Every finding on record at Excell Home Care Inc

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey from 12/6/2023 to 12/8/2023. Federal Intake Number:102150 Representing the Department of Public Health: Surveyor ID #45783, Health Facilities Evaluator Nurse Surveyor ID #45887, Health Facilities Evaluator Nurse Surveyor ID#44749, Health Facilities Evaluator Nurse Unduplicated Census: 7547 Active census:1349 Sample Size: 17 Home Visits: 7 Record review:10

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 observation, interview, and record review, the home health agency (HHA) staff failed to review all the medications and update the medication profile with the currently used medications for two of 17 sampled patients (Patient 2 and Patient 6). This deficient practice had the potential to put the patient at risk for medication errors and adverse (harmful) drug reactions. a.. A review of Patient 2’s clinical record indicated a start of care date (SOC) of 7/15/23 with diagnoses that included chronic venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes, such as varicose veins, swelling, or skin color changes on the affected leg; if the condition progresses, leg ulcers can form) and non-pressure chronic ulcer of other part of right lower leg with unspecified severity. An ulcer is defined as a break in skin or mucous membrane with loss of surface tissue. Non-pressure chronic ulcers commonly occur in patients with arterial (ischemic) disease, venous disease, neuropathy, or a combination of these diseases. During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 12/7/23 at 10 a.m., Patient 2 was observed awake, alert, and oriented. A medication review was completed during the home visit. Upon medication review, it was noted that Patient 2 was taking Sildenafil 20 mg, 1 tablet as needed prior to sexual activity. The filled date on the medication was 11/9/23. Patient 2 stated that he had been taking Sildenafil 20 mg for a couple of years. A review of Patient 2’s undated “Medication Profile,” indicated that Patient 2 was on the following medications: - Normal saline solution as a cleansing agent for wounds 3 times a week. - Triamcinolone Acetate 0.1% to apply on wound 3 times a week. - Aquacell AG to apply on wound 3 times a week. - Metformin HCl 500 mg, 2 tablets by mouth, twice a day with meals. - Insulin Regular Human Injection 100 unit/ml, with sliding scale. - Multivitamin, 1 packet by mouth daily. - Acetaminophen 500 mg, 2 caplets every 4-6 hours as needed for pain. - Aspir-Low Oral 81 mg, 1 tablet by mouth daily. - Hydrochlorothiazide Oral 25 mg, 1 tablet by mouth daily. - Simvastatin Oral 20 mg, 1 tablet by mouth every evening for high cholesterol. - Lisinopril Oral 20 mg, 1 tablet by mouth daily. - Humulin N subcutaneous 100 unit/ml, inject 72 units subcutaneously in the morning and 24 units in the evening for diabetes. Sildenafil 20 mg was not listed in Patient 2’s medication profile. During an interview with LVN 1 on 12/7/23 at 11:15 a.m., LVN 1 stated the primary nurse was the one responsible to review patient’s medications. When asked regarding how often the nurse should review the medications, LVN 1 stated, “At least once a week.” LVN 1 stated that if the patient had a change in medication, such as new medication, medication being discontinued, or a change of dose, the medication profile needed to be updated. LVN 1 stated that she had never seen Patient 2 before, so she was not aware that Patient 2 was on Sildenafil. During an interview with the Director of Patient Care Services (DPCS) on 12/8/23 at 1:50 p.m., the DPCS stated the visiting nurse had the responsibility to review patient’s medications. The DPCS stated that if a patient received daily visit, then the nurse would need to review the medications on the first visit of the week. DPCS further stated if the visiting nurse was not aware of the medications the patient was taking, he or she wouldn’t be able to provide the necessary teaching regarding side effects and/or drug interactions, and it could affect patient’s health status. A review of the agency’s undated policy, titled “Home Care Medication Management,” indicated that the purpose of medication profile is to document and maintain a current list of all medications taken by the patient. The policy indicated that: - On an ongoing basis, update the medication profile as orders are changed or new self-directed medication is taken. - Review the medication profile form ongoing by the staff responsible for performing medication monitoring activities. During an interview with the Director of Patient Care Services (DPCS) on 12/8/23 at 1:30 p.m., the DPCS stated that the primary nurse of the patient was responsible to provide the medication profile to the patient and/or the family member/caregiver. The DPCS stated that the agency provided each nurse with a laptop and a printer so they would be able to print necessary documents for the patients, such as the plan of care and medication profile. The DPCS further stated the primary nurse was also responsible to write the patient’s medications on the plastic board, so that the patient could put it on their refrigerator as a reminder. When asked about the purpose of providing a copy of medication profile to patient, DPCS stated, “So that patient knows the correct dose to take, the frequency of each medication. It’s also for the staff, if the regular nurse is not available, another nurse who’s not familiar with the patient can refer to the medication profile. It will be easier for the nurse to provide teaching for the patient when they can refer to the medication list.”

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to provide the patient/family/caregiver a copy of the current, and updated plan of care approved by the physician for two of 17 sampled patients (Patient 2 and Patient 6). This deficient practice had the potential to cause the patient and/or the family/caregiver lack of knowledge of the treatment plan, services provided by the HHA, and the patient's family and caregiver's continued participation in the care planning process to achieve the expected patient care goals. a. A review of Patient 2’s clinical record indicated a start of care date (SOC) of 7/15/23 with diagnoses that included chronic venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes, such as varicose veins, swelling, or skin color changes on the affected leg; if the condition progresses, leg ulcers can form) and non-pressure chronic ulcer of other part of right lower leg with unspecified severity. An ulcer is defined as a break in skin or mucous membrane with loss of surface tissue. Non-pressure chronic ulcers commonly occur in patients with arterial (ischemic) disease, venous disease, neuropathy, or a combination of these diseases. A review of Patient 2's “Home Health Certification and Plan of Care” for the certification period of 11/12/23 to 1/10/24, indicated the physician ordered the skilled nurse (SN) to three times a week for 2 weeks, then reassess. The SN’s responsibilities included assessment of patient, performing wound care as ordered, evaluating wounds for signs of infection at every dressing change, instructing patient on measures to relieve edema, and reporting any falls to the agency. During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 12/7/23 at 10 a.m., Patient 2 was observed awake, alert, and oriented. Patient 2 had a home health folder at his residence. There was no Plan of Care (POC) observed inside the patient’s home health folder. When Patient 2 was asked if the home health agency provided him with a care plan that specified visit frequency, his diagnoses, the goals set for him, and the interventions to achieve the goals, Patient 2 stated that all the documents he received from the agency were in the folder. During an interview with LVN 1 on 12/7/23 at 11:15 a.m., LVN 1 stated that it was the home health agency’s policy to not provide the patients with a copy of the plan of care. According to LVN 1, none of the agency’s patients was provided a copy of the plan of care. When LVN 1 was asked how the patient could learn about their plan of care such as visit frequency or schedule, goals, interventions, or wound care instruction, LVN 1 stated that the patient was informed verbally on the phone by the agency’s case manager who was assigned to the patient. During an interview with the Director of Patient Care Services (DPCS) on 12/8/23 at 1:30 p.m., the DPCS stated that the primary nurse of the patient was supposed to print the plan of care and provide it to the patient and/or the family member/caregiver. The DPCS stated that every time the plan of care got updated, the nurse would provide an updated copy of the plan of care. The DPCS stated that the agency provided each nurse with a laptop and a printer so they would be able to print necessary documents for the patients, such as the plan of care. The DPCS stated that providing patient and/or family member/caregiver with the plan of care was important so that they would understand what services to expect, when to expect them, and the goals and time frame set for the patient. A review of the agency’s policy, titled “Care Planning Process,” revised November 2021, indicated that the organization shall provide the patient and caregiver with a copy of written instructions outlining: a. Visit schedule, including frequency of visits by personnel and personnel acting on behalf of the organization. b. Patient medication schedule/instructions, including medication name, dosage and frequency, and which medications will be administered by the organization’s personnel and personnel acting on behalf of the organization. c. Education on the safe use, storage, and disposal of opioid medications. d. Any treatments to be administered by the organization’s personnel and personnel acting on behalf of the organization, including therapy services. e. Any other pertinent instruction related to the patient’s care and treatments that the organization will provide, specific to the patient’s care needs. f. Name and contact information of the organization’s clinical manager. b. A review of Patient 6's start of care (SOC) date of 4/13/2023, indicated a primary diagnosis of Type 2 diabetes mellitus with foot ulcer (Is the most common type of diabetes, is a disease that occurs when blood glucose, also called blood sugar, is too high, with some individuals developed an open sore or wound that occurs in approximately patients with diabetes and is commonly located on the bottom of the foot). A review of Patient 6's “Home Health Certification and Plan of Care” for the certification period of 12/9/23 to 2/6/24, indicated the physician ordered the skilled nurse (SN) to three times a week for 2 weeks, then reassess. The SN’s responsibilities included assessment of patient, performing wound care as ordered, evaluating wounds for signs of infection at every dressing change, instructing patient on measures to relieve edema, and reporting any falls to the agency. During a joint home visit with Licensed Vocational Nurse 2 (LVN 2) on 12/7/23 at 9:30 a.m., Patient 6 was awake, alert, and oriented, sitting comfortably on her reclining chair in her living room, denies any pain or discomfort. Patient 6 was unable to locate her home health folder at her residence. Patient 6 stated she is unable to remember if she has a copy of her Plan of Care (POC) inside her home health folder. When Patient 6 was asked if the home health agency provided her with a care plan that specified visit frequency, her diagnoses, the goals set for her, and the interventions to achieve the goals, Patient 2 stated that all the documents she received from the agency were in the folder and in Spanish language text as it is her primary language but was unable to remember. During an interview with LVN 2 on 12/7/23 at 10:15 a.m., LVN 2 stated that it was the home health agency’s policy to not provide the patients with a copy of the plan of care. LVN 2 stated that none of the agency’s patients was provided a copy of the plan of care unless they requested for it. LVN 2 stated that the patient was informed verbally via telephone by the agency’s case manager who was assigned to the patient or during skilled nurse visit. Findings: a. A review of Patient 2’s clinical record indicated a start of care date (SOC) of 7/15/2023, with diagnoses that included chronic venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes, such as varicose veins, swelling, or skin color changes on the affected leg; if the condition progresses, leg ulcers can form) and non-pressure chronic ulcer of other part of right lower leg with unspecified severity. An ulcer is defined as a break in skin or mucous membrane with loss of surface tissue. Non-pressure chronic ulcers commonly occur in patients with arterial (ischemic) disease, venous disease, neuropathy, or a combination of these diseases. A review of Patient 2's “Home Health Certification and Plan of Care” for the certification period of 11/12/2023 to 1/10/2024, indicated the physician ordered the skilled nurse (SN) to three times a week for 2 weeks, then reassess. The SN’s responsibilities included assessment of patient, performing wound care as ordered, evaluating wounds for signs of infection at every dressing change, instructing patient on measures to relieve edema, and reporting any falls to the agency. During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 12/7/23 at 10 a.m., Patient 2 was observed awake, alert, and oriented. Patient 2 had a home health folder at his residence. There was no Plan of Care (POC) observed inside the patient’s home health folder. When Patient 2 was asked if the home health agency provided him with a care plan that specified visit frequency, his diagnoses, the goals set for him, and the interventions to achieve the goals, Patient 2 stated that all the documents he received from the agency were in the folder. During an interview with LVN 1 on 12/7/23 at 11:15 a.m., LVN 1 stated that it was the home health agency’s policy to not provide the patients with a copy of the plan of care. According to LVN 1, none of the agency’s patients was provided a copy of the plan of care. When LVN 1 was asked how the patient could learn about their plan of care such as visit frequency or schedule, goals, interventions, or wound care instruction, LVN 1 stated that the patient was informed verbally on the phone by the agency’s case manager who was assigned to the patient. b. A review of Patient 6's start of care (SOC) date of 4/13/2023, indicated a primary diagnosis of Type 2 diabetes mellitus with foot ulcer (Is the most common type of diabetes, is a disease that occurs when blood glucose, also called blood sugar, is too high, with some individuals developed an open sore or wound that occurs in approximately patients with diabetes and is commonly located on the bottom of the foot). A review of Patient 6's “Home Health Certification and Plan of Care” for the certification period of 12/9/23 to 2/6/24, indicated the physician ordered the skilled nurse (SN) to three times a week for 2 weeks, then reassess. The SN’s responsibilities included assessment of patient, performing wound care as ordered, evaluating wounds for signs of infection at every dressing change, instructing patient on measures to relieve edema, and reporting any falls to the agency. During a joint home visit with Licensed Vocational Nurse 2 (LVN 2) on 12/7/23 at 9:30 a.m., Patient 6 was awake, alert, and oriented, sitting comfortably on her reclining chair in her living room, denies any pain or discomfort. Patient 6 was unable to locate her home health folder at her residence. Patient 6 stated she is unable to remember if she has a copy of her Plan of Care (POC) inside her home health folder. When Patient 6 was asked if the home health agency provided her with a care plan that specified visit frequency, her diagnoses, the goals set for her, and the interventions to achieve the goals, Patient 2 stated that all the documents she received from the agency were in the folder and in Spanish language text as it is her primary language but was unable to remember. During an interview with LVN 2 on 12/7/23 at 10:15 a.m., LVN 2 stated that it was the home health agency’s policy to not provide the patients with a copy of the plan of care. LVN 2 stated that none of the agency’s patients was provided a copy of the plan of care unless they requested for it. LVN 2 stated that the patient was informed verbally via telephone by the agency’s case manager who was assigned to the patient or during skilled nurse visit. During an interview with the Director of Patient Care Services (DPCS) on 12/8/23 at 1:30 p.m., the DPCS stated that the primary nurse of the patient was supposed to print the plan of care and provide it to the patient and/or the family member/caregiver. The DPCS stated that every time the plan of care got updated, the nurse would provide an updated copy of the plan of care. The DPCS stated that the agency provided each nurse with a laptop and a printer so they would be able to print necessary documents for the patients, such as the plan of care. The DPCS stated that providing patient and/or family member/caregiver with the plan of care was important so that they would understand what services to expect, when to expect them, and the goals and time frame set for the patient. A review of the agency’s policy, titled “Care Planning Process,” revised November 2021, indicated that the organization shall provide the patient and caregiver with a copy of written instructions outlining: a. Visit schedule, including frequency of visits by personnel and personnel acting on behalf of the organization. b. Patient medication schedule/instructions, including medication name, dosage and frequency, and which medications will be administered by the organization’s personnel and personnel acting on behalf of the organization. c. Education on the safe use, storage, and disposal of opioid medications. d. Any treatments to be administered by the organization’s personnel and personnel acting on behalf of the organization, including therapy services. e. Any other pertinent instruction related to the patient’s care and treatments that the organization will provide, specific to the patient’s care needs. f. Name and contact information of the organization’s clinical manager.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to provide to written information regarding the patient’s medication regimen to two of 17 sampled patients (Patient 2 and Patient 6). This deficient practice had the potential to put the patient at risk for medication errors, and the HHA staff unable to monitor for adverse reactions or medication’s efficacy. a. A review of Patient 2’s clinical record indicated a start of care date (SOC) of 7/15/23 with diagnoses that included chronic venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes, such as varicose veins, swelling, or skin color changes on the affected leg; if the condition progresses, leg ulcers can form) and non-pressure chronic ulcer of other part of right lower leg with unspecified severity. An ulcer is defined as a break in skin or mucous membrane with loss of surface tissue. Non-pressure chronic ulcers commonly occur in patients with arterial (ischemic) disease, venous disease, neuropathy, or a combination of these diseases. A review of Patient 2’s undated “Medication Profile,” indicated that Patient 2 was on the following medications: - Normal saline solution as a cleansing agent for wounds 3 times a week. - Triamcinolone Acetate 0.1% to apply on wound 3 times a week. - Aquacell AG to apply on wound 3 times a week. - Metformin HCl 500 mg, 2 tablets by mouth, twice a day with meals. - Insulin Regular Human Injection 100 unit/ml, with sliding scale. - Multivitamin, 1 packet by mouth daily. - Acetaminophen 500 mg, 2 caplets every 4-6 hours as needed for pain. - Aspir-Low Oral 81 mg, 1 tablet by mouth daily. - Hydrochlorothiazide Oral 25 mg, 1 tablet by mouth daily. - Simvastatin Oral 20 mg, 1 tablet by mouth every evening for high cholesterol. - Lisinopril Oral 20 mg, 1 tablet by mouth daily. - Humulin N subcutaneous 100 unit/ml, inject 72 units subcutaneously in the morning and 24 units in the evening for diabetes. During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 12/7/23 at 10 a.m., Patient 2 was observed awake, alert, and oriented. Patient 2 had a home health folder at his residence. There was no copy of medication profile in the folder. There was a piece of writeable plastic board with a magnetic field on the back. There was no information or writing on the plastic board. During an interview with LVN 1 on 12/7/23 at 11:10 a.m., LVN 1 stated that it was the home health agency’s policy to not provide the patients with a copy of the medication profile. LVN 1 stated, “If the patient wants, he can write down the medications he’s taking on this board, and then he can stick it on the refrigerator as a reminder. If any of his medications is changed, he can erase it and write the new one. We don’t provide them with a medication list.” During an interview with the Director of Patient Care Services (DPCS) on 12/8/23 at 1:30 p.m., the DPCS stated that the primary nurse of the patient was responsible to provide the medication profile to the patient and/or the family member/caregiver. The DPCS stated that the agency provided each nurse with a laptop and a printer so they would be able to print necessary documents for the patients, such as the plan of care and medication profile. The DPCS further stated the primary nurse was also responsible to write the patient’s medications on the plastic board, so that the patient could put it on their refrigerator as a reminder. When asked about the purpose of providing a copy of medication profile to patient, DPCS stated, “So that patient knows the correct dose to take, the frequency of each medication. It’s also for the staff, if the regular nurse is not available, another nurse who’s not familiar with the patient can refer to the medication profile. It will be easier for the nurse to provide teaching for the patient when they can refer to the medication list.” A review of the agency’s policy, titled “Care Planning Process,” revised November 2021, indicated that the organization shall provide the patient and caregiver with a copy of written instructions outlining: b. Patient medication schedule/instructions, including medication name, dosage and frequency, and which medications will be administered by the organization’s personnel and personnel acting on behalf of the organization. c Findings: a. A review of Patient 2’s clinical record indicated a start of care date (SOC) of 7/15/2023 with diagnoses that included chronic venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes, such as varicose veins, swelling, or skin color changes on the affected leg; if the condition progresses, leg ulcers can form) and non-pressure chronic ulcer of other part of right lower leg with unspecified severity. An ulcer is defined as a break in skin or mucous membrane with loss of surface tissue. Non-pressure chronic ulcers commonly occur in patients with arterial (ischemic) disease, venous disease, neuropathy, or a combination of these diseases. A review of Patient 2’s undated “Medication Profile,” indicated that Patient 2 was on the following medications: - Normal saline solution as a cleansing agent for wounds 3 times a week. - Triamcinolone Acetate 0.1% to apply on wound 3 times a week. - Aquacell AG to apply on wound 3 times a week. - Metformin HCl 500 mg, 2 tablets by mouth, twice a day with meals. - Insulin Regular Human Injection 100 unit/ml, with sliding scale. - Multivitamin, 1 packet by mouth daily. - Acetaminophen 500 mg, 2 caplets every 4-6 hours as needed for pain. - Aspir-Low Oral 81 mg, 1 tablet by mouth daily. - Hydrochlorothiazide Oral 25 mg, 1 tablet by mouth daily. - Simvastatin Oral 20 mg, 1 tablet by mouth every evening for high cholesterol. - Lisinopril Oral 20 mg, 1 tablet by mouth daily. Humulin N subcutaneous 100 unit/ml, inject 72 units subcutaneously in the morning and 24 units in the evening for diabetes. During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 12/7/2023 at 10 a.m., Patient 2 was observed awake, alert, and oriented. Patient 2 had a home health folder at his residence. There was no copy of medication profile in the folder. There was a piece of writeable plastic board with a magnetic field on the back. There was no information or writing on the plastic board. During an interview with LVN 1 on 12/7/23 at 11:10 a.m., LVN 1 stated that it was the home health agency’s policy to not provide the patients with a copy of the medication profile. LVN 1 stated, “If the patient wants, he can write down the medications he’s taking on this board, and then he can stick it on the refrigerator as a reminder. If any of his medications is changed, he can erase it and write the new one. We don’t provide them with a medication list.” b. A review of Patient 6's start of care (SOC) date of 4/13/2023, indicated a primary diagnosis of Type 2 diabetes mellitus with foot ulcer (Is the most common type of diabetes, is a disease that occurs when blood glucose, also called blood sugar, is too high, with some individuals developed an open sore or wound that occurs in approximately patients with diabetes and is commonly located on the bottom of the foot). A review of Patient 6's “Home Health Certification and Plan of Care” for the certification period of 12/9/23 to 2/6/24, indicated the physician ordered the skilled nurse (SN) to three times a week for 2 weeks, then reassess. The SN’s responsibilities included assessment of patient, performing wound care as ordered, evaluating wounds for signs of infection at every dressing change, instructing patient on measures to relieve edema, and reporting any falls to the agency. During a joint home visit with Licensed Vocational Nurse 2 (LVN 2) on 12/7/23 at 9:30 a.m., Patient 6 was observed awake, alert, and oriented. Patient 6 was unable to locate a home health folder at her residence and unable to locate a copy of her medication profile. There was a piece of writeable plastic board with a magnetic field on the back. There was no information or writing on the plastic board. Patient 6 stated she does not remember if she does have a copy or list of her medication profile. During an interview with LVN 2 on 12/7/23 at 10:15 a.m., LVN 2 stated that it was the home health agency’s policy to not provide the patients with a copy of the medication profile. LVN 2 stated that if the patient wants, she can write down the medications she is currently taking on the white board provided by the agency and then she can stick it on the refrigerator as a reminder. LVN 2 stated that if any of her medications is changed, she can remove it and write the new one. During an interview with the Director of Patient Care Services (DPCS) on 12/8/23 at 1:30 p.m., the DPCS stated that the primary nurse of the patient was responsible to provide the medication profile to the patient and/or the family member/caregiver. The DPCS stated that the agency provided each nurse with a laptop and a printer so they would be able to print necessary documents for the patients, such as the plan of care and medication profile. The DPCS further stated the primary nurse was also responsible to write the patient’s medications on the plastic board, so that the patient could put it on their refrigerator as a reminder. When asked about the purpose of providing a copy of medication profile to patient, DPCS stated, “So that patient knows the correct dose to take, the frequency of each medication. It’s also for the staff, if the regular nurse is not available, another nurse who’s not familiar with the patient can refer to the medication profile. It will be easier for the nurse to provide teaching for the patient when they can refer to the medication list.” A review of the agency’s policy, titled “Care Planning Process,” revised November 2021, indicated that the organization shall provide the patient and caregiver with a copy of written instructions outlining: b. Patient medication schedule/instructions, including medication name, dosage and frequency, and which medications will be administered by the organization’s personnel and personnel acting on behalf of the organization.

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, interview, and record review, the home health agency (HHA) staff failed to sanitize hands immediately after gloves removal while providing care for one of 17 sampled patients (Patient 2). This deficient practice had the potential to expose patient and/or caregiver to infection caused by pathogens (bacteria, virus, or other organisms than can cause disease). Findings: A review of Patient 2’s clinical record indicated a start of care date (SOC) of 7/15/2023 with diagnoses that included chronic venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes, such as varicose veins, swelling, or skin color changes on the affected leg; if the condition progresses, leg ulcers can form) and non-pressure chronic ulcer of other part of right lower leg with unspecified severity. An ulcer is defined as a break in skin or mucous membrane with loss of surface tissue. Non-pressure chronic ulcers commonly occur in patients with arterial (ischemic) disease, venous disease, neuropathy, or a combination of these diseases. A review of Patient 2's “Home Health Certification and Plan of Care” for the certification period of 11/12/2023 to 1/10/2024, indicated the physician ordered the skilled nurse (SN) to three times a week for 2 weeks, then reassess. The SN’s responsibilities included assessment of patient, performing wound care as ordered, evaluating wounds for signs of infection at every dressing change, instructing patient on measures to relieve edema, and reporting any falls to the agency. During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 12/7/2023 at 10 a.m., LVN 1 was observed performing wound care for Patient 2. On 12/7/23, at 10:40 a.m., observed LVN 1 cleanse Patient 2’s wound on the right lateral foot with wound cleanser and patted it dry with gauze. It was observed some drainage from the wound. LVN 1 applied Aquacel AG (a type of antimicrobial wound dressing) on the wound bed. LVN 1 also cleansed the wound on patient’s right shin with the wound cleanser and patted it dry with a gauze. Triamcinolone 0.1% cream was applied on the right shin, followed by Mepilex transfer. LVN 1 wrapped Patient ‘s right lower extremity with Coflex TLC Calamine Lite compression dressing from the base of the toes to the top of the calf. At 11 a.m., LVN 1 was observed removing her gloves after completing the wound care for Patient 2. LVN 1 put the gloves inside the trash bag, along with the patient’s old dressings. LVN 1 proceeded to sanitize her stethoscope and scissors with alcohol wipes, collecting her belongings, and asked the patient’s daughter to bring all the medications for review. LVN 1 did not sanitize hands immediately after removing the soiled gloves. During an interview with LVN 1 on 12/7/2023 at 11:20 a.m., LVN 1 stated she did not realize that she had not sanitized her hands after removing the gloves. LVN 1 stated that sanitizing hands after gloves removal was important to prevent the spread of infection, as the gloves might have caught germs during the wound care. During an interview with Director of Patient Care Services (DPCS) on 12/8/23 at 1:50 p.m., the DPCS stated that the agency was following the recommendations of Centers for Disease Control and Prevention (CDC) for hand hygiene. A review of the agency-provided document, titled “CDC vs WHO Hand Hygiene Guideline Comparison,” copyrighted 2008, indicated that CDC recommended sanitizing hands with hand antisepsis after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled. The CDC guideline also indicated hand antisepsis use after removing gloves.