Every finding on record at La Providencia Home Health Care Inc

An unannounced Recertification and Emergency Preparedness survey was conducted by the Puerto Rico State Agency surveyors at Arecibo Medical Home Care on February 4, 2025 (Event ID: 65414-H1) from 8:30 AM till 11:30 AM. As results of finding the facility was found to be in compliance with 42 CFR Part 484.102 Emergency Preparedness Requirements for Home Health Agency. However, four (4) standard level deficiencies were cited as listed below:

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 02/04/2025 at 8:30 AM through 11:30 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to have a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings include: During the review of the facilities Emergency Preparedness Program with the Executive Directors Assistant (employee #3) on 02/04/2025 at 9:00 AM it was noted that the facility failed to perform a risk assessment using ALL Hazard Approach, understanding community based risk and vulnerability.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 02/04/2025 at 8:30 AM through 11:30 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain updated contact information for the following: Federal, State, tribal, regional or local emergency preparedness staff and other sources of assistance. Findings include: During the review of the facilities Emergency Preparedness Program with the Executive Director Assistant (employee #3), it was noted that the facility failed to provide evidence of the Emergency Preparedness Communication Plan that included updated contact information for Federal, State, tribal, regional or local emergency preparedness staff and other sources of assistance.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on an Emergency Preparedness Program (EPP) survey performed on 02/04/2025 at 9:30 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan. Findings include: During the review of the facilities Emergency Preparedness Program with the Executive Director Assistant (employee #3), it was noted that the EP failed to develop and maintain an emergency preparedness training and testing program based on the facilities risk assessment.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on an Emergency Preparedness Program (EPP) survey performed on 02/04/2025 at 9:30 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to train in emergency preparedness policies and procedures to all new and existing employees, and individuals providing services under arrangement, consistent with their expected roles. Findings include: During the review of the facilities Emergency Preparedness Program with the Executive Director Assistant (employee #3), it was noted that the facility failed to provide documentation of training on emergency preparedness policies and procedures to all new and existing staff.

A Standard Recertification survey was conducted on February 4 through February 6, 2025, from 8:00 AM through 4:00 PM by the Puerto Rico State Agency surveyors at the Arecibo Medical Home Care (Event ID: 65414-H1), with ten (10) records reviewed and seven (7) home visits. As results of the findings, the facility was found in compliance with 42 CFR §484 Requirements for Home Health Agency with the following Standard level deficiencies listed below: Survey Date: 02/06/2025 Survey Census: 256 patients Sample Size: 17 Home Visits: 7 Record Review: 5 Closed Record Review Discharge: 5

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview and police and procedure reviewed, seven (7) home visits (H.V) performed on 02/04/2025 in company of facility Registered Nurse (employee #5, #6 and #7), it was determined that the facility failed to ensure that the Registered Nurse (RN) follows standard practice precautions to prevent the transmission of infectious agents for 3 out of 7 home visits during the urinary catheter insertion procedure and local ulcer care. (H.V #1, H.V #2 and H.V #5). 2. HV #1 is a 79-year-old female admitted on 12/21/2025 with a diagnosis of Hypertension, Alzheimer disease, Sacral ulcer stage III. The patient was visited on 02/04/2025 at 10:25 AM until 11:25 AM accompanied by the facility billing clerk (employee #1) and the register nurse (employee #7). During the visit it was observed that the patient was lethargic, not conscious, bedridden and totally dependent on activities of daily living. The patient has one Sacral Ulcer Stage III that is cleaned every 3-4 days. The patient was receiving a visit from the (employee #7) to provide ulcer care. This visit was the first of the week. The facility's nursing supervisor (employee #2), provided the policy and procedure named “MEDICION DE LA ULCERA” Ulcer Measure, on 02/04/2025 at 2:30 PM, was reviewed and states on page #2 in the procedure area, item #3 to take the ulcer measurement at the first visit of the week. a) It was observed that during the ulcer treatment procedure, Employee #7, completed the treatment process and did not perform the measurements. 3. HV #2 is a 79-year-old male admitted on 02/04/2021 with a diagnosis of Benign prostatic hyperplasia with lower urinary tract symptom, other retention urine, Type 2 Diabetes Mellitus. The patient was visited on 02/04/2025 at 11:56 AM until 1:10 PM accompanied by the facility billing clerk (employee #1) and the register nurse (employee #5). During the visit it was observed that the patient was alert, oriented in person, place and time, bedridden and totally dependent on ADL’s and dependent on urinary catheter for 5 years, with medical orders to change every 21 days. The patient was receiving a visit from the employee #5 to provide a change of urinary catheter. The facility provided the policy and procedure named “USO DE GUANTES NO ESTERILES”, Use of Non Sterile Gloves, it was reviewed on 02/05/2025 at 2:58 PM and states in section #3 that handwashing with soap and water or dry cleaning will be performed before putting on gloves, between changing gloves during the visit and when removing them. a) It was observed that after inserting the urinary catheter, Employee #5 removed her gloves and put on clean gloves without washing her hands, then proceeded to fix the urinary catheter on his right thigh. Finding include: 1. HV #5 is an 89-year-old male with SOC on 11/09/2024 with a diagnosis of obstructive uropathy and urine retention. The patient was visited on 02/04/2025 at 12:04 PM until 12:45 PM accompanied by a registered nurse from the facility (employee #6). During the visit the patient was observed to be alert and oriented, bedridden and fully dependent for activities of daily living. The patient has an indwelling urinary catheter with a physician's order for a change every 15 days. The patient was being visited by Employee #6 to provide the urinary catheter change. The facility provided a policy named “USO DE GUANTES NO ESTERILES” Use of Non Sterile Gloves, that was reviewed on 02/05/2025 at 2:58 PM, states in sentence 3 that the employee shall perform hand washing with soap and water or hand sanitizer before putting on gloves, between glove changes during the visit, and upon glove removal. a) Employee #6 was observed changing gloves 4 times after the urinary catheter insertion procedure, without washing her hands with soap and water or hand sanitizer. b) Employee #6 failed 4 of 7 opportunities to wash her hands with soap and water or hand sanitizer.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on review of the registered nurse educations (employee #5 and #6) conducted on 02/05/2025 at 2:10 PM with the Executive Director Assistant (employee #3), it was determined that the facility failed to provide assessment and education on nursing procedures, specifically for urinary catheter insertion. 2. Employee #5 educational and qualification record was reviewed on 02/05/2025 at 2:40 PM accompanied by employee #3 and it was determined that the facility did not provide an evaluation and education of the procedure of the urinary catheter insertion. 1. Findings include: 1. Employee #6, educational and qualification record was reviewed on 02/05/2025 at 2:10 PM accompanied by employee #3 and it was determined that the facility did not provide an evaluation and education of the procedure for the urinary catheter insertion.

An unannounced Emergency Preparedness (EP) survey was conducted by the Puerto Rico State Agency surveyor at Arecibo Medical Home Care on February 15 through 17, 2022. (Event ID 3855F-H1) As results of finding during the EP survey the facility was found in compliance with 42 CFR §484.102 requirements for Home Health Agency (HHA) facilities. Survey Date: 02/17/2022 Patient Census: 264

An unannounced abbreviated COVID-19 Focused Survey for Acute and Continuing Care Providers/ Emergency Preparedness and a Recertification was conducted by the Puerto Rico State Agency surveyor at Puerto Rico Home Health, on February 15 through 17, 2022. (Event ID 3855F-H1). As results of finding during the COVID-19 and Recertification survey resulted in a finding of substantial compliance with 42 CFR §484 the requirements for Home Health Agency (HHA) with the following standard-level deficiencies listed below: Survey Date: 02/15/2022 through 02/17/2022 Patient Census: 264 Home Visits: 7 Records Reviewed: 5 Close Record Review: 5 PUI-0 COVID-19 Positive Cases -0 Staff PUI- 0 Staff Positive COVID-19- 0 Staff Covid 19 Vaccine (3) doses or reinforce: 25 out of 41 (61%). Staff Covid 19 Vaccine (2) doses: 16 out of 41 (39 %). During the COVID- 19 Focused Infection Control Survey: Acute and continuing Care performed on 02/15/2022 through 02/17/2022 it was found that: The Facility have a sign posted in the entrance door that indicate to the personnel and visitor that it mandatory the use face mask, social distance of 6-foot hand wash, and if sick stay home. In the entrance facility have a screening process at the lobby that all personnel and visitor must take the temperature and registered and wash their hand. The facility failed to ask to the personnel or visitor and patient related to exposure to COVID, screening question and assess symptom. The facility visitor staff ask to the patient and relative the COVID 19 screening question and assess symptom, however no to all home visit performed with the surveyors. The staff was train related to question to ask and action to take to rapidly identify and isolate suspect COVID- 19 case. Facility provides evidence of policies and procedure related to Plan of Control of Exposition to COVID. The facility was taking the temperature to visitor before entering to the facility. Facility has a COVID 19 exposition Control Plan that cover all standard precaution and have policies and procedure for cleaning and disinfection of the non-critical equipment. Facility provides to all personnel, soap, paper towel, hand sanitizer and Personal Protective Equipment (PPE). During the Home visit performed on 02/15/2022 and 02/16/2022 with Nursing Services (RN), License Practice Nurse (LPN) and Physical Therapist Assistance (PTA), it was observed that personnel used adequate the PPE and performed Hand Washing in the entrance and outside of patient home and during ulcer care procedure wash the hand with hand sanitizer between glove change and change their glove when going from contaminated area to clean area. The facility did not reuse the PPE. The facility Clinical Manager stated on 02/16/2022 that they have enough PPE to cover 3-4 months. During interview with the personnel on 02/15/2022 through 02/17/2022, that performed the home visits, they stated that the facility provides weakly supply to them the PPE that's needed for all week and if need supplies, they call the clinical manager and he/she supply's more PPE if they need. The visitor personnel oriented all resident related to COVID- 19 and the precaution to not be infected. No patient with COVID 19 or suspected. The facility failed to document in the patient record the assessment of question related to exposure to COVID 19, screening question and assessment symptom. The facility personnel use PPE during facility environment cleaning.

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 re-certification survey, seven home visit (H.V) with records reviewed and ten records reviewed (R.R) with the agency clinical manager (employee #1), it was determined that the agency failed to ensure that professional services by the Registered Nurse (RN) and License Practical Nurse (LPN) was performed according of accepted standards of practice to prevent the transmission of infections and communicable diseases for 2 out of 7 home visit (H.V. #4 and #5). Findings include: 1. H.V. #4 is a 78 years old female who was admitted on 10/30/2021 with a principal diagnosis of Pressure Ulcer Sacral Region Stage 4. The patient was visit on 02/16/2022 at 9:00 AM. to evaluate the bed bath with the visiting LPN (employee #2) and the Home Health Clinical Manager (employee #1). The following was observed during the home visit: a. The employee #2 did not performed the COVID - 19 screening questions and assessment before to start the batting process. b. The employee #2 failed to close door to the patient's room for patient privacy during providing the bed bath. c. The Home Health Aide (HHA ) employee #2 prepare the materials before performed the hand washing. She put a robe, but she did not tie the cords and they stay loose and touch the floor. She disinfected the non-critical equipment removed her gloves and wash her hands with alcohol. She takes the vital signs to the patient at the end of the process of taking vital signs removed her gloves discard and applied alcohol. The employee #2 initiated and ended the bed bath with only with one water basin. Washed the head, neck, thorax, upper and lower limbs, feet, genital area and then rinsed from the head to the feet, removed gloves and discarded gloves, then put on gloves and added the back, buttocks, and posterior area of the lower limbs and rectum. Removed gloves applied alcohol and put a pair of gloves. She removed a gastrostomy bandage and offered local care with wound cleanser three times covered with clean gauze and fixed with adhesive tape. When finish dry front to back of the body. d. The HHA employee #2 did not performed the bed bath according of the bed bath procedure from the beginning to the end. 2. H.V. #5 is a 90 years old female who was admitted on 01/14/2022 with a principal diagnosis of Unilateral Primary Osteoarthritis Right Knee. The patient was visit on 02/15/2022 at 4:30 PM. to evaluate the physical therapy exercises accompanied by the Clinical Manager (employee #1). a.The physical therapy assistant (employee #3) wash her hands with soap and water and dry. Then she put on a gown, mask and face shield, put on the patient bed a blue pad, when she took the thermometer out of the briefcase the thermometer fell on the floor, she picked up and placed it on top of the blue pad, she did not disinfected it, then she did not wash her hands put on a pair of gloves and proceeded to disinfect the thermometer, stethoscope and sphygmomanometer with Lysol towels. Then she removed her gloves and discard applied and clean her hands with alcohol put a pair of gloves and took vital signs, then removed her gloves, discard, applied alcohol and put a pair of gloves to initiate a physical therapy exercises to the patient. b. The physical therapy assistant (employee #3) failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases. This practice place risk of cross contamination.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on a Standard rectification survey, performed on 02/15/2022 through 02/17/2022, three (7) Home visit with record review, ten record review with the Executive Director Assistant employee #4, it was determined that the facility failed to ensure that the clinical records contain complete clinical current findings for each home health patient related to ulcer measure documentation for 1 out of 17 record review. (H.V #3). Findings include: 1. H.V. #3 is a 79-year-old male who was admitted on 11/27/2021 with a diagnosis of Pressure Ulcer of Sacral Region Stage III according with the record review performed on 02/16/2022 at 3:00 pm, with the Executive Director Assistant employee #4 was found the following: Patient Plan of Care (485) establish Registered Nurse (RN) Services 3 visit per weeks for 9 weeks and indicate Pressure ulcer measure weakly. During the week of 01/9/2022to 01/15/2022, the RN visit the patient to provide ulcer care on 01/10/2022, on 01/12/2022, and on 01/14/2022, however no evidence was found in the nursing progress note related to the ulcer measure during this week. The RN failed to follow physician order to measure the ulcer weakly.