Every finding on record at Gadsden Home Care Services, LLC

A recertification survey was conducted on 8/26/25 to 8/27/25 at Alabama HomeCare of Gadsden. The agency was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted on 8/26/25 to 8/27/25 at Alabama HomeCare of Gadsden. Standard level deficiencies were cited and will require an acceptable Plan of Correction.

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 observations, agency policies and procedures, medical record (MR) review, and staff interview, it was determined the agency failed to ensure staff followed the physician's order for wound care. This affected one of three home visits (HV), including HV # 1, with wound care ordered and had the potential to negatively affect all patients with wounds serviced by the agency. Findings include: Agency Policy: Plan of Care Policy Number: 2.1.007 Revision Date: 4/1/25 Policy: Every patient has an individualized Plan of Care (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: ...b. Types, frequency, and duration of services required... f. Medications and treatments... i. Patient specific interventions... n. All patient care orders... 6. Physician/authorized practitioner's orders are obtained to update the POC. 7. Medications, treatments, and interventions are provided by authorized agency staff as ordered by the physician or authorized prescriber. Agency Policy: Wound Assessment, Documentation, and Photography Policy Number: 2.2.001 Revision Date: 9/1/24 Procedure: ...2. Perform wound care according to LHC adopted clinical skills guidelines and physician orders. HV # 1 was admitted to the agency on 6/6/25 with diagnoses including Encounter for Surgical Aftercare Following Surgery in the Skin Subcutaneous and Type Two Diabetes Mellitus with Diabetic Polyneuropathy. A HV was conducted on 8/26/25 at 1:38 PM with Employee Identifier (EI ) # 2, Licensed Practical Nurse, to observe wound care provided. Review of Home Health Certification and Plan of Care dated 8/5/25 to 10/3/25 revealed an order for Skilled Nurse (SN) to visit two times a week for nine weeks. Review of the physician's order dated 8/22/25 revealed SN to perform/instruct patient/caregiver procedure of wound care to wound # 2, right plantar foot, every SN visit and every other day by PT/CG on days Home Health does not visit. Cleanse with Vashe, Pat dry with clean gauze. Apply moisturizing lotion of patients choice to perimeter (peri) wound. Apply Prisma (wound dressing) moistened with normal saline. Apply Urgotul (wound dressing). Cover with gauze. Wrap right foot with Kerlix then Ace wrap using clean technique. EI # 2 failed to apply moisturizing lotion to peri wound, used Aquacel AG (wound dressing) and not Prisma, as ordered, and failed to wrap the right foot with an Ace wrap. EI # 2 failed to follow the physician's order for wound care. An interview was conducted on 8/27/25 at 3:28 PM with EI # 1, Interim Executive Director, who confirmed staff failed to follow the physician's order for wound care.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations, review of agency policy and procedure, and staff interview, it was determined the agency failed to ensure staff performed hand hygiene per agency policy. This did affect one of five home visits (HV) including HV # 1, and had the potential to 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 and to provide practice guidelines. Policy: Staff are required to perform hand hygiene prior to, at specific time points during, and following patient contact... Procedure: 1. Staff performs hand hygiene by handwashing with soap and water or using an alcohol based hand sanitizer: a. before direct contact with patients. b. before performing an aseptic task (ergo,...wound care). c. after contact with...wound dressings... 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...) in the immediate vicinity of the patient. f. before and after removal of personal protective equipment... 8. Other Aspects of Hand Hygiene: ...Change gloves during patient care if moving from a contaminated body site to a clean body site. HV # 1 was admitted to the agency on 6/6/25 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Skin Subcutaneously and Type Two Diabetes Mellitus with Diabetic Polyneuropathy. A HV was conducted on 8/26/25 at 1:38 PM with Employee Identifier (EI) # 2, Licensed Practical Nurse, to observe wound care provided. During the HV the following was observed: 1. EI # 2 failed to perform hand hygiene, after removing gloves, four times. 2. EI # 2 failed to perform hand hygiene prior to donning gloves three times, including prior to wound care. 3. During wound care, EI # 2 cleansed the wound with Vashe, patted dry with gauze, and reached into the clean supplies gathered at the patient's feet to obtain a package of q-tips to use the wrapper to measure the wound. EI # 2, while wearing the same gloves, picked up the EMR to take a picture of the wound, obtained a pen from his/her pocket to write wound measurements on the wrapper, took a second picture of the wound, cut the Aquacel AG with scissors to fit into the wound, placed the used scissors on the patients blanket, placed the Aquacel AG into the wound, opened the Urgotul and used the same scissors to cut it to fit into the wound, all while wearing the same pair of gloves. EI # 2 appeared to have difficulty removing the back of the Urgotul and removed the dirty pair of gloves and without performing hand hygiene or donning gloves, inserted the Urgotul into the wound with his/her bare hands, covered the wound with gauze and wrapped the foot with kerlix and secured it with tape. The pen was obtained from his/her pocket and the tape was dated with the change of dressing. An interview was conducted on 8/27/25 at 3:28 PM with EI # 1, Interim Executive Director, who confirmed staff failed to perform hand hygiene per the agency policy.

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 review of medical records (MR), policy and procedure, and staff interviews, it was determined the agency failed to ensure Visit Notes were completed within 24 hours according to policy. This affected MR # 2, MR # 3, MR # 4, MR # 7, Home Visit (HV) # 3, and MR # 8, in 6 of 13 MRs reviewed, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Date Revised: 9/1/24 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Policy: ...Identifying patient needs through assessment and communication with other health care providers. Procedure: ...5. d. Completed visit notes will be submitted to the agency via synchronization within 24 hours of visit for point of care agencies. e. Care planning information is available to all staff and contracted professionals providing care for the patient... 1. MR # 2 was admitted to the agency on 7/15/25 with diagnoses including Unspecified Fracture of Right Lower Leg, Subsequent for Closed Fracture with Routine Healing and Pain in Right Ankle and Joints of Right Foot. Review of the MR revealed the Visit Note Report (VNR) dated 7/29/25 was not signed by the Registered Nurse (RN) within 24 hours per the agency's policy. An interview was conducted on 8/27/25 at 3:10 PM with Employee Identifier (EI) # 1, Interim Executive Director, who confirmed staff failed to sign the VNR within 24 hours per the agency's policy. 2. MR # 3 was admitted to the agency on 12/5/24 with a diagnosis of Local Infection of Skin and Subcutaneous Tissue, unspecified. Review of the MR revealed the VNR dated 8/7/25 was not signed by the Licensed Practical Nurse (LPN) within 24 hours per the agency's policy. An interview was conducted on 8/27/25 at 3:03 PM with EI # 1, who confirmed staff failed to sign the VNR within 24 hours per the agency's policy. 3. MR # 4 was admitted to the agency on 7/22/25 with diagnosis of Encounter for Nonsurgical After Care Following Surgery on the Circulatory System. Review of the MR revealed VNRs dated 8/1/25, 8/6/25, 8/8/25, and 8/15/25 were not signed by the Physical Therapist (PT) within 24 hours per the agency's policy. An interview was conducted on 8/27/25 at 3:05 PM with EI # 1, who confirmed staff failed to sign the VNRs within 24 hours per the agency's policy. 4. MR # 7 was admitted to the agency on 12/20/25 with a diagnosis of Chronic Obstructive Pulmonary Disease. Review of the MR revealed the RN Oasis Admission dated 12/20/25 was not signed by the RN within 24 hours per the agency's policy. Further review of the MR revealed the RN Discharge dated 1/9/25 was not signed by the RN within 24 hours per the agency's policy. An interview was conducted on 8/27/25 at 3:18 PM with EI # 1, who confirmed staff failed to sign the Oasis Admission and RN Discharge within 24 hours per the agency's policy. 5. HV # 3 was admitted to the agency on 7/11/25 with a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. Review of the MR revealed the RN Oasis Admission dated 7/11/25 was not signed by the RN within 24 hours per the agency's policy. Further review of the MR revealed the VNR dated 7/16/25 was not signed by the LPN within 24 hours per the agency's policy. An interview was conducted on 8/27/25 at 3:15 PM with EI # 1, who confirmed staff failed to sign the Oasis Admission and VNR within 24 hours per the agency's policy. 6. MR # 8 was admitted to the agency on 8/19/24 with diagnoses including Obstructive and Reflux Uropathy, Unspecified and Type 2 Diabetes Mellitus with Hyperglycemia. Review of the MR revealed the VNR dated 9/5/24 was not signed by the PT within 24 hours per the agency's policy.. An interview was conducted on 8/27/25 at 3:16 PM with EI # 1, who confirmed staff failed to sign the VNR within 24 hours per the agency's policy.

A recertification survey was conducted on 03/16/2021 to 03/18/2021 for Gadsden Regional Home Health. The agency was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted on 3/16/21 to 3/18/21. Standard level deficiencies were 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 review of medical records (MR), policy and procedure, observations, and interviews, it was determined the agency failed to ensure staff reconciled medications for 4 of 7 Home Visits (HV) conducted. This affected HV # 6, HV # 1, HV # 7, and HV # 5, and had the potential to affect all patients served by the agency. Findings include: Policy: Monitoring Medications Policy Number: 10.008 Date Revised: 5/1/19 Purpose: To provide a 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... Procedure: ...b. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, creams and topical ointments... to identify issues... 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... 1. HV # 6 was admitted to the agency on 2/18/21 with diagnoses including Unspecified Fracture of Lower End of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, and Type 2 Diabetes Mellitus Without Complications. A HV was conducted to observe Employee Identifier (EI) # 3, RN (Registered Nurse) perform a Skilled Nursing Visit including wound care. EI # 2, Patient Care Manager, was also present on the visit. During the HV, the patient's medications in the home were compared to the Client Medication Report (CMR) printed on 3/16/21, and provided to the surveyor. The following discrepancies were observed: a. Methocarbamol 750 mg (milligrams), 2 tablets, three times daily was on the CMR. The patient's bottle in the home read 1 every 4 hours. b. Omeprazole 40 mg, 1 capsule, 2 times daily was on the CMR. The patient's bottle in the home read 20 mg, 2 times daily. c. Oxycodone 20 mg, 1 tablet, every 4 hours was on the CMR. The bottle in the home read 15 mg, 1 every 6 hours. d. Nitrostat 0.4 mg, 1 tablet sublingual every five minutes times three, prn (as needed) for chest pain, was in the home, and not listed on the CMR. Date filled 12/21/2020. During the HV, the medication discrepancies were confirmed by EI # 2. 2. HV # 1 was admitted to the home health agency on 02/08/2021 with diagnoses including Iron Deficiency Anemia and Essential (Primary) Hypertension. The HV on 3/16/21 was conducted to observe the Physical Therapy Assistant (LPTA) provide and instruct the patient on increasing physical activities. EI # 2, Patient Care Manager (PCM) was also present on the visit. During the home visit, the patient medications were compared to the CMR printed on 3/16/21 and provided to the surveyor. The following discrepancies were observed. a. Cetirizine Hydrochloride (HCL) 10 milligrams (mg) as needed for sinus issues. The above medication was on the CMR and was not found in the home. b. Tylenol 2 tablets as needed was on the CMR. Patient states she/ he does not take this medication at this time. c. TUMS and Complete Vitamins were in the home and were not on the CMR. Caregiver stated, patient takes it when she/ he needs the medicines. d. Ferrous Sulfate 325 mg (65 mg Iron) three times a day was found in the home. The CMR had Ferrous Sulfate 325 mg two times a day listed. Patient states she/he takes the medicine three times a day. An interview was conducted on 03/18/2021 at 8:30 AM with EI # 2 who confirmed the above mentioned findings. 3. HV # 7 was admitted to the home health agency on 03/10/2021 with diagnoses including Pneumonia, Unspecified Organism, Acute Respiratory Failure with Hypoxia, and Type 2 Diabetes Mellitus Without Complications. A HV was conducted to observe the Home Health Aide (HHA) perform Activities of Daily Living (ADL) Services for the patient. EI # 1, Executive Director, was also present during the visit. During the HV, the patient's medications in the home were compared to the CMR printed on 03/16/21, and provided to the surveyor. The following discrepancies were observed: a. Acetaminophen 500 mg over the counter (OTC) bottle was observed at the patient's bedside. The patient stated he/she takes the acetaminophen as needed. It was not listed on the CMR. b. Nateglinide 120 mg, 1 tablet two times daily before meals, with fill date of 12/07/20 on the bottle label, was observed in the home. The patient's caregiver (CG) stated over electronic smart device he/she takes daily. It was not listed on the CMR. c. Amlodipine Besylate 10 mg, 1 tablet daily, with fill date of 12/15/20 on bottle label, was observed in the home. The patient's CG stated over electronic smart device he/she takes daily. It was not listed on the CMR. d. Atorvastatin 10 mg, 1 tablet daily, with fill date of 12/15/20 on bottle label, was observed in the home. The patient's CG stated over electronic smart device he/she takes daily. It was not listed on the CMR. During the HV, the medication discrepancies were confirmed by EI # 1. 4. HV # 5 was admitted to the agency on 10/27/20 with diagnoses including Acute Cholecystitis with Chronic Cholecystitis, Encounter for Attention to Colostomy, and Encounter for Attention to Other Artificial Openings of Digestive Tract. A HV was conducted on 03/16/21 to observe EI # 7, RN, perform a Skilled Nursing Visit including wound care. During the HV, the patient's medications in the home were compared to the CMR printed on 03/16/21, and provided to the surveyor. The following discrepancy was observed: a. Zolpidem 10 mg tablet, 1 tablet at bedtime as needed, was listed on the CMR. The bottle observed in the home was 5 mg strength, with a fill date of 01/09/21 on the bottle label. During the HV, the medication discrepancies were confirmed by EI # 7.

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), policy and procedure, observations, and interviews, it was determined the agency failed to ensure staff followed physician orders for obtaining weights and performing wound care. This affected 1 of 12 open records reviewed, which included Home Visit (HV) # 6, and had the potential to affect all persons served by the agency. Findings include: Policy: Plan of Care (POC) Policy Number: 2.1.007 Date Revised: 01/01/20 Purpose: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To assure that physician's orders are followed. Policy: Each patient has an individualized POC developed in consultation with the patient, physician, and staff... to address patient problems, needs and goals... Procedure: 1. A POC is developed for all patients... 2. The POC includes: ...i. Patient specific interventions and education: measurable outcomes and goals... n. All patient care orders. 1. HV # 6 was admitted to the agency on 2/18/21 with diagnoses including Unspecified Fracture of Lower End of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Type 2 Diabetes Mellitus Without Complications, and Hypertensive Heart Disease with Heart Failure. Review of the Home Health Certification and Plan of Care dated 2/18/21 to 4/18/21 included the following orders for the Skilled Nurse (SN): Skilled nurse to obtain weight every SN visit and notify RN/MD (Registered Nurse/ Medical Doctor) of weight gain or loss of 5 lbs (pounds) within 1 week, instruct patient/ caregiver on importance of obtaining weight and keeping a weight log. Review of the MR revealed a SN Visit dated 2/21/21. There was no documentation the SN weighed the patient. Review of the SN Visit dated 2/23/21 revealed there was no weight documented. Further review of the MR revealed a physician order dated 2/23/21, "SN to obtain measurements of calf for assessment of fluid overload until pt (patient) able to weigh at SN Visits." There was no measurement of calf documented. Review of the SN Visit dated 2/25/21 revealed there was no weight or calf measurement documented. Review of the SN Visit dated 3/2/21 revealed there was no weight or calf measurement documented. A Home Visit was conducted on 3/16/21 to observe care provided by Employee Identifier (EI) # 3, RN. EI # 2, RN was also present during the HV. EI # 3 failed to weigh the patient as ordered, although a weight was documented in the MR on SN Visit Note dated the same date, 3/16/21. Prior to the HV, the surveyor received current orders, which included a wound care order dated 2/23/21, "Wound care to wound #6 coccyx stage IV: Cleanse wound with wound cleanser, pat dry with gauze. Pack with Drawtex. Cover with ABD (abdominal) pad. Secure with tape." During the HV the surveyor observed EI # 3 perform wound care to the stage IV coccyx wound. EI # 3 removed the packing from the wound, then packed the wound with Drawtex. EI # 3 failed to cleanse the wound with wound cleanser per order. Review of the SN Visit Noted dated 3/16/21 revealed the nurse documented the following wound care to wound # 6, "Cleansed wound with wound cleanser..." The SN documented wound care that she/he was not observed to perform. An interview was conducted on 3/18/21 at 8:50 AM with EI # 1, Executive Director, and EI # 2, who confirmed weights were not obtained as ordered, and wound care was not performed as ordered.

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 medical records (MR), agency policy, and staff interview, it was determined staff failed to notify the physician of changes in the patient's condition which included weight gain and increase in wound measurements. This affected 1 of 12 records reviewed including HV (Home Visit) # 6. This had the potential to negatively affect all patients served by the agency. Findings include: Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Date Revised: 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: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient's physician: a. When changes occur in the patient's condition or response to treatment... 1. HV # 6 was admitted to the agency on 2/18/21 with diagnoses including Unspecified Fracture of Lower End of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Type 2 Diabetes Mellitus Without Complications, and Hypertensive Heart Disease with Heart Failure. Review of the Home Health Certification and Plan of Care, dated 2/18/21 to 4/18/21, revealed the following orders for the Skilled Nurse (SN): SN to obtain weight every SN visit and notify RN/MD (Registered Nurse/ Medical Doctor) of weight gain or loss of 5 lbs (pounds) within 1 week. Instruct patient/caregiver on importance of obtaining weight and keeping a weight log. Further review of the MR revealed the following Physician's Order dated 2/23/21: Increase SN visits... due to caregiver inability to provide wound care. Wound care to wound # 6 coccyx stage IV: ...perform wound care every other day... Review of the SN Visit Note dated 2/27/21 revealed the SN documented the wound size of the coccyx wound was 3 cm (centimeters) length x 3 cm width x 5 cm in depth. An increase from the previous measurement on 2/23/21 of 2 cm x 1 cm x 5 cm. There was no documentation the SN notified the MD of the increase in wound size of 1 cm in length, and 2 cm in width. Review of the SN Visit Note dated 3/5/21 revealed the SN documented an increase in wound undermining at the 12 - 3 o'clock position from 8 cm on 2/27/21 to 12 cm, and at the 3 - 6 o'clock position from 5 cm on 2/27/21 to 12 cm. An increase of 4 cm and 7 cm, respectively. There was no documentation the SN notified the MD of the increase in wound undermining. Review of the SN Visit Note dated 3/5/21 revealed the patient weighed 204 lbs. Review of the SN Visit Note dated 3/9/21 revealed the patient weighed 210 lbs, an increase of 6 lbs in 4 days. There was no documentation the SN notified the MD of the increase in weight. During an interview on 3/18/21 at 8:50 AM with Employee Identifier # 1, Executive Director, it was confirmed the SN failed to notify the MD of changes in the patient condition.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), policy and procedures, and interviews, it was determined the agency failed to ensure the needs of the patient were met and were included in the Plan of Care. This affected 1 of 12 current records reviewed, including MR # 3, and had the potential to affect all patients served by the agency. Findings include: Policy: Plan of Care (POC) Revised Date: 01/01/21 Purpose: To ensure an appropriate plan of care is developed and revised in a timely manner for each patient. Policy: Each patient has an individualized Plan of Care...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: b. Types, frequency and duration of services required d. Functional limitations... i. Patient specific interventions... 6. Physician's orders are obtained to update the POC and may include problems and goals. 1. MR # 3 was admitted to the agency on 2/11/21 with diagnoses including Unspecified Displaced Fracture of Surgical Neck of Right Humerus, Subsequent Encounter for Fracture With Routine Healing and Encounter for Attention to Colostomy. Review of the medical record revealed MR # 3 sustained a fall resulting in a fracture of the right humerus. MR # 3's right arm was immobilized resulting in an inability to perform personal care without maximum assistance. The patient lived with the son, who was the primary caregiver and worked outside the home. Further review of the medical record revealed MR # 3 had a colostomy and had difficulty performing colostomy care due to immobilization of the right arm. It was documented in the record the son was not willing/able to provide colostomy care. Review of the skilled nurse visit note dated 2/22/21 revealed the patient "verbalized concerns regarding assist with ostomy care. SN (skilled nurse) spoke with other disciplines...OT (Occupational Therapy) and (name of aide) regarding assist." There was no documentation what specific assistance the disciplines would provide. Further review of the SN visit note dated 2/22/21 revealed MR # 3 had developed a stage 2 pressure ulcer to the coccyx. The SN contacted the supervisor and discussed increased SN visits to assist with ostomy care and development of skin breakdown on coccyx. Review of the POC revealed no increase in SNV to assist this immobilized patient with colostomy care and daily dressing changes to the coccyx area. An interview conducted on 3/18/21 at 8:35 AM with Employee Identifier # 2, Patient Care Manager, confirmed the patient's need for assistance was discussed and the POC was not updated.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations, policy and procedure, content of agency training provided to staff, and interview, it was determined the agency failed to ensure: 1. The staff followed facility approved procedures for hand hygiene, glove changes, and patient care equipment. 2. Staff adhered to mandatory protocol per company training for home care bag use. 3. Staff adhered to company training for personal hygiene including bathing and perineal care. This affected 1 of 1 Home Visits (HV) with Home Health Aide (HHA), which included HV # 7, and had the potential to affect all patients served by the agency. Findings include: Policy: Standard Precautions Policy Number: 8.005 Revised Date: 03/01/09 Purpose: To prevent the 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 diagnoses 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) guidelines for Standard Precautions, which applies to 1) blood; 2) all body fluids, secretions, and excretions except sweat..... Procedure: ...4. Standard Precautions include: a. Hand Hygiene ..ii. Perform hand hygiene immediately after gloves are removed, ...and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. b. Gloves ..iii. Change gloves between tasks and procedures on the same patient and after contact with material that may contain a high concentration of microorganisms. iv. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and perform hand hygiene immediately after completing patient care activities to avoid transfer of microorganisms to other patients or environments. ..d. Patient Care Equipment ..ii. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned appropriately. LHC Group E Train: Home Care Bag Protocol Job Aid Revised: 07/20/20 Field staff can use this job aid as a guide to home care bag use. The home care bag allows you to safely transport basic equipment and supplies necessary to perform a standard home visit. Use the home car bag to prevent the potential spread of infection among staff, patients, and the community...Adherence to this protocol is mandatory. Home Care Bag Protocol: ..7. After entering the patient's home, place the bag on a clean, dry surface and a barrier placed between the bag and the surface.... ...14. Never return soiled equipment to the bag. Items such as stethoscopes shall be cleaned per policy/procedure and allowed to dry prior to returning them to the bag. Elsevier Clinical E Learning Lesson: Personal Hygiene: Bathing and Perineal Care Copyright: 2017 Procedure: Giving Female Perineal Care Pre-procedure: ..2. Collect the following: a. At least four washcloths. ..23. Clean the perineum. Change washcloths as needed. ..29 Clean and rinse the rectal area. ..c. Rinse the rectal area using a clean washcloth. Post Procedure: ..45. Remove and discard the gloves. Practice hand hygiene. HV # 7 was admitted to the home health agency on 03/10/2021 with diagnoses including Pneumonia, Unspecified Organism, Acute Respiratory Failure with Hypoxia, and Type 2 Diabetes Mellitus Without Complications. A HV was conducted to observe Employee Identifier (EI) # 4, HHA perform Activities of Daily Living (ADL) Services for the patient, including a bed bath. EI # 1, Executive Director (ED) was also present during the visit. During the visit, the surveyor observed EI # 4 place the home care bag on top of a chair with a barrier underneath. After taking the vital signs of the patient, EI # 4 placed the equipment used to take the vital signs on top of the home care bag immediately after use. They were not placed on a separate barrier. EI #4 then proceeded with the bed bath and used one washcloth to wash and rinse the face, chest, upper, and lower extremities of the patient. EI # 4 then changed out the used water in the basin and replaced it with fresh water. EI # 4 continued with the bathing process utilizing the same washcloth to wash and rinse the perineal area, then proceeded to wash and rinse the patient's back, then buttocks and rectal area. Only one washcloth was utilized for the entire bath. EI # 4 did not follow the agency training lesson for personal hygiene to use at least four washcloths. When the bed bath was completed, EI # 4 gathered used linens and clothing still wearing the same gloves utilized for bathing the patient, and without changing gloves, got a cleansing wipe from the outside pocket of the home care bag and proceeded to cleanse the vital sign equipment that had been placed on top of the home care bag prior to the bath, and placed the equipment next to the bag on top of the barrier. EI # 4 did not cleanse the top of the home care bag after removing the used equipment. In an interview conducted on 03/18/21 at 8:45 AM, EI # 1 confirmed the observations, and that EI # 4 did not follow the agency policy for standard precautions, home care bag protocol, or training for personal hygiene.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on review of medical records (MR), policy and procedures, and interviews, it was determined the agency failed to ensure the personal care needs of a colostomy patient were met and included in the Home Health Aide (HHA) Plan of Care. This affected 1 of 4 HHA records reviewed including MR # 3, and had the potential to affect all patients with HHA services. Findings include: Policy: Plan of Care (POC) Revised Date: 01/01/21 Purpose: To ensure an appropriate plan of care is developed and revised in a timely manner for each patient. Policy: Each patient has an individualized Plan of Care...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: d. Functional limitations... i. Patient specific interventions... 14. An aide plan of care will be developed by the Registered Nurse (RN) or other appropriate skilled professional...that is familiar with the patient... 18. The aide plan of care will be reviewed and updated...as needed... 1. MR # 3 was admitted to the agency on 2/11/21 with diagnoses including Unspecified Displaced Fracture of Surgical Neck of Right Humerus, Subsequent Encounter for Fracture With Routine Healing and Encounter for Attention to Colostomy. Review of the medical record revealed MR # 3 sustained a fall resulting in a fracture of the right humerus. MR # 3's right arm was immobilized resulting in an inability to perform personal care without maximum assistance. The patient's son was the primary caregiver and worked outside the home. Further review of the medical record revealed MR # 3 had a colostomy and had difficulty performing colostomy care due to immobilization of the right arm. It was documented in the record the son was not willing/able to provide colostomy care. Review of the Home Health Certification and Plan of Care revealed Home Health Aide Service for assistance with personal care and ADL's (activities of daily living) secondary to functional limitations, which prevent self-care. Review of the Aide Care Plan Report dated 2/12/2021 revealed the following Care Plan Category/Service: Intake/Output: Date of Last BM (bowel movement): Every Visit: Report if no BM in 3 Days. There was no documentation on the Aide Care Plan that the patient had a colostomy and right arm immobilizer. There were no instructions for the aide regarding the colostomy and the arm immobilizer. Review of the skilled nurse visit note dated 2/22/21 revealed the patient "verbalized concerns regarding assist with ostomy care. SN (skilled nurse) spoke with other disciplines...OT (Occupational Therapy) and (name of aide) regarding assist." There was no documentation what assistance the disciplines would provide. An interview conducted on 3/18/21 at 8:35 AM with Employee Identifier # 2, Patient Care Manager, confirmed the HHA POC did not include colostomy care and had not been updated to reflect the patient's need for assistance with colostomy care.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on review of medical records (MR), policy and procedure, observations, and interviews, it was determined the agency failed to ensure wound care documentation was accurate and completed according to agency policy. This affected 2 of 7 wound care records reviewed including MR # 2, Home Visit (HV) # 4 and had the potential to affect all patients with wounds served by the agency. Findings include: Policy: Negative Pressure Wound Therapy (NPWT) Revised Date: 01/01/20 Purpose: To promote wound healing and establish competency assessment guidelines when utilizing negative pressure wound therapy. Procedure: 4. The clinician will document the number of foam/sponge pieces placed in the wound bed and the number of foam/sponge/filler pieces removed from the wound. 1. MR # 2 was admitted to the agency on 3/6/2021 with diagnoses of Encounter for Other Orthopedic Aftercare, Spondylosis Without Myelopathy or Radiculopathy, Lumbosacral Region, and Other Intervertebral Disc Displacement, Lumbosacral Region. Review of the Home Health Certification and Plan of Care (HHC POC) dated 3/6/21 to 5/4/21 revealed: SN (skilled nurse) to cleanse wound # 1 mid low back surgical incision with wound cleanser or soap and water, pat dry, fill entire cavity with white foam, secure into place with transparent drape, apply trac pad on top of black foam, apply negative pressure device at 125 mm/hg (millimeters of mercury) continuous.... Review of the SN visit notes dated 3/6/21, 3/8/21, 3/10/21, 3/12/21 and 3/15/21 revealed no documentation of the number of foam pieces removed and placed in the wound bed. An interview conducted 3/18/21 at 8:30 AM with Employee Identifier (EI) # 2, Patient Care Manager, confirmed there was no documentation of the number of foam pieces removed and placed at each dressing change. 2. HV # 4 was admitted to the agency on 3/13/21 with diagnoses including Essential Hypertension and Pressure Ulcer of Sacral Region, Unspecified Stage. Review of the HHC POC dated 3/13/21 to 5/11/21 revealed: Skilled Nurse to perform / instruct...wound care to wound # 2 left buttocks stage 2 pressure ulcer... Review of the RN (Registered Nurse) admission visit note dated 3/13/21 revealed wound # 2 buttock, left, pressure ulcer stage II. A home visit conducted 3/16/21 at 2:00 PM with EI # 6, Licensed Practical Nurse, to observe wound care. The surveyor observed a stage 2 pressure wound to the right buttock and not the left buttock as documented in the medical record. An interview conducted on 3/18/21 at 8:43 AM with EI # 5, Patient Care Manager, confirmed the wound was on the right buttock and not the left buttock as documented in the record.