Every finding on record at Elite Home Rehab and Healthcare Corp

This visit was for the Federal and State Complaint survey of a Deemed Home Health Provider. A partially extended complaint investigation was announced on 12/07/2023. Complaint: 102599 Facility ID: 014023 Survey Dates: 12-04-23, 12-05-23, 12-06-23, 12-07-23, 12-08-23, 12-11-23, and 12-12-23. 12-Month Unduplicated Skilled Admissions: 1437. Non-condition level deficiencies were cited at 42 CFR 484.50 Patient Rights and 484.60 Care Planning Coordination, Quality of Care. QR Completed by A2 on 12/18/2023.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to communicate with the patient regarding missed visits for 1 of 5 discharged records reviewed. (Patient #15) Findings Include: 1. A review of agency policy “Patient Bill of Rights”, indicated that the patient has the right to receive and access services consistently, with continuity, and in a timely manner from the agency to his/her request for service. The agency must document its communication with the patient, as well as the measures the Agency took to get in contact with the patient. 2. A review of a list of agency patients discharged indicated Patient #15 was discharged on 11/14/2023, reason documented was “patient refused care.” 3. A review of documents titled “Missed Visit Note”, dated 11/07/2023 and 11/08/2023 indicated that Patient #15 did not answer phone calls from the agency and that the physician was made aware of the missed visits. 4. A review of Patient #15's schedule in the electronic medical record indicated a lack of documentation by the agency of visit notes, missed visit notes, or attempted contacts to reach the patient starting the week of 10/15/2023 through the week of 11/04/2023. No documentation of attempts to reach Patient #15 was provided until 11/07/2023, a missed visit note with an attempted phone call. 5. A review of document titled “Home Health Certification and Plan of Care”, dated 10/25/2023, certification period 10/17/2023 to 12/15/2023 indicated Patient #15 was to have a skilled nurse visit once a week for nine weeks. 6. During an interview on 12/11/2023 at 3:31 PM, the Administrator indicated that all documentation regarding phone calls and missed visits for Patient #15 had been provided to the surveyor and that no other documentation regarding attempted contacts/missed visit notes were documented. 7. During an interview on 12/11/2023 the Administrator indicated that staff are to contact patients and leave a voicemail for the patient to call back if unavailable. Staff are to call a couple times and if the patient still does not answer or call back, we get the Marketer involved and have them go to the patients house and contact them that way. 8. During an interview on 12/11/2023 at 9:26 AM, PT #2 indicated that missed visits are to be rescheduled for the same week, the physician is to be notified, with attempts to get in contact with patients any way they can.

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, record review, and interview, the home health agency failed to ensure all required elements were included in the plan of care (POC) for 2 of 2 patients both receiving anticoagulant (blood thinner) therapy and with home visit observations (Patient #1 and #3). Findings include: 1. The Patient Assessments / Plan of Care policy indicated the plan of care (POC) must include the patient’s required equipment, all medications, and safety measures to protect against injury. 2. The Medication Review policy indicated the medication profile should include all current patient medications, including but not limited to the dosage and frequency, and that drug regimen review should occur as an ongoing part of the patient’s care. 3. During a home visit observation on 12/04/23, Registered Nurse (RN) 1 provided care for Patient #1. A hospital bed and bedside commode were in the patient’s home. Tylenol, a medication used to relieve minor pain and fever, 500 milligrams (mg) and an Albuterol inhaler, a medication that helps open the airway to make breathing easier, with instructions to take 2 puffs as needed for wheezing or shortness of breath was also located in the home. Patient #1 indicated they used the Tylenol as needed for pain since before beginning agency services and had been using the inhaler as needed for 1 week for wheezing. During an interview on 12/05/23 at 4:02 PM, the Clinical Manager relayed all equipment and supplies used by the patient should be in the POC and indicated the POC did not include a hospital bed or bedside commode. The Clinical Manager indicated all medications the patient is taking should be included in the POC medication list but that Tylenol and Albuterol inhaler were not included in Patient #1’s POC medication list. During an interview on 12/06/23 at 4:28 PM, the Administrator indicated bleeding precautions should be included in the POC for a patient on anticoagulant therapy and that Patient #1’s POC did not include bleeding precautions. Patient #1’s clinical record included a POC for certification period 11/17/23 to 01/15/24 which failed to evidence a hospital bed or bedside commode. The POC failed to evidence Tylenol or an albuterol inhaler on the medication list. The POC included Eliquis, a medication used to reduce blood clotting, 2.5 mg oral tablet to be taken twice daily. The POC failed to evidence bleeding precautions for Patient #1. 4. During a home visit observation on 12/05/23, Physical Therapy Assistant (PTA) 1 provided care for Patient #3. Received a facility medication list from Entity 1’s licensed practical nurse. Entity 1’s medication list indicated Patient #3’s required medications to be administered by the facility and included but not limited to Acetaminophen, a medication used to treat pain and fever, 325 mg with instructions to take 1 tablet by mouth 3 times per day as needed; Vitamin B-12 1,000 micrograms tablet daily; Ferrous Sulfate (Iron) 325 mg tablet with instructions to discontinue on 12/1/23; Sodium Bicarbonate, a medication used to relieve heartburn and indigestion or to make the blood or urine less acidic, 325 mg tablet twice daily; Neosporin, an antibiotic ointment, applied to left great toe; Calmoseptine ointment, a barrier cream used to protect and help heal skin irritations, topically to bilateral glutes (buttocks), coccyx (tailbone), and groin every 4 hours as needed following incontinence care; and Fungi-nail, a medication used to treat nail fungus, with instructions to apply to right toenail twice daily as needed. Patient #3’s clinical record included a POC for certification period 10/20/23 to 12/18/23 which included Acetaminophen 325 mg oral tablet every 4 hours as needed for pain; Diclofenac Sodium, a medication used to treat swelling and pain, 50 mg oral delayed release tablet twice daily as needed for pain, Diclofenac Sodium 75 mg oral tablet twice daily, Ferrous Sulfate 325 mg oral tablet twice daily, and Vitamin B complex tablet. The POC failed to include the correct dosage and frequency for Acetaminophen and failed to include Vitamin B-12, Sodium Bicarbonate, Neosporin, Calmoseptine ointment, and Fungi-nail. The POC incorrectly included Diclofenac Sodium, Ferrous Sulfate, and Vitamin B complex. The POC included the anticoagulant Xarelto, a medication used to treat and prevent blood clots. The POC failed to include bleeding precautions for Patient #3. During an interview on 12/08/23 at 3:14 PM, the Administrator indicated the agency’s medication list should include the same information as the ALF’s medication list and relayed the agency’s POC medication list did not include the same dosage and frequency as Entity 1’s medication list for Acetaminophen and did not include the Vitamin B-12, Sodium Bicarbonate, Neosporin, Calmoseptine ointment, and Fungi-nail that were included in Entity 1's medication list. The Administrator relayed the POC included Ferrous Sulfate and Vitamin B complex and that the Diclofenac from the agency POC was not included in Entity 1’s medication list. During an interview on 12/06/23 at 4:28 PM, the Administrator indicated bleeding precautions should be included in the POC for a patient on anticoagulant therapy. During an interview on 12/08/23 at 3:14 PM, the Administrator relayed Patient #3’s POC did not include bleeding precautions.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview the home health agency failed to ensure physician orders were obtained prior to clinicians providing care for 2 of 2 patients both receiving anticoagulant (blood thinner) therapy and with home visit observations (Patient #1 and #3.) Findings include: 1. The Verbal Orders policy indicated physician orders, which are signed, timed, and dated by the physician, are required for all services rendered by the agency and verbal orders are to be recorded in the patient’s clinical record by the professional receiving them and must include the date, time, and signature. 2. Patient #1’s clinical record included a plan of care (POC) for certification period 11/17/23 to 01/15/24 which the agency received signed by the physician on 12/07/23. Patient #1’s clinical record included skilled nursing (SN) visits where wound care was performed on 11/20/23, 11/22/23, 11/24/23, 11/27/23, 11/29/23, 12/01/23, and 12/04/23. The clinical record failed to evidence the agency had physician orders for these visits. During an interview on 12/07/23 at 2:26 PM, RN 1 relayed they had left a message for Patient #1’s physician with the POC details but had not received a call back with verbal orders for the services and frequencies included in the POC. During an interview on 12/08/23 at 3:14 PM, the Administrator relayed their expectation for a verbal order included the clinician speaking with someone in the patient’s provider’s office and receiving verbal confirmation of the requested order. 3. Patient #3’s clinical record included a POC for certification period 10/20/23 to 12/18/23 which the agency received signed by the physician on 10/24/23. Patient #3’s clinical record included a SN visit with wound care performed on 10/23/23 and a physical therapy assistant (PTA) visit with therapy services provided on 10/20/23. The clinical record failed to evidence the agency had physician orders for these visits. During an interview on 12/08/23 at 9:07 AM, RN 2 relayed they did not receive a verbal order for services and frequencies included in the POC and that the POC had been faxed to the physician’s office on 10/20/23 for review and signature and had been received back signed by the physician on 10/24/23. During an interview on 12/08/23 at 3:14 PM, the Administrator relayed their expectation for a verbal order included the clinician speaking with someone in the patient’s provider’s office and receiving verbal confirmation of the requested order.

This visit was for a Federal and State Complaint survey of a Deemed Home Health provider. Complaint 94479: Substantiated-. Federal and State Deficiencies were cited. Survey Dates: 2/8/23. 2/9/23, 2/10/23 Unduplicated Census: 412 QA Area 4 2/20/2022

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure updates and revisions to the comprehensive assessment were made, including changes to the plan of care, when a patient experienced a change in condition in 1 of 5 clinical records reviewed. (Patient 5) Findings include: 1. Review of a 2018 dated agency document "2.7 GUIDELINES FOR ASSESSMENT" page 3 stated, "Reassessment... To ensure that the patient/client's current problems and needs are continually evaluated and the care provided is adjusted accordingly, the patient/client's status is reviewed periodically. The reassessment process is ongoing throughout the patient/client's contact with the Agency. Each patient/client is reassessed to determine the patient/client's response to care or services. Reassessment occurs: 1. When the patient/client's condition significantly changes. 2. When the patient/client's diagnosis changes...4. Within 48 hours of the patient's return home from a hospital admission of 24 hours or more for any reason except diagnostic tests or on physician-ordered resumption date. 5. Every 60 days when the patient/client is receiving skilled services." 2. Review of a 2016 dated agency document "2.8 CARE PLAN" page 19 stated, "Development of Care Plan … In order to ensure that a patient's needs are being met adequately and appropriately, and services are adapted and adjusted within an individual patient situation as needed, a care plan is essential." "...Continuing evaluation and service modifications are provided as indicated as an integral part of the ongoing provision of Agency services …" "The patient care plan shall be updated as often as the patient's condition indicates but at least every sixty (60) days for skilled patients." Page 21 stated, "11. Revision of the plan of care as frequently as necessary to reflect the changing care needs of the patient but no less frequently as every 60 days …" 3. On 2/9/23 at 1:22 PM, during a home visit observation for wound care with Patient 5, RN 3 was observed providing wound care to the left leg and to three (3) separate abdominal sites. The nurse stated the patient’s abdominal wounds were related to a recent laparoscopic procedure where the patient’s kidney had been removed. 4. During a review of the clinical record for Patient 5, for the certification period of 1/16/23 through 3/16/23, evidenced a document titled "Home Health Certification and Plan of Care" dated 1/13/23. The document stated, "Principle Diagnosis...Type 2 diabetes mellitus with foot ulcer." The next section, titled "Surgical Procedure" was left blank. The following section titled '"Other Pertinent Diagnosis" contained the following diagnosis, "Non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin, Non-pressure ulcer of other part of left lower leg limited to breakdown of skin, Essential (primary) hypertension, anxiety disorder, unspecified, spinal stenosis, Hypothyroidism, hyperlipidemia, Long-term (current) use of oral hypoglycemic drugs, History of falling". The document failed to evidence any recent surgical procedures that had been performed during the last 60 days and failed to evidence the record had been updated with any new corresponding diagnoses. During a review of the clinical record for Patient 5, a document dated 1/13/23, titled "OASIS Recertification" was reviewed. The document indicated Patient 5's Primary diagnoses as Type 2 diabetes with foot ulcer and other diagnoses included non-pressure chronic ulcers of multiple parts of the right lower leg limited to breakdown of skin, essential (primary) hypertension, anxiety disorder, unspecified, spinal stenosis, hypothyroidism, hyperlipidemia, long-term (current) use of oral hypoglycemic drugs, and a history of falling. Patient 5's pertinent history failed to include cancer, surgery, and prior hospitalizations. Page 18 stated further, "Patient Contact with Physician … Physician: ['Physician H' typed in] … Was the visit related to the primary reason for Home health? [box marked "Yes" was checked] … Reason for visit: Wound care … Date last visited: 11/08/2022. The Goals and Interventions Summary indicated the patient was referred to home health care for wound care. Wound care orders included "SN [Skilled Nurse] to perform wound care to left lower leg (upper wound)…left lower leg (lower wound) … SN to perform wound care to left lower abdominal [area]. Cleanse wound with bleach solution soak for 10 minutes, rinse with NS (Normal Saline), apply xeroform (iodine-impregnated gauze), cover and secure with [bordered foam] dressing 3x3, using aseptic technique, to be changed by SN, 2 times per week … SN to perform wound care to the left upper abdominal [area]. Cleanse wound with bleach solution soak for 10 minutes, rinse with NS, apply xeroform, cover and secure with [bordered foam] dressing 3x3, using aseptic technique, to be changed by SN, 2 times per week … SN to perform wound care to midline upper abdominal [area]. Cleanse wound with bleach solution soak for 10 minutes, rinse with NS, apply xeroform, cover and secure with [bordered foam] dressing 3x3, using aseptic technique, to be changed by SN, 2 times per week … SN to perform wound care to all abdominal surgery sites. Cleanse wound with hibicleanse [sic], apply Prisma, cover and secure with Allevyn 4x4, using aseptic technique, to be changed by SN, 2 times per week." The document contained evidence of a recent surgical procedure not included in the clinical record, and evidenced conflicting wound care orders. The clinical record failed to evidence agency documentation of a new corresponding diagnosis of malignant neoplasm of the left kidney and failed to evidence documentation of the patient's recent laparoscopic surgery for partial removal of the left kidney. 5. In an interview on 2/10/23 at 10:50 AM, RN C (with Entity B) indicated that Entity B has been providing wound care to Patient 5 related to the patient's laparoscopic surgery on 12/21/23 for a left partial nephrectomy, related to a malignant neoplasm of the left kidney, leaving the patient with several abdominal surgical sites. RN C indicated that after the patient's post-surgical visit with the surgeon on 1/16/23, Entity B was asked to be involved in the patient's abdominal wounds (Entity B had been caring for the leg wound as well at the time). RN C indicated further that Entity B had been faxing wound care orders on Patient 5's abdominal wounds to Elite Rehab weekly since 1/17/23. 6. On 2/10/23 at 11:18 AM, discussed concerns regarding conflicting wound care orders, care performed versus what the physician ordered, and orders that were not timely and therefore inaccurate, written by RN 3 for Patient 5, the Administrator offered no comment and no documentation to show compliance. IAC 410 17-14-1(a)(1)(B)

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure treatments or care were furnished in accordance with current physician orders in 1 of 5 home visits observed. (Patient 5) Findings include: 1. On 2/9/23 at 1:22 PM, during a home visit for Patient 5, RN (Registered Nurse) 3 was observed providing wound care to 4 separate sites (a left leg wound, and 3 abdominal wounds.) All sites were cleansed using gauze and normal saline. Hibiclens was not used during the observation. 2. On 2/9/23, reviewed a document “Change Orders” dated 2/06/23, for Patient 5. The document indicated the following, “SN (Skilled Nurse) to perform wound care to left lower leg. Cleanse wound with bleach solution 10-minute soak, Hibiclens, [rinse] with NS (normal saline), apply Prisma (wound dressing) with Silver (antimicrobial wound covering) to wound bed, cover with gauze and secure with [Kirlex ] followed by ace wrap, using aseptic technique." 3. On 2/10/23 the Administrator submitted an agency document dated, 2/9/23 titled "Change Orders" and indicated RN 3 had completed these orders after the home observation on 2/9/23. The orders stated, "Changed Interventions - Previous: SN to perform wound care to the left lower leg. Cleanse with bleach solution 10-minute soak, Hibiclense [sic], rince [sic] with NS, apply Prisma with Silver to wound bed, cover with gauze and secure with [Kirlex] followed by ace wrap, using aseptic technique … Changed to: SN to perform wound care to left lower leg (upper wound). Cleanse wound with bleach solution 10 minute soak, Hibiclense [sic], [rinse] with NS, apply Xeroform, covered with [bordered] foam dressing, using aseptic technique." "Previous: SN to perform wound care to right foot. Apply Allevyn to newly healed wound for protection, using aseptic technique, to be changed by nurse 2 times per week...Changed to: SN to perform wound care to left lower leg (lower wound). Cleanse with bleach solution 10-minute soak, Hibiclense [sic], rince [sic] with NS, apply Xeroform, cover with [bordered] foam dressing, using aseptic technique..." 410 IAC 17-13-1(a)

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, record review and interview the agency failed to ensure staff followed accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases in 2 of 3 home visits observed. (Patients 1 and 5) Findings include: 1. A review of an agency document "2.78 BAG TECHNIQUE" stated, "Policy: The Agency provides guidelines for the use of the bag used to carry equipment and supplies into the patient's home. It is the policy of this Agency that all staff shall utilize proper bag technique, following the agency procedure when conducting home visits... Purpose: To maximize infection control and minimize potential for cross-contamination of infectious microorganisms … ALL FIELD STAFF ARE EXPECTED TO: 1. Select and prepare adequate workspace from which to use the bag. Since floors are considered to be highly contaminated, bags are never to be placed on the floor … 5. The most effective form of infection control is good handwashing. Employees must cleanse hands before entering/removing supplies from the bag, before examination, and after patient care … 7. If additional supplies are needed during the visit, hands are to be cleansed before re-entering the bag. Alcohol-based hand sanitizer gel may be used. Careful planning limits this occurrence..." 2. A review of an agency document "2.79 HAND WASHING POLICY - IN PATIENT'S HOMES" stated "Policy: It is the practice of this agency to assure that every effort is made to reduce the risk for infection in patients and staff members. Thorough hand washing/hand antisepsis is required for all employees. The agency has established guidelines for all staff and will provide education and direction on accepted practices. Purposes: To improve hand-hygiene practices of agency staff and reduce transmission of pathogenic microorganisms to patients and personnel in the home care setting. Special Instructions: a. 1. Use of alcohol-based hand sanitizer is preferred (until dry). If antimicrobial soap is used, it must be for a period of at least 15 seconds. (www.cdcgov/handhygiene/training/interactiveEducation). b. a. Before and after caring for patients, or when coming into contact with inanimate objects/equipment in the immediate vicinity of the patient … Between tasks on the same patient … After removing gloves … After touching objects that are potentially contaminated … When hands are visibly dirty/soiled or contaminated with proteinaceous material or other body fluids soap and water should be used first. a. (1) An alcohol-based hand rub for routinely decontaminating hands in all other clinical situations are acceptable … OTHER ASPECTS OF HAND HYGIENE … 3. Gloves are to be worn during patient care when there is a risk of contact with blood or other potentially infectious materials, mucus membranes, and no-intact skin could occur." 3. A review of a 2016 dated agency document "5.7 STANDARD PRECAUTIONS FOR ALL HEALTHCARE WORKERS" stated, "1. Standard Precautions shall be observed by every health care worker for all patients receiving care … 2. WASH HANDS - hands must be washed before and after contact with each patient under a steady stream of water with an appropriate antibacterial solution for at least 20 seconds. In the absence of water, an appropriate antibacterial solution must be used. 3. Gloves, such as vinyl or latex medical gloves, must be worn... including but not limited to the following: … b. dressing changes …4. Gloves should be changed after each patient contact. When gloves are removed, thorough hand washing is required. Gloves do not take the place of hand washing." 4. On 2/9/23 at 10:25 AM, during a home observation for wound care with Patient 1, RN 2 was witnessed approaching the front door with a surgical mask secured around both ears, but sitting under the chin. The nurse, with a bare hand, raised the mask up to cover the nose and mouth before entering the home. Later in the visit, the nurse sanitized hands, donned gloves, and removed Kerlix (rolled gauze) and Coban (a self-adhering, light compression, rolled bandage) wrappings from both legs, which were in place from just below the knee, covering the foot, but ended just before the toes. (The left leg had an open weeping wound, and the right leg was without wounds). Using the same gloves the nurse proceeded to wash the right leg with an aqua-colored washcloth given to the nurse by the patient's family member and washed the leg with water from a basin that was also provided by the family member. A family member in the room informed the nurse that the patient was scheduled to see a dermatologist soon, to figure out why the wound hasn't healed and stated "it has been about a year" that the patient has had the wound. When inquiring as to what else was in the water in the basin, it was discovered that there were no additives in the basin of water. The nurse then doffed gloves, grabbed a container of liquid soap, dispensed a few pumps of soap into the basin, sanitized both hands with hand sanitizer, donned new gloves, and proceeded to wash both legs with the soap and water. The same aqua-colored washcloth was used to wash both legs, and the basin of water was not changed out between the cleansing of each leg. The nurse then doffed gloves after cleansing both legs and reached for a package of 'Water Wipes', and used these wipes to remove soap residue from the legs, doffed gloves, retrieved a jar of Aquafor, sanitized hands, and donned new gloves. The nurse opened the jar of Aquafor, reached into the jar, and applied Aquafor to the other gloved hand, this was then spread over the surface of both legs with both gloves. With the same gloves still on, an Unna boot (a calamine-infused rolled gauze) was applied to the left leg. With the same gloves still in place, both the left and right legs were re-wrapped with new kerlix, then new Coban. Later, while assessing vitals, the nurse, with the right bare hand, touched a smartwatch on their left wrist and then used the same right hand to assess the patient’s right radial pulse. 5. On 2/9/23 at 1:22 PM, during a home observation for wound care with Patient 5, RN 3 was observed providing wound care to 4 separate sites (one leg wound, and three abdominal wounds). The nurse stated the patient’s abdominal wounds were related to a recent laparoscopic procedure where the patient’s kidney was removed. Care was performed in a swivel chair that did not recline. The patient was in an upright seated position for the duration of the visit. The patient attempted to assist with the dressing change with bare hands, keeping his/her sweatshirt lifted up away from the lower abdomen, while also attempting to retract any loose abdominal skin from falling over onto the three (3) small abdominal surgical sites. Using gloved hands, the nurse removed all three abdominal dressings then placed individual pieces of gauze soaked with a bleach solution on all three abdominal sites, then left these to sit for an undetermined amount of time. The nurse then doffed gloves and failed to perform hand hygiene. The nurse donned new gloves, then picked up a few stapled pages of new orders from the wound clinic, reviewed them, then set the papers back down. Using the same gloves, the nurse removed a dressing on the medial aspect of the left lower leg and placed another bleach-soaked gauze on the leg wound to stay in place for a time. While wounds were soaking, the patient was no longer retracting skin over the sites. The nurse then doffed gloves and failed to perform hand hygiene. While crouched down near the patient, the nurse became aware his/her pink surgical mask had slipped down below the tip of the nose. The nurse reached up with the right bare hand and adjusted the mask back up over the nose. Hands were not sanitized. New gloves were donned, and the nurse proceeded to wipe down vital sign equipment with sanitizing wipes, then doffed gloves. The nurse failed to perform hand hygiene. The nurse unzipped and reached into the nursing bag for new gloves, and donned these gloves. The nurse then returned to the wounds and cleansed the abdominal wound nearest the umbilicus with gauze and normal saline, applied xeroform and covered it with bordered gauze, then doffed gloves. The nurse failed to perform hand hygiene. New gloves were donned. The remaining two abdominal wounds were cleansed with the same piece of gauze and saline. The patient had stopped retracting the skin over the remaining sites and the patient’s skin fell over the lower site (near the beltline), the loose skin was lifted up out of the way and xeroform was applied, followed by bordered gauze. The middle remaining wound also had a portion of the sweatshirt and skin lay over the site after xeroform had been applied, and the loose skin was simply lifted up and a bordered gauze was secured in place. (The wounds were not re-cleansed/re-dressed after having been contaminated). Gloves were doffed and placed in the trash. The nurse failed to perform hand hygiene. The nurse unzipped, then entered the nursing bag to retrieve new gloves and donned them. Later, with bare hands, the nurse tied up a trash bag used for wound care, handled and carried this bag to be disposed of in the patient’s kitchen trash receptacle. 6. On 2/9/23 at 4:38 PM in an interview with the Administrator, when discussing infection control breaches witnessed during the home observations, she indicated she would have expected the clinicians would have washed their hands in between changing gloves. Also, indicated she would have expected that wound care would have been performed on one site first, and then the other(s). The administrator further indicated she plans to re-educate staff, send out the Clinical Manager to go along with clinicians on home visits, and review infection control measures with staff. IAC 410 17-12-1(m)