AM with EI # 1, Interim Executive Director, who confirmed staff failed to perform HH and maintain sterility throughout the dressing change per agency infection control policies.

Based on review of the agency Emergency Preparedness Plan and interview it was determined Homecare of East Alabama Medical Center was in substantial compliance with 484.102 Conditions of Participation: Emergency Preparedness.

A recertification survey was conducted on 4/12/22 - 4/14/22 with standard level deficiencies cited.

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, review of medical records (MR), agency policy and procedure, and interviews, it was determined the agency failed to ensure staff reconciled medications in 4 of 7 Home Visits (HV) conducted, including HV # 1, HV # 2, HV # 6, HV # 4, and had the potential to negatively affect all patients receiving services by this agency. Findings include: Agency Policy: Monitoring Medications Policy Number: 10.008 Revised Date: 5/1/19 Purpose: To provide process to ensure continuous monitoring of medications in the patient's home. Policy: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. ...The physician is contacted immediately if any discrepancies between agency information and patient medications are found. Procedure: 1. The discipline responsible for the drug regimen will: a. Compare medication list obtained from the facility from which the patient was transferred and/or physician orders to actual medications patient is taking. b. Review all medications including over the counter (OTC) medications, vitamins... to identify such issues such as: ...viii. Noncompliance with drug therapy; ix. Dosage errors; and x. Drug omissions. e. Notify the physician of any of the above identified issues / discrepancies. Collaborate with the Patient Care Manager and ensure that supportive documentation is evident in the medical record. 2. All clinicians participating in the patient's care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care. During the patient's episode of care the following will occur: a. Through a collaborative process the care team will: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies... b. The Physician will be notified of discrepancies and documentation of notification must be evident in the medical record. 3. HV # 6 was admitted to the agency on 3/12/22 with diagnoses including Type 2 Diabetes Mellitus With Other Specified Complication, and Osteomyelitis Unspecified. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/12/22 to 5/10/22 revealed SN ordered visits for 1WK 9. A HV was conducted on 4/13/22 at 9:40 AM to observe care provided by the EI # 7, RN (Registered Nurse). EI # 9, PCM was also present during the visit. Prior to the HV, the surveyor was provided a ML by the agency dated 4/13/22. During the HV, a comparison was made between medications observed in the home and medications on the ML with the following discrepancies: OTC Vitamin C 250 mg gummies, the patient stated he/she had been taking 2 gummies daily for several months. It was not on the ML. OTC Women's MVI (multivitamin) gummies, the patient stated he/she had been taking 2 gummies daily for several months. It was not on the ML. OTC Vitamin D 3 50 mg gummies, the patient stated he/she had been taking 2 gummies daily for several months. It was not on the ML. OTC Calcium 500 mg with Vitamin D 3 25 micrograms (mcg) gummies, the patient stated he/she had been taking 2 gummies daily for several months. It was not on the ML. OTC Zinc 15 mg with Vitamin C 270 mg chew tabs, the patient stated he/she had been taking 2 chew tabs daily for several months. It was not on the ML. OTC Iron supplement with B complex, Zinc, Vitamin C and other minerals tabs, the patient stated he/she had been taking 2 tabs daily for several months. It was not on the ML. In an interview conducted 4/14/22 at 10:25 AM, EI # 9, confirmed the ML was not reconciled with medications the patient was taking in the home. 4. HV # 4 was admitted to the agency on 4/7/22 with diagnoses including Unspecified Atrial Flutter, Shortness of Breath, and Pneumonia Unspecified Organism. Review of the HHC and POC dated 4/7/22 to 6/5/22 revealed a SN visit frequency of 1WK1, 2WK1, 1WK 7, a PT visit frequency of 2WK4 effective 4/10/22, and an OT visit frequency of 1WK1 effective 4/10/22. A HV was conducted on 4/12/22 at 11:15 AM to observe care provided by EI # 5, PT. EI # 11, PCM was also present during the visit. Prior to the visit, a ML was provided to the surveyor dated 4/12/22. During the HV, a comparison was made between the ML and medications observed in the home with the following discrepancies: Metoprolol Tartrate, 25 mg tablet, 2 tablets every 12 hours was on the ML. Metoprolol Succinate (an extended release tablet) 25 mg tablet, take one tablet daily, with fill date 4/5/22 was observed in the home. Combivent Respimat 20 mcg (micrograms) - 100 mcg Actuation Solution for Inhalation 1 puff 4 times daily as needed for shortness of breath was on the ML. HV # 4 stated he/she had never had any inhaler. In an interview conducted 4/14/22 at 9:40 AM, EI # 1, Executive Director confirmed the medications were not reconciled. 2. HV # 2 was admitted to the agency on 3/21/22 with diagnoses including Unspecified Atrial Fibrillation and Unspecified Atrial Flutter. Review of the Client Coordination Note dated 3/24/22 revealed a Certified Registered Nurse Practioner (CRNP) order to discontinue Diclofenac, Glipizide, Meclizine and Metformin. Review of the ML printed by the agency on 4/12/22 revealed documentation the patient was taking: Diclofenac Sodium 75 mg 1 tablet twice daily. Glipizide 10 mg 1 tablet twice daily. Meclizine 25 mg 1 tablet as needed three times daily for dizziness. Metformin 500 mg 2 tablets twice daily . A HV was conducted on 4/12/22 at 12:37 PM with EI # 3, Occupational Therapist, to observe care provided. EI # 9, PCM, was present during HV. During the HV, the patient confirmed she/he was taking the Diclofenac Sodium, Glipizide, Meclizine and Metformin as documented on the agency ML. Review of MR revealed no documentation the patient was notified of the discontinued Diclofenac, Glipizide, Meclizine and Metformin. An interview was conducted on 4/14/22 at 9:25 AM with EI # 10, PCM, who confirmed there was no documentation the patient was instructed to discontinue the above medications per the CRNP order. 1. HV # 1 was admitted to the agency 3/14/22 with diagnoses including Parkinson's Disease and Pressure Ulcer of Sacral Region, Stage 2. Review of the Home Health Certification and Plan of Care dated 3/14/22 to 5/12/22 revealed Skilled Nurse (SN) 1wk9 (1 time a week for 9 weeks); PT (Physical Therapy) 1wk9; OT (Occupational Therapy) 2wk1,1wk8; ST (Speech Therapy) 1wk1,2wk2,1wk2... A HV was conducted on 4/12/22 at 12:27 PM to observe care provided by Employee Identifier (EI) # 2, Home Health Aide. EI # 10, Patient Care Manager (PCM), was also present during the HV. Prior to the HV, the surveyor received a current Medicine List (ML) printed 4/12/22. The list was compared to the medications in the home with EI # 10, and the following discrepancies were observed: Austedo 5 mg (milligrams) tablet 1 tablet daily was on the Medicine List. The patient's caregiver stated, he discontinued this medication several weeks ago. Review of the MR revealed the SN conducted a visit on 4/9/22 and failed to reconcile the patient's medications. Oxycodone-Acetaminophen 5 mg-325 mg tablet 1 tablet as needed was on the agency ML, and the prescription bottle dated 9/9/21 read Oxycodone-Acetaminophen 10-mg-325mg 1 tablet as needed. The caregiver stated the patient has been taking this dosage for 4-5 years. Venlafaxine 25 mg 1 tablet daily was on the agency ML, and the prescription bottle dated 3/14/22 read Venlafaxine 150 mg 1 tablet daily. The caregiver stated the patient has been taking this dosage for about a year. Fluromethol 0.1 % (percent) install 1 drop left eye twice daily, prescription dated 2/28/22 was in the home but not listed on the agency ML. The caregiver stated the patient started these eye drops years ago. Women's MVI (Multivitamin) 1 tablet daily was in the home but not listed on the agency ML. The caregiver stated the patient has taken it for years. An interview as conducted on 4/14/22 at 9:19 AM with EI # 10, who verified the staff failed to reconcile medications on HV # 1 per agency policy.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) 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. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, medical record (MR) review and interview, it was determined the agency failed to ensure an individualized Plan of Care (POC) was developed to meet the needs of a patient with a Mediport (Implanted Venous Access). This deficient practice did affect Home Visit (HV) # 5, 1 of 1 medical records reviewed with a Mediport and had the potential to negatively affect all patients served by the agency. Findings Include: Agency Policy: Plan of Care Policy Number: 2.1.007 Revised Date: 12/1/21 Purpose: To assure an appropriate plan of care is developed and revised in a timely manner for each patient... Policy: Each patient has an individualized POC developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. Procedure: 1. A POC is developed for all patients and updated no less than every 60 days... 2. The POC includes: b. Types, frequency, and duration of services required f. Medications and treatments g. Safety measures to protect against injury i. Patient specific interventions and education;... l. Patient/caregiver education and training... n. All patient care orders 9.The patient is monitored for response to treatment and progress towards goals. 1. HV # 5 was admitted to the agency on 3/28/22 with diagnosis including Cellulitis of Abdominal Wall and Cutaneous Abscess of Abdominal Wall. Review of the Visit Note Report by the Registered Nurse (RN) dated 3/28/22 revealed, "Mediport right upper chest"... Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/28/22 to 5/26/22 revealed orders for, "skilled nurse to evaluate patient and develop POC in coordination with physician." There were no orders for the mediport. A HV was performed on 4/13/22 at 9:05 AM with Employee Identifier (EI) # 6 Licensed Practical Nurse (LPN) to observe wound care. During the visit, HV # 5 revealed he/she had a mediport to the Right upper chest. An interview conducted on 4/14/22 at 9:05 AM with EI # 12, Patient Care Manager confirmed HV # 5 had a mediport and the POC did not include the mediport and should have.

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 review of medical records (MR), agency policies and procedures, and interviews with staff it was determined the agency failed to ensure conformance with physician orders for laboratory (lab) and as needed (prn) visits. This affected 2 of 17 MR's reviewed including MR # 6, MR # 7 and had the potential to negatively affect all patients at this agency. Findings include: Agency Policy: Plan of Care (POC) Policy Number: 2.1.007 Revised Date: 12/1/21 Purpose: ...To ensure that physician/authorized practitioner's orders are followed. Policy: Each patient has an individualized POC developed in consultation with the...physician...to address specific services being provided... Procedure: ...7. ...interventions are provided by qualified agency staff as ordered by the physician or authorized practitioner. Agency Policy: Physician Orders Policy Number: 2.1.008 Revised Date: 11/1/21 ...Policy: No medications, treatments, diagnostic studies or therapeutics will be administered without the order of a qualified physician or authorized practitioner... ...Procedure: ...10. Services are provided according to the most recent orders updating the patient's POC. 1. MR # 6 was admitted to the agency on 1/1/22 and recertified for continued care from 3/2/22 to 4/30/22 with the diagnoses of Encounter for Fitting and Adjustment of Urinary Device and Paroxysmal Atrial Fibrillation. Review of the Physician Orders dated 3/14/22 revealed an order for "schedule SN (Skilled Nurse) prn visit on 3/15/22 for lab recollect due to inability to obtain lab specimen on 3/14/22. SN to obtain lab specimen via venipuncture for Anemia Profile week of 3/13/22." Review of the SN Visit Note Report(s) (VNR) revealed no documentation a SN visit was performed on 3/15/22. An interview was conducted on 4/14/22 at 9:47 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed there was no documentation of a SN visit on 3/15/22. 2. MR # 7 was admitted to the agency on 3/9/22 with diagnoses of Other Pulmonary Embolism Without Acute Cor Pulmonale and Essential (Primary) Hypertension. Review of the Physician Order dated 3/16/22 revealed an order for the SN to obtain a UA with Culture and Sensitivity (C&S) on 3/16/22. Review of the SN VNR dated 3/16/22 revealed no documentation a urine specimen was obtained for the UA with C&S. Review of the Physician Order dated 4/4/22 revealed an order for the SN to obtained for a UA with C&S. Review of the SN VNR dated 4/7/22 revealed documentation the Patient Care Manager (PCM) was notified the "urine specimen collected as ordered" and narrative documentation of "...unable to obtain clean catch urine specimen at this time..." There was no documentation the physician was notified of the SN inability to obtain urine specimen at the visit. Review of the Client Coordination Note dated 4/7/22 revealed documentation of "unable to obtain clean catch urine specimen this visit. SN to collect UA / CS (UA with C&S) the week of 4/11." Review of the Physician orders and SN VNRs dated 4/7/22 - 4/13/22 revealed no documentation of a physician order to reschedule the UA C&S to the week of 4/11/22 nor documentation the UA with C&S was obtained. An interview was conducted on 4/14/22 at 10:04 AM with EI # 9, PCM, confirmed a urine sample for ordered UA was not documented as collected on 3/16/22, 4/7/22 nor the week of 4/11/22 per physician orders.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on review of agency policies and procedures, Licensed Practical Nurse (LPN) job description, medical records (MR) and interviews, it was determined the agency staff failed to notify the physician timely with changes in the patient's condition and/or Plan of Care including: 1. Assessment of a new wound. 2. Noncompliance with ordered blood sugar (BS) testing. 3. Ordered urinalysis (UA) not obtained. This affected 4 of 17 MR's reviewed with wounds including Home Visit (HV) # 2, MR # 5, MR # 6, MR # 7 and had the potential to negatively affect all patients served by this agency with newly developed wounds. Findings include: Agency Policy: Coordination of Care... Policy Number: 2.1.017 Revised Date: 8/1/19 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by...identifying patient needs through assessment and communication with other health care providers. ...Procedure: ...4. Coordination of care with physician: ...throughout care...coordination of services is promoted through routine communication with the patient's physician: a. When changes occur in the patient's condition... ...e. When there is a need to change the patient's plan of care.... Agency Job Description: LPN ...Communicates timely and effectively with physicians...regarding any patient care issues or needs... 1. HV # 2 was admitted to the agency on 3/21/22 with diagnoses including Unspecified Atrial Fibrillation and Unspecified Atrial Flutter. Review of the LPN Visit Note Report dated 3/29/22 revealed documentation of "open area noted to coccyx area. PCM's (Patient Care Manager's) notified via email so RN (Registered Nurse) can assess and add to ICC (computer system)..." Further review of the LPN Visit Note Report (VNR) dated 3/29/22 revealed no documentation LPN notified the physician in order to provide the physician with the nursing assessment of the newly developed coccyx wound and attempt to obtain wound care orders. Review of the physician orders revealed an order dated 3/29/22 to "schedule RN to assess new wound to coccyx area at next nursing visit..." Review of the Skilled Nursing VNR's revealed the next nursing visit was conducted on 4/4/22, 6 days after the development of the wound to the coccyx area was documented, to perform the wound assessment. An interview was conducted on 4/14/22 at 9:25 AM with EI # 10, PCM, who confirmed there is no documentation the LPN notified the physician of the new coccyx wound assessment and verbalized the LPN is expected to enter the wound assessment in the narrative note, call the physician, and write the physician's order for wound care. 2. MR # 5 was admitted to the agency on 10/29/21 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Circulatory System and Type 2 Diabetes Mellitus without Complications. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 10/29/21 to 12/27/21 revealed physician orders for the "pt/cg to perform blood glucose (BG) testing daily. Patients therapeutic CBG (Capillary Blood Glucose ) range is 70 mg/dl (milligrams per decilitre) to 250 mg/dl" Review of the SN VNR dated 11/3/21 and 11/17/21 revealed documentation the pt/cg does not monitor BG. There was no documentation the physician was notified of the pt/cg's noncompliance with ordered BG monitoring. An interview was conducted on 4/14/22 at 9:34 AM with EI # 1, Executive Director, who confirmed there was no documentation the physician was notified of the pt/cg's noncompliance with ordered BG monitoring. 3. MR # 6 was admitted to the agency on 1/1/22 and recertified for continued care from 3/2/22 to 4/30/22 with the diagnoses of Encounter for Fitting and Adjustment of Urinary Device and Paroxysmal Atrial Fibrillation. Review of the Physician Orders dated 3/18/22 revealed an order for "SN to collect urine sample for UA and culture on 3/18/22 due to dark/cloudy urine..." Review of the SN VNR revealed no documentation a urine specimen was obtained with a UA and culture. Review of the Client Coordination Note dated 3/18/22 revealed SN documentation of "...unable to obtain urine specimen this visit..." Further review of the SN VNR and Client Coordination note dated 3/18/22 revealed no documentation the physician was notified of the SN inability to obtain the urine specimen for the ordered UA and culture during the visit. An interview was conducted on 4/14/22 at 9:47 AM with EI # 1, who confirmed there was no documentation the SN notified the physician of the inability to obtain the urine specimen for the ordered UA and culture during the visit. EI # 1 also verbalized there was no documentation the UA and culture had been obtained on 3/18/22 or at a later dated SN visit. 4. MR # 7 was admitted to the agency on 3/9/22 with diagnoses of Other Pulmonary Embolism Without Acute Cor Pulmonale and Essential (Primary) Hypertension. Review of the Physician Order dated 3/16/22 revealed an order for the SN to collect a UA with Culture and Sensitivity (C&S) on 3/16/22. Review of the SN VNR dated 3/16/22 revealed no documentation of an attempt to obtain a urine specimen for the UA with C&S as ordered by the physician. An interview was conducted on 4/14/22 at 10:04 AM with EI # 9, PCM, confirmed there was no documentation of an attempt to obtain a urine specimen nor was the urine specimen obtained for the UA with C&S as ordered by the physician on 3/16/22.

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 observation, review of agency policies and procedures, and interviews with agency staff, it was determined the agency failed to ensure staff: 1. Followed their policy and procedure for bed bath and perineal care. 2. Followed their policy and procedure for cleaning of re-useable equipment. 3. Followed their policy and procedure for performing site care to a PICC (peripherally inserted central catheter) line. This did affect 3 of 7 Home Visits (HV) conducted, including HV # 1, HV # 7, HV # 6 and had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: Complete or Partial Bed Bath 22. ...Place soiled linen in a designated laundry hamper or basket... Do not place soiled linens on the floor. ...34. Change the bath water before perineal care. Agency Procedure: Giving Female Perineal Care Pre-Procedure: 2. Collect the following: a. At least 4 washcloths Procedure: 22. ...Put used washcloths in the laundry bag. 23. ...Change washcloths as needed. Agency Policy: Cleaning of Re-Useable Equipment Policy Number: 8.006 Revised Date: 11/1/2020 Purpose: To assure equipment required for patient care is clean and sanitized to prevent the spread of infections. Policy: Equipment used for more than one patient is cleaned between each patient use. Definitions; 1. Low-Level Disinfection...include 70% isopropyl alcohol/ethyl alcohol. 3. Non-Critical Items - Equipment that is only meant to come in contact with intact patient skin and thus should be cleaned for use by undergoing low-level disinfection (e.g., stethoscopes, blood pressure cuffs, pulse-oximeters...) Procedure: 1. Non-critical items which will come in contact with intact patient skin will undergo a low-level disinfection between each patient use. 6...a. The hand-held computer device (i.e. tablet...) should be wiped down with a low-level disinfectant at the beginning and end of each visit. 7. Stethoscopes are cleaned with a low-level disinfectant wipe after each patient use and before being returned to the staff bag. 9. Blood pressure cuffs are cleaned with a low-level disinfectant wipe after each patient use and before being returned to staff bags. Agency Policy: Dressing Change Procedure For Central Venous, Midline, And Peripherally Inserted Central Catheters (PICC) Policy Number: 10.027 Revision Date: 10/01/16 Purpose: To keep insertion sites clean, stabilize catheters and minimize the risk of infection. Policy: ...Sterility will be maintained throughout this procedure. Procedure: ...5. ..remove the old dressing... ...7. Remove gloves, perform hand hygiene and don sterile gloves. ...9. Cleanse the site... ...12. Secure the catheter in place... 13. Apply a sterile dressing to the site... ...15. ...remove gloves and PPE (personal protective equipment) 3. HV # 6 was admitted to the agency on 3/12/22 with diagnoses including Type 2 Diabetes Mellitus With Other Specified Complication, and Osteomyelitis Unspecified. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/12/22 to 5/10/22 revealed orders for the SN (Skilled Nurse) to perform site care for infusion access device right upper arm PICC line with sterile occlusive dressing changes once a week and PRN (as needed) for loose or soiled dressing beginning week of 3/13/22. A HV was conducted on 4/13/22 at 9:40 AM to observe care provided by the EI # 7, RN. EI # 9, PCM (Patient Care Manager) was also present during the visit. During observation of PICC site care performed by the SN, the SN removed the old dressing, donned his/her sterile gloves, cleansed the site, and while searching for the biopatch he/she had dropped onto the sterile field, knocked over a bottle of hand sanitizer. The SN then picked up the bottle of hand sanitizer while wearing his/her sterile gloves, obtained the biopatch, and completed PICC dressing care wearing the same sterile gloves. The SN failed to follow agency policy to maintain sterility throughout the procedure. In an interview conducted on 4/14/22 at 10:25 AM, EI # 9 confirmed the SN did not maintain sterility while performing PICC site care. 2. HV # 7 was admitted to the agency on 3/23/22 with diagnosis including Hypertensive Heart Disease with Heart Failure and Acute on Chronic Combined Systolic and Diastolic Heart Failure. A HV was conducted on 4/14/22 at 9:55 AM with EI # 8, COTA (Certified Occupational Therapy Assistant) to observe patient care. During the visit, EI # 8 assessed HV # 7's blood pressure using a blood pressure cuff and stethoscope. EI # 8 then placed the blood pressure cuff and stethoscope on a clean barrier. Prior to ending the visit, EI # 8 opened a single alcohol prep pad and made a single wipe on a small portion of the bell of the stethoscope failing to clean the entire surface of the bell of the stethoscope that came in contact with the patients skin and then dropped the uncleaned stethoscope in the staff bag. EI # 8 then opened another single alcohol prep pad and lightly cleaned a narrow strip along one edge of the blood pressure cuff failing to clean all surfaces that came in contact with the patient's skin and placed the uncleaned blood pressure cuff into the staff bag. EI # 8 then utilized a hand held computer device and obtained EI # 8's signature on the device and exited the home without cleaning the device per policy. An interview conducted on 4/14/22 at 9:55 AM with EI # 10 confirmed the equipment was not cleaned per policy. 1. HV # 1 was admitted to the agency 3/14/22 with diagnoses including Parkinson's Disease and Pressure Ulcer of Sacral Region, Stage 2. A HV was conducted on 4/12/22 at 12:27 PM to observe bed bath provided by Employee Identifier (EI) # 2, Home Health Aide. EI # 10, Patient Care Manager, was also present during the HV. EI # 2 bathed HV # 1's buttocks area with a washcloth, then rinsed the buttocks area with another washcloth and placed both of the soiled washcloths on the floor. EI # 2 failed to place the soiled linen in a laundry bag or hamper as directed per the agency policy. EI # 2 then prepared to perform perineal care on HV # 1. EI # 2 placed a clean washcloth on HV # 1's walker and during the process of changing out the bath water, the clean washcloth fell to the floor. EI # 2 retrieved the washcloth from the floor and proceeded to perform HV # 1's perineal care with the washcloth. EI # 2 failed to use a clean washcloth to perform perineal care. An interview was conducted on 4/12/22 at 1:50 PM with EI # 10, who verified the staff failed to follow the agency policy for bed bath and perineal care.

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 review of agency policies and procedures, Licensed Practical Nurse (LPN) job description, medical records (MR) and interviews, it was determined the agency staff failed to document an assessment of a new wound was completed upon development of the wound. This affected 1 of 7 MR's reviewed with wounds including Home Visit (HV) # 2 and had the potential to negatively affect all patients served by this agency with newly developed wounds. Findings include: Agency Policy: Wound Assessment, Documentation... Policy Number: 2.2.001 Revised Date: 12/1/21 Purpose: To ensure the accurate and consistent assessment and documentation of wounds. Policy: ...Wound location and description documentation is completed on all patients with wounds...upon development of a wound.... Procedure: ...3. Document the following in the MR: a. Wound type... b. Location and laterality. c. Stage or Thickness... wound size... d. Undermining and/or Tunneling... e. Wound Bed... f. Wound Edges... g. Drainage... h. Periwound condition... Agency Policy: Coordination of Care... Policy Number: 2.1.017 Revised Date: 8/1/19 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by...identifying patient needs through assessment and communication with other health care providers. ...Procedure: ...4. Coordination of care with physician: ...throughout care...coordination of services is promoted through routine communication with the patient's physician: a. When changes occur in the patient's condition... ...e. When there is a need to change the patient's plan of care.... Agency Job Description: LPN ...Communicates timely and effectively with physicians...regarding any patient care issues or needs... 1. HV # 2 was admitted to the agency on 3/21/22 with diagnoses including Unspecified Atrial Fibrillation and Unspecified Atrial Flutter. Review of the LPN Visit Note Report dated 3/29/22 revealed documentation of "open area noted to coccyx area. PCM's (Patient Care Manager's) notified via email so RN (Registered Nurse) can assess and add to ICC (computer system)..." Further review of the LPN Visit Note Report (VNR) dated 3/29/22 revealed no documentation of the newly developed coccyx wound type, stage or thickness, wound size, undermining and/or tunneling, wound bed, wound edges, drainage and peri wound condition. Review of the physician orders revealed an order dated 3/29/22 to "schedule RN to assess new wound to coccyx area at next nursing visit..." Review of the Skilled Nursing VNR's revealed the next nursing visit was conducted on 4/4/22, 6 days after the development of the wound to the coccyx area was documented, to perform the wound assessment. An interview was conducted on 4/14/22 at 9:25 AM with EI # 10, PCM, who verified the LPN staff failed to document an assessment of a new coccyx wound was completed upon development of the wound. EI # 10 also verbalized the LPN is expected to enter the wound assessment in the narrative note, call the physician, and write the physician's order for wound care.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, and interviews with staff it was determined the agency failed to ensure the patient/caregiver (pt/cg) were provided education and/or provided a return demonstration of the following: 1. Wound care per the physician's orders. 2. Blood sugar monitoring per the physician's orders. 3. Use of the glucometer. This affected 4 of 17 MR's reviewed including Home Visit (HV) # 1, HV # 2, MR # 5, HV # 5 and had the potential to negatively affect all patients at this agency. Findings include: Agency Policy: Patient Education Policy Number: 3.001 Revised Date; 11/1/17 Policy: The agency plans, supports, and coordinates patient and caregiver educations designed to promotes optimal patient health and safety. Patients receive oral and/or written information for this purpose on an ongoing basis while being cared for by the agency. Procedure: 2. Education provided is coordinated among the interdisciplinary team, in accordance with the plan of care. …7. Using the progress/visit note, the clinician documents the level of pt/cg comprehension, pt/cg return demonstration of skill (s) taught, compliance, and any follow-up with team members. Concerns are reported to the patient’s physician. 4. HV # 5 was admitted to the agency on 3/28/22 with diagnosis including Cellulitis of Abdominal Wall and Cutaneous Abscess of Abdominal Wall. Review of the HHC and POC dated 3/28/22 to 5/26/22 revealed, "SN to cleanse wound # 1 lower mid (Midline) abdominal surgical incision with normal saline, pat dry, prepare peri-wound area with vac (Wound Vacuum) tape. Fill tunneled area with white foam, then apply black foam to wound bed. Cover with transparent drape and apply tubing. Apply negative pressure device at 125 mm/hg (millimeters of mercury) continuous using clean technique. Dressing to be changed 3 times weekly. May use the following protocol as an alternate dressing as needed for peri-wound maceration/breakdown, pump failure or other complications: Instruct caregiver on how to remove vac dressing and cleanse with normal saline, pat dry, apply saline moistened gauze to wound bed, cover with dry gauze then ABD (Abdominal Dressing) pad, and secure with tape using clean technique. Instruct patient/caregiver on troubleshooting techniques and canister changes; Instruct on signs/symptoms of wound infection. Review of the SN Visit Note Reports dated 3/28/22, 3/30/22, 4/1/22, 4/4/22, 4/6/22 and 4/8/22 revealed no documentation the caregiver demonstrated knowledge on how to remove the wound vac dressing, cleanse with normal saline, pat dry, apply saline moistened gauze to the wound bed, cover with dry gauze then ABD pad and secure with tape using clean technique and no documentation of a return demonstration on how to change the canister. An interview conducted on 4/14/22 at 10:17 AM with EI # 12, PCM confirmed there was no documentation the caregiver performed a return demonstration of wound vac dressing removal and cannister change and should have. 2. HV # 2 was admitted to the agency on 3/21/22 with diagnoses including Unspecified Atrial Fibrillation and Unspecified Atrial Flutter. Review of the Physician order dated 4/4/22 revealed an order for "SN to perform wound care to wound # 11 coccyx as follows: Cleanse with wound cleanser/Saline. Pat dry with a gauze. Apply Medihoney to wound bed using cotton tip applicator. Cover with Optifoam dressing using clean technique. Would care to be performed every 3 days or prn (as needed) for soiling. Cg (caregiver)/Patient to perform care in absence of SN..." Review of SN Visit Note Report (VNR) dated 4/4/22 revealed documentation of a Pressure Ulcer Stage 2 to the coccyx with an onset date of 4/4/22. Further reviewed revealed no documentation the patient and/or caregiver was provided education on how to perform wound care to the new wound. An interview was conducted on 4/14/22 at 9:25 AM with EI # 10, PCM, who verbalized the next SN visit, following the visit on 4/4/22, was performed on 4/13/22 and wound care education was not provided until the 4/13/22 visit, which was 9 days following the initial wound care being performed. 3. MR # 5 was admitted to the agency on 10/29/21 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Circulatory System and Type 2 Diabetes Mellitus without Complications. Review of the HHC and POC dated 10/29/21 to 12/27/21 revealed physician orders for SN to "...provide/instruct/reinforce...closed incision/suture line daily" wound care of "cleanse with soap and water, pat dry, leave open to air. Pt/cg to perform in absence of SN" to wounds # 2, # 3, # 4, # 5 and "pt/cg to perform blood glucose (BG) testing daily..." Review of the SN VNR notes revealed no documentation the pt/cg provided a return demonstration of the wound care to wounds # 2, # 3, # 4, # 5 and the use of the glucometer to perform BG testing. An interview was conducted on 4/14/22 at 9:34 AM with EI # 1, Executive Director, who confirmed there was no documentation of a return demonstration of the wound care to wounds # 2, # 3, # 4, # 5 and the use of the glucometer to perform BG testing. 1. HV # 1 was admitted to the agency 3/14/22 with diagnoses including Parkinson's Disease and Pressure Ulcer of Sacral Region, Stage 2. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/14/22 to 5/12/22 revealed a Skilled Nurse (SN) frequency of 1 week (wk) 9. SN to perform/instruct/reinforce patient/caregiver procedure of wound care to wound # 1 Coccyx PU (Pressure Ulcer) Stage II (2) every 3 days or prn (as needed) soilage. Cleanse with soap and water or normal saline. Pat dry. Cover with Hydrocolloid dressing… Review of the SN Visit Note Reports dated 3/14/22 and 3/23/22 revealed there was no documentation the SN instructed the pt/cg in the procedure of wound care to be performed to the Coccyx PU, Stage 2 per agency policy. An interview was conducted on 4/14/22 at 9:19 AM with Employee Identifier (EI) # 10, Patient Care Manager (PCM), who verified the staff failed to ensure the pt/cg were educated/instructed on the wound care to the Coccyx PU, Stage 2 per the agency policy and procedure.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, medical records (MR) and interviews, it was determined the agency failed to ensure medical record documentation was complete and accurate with all events, and treatments administered which included specific and accurate wound care provided. This affected 4 of 7 Home Visits (HV) including HV # 1, HV # 2, HV # 5, HV # 4, and had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: Home Care Record Policy Number: 7.003 Revised Date: 11/1/21 Purpose: To define the contents and requirements of the clinical home care record. Policy: A medical record is maintained for all patients receiving services and care from the agency. All entries in the patient care record will also reflect date and time care performed. Procedure: ...2. The patient home care record shall contain the following clinical information: ...e. Interventions, including medication administration, treatments, and services, and responses to those interventions. ...j. Education needs including ability, motivation, and readiness to learn. 4. HV # 4 was admitted to the agency on 4/7/22 with diagnoses including Unspecified Atrial Flutter, Shortness of Breath, and Pneumonia Unspecified Organism. Review of the HHC and POC dated 4/7/22 to 6/5/22 revealed a SN visit frequency of 1WK1, 2WK1, 1WK 7, and orders for the SN to perform/instruct wound care for a stage 3 pressure ulcer to the coccyx which included cleansing the wound with soap and water or saline cleanser. Review of the SN Visit Note Report dated 4/7/22 revealed, "Cleansed with soap and water or saline/cleanser." There was no documentation to clarify if the wound was cleansed with soap and water or saline cleanser. An interview was conducted on 4/14/22 at 9:40 AM with EI # 1, Executive Director who verified the staff failed to document the specific wound care provided to HV # 4's Stage 3 PU. 3. HV # 5 was admitted to the agency on 3/28/22 with diagnosis including Cellulitis of Abdominal Wall and Cutaneous Abscess of Abdominal Wall. Review of the HHC and POC dated 3/28/22 to 5/26/22 revealed, "SN to cleanse wound # 1 lower mid abdominal surgical incision with normal saline, pat dry, prepare peri-wound area with vac (wound vacuum) tape. Fill tunneled area with white foam, then apply black foam to wound bed. Cover with transparent drape and apply tubing. Apply negative pressure device at 125 mm/hg (millimeters of mercury) continuous using clean technique. Dressing to be changed 3 times weekly... The POC included no orders for a mediport (Implanted Infusion Device). Review of the Visit Note Report (VNR) by the RN (Registered Nurse) dated 3/28/22 revealed, "Mediport R (Right) upper chest and tunneling to the mid abdominal surgical incision. Review of the VNR by the SN dated 3/30/22, 4/1/22, 4/6/22, and 4/8/22 revealed, "no infusion access" was documented and no tunneling to the mid abdominal surgical incision was documented. A HV was conducted on 4/13/22 at 9:05 AM with EI # 6 LPN (Licensed Practical Nurse) to observe care provided by the agency. During the visit, EI # 6 measured tunneling to the mid abdominal surgical incision and HV # 5 revealed a mediport to the R upper chest. An interview conducted on 4/14/22 at 10:17 AM with EI # 12, PCM confirmed there was incorrect and incomplete documentation of the mediport and wound tunneling on 3/30/33, 4/1/22,4/6/22 and 4/8/22 VNR's. 2. HV # 2 was admitted to the agency on 3/21/22 with diagnoses including Unspecified Atrial Fibrillation and Unspecified Atrial Flutter. Review of the Physician Order dated 4/4/22 revealed an order for "SN to perform wound care to wound # 11 coccyx as follows: Cleanse with wound cleanser/Saline..." Review of the SN Visit Note Report dated 4/4/22 revealed documentation of "Cleansed with wound cleanser/Saline..." There was no documentation to clarify if the wound was cleansed with wound cleanser or normal saline. An interview was conducted on 4/14/22 at 9:25 AM with EI # 10, PCM, who verified the staff failed to document the specific wound care provided to HV # 2's coccyx wound on 4/4/22. 1. HV # 1 was admitted to the agency 3/14/22 with diagnoses including Parkinson's Disease and Pressure Ulcer of Sacral Region, Stage 2. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/14/22 to 5/12/22 revealed a Skilled Nurse (SN) frequency of 1 week (wk) 9. SN to perform/instruct/reinforce patient/caregiver procedure of wound care to wound # 1 Coccyx PU (Pressure Ulcer) Stage II (2) every 3 days or prn (as needed) soilage. Cleanse with soap and water or normal saline. Pat dry. Cover with Hydrocolloid dressing… Review of the SN Visit Note Reports dated 3/14/22, 3/23/22, 3/30/22, 4/1/22 and 4/9/22 revealed, "Cleansed with soap and water or saline". There was no documentation to clarify if the wound was cleansed with soap and water or normal saline. An interview was conducted on 4/14/22 at 9:19 AM with Employee Identifier (EI) # 10, Patient Care Manager (PCM), who verified the staff failed to document the specific wound care provided to HV # 1's Stage 2 PU.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on medical record (MR) review, agency policies and procedures, and interview, it was determined the agency failed to ensure agency staff completed clinical notes per policy. This deficient practice affected 1 of 12 active records reviewed, including MR # 10, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Home Care Record Policy Number: 7.003 Revision Date: 11/01/21 Purpose: To define the contents and requirements of the clinical home care record. Policy: A medical record is maintained for all patients receiving services and care from the agency... Procedure: ...2. The patient home care record shall contain the following clinical information: ...b. Signed, dated and timed clinical notes and progress notes. ...4. Clinical notes for all services the patient has received shall be: a. Turned in to the agency in person or by fax, at least within 2 days from visit. For Point of Care users, synchronization will occur within 24 hours from visit.... b. Incorporated into the medical record... Agency Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Revision Date: 8/1/19 Policy: The agency provides care and services within an integrated continuum of care system. Procedure: ...5. Coordination of care among disciplines: ...d. Completed visit notes will be submitted to the agency via synchronization within 24 hours of visit for point of care agencies. 1. MR # 10 was admitted to the agency on 1/10/22 with diagnoses including Type 2 Diabetes Mellitus With Hyperglycemia, and Essential Primary Hypertension. A review of the following Skilled Nurse (SN) Visit Note Reports (VNR) revealed the SN did not complete the VNR within agency policy of 24 hours: a. SN visit 3/17/22, the VNR was signed electronically 3/24/22, which was 7 days later. b. SN visit 3/24/22, the VNR was signed electronically 3/28/22, which was 4 days later. c. SN visit 3/30/22, the VNR was signed electronically 4/4/22, which was 5 days later. d. SN visit 4/6/22, the VNR was signed electronically 4/9/22, which was 3 days later. In an interview conducted on 4/14/22 at 9:50 AM with Employee Identifier (EI) # 9, RN (Registered Nurse) Patient Care Manager, EI # 9 confirmed the notes were not completed per agency policy of 24 hours.