Every finding on record at HHC, Inc.

An Emergency Preparedness survey was conducted on 4/28/2025 through 4/30/2025 with the recertification survey. The facility meets all requirements reviewed for Emergency Preparedness.

A recertification survey was conducted along with an Emergency Preparedness survey conducted on 4/28/2025 through 4/30/2025. An entrance conference was held with the Director of Operations. An exit conference was held on 4/30/2025 with the Area Vice President of Operations, Area Vice President of Clinical, Director of Operations #2, Director of Operations #3, Director of Operations #4, Vice President of Operations, Vice President of Clinical, Clinical Manager #1 and Clinical Manager #2.

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 policy review, medical record review, and interview, the agency failed to update the medication profile for 3 of 7 (Patient #1, #2, and #7) patients reviewed. The findings included: 1. Review of the agency's "Drug Regimen Review," policy last revised 12/9/2024, revealed, "...Purpose: To identify appropriateness, inconsistencies, and/or significant drug interactions in the patient’s current medication regimen, as well as ensure the comprehensive list of medications are updated any time there is a medication change including dose changes, new medications, and any medications discontinued…” 2. Review of the medical record revealed Patient #1 was admitted with a start of care date of 3/20/2025 with diagnoses of Dehiscence of Abdominal Wound, Malignant Neoplasm of Right Ovary, Diabetes Mellitus, and Hypertension. Review of the Physician Orders revealed: Minocycline (treats infection) 100 mg (milligrams) orally twice daily. Observations in Patient #1's home on 4/28/2025 at 2:17 PM, revealed the following medications: Eliquis (anticoagulant) 2.5 mg orally twice daily. Over the counter (OTC) Vitamin E (supplement) 180 mg (400 IU [international units]) orally every day. The Eliquis and OTC Vitamin E were not listed on Patient #1's medication list from the agency. During an interview on 4/28/2025 at 3:05 PM, Patient #1 confirmed she was taking Eliquis and Vitamin E, but she was not taking Minocycline. 3. Review of the medical record revealed Patient #2 was admitted with a start of care date of 4/17/2025 with diagnoses of Orthopedic Aftercare and Presence of Right Artificial Hip Joint. Review of the Physician Orders revealed: Amlodipine (treats high blood pressure) 5 mg orally every day. Cefadroxil (treats infection) 500 mg orally every day. Observations in Patient #2's home on 4/28/2025 at 3:15 PM, revealed the following medications: OTC Jet-Asleep Nighttime Hydroxyzine 50 mg orally three times daily Furosemide (treats fluid retention and swelling) 20 mg orally every day. OTC Allergy Relief 4 mg orally as needed. The OTC Jet-Asleep Nighttime, hydroxyzine, furosemide, and OTC Allergy Relief medications were not listed on Patient #2's medication list from the agency. During an interview on 4/28/2025 at 4:10 PM, Patient #2 stated “If it is not in that basket, I don’t take it.” She confirmed she had not taken Amlodipine in a long time and was not currently taking the cefadroxil. 4. Review of the medical record revealed Patient #7 was admitted with a start of care date of 1/28/2025, with diagnoses of Stage 3 Sacral Pressure Ulcer, Non-Pressure Chronic Ulcer of Left Lower Leg, Burn of Left Lower Leg, Adjustment of Urinary Catheter, Anxiety, and Paraplegia. Review of the Physician Orders revealed: Potassium chloride 10 extended release 10 meq 2 tablets twice daily. Observations in Patient #7's home on 4/29/2025 at 11:35 AM, revealed the following medications: OTC naproxen (treats symptoms of arthritis) 2 bottles of OTC aspirin (treats pain) 325 mg orally as needed. L-Lysine (enzyme) 75 mcg (microgram) orally every morning. 1 bottle of OTC ibuprofen. 1 bottle of OTC milk thistle 175 mg 1 bottle of Milk of Magnesia 1 bottle of potassium chloride liquid 20 meq (milliequivalent)/5 ml (milliliter) 15 ml (60 meq) orally twice daily OTC triamcinolone acetonide nasal spray There were no potassium chloride 10 meq extended release tablets observed with Patient #7's medications. The naproxen, aspirin, L-lysine, ibuprofen, milk thistle, Milk of Magnesia, potassium chloride liquid, and OTC triamcinolone acetone nasal spray were not listed on Patient #7's medication list from the agency. During an interview on 4/29/2025 at 11:05 AM, LPN #2 stated, “…the daughter gives the patient her medications, and they come from the pharmacy in a bubble pack…” During a telephone interview on 4/29/2025 at 2:01 PM, Pharmacist #1 confirmed Patient #7 received her medications from their pharmacy. Pharmacist #1 stated, “…We do pack this patient’s [Patient #7] medications. A receipt and medication information are stapled to the bag of bubble packs when they are paid for and picked up…” 5. During an interview on 4/30/2025 at 9:20 AM, Director of Operations #1 confirmed medications were to be reconciled with each home visit.

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 policy review, observation, and interview, the agency failed to perform appropriate hand hygiene by 1 of 2 (Licensed Practical Nurse (LPN) #2) nurses observed performing wound care. The findings included: Review of the agency's “Hand Hygiene,” policy dated 6/26/2024, revealed, “…The term hand-hygiene includes both handwashing with soap and water and use of alcohol-based products that do not require the use of water…Perform hand hygiene as follows…Before donning gloves…After removing gloves…” Review of the medical record revealed Patient #7 was admitted with a start of care date of 1/28/2025 with diagnoses of Stage 3 Sacral Pressure Ulcer, Non-Pressure Chronic Ulcer of Left Lower Leg, Burn of Left Lower Leg, Adjustment of Urinary Catheter, Anxiety, and Paraplegia. Review of the physician order dated 4/21/2025, revealed, “…CLEAN WITH WOUND CLEANSER AND PAT DRY…APPLY SKIN PROTECTANT TO ALL SURROUNDING SKIN FOR INCREASED PROTECTION FROM URINE…APPLY CALCIUM ALGINATE [substance that forms a protective gel and non-adherence to the wound] TO OPEN SORE AND COVER WITH BORDERED GAUZE [dressing with a non-adherent pad in the center surrounded by a flexible adhesive border to secure the dressing in place]…NURSING TO CHANGE 1XWEEK [one time each week] AND CAREGIVER TO CHANGE IF LOOSE OR SOILED…” Observations in Patient #7's home on 4/29/2025 at 11:05 AM, revealed LPN #2 performed a dressing change to Patient #7’s sacrum. LPN #2 failed to perform hand hygiene 3 times between glove changes during the removal of the soiled dressing and the cleaning of the wound and failed to perform hand hygiene 2 times between glove changes during the application of the new dressing. During an interview on 4/29/2025 at 11:45 AM, LPN #2 confirmed she was supposed to perform hand hygiene between each glove change. During an interview on 4/30/2025 at 915 AM, Director of Operations #1 confirmed staff were to perform hand hygiene between glove changes.

An Emergency Preparedness recertification and re-licensure survey was conducted on 8/28/2023-8/30/2023. The facility meets all of the requirements for Emergency Preparedness. There were no deficiencies identified.

A recertification survey was conducted on 8/28/2023-8/30/2023. An entrance conference was held on 8/28/2023 AM, with the Director of Operations. An exit conference was held on 8/30/2023 at 12:50 PM, with the agencies administration.

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 policy review, medical record review, and interview, the agency failed to update the medication profile for 4 of 7 (Patient #1, #3, #5, and #13) patients reviewed. The findings included: Review of the agencies "Drug Regimen Review,” policy dated 11/2020, revealed “…The clinician completing the OASIS Assessment must complete a comprehensive drug regimen review of all medications the patient is currently taking at the time of admission, recertification, resumption of care and with any major change in condition. The medication profile is completed by documenting – All of the patient’s medications which includes: Medications on written prescriptions and medication bottles; over-the-counter medications; herbal products; Vitamins and Supplements and Oxygen…The clinician will also ask the patient to periodically allow them to visualize all the medications the patient is currently taking…The visualized medications are compared to the current medication profile to ensure accuracy of the medication profile. Any discrepancies should be clarified with the patient’s Physician and documented in the clinical record…” Review of the medical record revealed Patient #1 was admitted to the agency on 6/23/2023 with diagnoses of Diabetes Mellitus, Osteomyelitis, Hypertension, Anemia, and Rheumatoid Arthritis. Review of the Resumption of Care Order dated 8/14/2023, revealed “…Banophen [Antihistamine] 25 mg [milligram]…po [orally] every 8 hours prn [as needed]…Celebrex [Anti-inflammatory] 200 mg…daily as needed for pain…Cyclobenzaprine [Muscle Relaxant] 10 mg…daily…Cyclosporin [treats dry eye] 0.05% eye drops…one drop to eyes daily…Cyproheptadine [relieves allergic reactions] 4 mg…daily…Glipizide [Antihyperglycemic]…2.5 mg…daily…Hydroxyzine…25 mg…po tid [three times a day] prn…Oxycodone [Narcotic] 5 mg…every 4 hours as needed for pain…Potassium Gluconate [Supplement] 550 mg (90 mg)…daily…Tramadol [Narcotic] 50 mg…daily…Protonix [treats reflux] 40 mg…daily…” Review of Patient #1’s home medications revealed 4/3/2023…Lyrica [treats nerve pain] 25 mg po twice daily…10/11/2022…Amlodipine [Antihypertensive] 5 mg po (1/2 tablet when needed…Refresh eye drops. Interview with Patient #1’s daughter on 8/28/2023 at 1:35 PM, she stated “…She [Patient #1] takes the Lyrica on as needed basis and the Amlodipine was recently changed to ½ tablet. The Nurse Practitioner stopped her Celebrex because she ordered the antibiotics. These other medications [Banophen, Cyclobenzaprine, Cyproheptadine, Glipizide, Hydrocodone/ APAP, Hydroxyzine, Potassium, and Tramadol) were discontinued when she recently came home from the hospital. She uses the Refresh eye drops and Humalog per sliding scale. During a conversation between Registered Nurse (RN) #1 and Patient #1’s daughter, the daughter asked for clarification from RN #1 regarding the Patient #1 taking Protonix and Pantoprazole. RN #1 instructed Patient #1’s daughter to call the Nurse Practitioner. During an interview with RN #1 on 8/28/2023 at 1:45 PM, RN #1 was asked if she would call the physician regarding the discrepancies in Patient #1’s medication orders. RN #1 stated “…Normally I don’t call the physician if the medications are in the home…” During an interview with the Director of Operations on 8/28/2023 at 2:30 PM, she was asked if RN #1’s answer regarding the discrepancies was policy. She stated “…Oh No. Medications should be reconciled at least once a week…” Review of the medical record revealed Patient #3 was admitted to the agency on 2/25/2023 with diagnoses of Stage 2 Right Buttock Pressure Ulcer, Stage 2 Left Buttock Pressure Ulcer, Hemiplegia, Diabetes Mellitus, Hypertensive Heart Disease, Dysphagia, and Atrial Fibrillation. Review of the Client Medication Report dated 8/21/2023, revealed “…6/25/2023…Amiodarone [Antiarrhythmic] 200 mg…daily…oral…Atorvastatin [treats high cholesterol] 10 mg…bedtime…oral…6/25/2023…Cephalexin [Antibiotic] 250 mg…2 times…daily…4/17/2023…Diltiazem [Antihypertensive] 30 mg…3 times daily…oral…6/25/2023…Pantoprazole [treats acid reflux] 40 mg…daily…oral…2/25/2023…Vitamin D2 [Supplement] 1,250 mcg [microgram]…weekly…oral…” During an interview with Patient #3’s daughter on 8/29/2023 at 12:35 PM, she stated “…The Amiodarone, Atorvastatin was discontinued after my mom’s last hospital stay in June. She takes the Cephalexin as needed now, and no longer takes the Vitamin D. Her Diltiazem was increased to 60 mg also after her hospital stay…” RN #2 confirmed Patient #3’s medications had not been reconciled. Medical record review revealed Patient #5 was admitted to the agency on 7/18/2023 with diagnoses of Neck of Right Femur Fracture, Rheumatoid Arthritis, Hypertension, Atherosclerosis of the Aorta, Chronic Obstructive Pulmonary Disease, Anxiety, and Depression. Review of the Home Health Certification and Plan of Care dated 8/16/2023, revealed “….7/18/2023…Buspirone [treats anxiety] 10 mg…2 times daily…oral…” During an interview with Patient #5 on 8/29/2023 at 11:25 AM, she stated she does not take the Buspirone. Occupational Therapist #1 confirmed the Buspirone was ordered and would let the case manager know. Review of the medical record revealed Patient #13 was admitted to the agency on 7/28/2023 with diagnoses of Diabetes Mellitus, Hypertension, Obesity, and Complications of a Medical Procedure. Review of the Home Health Certification and Plan of Care dated 8/16/2023, revealed “…7/28/2023…Fentanyl [Narcotic] 12 mcg/hr [hour] transdermal patch…1 patch…72 hours…” Review of the home medications revealed 8/1/2023 Aspirin 81 mg by mouth every day; 8/14/2023 Lisinopril 20 mg by mouth every day; and 8/2/2023 Atorvastatin 20 mg by mouth in the evening; and 7/28/2023 Oxycodone [Narcotic] 10 mg every 6 hours by mouth. During an interview with Patient #13 on 8/30/2023 at 10:45 AM, she stated “…I never took the Fentanyl and only take the Oxycodone 5 mg before my dressing changes. The Lisinopril and Atorvastatin was prescribed 2 weeks ago. RN #3 confirmed the medications were not reconciled but she was not Patient #13’s regular nurse as she works prn. Based on policy review, medical record review, and interview, the agency failed to update the medication profile for 4 of 7 (Patient #1, #3, #5, and #13) patients reviewed. The findings included: Review of the agencies "Drug Regimen Review,” policy dated 11/2020, revealed “…The clinician completing the OASIS Assessment must complete a comprehensive drug regimen review of all medications the patient is currently taking at the time of admission, recertification, resumption of care and with any major change in condition. The medication profile is completed by documenting – All of the patient’s medications which includes: Medications on written prescriptions and medication bottles; over-the-counter medications; herbal products; Vitamins and Supplements and Oxygen…The clinician will also ask the patient to periodically allow them to visualize all the medications the patient is currently taking…The visualized medications are compared to the current medication profile to ensure accuracy of the medication profile. Any discrepancies should be clarified with the patient’s Physician and documented in the clinical record…” Review of the medical record revealed Patient #1 was admitted to the agency on 6/23/2023 with diagnoses of Diabetes Mellitus, Osteomyelitis, Hypertension, Anemia, and Rheumatoid Arthritis. Review of the Resumption of Care Order dated 8/14/2023, revealed “…Banophen [Antihistamine] 25 mg [milligram]…po [orally] every 8 hours prn [as needed]…Celebrex [Anti-inflammatory] 200 mg…daily as needed for pain…Cyclobenzaprine [Muscle Relaxant] 10 mg…daily…Cyclosporin [treats dry eye] 0.05% eye drops…one drop to eyes daily…Cyproheptadine [relieves allergic reactions] 4 mg…daily…Glipizide [Antihyperglycemic]…2.5 mg…daily…Hydroxyzine…25 mg…po tid [three times a day] prn…Oxycodone [Narcotic] 5 mg…every 4 hours as needed for pain…Potassium Gluconate [Supplement] 550 mg (90 mg)…daily…Tramadol [Narcotic] 50 mg…daily…Protonix [treats reflux] 40 mg…daily…” Review of Patient #1’s home medications revealed 4/3/2023…Lyrica [treats nerve pain] 25 mg po twice daily…10/11/2022…Amlodipine [Antihypertensive] 5 mg po (1/2 tablet when needed…Refresh eye drops. Interview with Patient #1’s daughter on 8/28/2023 at 1:35 PM, she stated “…She [Patient #1] takes the Lyrica on as needed basis and the Amlodipine was recently changed to ½ tablet. The Nurse Practitioner stopped her Celebrex because she ordered the antibiotics. These other medications [Banophen, Cyclobenzaprine, Cyproheptadine, Glipizide, Hydrocodone/ APAP, Hydroxyzine, Potassium, and Tramadol) were discontinued when she recently came home from the hospital. She uses the Refresh eye drops and Humalog per sliding scale. During a conversation between Registered Nurse (RN) #1 and Patient #1’s daughter, the daughter asked for clarification from RN #1 regarding the Patient #1 taking Protonix and Pantoprazole. RN #1 instructed Patient #1’s daughter to call the Nurse Practitioner. During an interview with RN #1 on 8/28/2023 at 1:45 PM, RN #1 was asked if she would call the physician regarding the discrepancies in Patient #1’s medication orders. RN #1 stated “…Normally I don’t call the physician if the medications are in the home…” During an interview with the Director of Operations on 8/28/2023 at 2:30 PM, she was asked if RN #1’s answer regarding the discrepancies was policy. She stated “…Oh No. Medications should be reconciled at least once a week…” Review of the medical record revealed Patient #3 was admitted to the agency on 2/25/2023 with diagnoses of Stage 2 Right Buttock Pressure Ulcer, Stage 2 Left Buttock Pressure Ulcer, Hemiplegia, Diabetes Mellitus, Hypertensive Heart Disease, Dysphagia, and Atrial Fibrillation. Review of the Client Medication Report dated 8/21/2023, revealed “…6/25/2023…Amiodarone [Antiarrhythmic] 200 mg…daily…oral…Atorvastatin [treats high cholesterol] 10 mg…bedtime…oral…6/25/2023…Cephalexin [Antibiotic] 250 mg…2 times…daily…4/17/2023…Diltiazem [Antihypertensive] 30 mg…3 times daily…oral…6/25/2023…Pantoprazole [treats acid reflux] 40 mg…daily…oral…2/25/2023…Vitamin D2 [Supplement] 1,250 mcg [microgram]…weekly…oral…” During an interview with Patient #3’s daughter on 8/29/2023 at 12:35 PM, she stated “…The Amiodarone, Atorvastatin was discontinued after my mom’s last hospital stay in June. She takes the Cephalexin as needed now, and no longer takes the Vitamin D. Her Diltiazem was increased to 60 mg also after her hospital stay…” RN #2 confirmed Patient #3’s medications had not been reconciled. Medical record review revealed Patient #5 was admitted to the agency on 7/18/2023 with diagnoses of Neck of Right Femur Fracture, Rheumatoid Arthritis, Hypertension, Atherosclerosis of the Aorta, Chronic Obstructive Pulmonary Disease, Anxiety, and Depression. Review of the Home Health Certification and Plan of Care dated 8/16/2023, revealed “….7/18/2023…Buspirone [treats anxiety] 10 mg…2 times daily…oral…” During an interview with Patient #5 on 8/29/2023 at 11:25 AM, she stated she does not take the Buspirone. Occupational Therapist #1 confirmed the Buspirone was ordered and would let the case manager know. Review of the medical record revealed Patient #13 was admitted to the agency on 7/28/2023 with diagnoses of Diabetes Mellitus, Hypertension, Obesity, and Complications of a Medical Procedure. Review of the Home Health Certification and Plan of Care dated 8/16/2023, revealed “…7/28/2023…Fentanyl [Narcotic] 12 mcg/hr [hour] transdermal patch…1 patch…72 hours…” Review of the home medications revealed 8/1/2023 Aspirin 81 mg by mouth every day; 8/14/2023 Lisinopril 20 mg by mouth every day; and 8/2/2023 Atorvastatin 20 mg by mouth in the evening; and 7/28/2023 Oxycodone [Narcotic] 10 mg every 6 hours by mouth. During an interview with Patient #13 on 8/30/2023 at 10:45 AM, she stated “…I never took the Fentanyl and only take the Oxycodone 5 mg before my dressing changes. The Lisinopril and Atorvastatin was prescribed 2 weeks ago. RN #3 confirmed the medications were not reconciled but she was not Patient #13’s regular nurse as she works prn.