Every finding on record at Infirmary Home Health Agency, Inc.

A recertification survey was conducted on 3/25/25 to 3/27/25 and Infirmary Homecare was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted on 3/25/25 to 3/27/25 at Infirmary HomeCare. Standard level deficiencies were citied that will require an acceptable plan of correction.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on Medical Record (MR) review, agency policy and procedure, and interviews with staff it was determined the agency failed to provide the patient with notification prior to discharge. This deficient practice did affect MR # 2, one of five discharge charts reviewed and had the potential to affect all patients served by this agency. Findings include: Agency Policy: Coordination of Care , from Admit Through Discharge. Policy Number: 2.1.017 Revised Date: 9/1/24 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: ...7. Coordination of care with patient and caregiver:... Ongoing, the patient /caregiver will be notified of:... d. Transfer or discharge... 1. MR # 2 was admitted to the agency on 7/13/23 and recertified for continued care on 11/4/24 to 1/2/25 with a primary diagnosis of Pressure Ulcer of Sacral Region Stage Four. A review of the Home Health Certification and Plan of Care dated 11/4/24 to 1/2/25 revealed an order for the Skilled Nurse (SN) one time a week for nine weeks, for the SN to perform/instruct patient/caregiver in the procedure of wound care to right and left upper buttocks and coccyx A review of the MR revealed the SN visit notes dated from 11/8/24 to 12/20/24 had no documentation the patient was notified of the upcoming discharge for cause on 12/30/2024. An interview was conducted on 3/27/25 at 12:08 PM with Employee Identifier # 1, Area Administrator, who confirmed there was no documentation of the patient's notification prior to discharge.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on Medical Record (MR) review, agency policy and procedure, and interviews with staff it was determined the agency failed to document efforts to resolve the problem prior to discharge. This deficient practice did affect MR # 2, one of five discharge charts reviewed and had the potential to affect all patients served by this agency. Findings include: Agency Policy: Coordination of Care, from Admit Through Discharge. Policy Number: 2.1.017 Revised Date: 9/1/24 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: ...7. Coordination of care with patient and caregiver:... Ongoing, the patient /caregiver will be notified of:... d. Transfer or discharge... 1. MR # 2 was admitted to the agency on 7/13/23 and recertified for continued care on 11/4/24 to 1/2/25 with a primary diagnosis of Pressure Ulcer of Sacral Region Stage Four. A review of the Home Health Certification and Plan of Care dated 11/4/24 to 1/2/25 revealed an order for the Skilled Nurse (SN) one time a week for nine weeks. A review of the MR revealed the SN visit notes dated from 11/8/24 to 12/20/24 had no documentation of attempts to ensure the patient adhered to the plan of care prior to the discharge on 12/30/2024. An interview was conducted on 3/27/25 at 12:08 PM, with Employee Identifier # 1, Area Administrator, who confirmed there was no documentation of attempts to resolve the non-compliance prior to discharge.

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 medical record (MR) review, agency policy and procedure, and interviews with staff, patients, and caregivers, it was determined the agency failed to ensure medications were reconciled to include all current medications and dosages. This deficient practice affected four of seven Home Visit (HV) patients including HV # 3, HV # 5, HV # 7, and HV # 2, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Monitoring Medications Policy Number: 10.008 Revised: 7/1/24 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: ...a. Through a collaborative process the care team will: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies... 4. HV # 2 was admitted on 2/27/25 with diagnoses including Abscess of Liver and Malignant Neoplasm of Pancreas, Unspecified. A review of the HHC and POC dated 2/27/25 revealed physician's order for Skilled Nurse two visits for week one and one visit per week for eight weeks. A HV was conducted on 3/25/25 at 3:00 PM to observe care provided by EI # 7, Registered Nurse . During the HV, a review of the current medications was conducted with EI # 7 and HV # 2 and compared to the Medicine List dated 3/25/25, the following discrepancies were found: Amlodipine 5 mg tablet. One tablet PO (by mouth) daily for hypertension. HV # 2 said he/she has been off this medication for several months, at least since last July. Ondansetron 8 mg ODT (orally disintegrating tablet). One tablet every 8 hours/PRN (as needed) for nausea, was present in the home but not listed on the Medicine List with a fill date of 12/30/24. HV # 2 stated he/she took this only when needed. Meloxicam 15 mg tablet. One tablet daily/PRN for pain was present in the home but not listed on the Medicine List with a fill date of 2/9/24. HV # 2 said he/she had been on that forever. Cetirizine 10 mg tablet. One tablet daily for allergies with a fill date of 3/15/25. He/she said the "doc" just started me on that a couple of weeks ago. Aloe Burn Relief 0.5 % (percent) topical spray weekly/PRN for pain relief when changing mediport dressing was present in the home but not on the Medicine List.. HV # 2 said his/her wife/husband purchased that a few weeks ago and asked the nurses to use it when changing the mediport dressing. An interview was conducted on 3/27/25 at 11:53 with EI # 1, Area Administrator of Operations, who confirmed the agency failed to reconcile medications per agency policy. 2. HV # 5 was admitted to the agency on 3/3/25 with diagnoses including Fracture of Unspecified Part of Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing and Hypothyroidism, Unspecified. A HV was conducted on 3/25/25 at 1:54 PM with EI # 6, Physical Therapist, to observe care provided. During the HV, the surveyor compared the medications found in home to the agency medicine list (ML). The patient verified the following medication discrepancies: Aspirin 81 mg 1 tablet twice daily was found in the home. The caregiver verbalized taking the 81 mg twice daily dosage since 2/6/25 or 2/7/25. Aspirin 81 mg 1 tablet daily was on the agency ML. Meloxicam 7.5 mg 1 tablet daily was on the agency ML. The caregiver verbalized the patient had not taken Meloxicam since 2022. An interview was conducted on 3/27/25 at 12:51 PM with EI # 2, Clinical Director, who confirmed the agency failed to ensure the medications were reconciled. 3. HV # 7 was admitted to the agency on 2/6/25 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hypertensive Heart and Chronic Kidney Disease without Heart Failure, with Stage 1 through Stage 4 Chronic Kidney Disease. A HV was conducted on 3/26/25 at 9:12 AM with EI # 3, Occupational Therapist, to observe care provided. During the HV, EI # 3 and the surveyor compared the medications found in home to the agency ML. The patient verified the following medication discrepancies: Aspirin 325 mg 1 tablet daily was found in the home. The patient verbalized taking the 325 mg dosage since August 24. Aspirin 81 mg 1 tablet daily was on the agency ML. Hydrochlorothiazide (HCTZ) 25 mg 1 tablet daily was found in the home. The patient verbalized taking the 25 mg dosage since December 24. HCTZ 12.5 mg three times day was on the agency ML. Magnesium Citrate 200 mg 1 tablet daily was found in the home. The patient verbalized taking the magnesium citrate since January 25. There was no documentation of the magnesium citrate on the agency ML. Tramadol 50 mg 1 to 2 tablets every 8 hours as needed for pain was found in the home. The patient verbalized taking the Tramadol for the last three or four years. There was no documentation of the Tramadol on the agency ML. Valacyclovir 1 gm (gram) 1 tablet twice daily was found in the home. The patient verbalized taking the Valacyclovir since February 25. There was no documentation of the Valacyclovir on the agency ML. An interview was conducted on 3/27/25 at 12:59 PM with EI # 2 who confirmed the agency failed to ensure the medications were reconciled. 1. HV # 3 was admitted on 2/6/25 with diagnoses including Urinary Tract Infection, Unspecified Atrial Fibrillation, and COVID-19. A review of the Home Health Certification and Plan of Care (HHC and POC) dated 2/6/25 revealed physician's orders for Skilled Nurse (SN) one visit per week for nine weeks. A HV was conducted on 3/25/25 at 12:15 PM to observe care provided by Employee Identifier (EI) # 4, Licensed Practical Nurse (LPN). A review of the current medications was conducted with EI # 4 and HV # 3 and compared to the Medication List dated 3/25/25. The following is a list of the discrepancies: a. Lasix 40 milligrams (mg) take one tablet two times a day was listed on the Medication List. HV # 3 stated he/she had been taking one tablet one time a day for one year. b. Coreg 3.125 mg, take one tablet daily was on the Medication List. HV # 3 stated the dosage was increased to 12 mg during her last physician office visit on 3/10/25. HV # 3 stated he/she had been taking three to four of the 3.125 mg tablets a day to increase the dosage. There was no new prescription of Coreg in the home. c. Jardiance 10 mg, take one daily, filled 3/10/25, was in the home with the current medications. HV # 3 stated the new prescription was added during her physician office visit on 3/10/25. An interview was conducted on 3/27/25 at 12:25 PM with EI # 9, Registered Nurse (RN), who confirmed the agency failed to ensure the medications were reconciled per agency policy.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on review of agency policy and procedure, medical records (MR), and staff interviews it was determined the agency failed to follow Plan of Care (POC) ordered visit frequency. This deficient practice did affect two of 17 MRs reviewed including Home visit (HV) # 7, MR # 6, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: POC Policy Number: 2.1.007 Revised Date: 9/1/24 Purpose: To assure an appropriate POC is developed and revised in a timely manner for each patient. To ensure that physician/authorized practitioner's orders are followed. Policy: Each patient has an individualized POC developed...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... i. Patient specific interventions...measurable outcomes and goals identified by the agency and patient. 2. MR # 6 was admitted on 2/11/25 with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia, Hypertensive Heart and Chronic Kidney Disease, and Chronic Diastolic (Congestive) Heart Failure. Review of the Home Health Certification and Plan of Care dated 2/11/25 revealed physicians orders for Skilled Nurse (SN) one visit per week for one week, two visits per week for one week, then one visit per week for seven weeks and Physical Therapist (PT) one visit for one week, then two visits per week for eight weeks. Review of the SN and PT Visit Notes for the week 2/23/25 to 3/1/25 revealed no SN visits were completed and one of two PT visits were completed. There was no documentation the physician was notified of the missed visits and no documentation the agency attempted to reschedule the visits. An interview was conducted on 3/27/25 at 12:15 PM with EI # 9, Registered Nurse, who confirmed the agency failed to ensure the physician's orders for visit frequency were followed. 1. HV # 7 was admitted to the agency on 2/6/25 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hypertensive Heart and Chronic Kidney Disease without Heart Failure, with Stage 1 through Stage 4 Chronic Kidney Disease. Review of the Physician Order dated 3/11/25 revealed an order for HHA (home health aide) once a week for four weeks. Review of the missed visit notification dated 3/13/25 (Thursday) revealed a missed HHA visit due to the patient having a physician appointment. Review of the HHA visit notes dated 3/11/25 to 3/15/25 revealed no documentation of a HHA visit or an attempt to reschedule the missed HHA visit. An interview was conducted on 3/27/25 at 12:57 PM with Employee Identifier (EI) # 2, Clinical Director, who confirmed there was no documentation of a HHA visit or an attempt to reschedule the missed HHA visit.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, medical records (MR), and staff interviews it was determined the agency failed to include patient specific interventions, measurable outcomes and goals for a peripherally inserted central catheter (PICC) in the plan of care (POC). This deficient practice did affect MR # 9, one of one MR reviewed with a PICC, and had the potential to effect all patients with a PICC served by the agency. Findings include: Agency Policy: POC Policy Number: 2.1.007 Revised Date: 9/1/24 Purpose: To assure an appropriate POC is developed and revised in a timely manner for each patient... Policy: Each patient has an individualized POC developed...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: ...i. Patient specific interventions...measurable outcomes and goals identified by the agency and patient. 1. MR # 9 was admitted to the agency on 12/20/24, and recertified for continued care from 2/18/25 to 4/18/25, with diagnoses including Cellulitis of Left Lowers Limb and Disruption of External Operation (Surgical) Wound, Not Elsewhere Classified, Subsequent Encounter. Review of the Home Health Certification (HHC) and POC dated 2/18/25 to 4/18/25 revealed an order for a skilled nurse (SN) frequency of once a week for eight weeks. There was no documentation of interventions, measurable outcomes, and goals for a PICC. Review of the Recertification nursing note (comprehensive assessment) dated 2/18/25 revealed the patient had a PICC to the right upper extremity. Review of six of six SN visits from 2/18/25 to 3/18/25 revealed site care, flushing, and/or blood was removed from the PICC line during the visit. An interview was conducted on 3/27/25 at 1:02 PM with Employee Identifier (EI) # 2, Clinical Director, who confirmed there was no interventions, measurable outcomes, and goals for a PICC on the patients POC.

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, medical record (MR) review, agency policy and procedure and interviews with staff, it was determined the agency failed to ensure: a. Staff performed hand hygiene (HH) per agency policy. b. Staff cleaned re-usable equipment per agency policy. This deficient practice did affect three of seven home visits (HV) patients including HV # 3, HV # 2, HV # 4, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Cleaning of Re-Useable Equipment Policy Number: 8.006 Revised: 6/1/22 Purpose: To assure equipment required for patient care is clean and sanitized to prevent the spread of infections. Policy: Equipment used for more than one patient is cleaned between each patient use. Definitions: Low-Level Disinfection - destroys most bacteria...Examples include at least 70 % isopropyl alcohol/ehtyl alcohol...3. Non-Critical Items - Equipment that is only meant to come in contact with intact patient skin...(...stethoscopes, blood pressure cuffs, pulse oximeters...) Procedure: Non-critical items which will come in contact with intact patient skin will undergo a low-level disinfection between each patient use... Agency Policy: Hand Hygiene Policy Number: 8.004 Revised Date: 5/1/19 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 (HH) prior to, at specified time points during, and following patient contact… Procedure: 1. Staff performs HH … a. Before direct contact with the patient. b. Before performing an aseptic task (ergo, insertion of invasive devices, wound care). c. After contact with wound dressing, contaminated surfaces. d. If moving from a contaminated body site to a clean body site. e. After contact with inanimate objects. 5. a. …Gloves will be worn during any patient care activities or interaction with any potentially contaminated surfaces or items… 8. c. …Change gloves during patient care if moving from a contaminated body site to a clean body site. 2. HV # 2 was admitted on 2/27/25 with diagnoses including Abscess of Liver and Malignant Neoplasm of Pancreas, unspecified. Review of the Home HHC and POC 2/27/25 revealed physician's orders for Skilled Nurse (SN) two visits for one week and then one visit for eight weeks. Further review of the HHC and POC revealed SN to obtain IV (intravenous) access via aseptic technique using Huber Needle. SN to change Huber needle 1x (time) a week and PRN (as needed) contamination/malfunction. Flush IV access with 10 ml (milliliter) of Normal Saline (NS) before infusion and 10 ml NS and Heparin 100 Units / (per) ml after infusion. Cleanse site with Chlorhexidine. Air dry. Apply transparent dressing weekly. A HV was conducted on 3/25/25 at 3:00 PM to observe IV care provided by EI # 7, Registered Nurse (RN). EI # 7 performed HH, donned gloves and began opening supplies to change the Huber Needle and begin infusion of HV # 2's antibiotic. While opening wrapped 3 ml syringes of NS, a wrapper fell to the floor. EI # 7 picked up the wrapper off of the floor and put it in the trash. EI # 7 continued opening supplies, wearing the same pair of gloves. EI # 7 opened a pair of sterile gloves which were donned over the contaminated gloves and began to clean the site with the Chlorhexidine prep stick. The sterile gloves were removed and a second pair of sterile gloves were donned over the previously contaminated gloves. The Huber Needle was inserted into the port site, and the dressing change was completed. The sterile gloves were removed while the contaminated non sterile gloves remained on EI # 7's hands. More adhesive was applied to the site and the non sterile gloves were removed. The trash was disposed of into HV # 2's garbage and HH was then performed. EI # 7 failed to follow the agency policy for HH and glove use. An interview was conducted on 3/27/25 at 11:53 PM with EI # 1, Area Administrator of Operations, who confirmed the agency failed to ensure staff followed the agency HH policy. 3. HV # 4 was admitted on 3/15/25 with diagnoses including Type Two Diabetes Mellitus with Diabetic Polyneuropathy and Hypertensive Chronic Kidney Disease with Stage 1-4 Unspecified Chronic Kidney Disease. Review of the HHC and POC revealed Physical Therapy two times a week for seven weeks effective 3/16/25. A HV was conducted on 3/25/25 at 4:25 PM to observe care provided by EI # 8, Physical Therapy Assistant . EI # 8 placed a barrier on a television stand with his/her bag in the middle of the barrier. HH was performed, gloves were donned and equipment was removed from the bag and placed on the right side of the bag, on the barrier. Vital signs were obtained and used equipment was placed back on the right side of the bag, onto the barrier, contaminating the right side of the bag. Gloves were removed and without performing HH, an ankle circumference was obtained. Without performing HH or donning gloves, a Sani Cloth was used to clean the used equipment that was then placed back on the contaminated right side of the barrier. The equipment was allowed to dry and without performing HH, placed back in the bag. EI # 8 failed to follow the agency policy for HH. An interview was conducted on 3/27/25 at 12:03 PM with EI # 1, who confirmed the agency failed to ensure the staff followed the agency HH policy. 1. HV # 3 was admitted on 2/6/25 with diagnoses including Urinary Infection, Unspecified Atrial Fibrillation, and COVID-19. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 2/6/25 revealed physician's orders for SN one visit per week for nine weeks. Review of the Physician Order dated 2/19/25 revealed orders for wound care to left dorsal foot, cleanse with saline moistened gauze, apply enzymatic debriding agent Santyl Ointment to the wound bed, pack wound with Isosorbide 1/4 inch packing, cover with two inch cling, and cover with cling every day. A home visit was conducted on 3/25/25 at 12:15 PM to observe wound care provided by Employee Identifier (EI) # 4, Licensed Practical Nurse. EI # 4 placed a barrier on a chair for bag and clean items. Blood pressure cuff and stethoscope removed from the bag, vital signs taken, and dirty items placed back on the same barrier. EI # 4 then wiped the reusable items with sanitizing wipes then placed the items back onto the same location of the barrier the contaminated items were removed from. EI # 4 then placed a barrier under HV # 3's left foot onto the floor. EI # 4 then placed HV # 3's wound supply bag onto the barrier and removed the wound supplies. EI # 4 then removed the dressing from the left foot and disposed of the soiled dressing in a plastic bag. After providing wound care, EI # 4 removed HV # 3's wound care supplies from the side of the barrier and placed them back into the box with the patient's clean supplies. An interview was conducted on 3/27/25 at 12:25 PM with EI # 9, Registered Nurse, who confirmed the agency failed to ensure the staff followed agency infection prevention policy.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policies and procedure, and interviews it was determined the agency failed to ensure: 1. Wounds were measured per the agency policy. 2. Measure the external length of a peripherally inserted central catheter (PICC) line per the agency policy. 3. Measure the upper arm circumference of the arm with a PICC inserted. This deficient practice affected two of 17 MRs reviewed including MR # 9, and MR # 2, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Wound Assessment, Documentation, and Photography Policy Number: 2.2.001 Revised: 9/1/24 Purpose: To ensure the accurate and consistent assessment and documentation of wounds. Policy: Upon initial visit and subsequently as indicated below, all wounds will be assessed with appropriate documentation within the MR... assess wounds at least: ...every other week for patients receiving wound care by the agency at a frequency less than daily... The assessment includes measurement of the length, width, and depth... Agency Policy: Dressing Change Procedure for Central Venous, Midline, and PICC. Policy Number: 10.027 Revised: 10/1/16 Purpose: To keep insertion sites clean, stabilize catheters, and minimize the risk of infection. ...Procedure: ...8. Inspect catheter, catheter exit site, and surrounding skin and patient's arm, chest, and neck area. ...c. Obtain upper arm circumference... d. Measure external length of catheter from the insertion site to the catheter hub... 2. MR # 2 was admitted to the agency on 7/13/23 and recertified for continued care on 11/4/24 to 1/2/25 with a primary diagnosis of Pressure Ulcer of Sacral Region Stage Four. A review of the HHC and POC dated 11/4/24 to 1/2/25 revealed an order for the SN one time a week for nine weeks, for the SN to perform/instruct patient/caregiver in the procedure of wound care to right and left upper buttocks and coccyx. A review of two of the eight SN visit notes dated 12/12/24 and 12/20/24 revealed no documentation of a wound measurement for the right buttock, left buttock and coccyx. An interview was conducted on 3/27/25 at 12:08 PM with EI # 1, Area Administrator, who confirmed the wounds were not measured per the agency policy. 1. MR # 9 was admitted to the agency on 12/20/24, and recertified for continued care from 2/18/25 to 4/18/25, with diagnoses including Cellulitis of Left Lowers Limb and Disruption of External Operation (Surgical) Wound, Not Elsewhere Classified, Subsequent Encounter. Review of six of six nursing notes dated 2/18/25 to 3/18/25 revealed the patient had a PICC to the right upper arm. Further review of the nursing notes dated 2/26/25, 3/4/25, and 3/12/25 revealed documentation a PICC dressing change was completed. There was no documentation of the external catheter length of the PICC on 2/26/25, 3/4/25, and 3/12/25. There was no documentation of an upper arm circumference on 3/4/25 and 3/12/25. An interview was conducted on 3/27/25 at 1:02 PM with EI # 2 who confirmed the external catheter length and upper arm circumference were not documented 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 Medical Record (MR) review, The Alabama Board of Nursing 610-X-6-.06 Documentation Standards, and staff interviews it was determined the agency failed to ensure the staff documented accurately in the patient record. This deficient practice did affect MR # 2, one of two indwelling catheter charts reviewed, and had the potential to affect all indwelling catheter patients served by this agency. Findings include: Alabama Board of Nursing Chapter 610-x-6: Standards of Nursing Practice Supp (Supplement): 12/31/21 610-X-6-.06 Documentation Standards (1) The standards of documentation of nursing care provided to patients by registered nurses or licensed practical nurses are based on principles of documentation regardless of the documentation format. (2) Documentation of nursing care shall be: (a) Legible (b) Accurate (c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, response, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient... " 1. MR # 2 was admitted to the agency on 7/13/23 and recertified for continued care on 11/4/24 to 1/2/25 with a primary diagnosis of Pressure Ulcer of Sacral Region Stage Four. A review of the Home Health Certification and Plan of Care dated 11/4/24 to 1/2/25 revealed an order for the SN one time a week for nine weeks, for the Skilled Nurse (SN) to perform an insertion of a 24 French 10 cubic centimeter balloon, suprapubic catheter every month, and as needed for dislodgement or blockage. A review of the skilled nurse visit note dated 11/13/24 revealed documentation of the suprapubic catheter change. A review of the SN visit notes revealed the nurse documented on 11/8/24,11/22/24, 11/29/24, 12/6/24, and 12/12/24 inaccurate dates for the insertion of the suprapubic catheter. An interview was conducted on 3/27/25 at 12:08 PM, with Employee Identifier # 1, Area Administrator, who confirmed the nurse failed to accurately document the insertion date of the suprapubic catheter.

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

A recertification survey was conducted on 3/15/22 - 3/17/22 with standard level deficiencies cited.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, medical record (MR) reviews and interviews, it was determined the agency failed to ensure the medications were current for 4 of 17 MR's reviewed, including Home Visit (HV) # 1, MR # 9, HV # 3 and HV # 7 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Monitoring Medications Policy Number: 10.008 Revised Date: 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: 2. All clinicians participating in the patient's care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care. During the patient's episode of care the following will occur: a. Through a collaborative process the care team will: Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies... b. The Physician will be notified of discrepancies and documentation of notification must be evident in the medial record. 4. HV # 7 was admitted to the agency on 2/7/22 with admitting diagnoses of Abscess of The Breast and Nipple and Necrotizing Fasciitis. A HV was conducted on 3/16/22 at 12:00 PM and the medications were reviewed with the patient during this visit using the medication bottles and the Medication List provided to the surveyor by the facility. During the review of the medications the following medication was on the list and the patient stated was no longer taking the medication: Amlodipine 10 mg 1 tablet daily. Discontinued about 3 weeks ago according the patient. A skilled nurse made a visit on 3/9/22 and the medication had been discontinued prior to the 3/9/22 visit and was not removed from the Medication List. The following medication was on the Medication List and not in the home: Zinc Sulfate 50 mg 1 capsule daily. The patient stated she should be taking it and ran out and has not gotten any more. An interview was conducted on 3/17/22 at 9:35 AM with EI # 6, who confirmed the medications should be reviewed on every visit and corrections should be made at that time. 2. MR # 9 was admitted to the agency on 1/15/22 with diagnoses including Epilepsy and Quadriplegia. Review of the SN visit note dated 2/23/22 revealed the nurse documented "...with Tracheostomy patent and conncted (connnected) to humidified O2 (oxygen)..." Review of the Home Health Certification and Plan of Care dated 1/15/22, Medications, revealed no order for Oxygen therapy. In an interview conducted on 3/16/22 at 4:30 PM, EI # 6, Process Improvement Coordinator, confirmed Oxygen was not listed on the medication list provided and there was no order documented for Oxygen therapy. 3. HV # 3 was admitted to the agency on 2/21/22 with diagnoses including Spinal Stenosis and Paroxysmal Atrial Fibrillation. Review of the Home Health Certification and Plan of Care dated 2/21/22 revealed orders for Physical Therapy 2 x a week for 6 weeks. A HV was conducted on 3/15/22 at 12:50 PM to observe care provided by EI # 11,Physical Therapist. EI # 9, Patient Care Manager, was also on the HV for observation. During the HV a review of the medications in the home were compared to the medication list provided to the surveyor on 3/15/22. Red Yeast Rice 600 mg dated 3/8/22 was in the home but not on the medication list. HV # 3 stated he/she had been taking the medication "for about 5 years". In an interview conducted on 3/15/22 at 1:50 PM, EI # 9, confirmed the medication was current but not on the Medication List. 1. HV # 1 was admitted to the agency on 2/8/22 with diagnoses including Arthritis Due to Other Bacteria, Vertebrae and Essential (Primary) Hypertension. A HV was conducted on 3/15/22 to observe Employee Identifier (EI) # 2, Registered Nurse perform a skilled visit. During the visit, the patient's medications were reviewed by the surveyor, EI # 2 and EI # 7, Patient Care Manager and compared to the Medicine List printed for the surveyor on 3/15/22 and the following discrepancies were observed: Loratadine 10 mg (milligram) tablet, one daily on the Medicine List and per HV # 1, "I don't take it that often. The last time was 6 months ago." Omeprazole 40 mg capsule, one capsule daily on the Medicine List and per HV # 1, "I stopped taking it 2 years ago." Ondansetron 4 mg disintegrating tablet, one every 8 hours as needed on the Medicine List and per HV # 1, "I have not taken it in about a year." Pennsaid 20 mg/gram/actuation (2%) Topical Solution in metered-dose pump topical 40 mg daily as needed on the Medicine List and per HV # 1, "I never had the medicine (in the home)." An interview conducted on 3/17/22 at 8:30 AM with EI # 1, Administrator confirmed the medication profile was not updated per agency policy.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of Medical Records (MR), agency policies and procedures and staff interviews it was determined the agency failed to ensure physician orders were followed for pulse oximetry, visit frequency, and wound care. This deficient practice did affect 3 of 17 MRs reviewed including, MR # 4, MR # 8, and Home Visit (HV) # 6 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Plan of Care (POC) Policy Number: 2.1.007 Revised Date: 12/1/21 Purpose: ...To ensure that physician/authorized practitioner's orders are followed. ...Procedure: ...2. The POC includes: ...All patient care orders... Agency Policy: The Role of the Physician Policy Number: 5.011 Revised Date: 11/1/21 ...Procedure: ...2...a. The agency's responsibilities to the physician: I. provides services to the patient only as ordered by the physician. Agency Policy: Dressing Change Procedure for Central Venous , Midline, and Peripherally Inserted Central Catheters Policy Number: 10.027 Revised: 10/01/2016 ...Procedure: ... 9. Cleanse the site with chlorhexidine (preferred) in a back and forth motion for at least 30 seconds. If povidone-iodine is used, use swabs to apply in a circular motion... 3. HV # 6 was admitted to the agency on 2/28/22 with diagnoses including Hypertensive Heart Disease, Heart Failure, and Encounter for Adjustment and Management of Vascular Access Device. Review of the HHC and POC dated 2/28/22 revealed orders including for the Skilled Nurse to perform site care for infusion access device to the right arm midline site weekly using sterile technique "cleanse site with alcohol swabs x 3..." Review of the Visit Note Reports dated 3/8/22 and 3/14/22 revealed the nurse documented the infusion access site was "cleansed with Betadine swabs x 3 followed by alcohol swabs x3..." There was no order documented to cleanse the site with Betadine. In an interview conducted on 3/17/22 at 9:30 AM EI # 8, PCM, confirmed there was no order documented for the use of Betadine. 1. MR # 4 was admitted to the agency on 1/14/22 with diagnoses including Aftercare following Joint Replacement surgery, Essential (Primary) Hypertension, and Dependence on Supplemental Oxygen. Review of the Home Health Certification (HHC) and POC dated 1/14/22 to 3/14/22 revealed documentation of a Physical Therapy (PT) frequency of 1wk1, 3wk1,1wk1 (once a week for 1 week, three times a week for 1 week) and a physician's order for "PT to perform pulse oximetry each visit in order to monitor patients respiratory status." Review of the PT Visit Note Reports (VNR) dated 1/14/22, 1/19/22 and 1/21/22 revealed no documentation a pulse oximetry reading was obtained. An interview was conducted on 3/16/22 at 3:51 PM with Employee Identifier (EI) # 7, Patient Care Manager (PCM), who confirmed there was no documentation a pulse oximetry reading was obtained on the above dates. 2. MR # 8 was admitted to the agency on 2/19/22 with diagnoses of Encounter for Orthopedic Aftercare following Surgical Amputation, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene and End Stage Renal Disease. Review of Client Coordination Note Report revealed documentation dated 2/17/22 the patient went to dialysis on Monday, Wednesday and Friday of each week Review of the HHC and POC dated 2/19/22 to 4/19/22 revealed a Skilled Nurse (SN) frequency of once a week for 9 weeks and a physician order for the "SN to assess wound VAC (Vacuum-assisted closure) dressing. No wound care/wound vac orders at this time. Patient to follow up with (physician identified)...on 2/22/22..." Review of the Client Coordination Note Reports revealed documentation of SN attempted visit on Friday 2/25/22 (week of 2/20/22 to 2/26/22) and Friday 3/4/22 (week of 2/27/22 to 3/5/22). There was no documentation the SN attempted to scheduled a visit for a day the patient was not at dialysis and/or reschedule the SN visit for the weeks of 2/20/22 to 2/26/22 and 2/27/22 to 3/5/22. An interview was conducted on 3/16/22 at 3:59 PM with EI # 7, who confirmed there was no documentation the SN attempted to complete the physician ordered visits for the above week on a day when the patient did not have dialysis and/or attempted to reschedule the SN visits.

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 Procedure and interviews, it was determined the agency failed to ensure the relevant physician was notified of Wound VAC (Vacuum-assisted closure) treatments not being provided in home. This deficient practice affected 1 of 5 MR with wounds including MR # 8 and had the potential to negatively affect all patients admitted to this agency. Findings include: Agency Policy: The Role of the Physician Policy Number: 5.011 Date revised: 11/1/21 Purpose: ...To describe the process of notifying the physician of these roles and responsibilities. Procedure: ...2...a. The agency's responsibilities to the physician: ...ii. provides the physician with accurate, complete, up to date information on the patient. ...notifies the physician of significant changes. 1. MR # 8 was admitted to the agency on 2/19/22 with diagnoses of Encounter for Orthopedic Aftercare following Surgical Amputation, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene and End Stage Renal Disease. Review of the Home Health Certification and Plan of Care (POC) dated 2/19/22 to 4/19/22 revealed documentation of "Skilled Nurse (SN) to assess wound VAC dressing. No wound care/wound VAC orders at this time. Patient to follow up with (physician identified)...on 2/22/22..." Review of the Client Coordination Note Reports revealed documentation of SN unsuccessful attempted visits on Friday 2/25/22 (week of 2/20/22 to 2/26/22), Friday 3/4/22 (week of 2/27/22 to 3/5/22) and Saturday 3/12/22 (week of 3/6/22 to 3/12/22). Further review of the Client Coordination Note Reports revealed the SN missed visit notifications for 2/25/22, 3/4//22 and 3/12/22 were sent to the patient's primary care physician for the agency. Review of the MR revealed no documentation the physician identified in the patient's POC following the wound VAC therapy was notified of the SN missed visits on 2/25/22, 3/4/22 and 3/12/22. An interview was conducted on 3/16/22 at 3:59 PM with EI # 7, Patient Care Manager, who confirmed there was no documentation the physician identified in the patient's POC who was following the wound VAC therapy was notified of the SN missed visits on 2/25/22, 3/4/22 and 3/12/22.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations, review of agency policies and procedures and interviews, it was determined the agency failed to follow their policy on infection control including hand hygiene (HH), PICC (Peripherally Inserted Central Cather) line care, venipuncture and cleaning of devices. This deficient practice affected 1 of 2 patients reviewed with a PICC line, including Home Visit (HV) # 1 and and 2 of 7 HV observations for hand hygiene, including HV # 7 and HV # 2 and had the potential to negatively affect all patients served by the facility. Findings include: Agency Policy: Hand Hygiene Policy Number 8.004 Revised Date 5/1/19 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 specified time points during, and following patient contact... Procedure: b. before performing an aseptic task (e.g., insertion of invasive devices,...) c. after contact with blood,... d. if moving from a contaminated body site to a clean body site during patient care. e. after contact with inanimate objects f. before and after removal of personal protective equipment (PPE).... Agency Policy: Dressing Change Procedure for Central Venous, Midline, and Peripherally Inserted Central Catheters Policy Number: 10.027 Revised Date: 10/1/16 Purpose: To keep insertion sites clean, stabilize catheters and minimize the risk of infection. Policy: ...Sterility will be maintained throughout this procedure... Agency Skills Quick Sheet: Blood Specimen Collection: Venipuncture Syringe Method Published Date: August 2021 31. ...perform hand hygiene, and don clean gloves. 34. Prepare the venipuncture site. a. Cleanse the site with friction using a gauze pad and 70% isopropyl alcohol solution. b. Allow the area to air-dry.... Do not touch the site after preparation unless sterile gloves are worn. Agency Policy: Infection Control Plan Policy Number 8.001 Revised Date 11/1/21 Purpose: To enhance the safety and quality of patient care provided by the agency... Policy: The agency will establish a comprehensive infection control program... Program Goals: ...Ensure proper sanitation of medical equipment, devices and supplies... 2. HV # 7 was admitted to the agency on 2/7/22 with admitting diagnoses of Abscess of The Breast and Nipple and Necrotizing Fasciitis. A HV was conducted on 3/16/22 with EI # 5, Licensed Practical Nurse (LPN) to observe wound care provided. On arrival to HV # 7's home EI # 5 was at his/her car with the trunk open. EI # 5 had gloves on and was obtaining supplies and bag from the trunk. EI # 5 entered the home with the gloves on used to close the trunk. EI # 5 entered the patient's bedroom and placed barriers on 2 chairs wearing the same gloves used to open and close the trunk of the car. After placing the 2 clean barriers on the chairs EI # 5 removed gloves and sanitized hands and donned clean gloves. EI # 5 placed the tablet for documentation on the dresser in a basket which contained the patient Home Health folder and other patient belongings without placing a barrier. EI # 5 donned clean gloves after sanitizing hands and removed the old dressing from the right breast area. EI # 5 disposed of old dressing, removed gloves and donned clean gloves and did not sanitize hands. EI # 5 cleaned the scissors and did not remove gloves or sanitize hands and cut the Alginate with scissors and placed on the wound using the same gloves to clean the scissors. EI # 5 removed gloves and sanitized hands. EI # 5 donned clean gloves and cleaned equipment and placed on the clean barrier. Once the cleaning of the equipment was complete, using the same gloves to clean the equipment EI # 5 picked up the clean equipment and placed in the nursing bag contaminating the equipment after cleaning. An interview was conducted with EI # 9, RN at 12:45 PM who confirmed EI # 5 should have changed gloves and sanitized after cleaning the wound, EI # 9 confirmed EI # 5 should have changed gloves and sanitized hands after cleaning the scissors and opening the Alginate and placing on the wound and prior to touching the clean equipment. 3. HV # 2 was admitted to the agency on 3/9/22 with admitting diagnoses of Essential Primary Hypertension and Unspecified Protein-Calorie Malnutrition. A HV was conducted on 3/15/22 at 9:07 AM with EI # 3, MSW (Medical Social Worker) to observe care provided. EI # 3 sanitized hands outside in the patient's yard and placed the bottle of hand sanitizer in pants pocket and then entered the home after opening the screen door and the front door with bare hands. EI # 3 then went to the patient's room and removed a barrier from the bag, placed barrier on a stack of items in the patient's room and placed the MSW bag on the barrier. EI # 3 did not sanitize hands after entering home and prior to placing the barrier on the stack of items. EI # 3 spoke with the patient at length and once the conversation was complete EI # 3 documented on the tablet. EI # 3 failed to sanitize hands prior to documentation on the tablet or after completion of the documentation. EI # 3 removed a garbage bag and from the MSW bag and placed the barrier in the partially opened garbage. EI # 3 went to the kitchen to talk with the caregiver and to sign the visit note in the tablet and the used barrier fell out of the garbage bag and on to the kitchen floor. EI # 3 picked up the barrier and again placed in the partially opened garbage bag and threw the bag in the home trash can. EI # 3 exited the home, removed the bottle of hand sanitizer from pants pocket and sanitized hands and placed bottle back in pocket. EI # 3 was heading to the car and the surveyor asked what EI # 3 was going to do with the tablet. EI # 3 said he/she was going to put it in his/her car, paused and stated the tablet would be cleaned and then removed an alcohol wipe and cleaned the tablet outside in the patient's yard and placed the used alcohol pad in the outside garbage can. An interview was conducted on 3/15/22 at 10:15 AM with EI # 1, Executive Director, who confirmed hand hygiene was not properly performed during the visit, The tablet should have been cleaned prior to use and after use in the home. 1. HV # 1 was admitted to the agency on 2/8/22 with diagnoses including Arthritis Due to Other Bacteria, Vertebrae and Essential (Primary) Hypertension. A HV was conducted on 3/15/22 to observe Employee Identifier (EI) # 2, Registered Nurse (RN) perform PICC line access and care and obtain blood specimens. EI # 7, Patient Care Manger (PCM) attended the visit with the surveyor. During the visit, EI # 2 performed HH and opened a sterile package containing individually wrapped sterile packages of supplies to perform PICC line care. EI # 2 placed a sterile barrier on the surface and without donning sterile gloves, removed the sterile packages from the sterile container and placed them on the sterile barrier. EI # 2 then performed HH and donned sterile gloves to open the sterile packages that were placed on the sterile barrier to complete PICC line care. EI # 2 then attempted to obtain a blood sample from the PICC line unsuccessfully and informed HV # 1 that a blood sample would be obtained from a venipuncture. EI # 2 doffed gloves, performed HH and cleaned the venipuncture site on the left hand with ChloraPrep and then touched the point of entry site with a gloved hand to palpate the vein. EI # 2 then performed a venipuncture attempt without re-cleaning the site. The attempt to obtain a blood sample was unsuccessful. EI # 2 then doffed gloves, performed HH, obtained clean venipuncture supplies, donned clean gloves and cleaned another site on the left hand with alcohol. EI # 2 then touched the cleaned area to palpate the vein and without re-cleaning the site, performed the venipuncture to obtain the blood sample, but was unsuccessful. Prior to ending the visit, EI # 2 cleaned the electronic device used to document the visit and handed the device to HV # 1 to sign the tablet and without cleaning the device, placed it in his/her pocket. An interview conducted on 3/15/22 at 2:15 PM with EI # 7 confirmed the nurse did not follow their policy for infection control including hand hygiene, PICC line care, venipuncture and cleaning reusable equipment.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on Medical Record (MR), Agency Policy and Procedure, and interviews, it was determined the agency failed to ensure the patients and/or caregivers (pt/cg) received education and training appropriate for care. This deficient practice affected 2 of 5 records reviewed with wounds including MR # 4 and HV (Home Visit) # 7, and 1 of 2 records reviewed with a PICC (Peripherally Inserted Central Catheter) line including HV # 1 had the potential to negatively affect all patients admitted to this agency. Agency Policy: Patient Education Policy Number: 3.001 Date Revised: 11/1/17 Purpose: To describe pt/cg interactions designed to promote and maximize patient health and safety. Policy: The agency plans, supports, and coordinates pt/cg education designed to promote optimal pt health and safety. Patients receive oral and/or written information for this purpose on an ongoing basis while being cared for by the agency. Procedure: ...3. The pt/cg receive ongoing information specific to the identified needs...including: b. Pt/cg Plan Of Care responsibilities. ...7. Using the progress/visit note, the clinician documents the level of pt/cg comprehension, pt/cg return demonstration of skill(s) taught... 3. HV # 1 was admitted to the agency on 2/8/22 with diagnoses including Arthritis due to Other Bacteria, Vertebrae and Essential (Primary) Hypertension. Review of the HHC and POC dated 2/8/22 revealed a Skilled Nurse (SN) frequency of 1WK9 (one time per week for 9 weeks) and orders to instruct pt/cg on administering the following medication Nafcillin 2 GM (Grams) IV (Intravenous) every 4 hours. Pt/cg to flush IV site with 10 ml (Milliliters) of Normal Saline before infusion and 10ml of normal saline and Heparin units/ml 3-5 ml after infusion. Instruct pt/cg regarding infusion procedure, care and use of infusion equipment and signs and symptoms of complications of IV therapy. Review of the VNR by the SN dated 2/8/22, 2/12/22, 2/15/22, 2/22/22, 3/1/222, and 3/8/22 revealed no documentation of pt/cg return demonstration of accessing of the PICC line, flushing the line and administering Nafcillin via PICC line. An interview conducted on 3/17/22 at 8:30 AM with EI # 1, Executive Director confirmed there was no documentation of a return demonstration of accessing of the PICC line, flushing the line and administering Nafcillin via PICC line per agency policy. 2. HV # 7 was admitted to the agency on 2/7/22 with admitting diagnoses of Abscess of The Breast and Nipple and Necrotizing Fasciitis. Review of the Certification and Plan of Care dated 2/7/22 revealed the following wound care orders: SN to perform/instruct/reinforce patient/caregiver procedure of wound care to RT (Right) breast. Cleanse with Dakins solution, apply silver Alginate, cover with dry gauze, secure with tape using clean technique... change daily. Instruct patient/caregiver signs/symptoms of wound infection and proper disposal of dressings. Review of the RN (Registered Nurse) OASIS dated 2/7/22 revealed no documentation of the specific education for wound care and no documentation of a return demonstration by the caregiver. Review of the SN visit notes dated 2/16/22, 2/21/22 and 2/23/22 revealed no documentation of a return demonstration by the caregiver or the patient for the wound care. Review of the physician order dated 3/4/22 revealed an order for wound care as follows: Right breast: May shower using liquid antibacterial soap or cleanse with normal saline, rinse well and pat dry, Cover with Silver Alginate. Change dressing daily and as needed. Cover and secure with ABD (Abdominal) pad or absorptive pad equivalent, may use incontinence pad as substitute. Secure in place with Medipore tape or may or may not use sports bra to hold dressing in place ensuring elastic band does not rub against wound. Review of the SN notes dated 3/9/22 revealed no documentation of the new wound care nor was there documentation of a return demonstration for the new wound care. An interview was conducted on 3/17/22 at 9:35 AM with EI # 6, Performance Improvement Coordinator, who confirmed there was no documentation of a return demonstration or of specific teaching. 1. MR # 4 was admitted to the agency on 1/14/22 with diagnoses including Aftercare following Joint Replacement surgery, Essential (Primary) Hypertension, and Dependence on Supplemental Oxygen. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 1/14/22 to 3/14/22 revealed documentation of a Physical Therapy (PT) frequency of 1wk1, 3wk1,1wk1 (once a week for 1 week, three times a week for 1 week) and a physician's order for "PT to provide/instruct/reinforce to pt/cg wound care to Right Knee Surgical wound daily. Cleanse with Antimicrobial Soap. Cover with Island Dressing. Review of the PT Visit Note Reports (VNR) revealed no documentation the PT provided education to the pt/cg on how to provide wound care and obtained a return demonstration of the wound care to ensure competency. An interview was conducted on 3/16/22 at 3:51 PM with Employee Identifier (EI) # 7, Patient Care Manager (PCM), who confirmed there was no documentation wound care education was provided to the pt/cg and a return demonstration was obtained.