Adoration Home Health

“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, review of the agency policy and procedure, and staff interview it was determined the agency failed to ensure the staff followed the policy for Hand Hygiene, Dressing change for Peripherally Inserted Central Catheters (PICC), and Cleaning of Re-Useable Equipment. This affected three of seven home visits (HV) to include HV # 5, HV # 7 and HV # 4, and has the potential to affect all patients served by this agency. 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 provide practice guidelines. Policy: The staff are required to perform hand hygiene prior to, and at specific time points during, and following patient contact... Procedure: 1. Staff performs hand hygiene by handwashing with soap and water or using alcohol-based hand sanitizer. a. before direct contact with patients... f. before and after removal of personal protectant equipment... Agency Policy: Dressing Change Procedure For Central Venous Midline, And Peripherally Inserted Central Catheters Policy Number: 10.027 Revised Date: 10/1/2016 Purpose: To keep insertion sites clean, stabilize catheters and minimize the risk of infection Policy: ...Sterility will be maintained throughout this procedure... Procedure: ... 7. Remove gloves, perform hand hygiene, and don sterile gloves... Agency Policy: Cleaning of Re-Useable Equipment Policy Number: 8.006 Revised Date: 6/1/25 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. Procedure: ...8. Stethoscopes are cleaned with a low-level disinfectant wipe before being returned to the staff bag, 9. Thermometers: ...Digital thermometers will be cleaned, after disposing of the disposable cover, with a low-level disinfectant. 10. Blood pressure cuffs are cleaned with a low-level disinfectant wipe before being returned to staff bag. 3. HV # 4 was admitted on 8/12/25 and recertified for continued care on 10/11/25 to 12/9/25 with a primary diagnosis of Encounter for Orthopedic Aftercare following Surgical Amputation. A HV was conducted on 11/19/25 at 8:37 AM to observe care provided by Employee Identifier (EI) # 6, SN. EI # 6 obtained blood pressure, temperature, pulse oximetry, and used stethoscope to listen to HV # 4’s heart and lungs. EI # 6 then placed equipment on barrier with clean equipment. EI # 6 then cleaned equipment with low-level disinfectant wipe, placed on barrier with dirty equipment, and returned equipment to staff bag. An interview was conducted on 11/20/25 at 10:30 AM with EI # 1, who confirmed staff failed to follow the agency policy and procedure for cleaning of re-usable equipment. 2. HV # 7 was admitted to the agency on 4/30/25 with a primary diagnoses of Chronic Venous Hypertension with Ulcer and Inflammation of Left Lower Extremity. Review of the plan of care (POC) dated 10/27/25 to 12/25/25 revealed an order for the left upper arm PICC line dressing change to be conducted weekly using sterile technique. A HV was conducted on 11/19/25 at 8:45 AM to observe the care provided by EI # 8, Registered Nurse. EI # 8 was observed using his/her sterile gloved left hand to reposition the patient’s extension tubing connected to the PICC line during the sterile PICC line dressing change. EI # 8 was also observed using their left hand to stabilize the PICC line while cleaning with his/her right hand. An interview was conducted on 11/20/25 at 10:40 AM with EI # 1, who confirmed the staff failed to follow the agency policy regarding dressing change procedure for peripherally inserted central catheters. 1. HV # 5 was admitted to the agency on 10/14/25 with a primary diagnosis of Hemiplegia following a Cerebral Infarction affecting Right Dominate Side. An observation was performed on 11/19/25 with Employee Identifier (EI) # 5, Certified Occupational Therapy Assistant to observe care provided. During the visit EI # 5, removed their gloves after cleaning vital sign equipment and continued to perform patient care without performing hand hygiene. An interview was conducted on 11/20/25 at 10:58 AM with EI # 1, Executive Director, who confirmed the staff failed to follow the agency policy regarding hand hygiene.”

“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 observations, medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure medications were reconciled each Skilled Nurse (SN) visit per agency policy. This deficient practice affected five of seven home visit (HV) patients including HV # 1, HV # 4, HV # 6, HV # 3, and HV # 2, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Medication Management 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: ...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: ...i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies. 5. HV # 2 was admitted to the agency on 9/22/25 with a primary diagnosis of Nondisplaced Fracture of the Proximal Phalanx of Right Index Finger. A HV was conducted on 11/18/25 at 1:30 PM to observe care provided by EI # 3, Physical Therapist. During the HV, EI # 3 reviewed the medications with HV # 2’s caregiver and compared the medications with the agency ML dated 11/18/25. The following is a list of the discrepancies: Glipizide 5mg by mouth daily was discontinued on 6/4/25 per the caregiver report. Glipizide was documented as an active medication on the agency ML. MiraLAX 17 gram daily as needed for constipation was not listed on the agency ML. A resumption of care was performed on 10/21/25 with an order for MiraLAX 17 gram as needed for constipation, and a recertification visit was performed by the SN on 11/17/25 and the medication was not added to the agency ML. An interview was conducted on 11/20/25 at 10:52 AM with EI # 1, who confirmed the staff failed to reconcile the patient medications per the agency policy. 4. HV # 3 was admitted to the agency on 7/12/25 with a primary diagnosis of Paroxysmal Atrial Fibrillation. A HV was conducted on 11/18/25 at 3:10 PM to observe the care provided by EI # 9, Licensed Practical Nurse. During the HV, EI # 9 reviewed the medications with HV # 3 and compared the medication with the agency ML dated 11/18/25. The following is a list of the discrepancies: Cefuroxime Axetil 500 milligrams (MG) one oral tablet every twelve hours for seven days for urinary tract infection (UTI) prescribed 10/8/25 is on the agency ML. HV # 3 stated he/she has not taken this medication since October. Hydrocodone 5 mg- Acetaminophen 325 mg one oral tablet every six hours as needed for pain above 5 on a 1-10 scale prescribed 2/3/25 is listed on the agency ML. HV # 3 stated he/she has not taken this medication in a long time. HV # 3 stated the medication was ordered only short term for pain control. Zinc 50 mg one oral tablet daily was found in home and was not listed on the agency ML. HV # 3 stated the medication was started in September to help with his/her immune system. Vitamin C 500 mg one oral tablet daily was found in home and was not listed on the agency ML. HV # 3 stated the medication was started in September to help with his/her immune system. An interview was conducted on 11/20/25 at 10:47 AM with EI # 1, who confirmed the staff failed to reconcile the patient medications per the agency policy. 1. HV # 1 was admitted on 10/25/25 with a primary diagnosis of Encephalopathy, unspecified. A HV was conducted on 11/18/25 at 12:06 PM to observe care provided by Employee Identifier (EI) # 4, Occupational Therapist. During the HV, EI # 4 reviewed the medications with HV # 1 and compared the medications with the agency Medicine List (ML) dated 11/18/25. The following is a list of the discrepancies: Entresto 24-26 mg tablet take 1 daily was on the ML, but Entresto 24-26 mg take 1/2 tablet twice a day was in the home and prescription was dated 8/25/25. HV # 2 stated he/she was currently taking Entresto 24-26 mg 1/2 tablet twice a day. Guaifenesin Extended Release 600 mg once daily was in the home and was not on the agency ML. HV # 1 said he/she had been taking about ten years. Mirtazapine 15 mg tablet at bedtime was on the agency ML and was not in the home. HV # 1 stated, “I don’t remember even taking it.” Amitriptyline 75 mg tablet at bedtime was on the agency ML and was not in the home. HV # 1 stated, “I haven’t taken it for three to four months.” Hydrocodone 5 mg-Acetaminophen 325 mg tablet, one tablet every six hours-take only as needed for severe pain was on the agency ML. Hydrocodone 5 mg-Acetaminophen 325 mg tablet, one tablet three times daily was in the home and the prescription was dated 8/4/25. HV # 1 stated he/she was currently taking Hydrocodone 5 mg-Acetaminophen 325 mg tablet three times daily. Ipratropium 0.5 mg-Albuterol 3 mg (2.5 mg base) 3 milliliters (ml) Nebulization Solution-Inhalation 3 ml three times a day was on the agency ML. HV # 1 stated, “I haven’t used that in three years.” Zaleplon 5 mg one capsule at bedtime as needed was in the home, and was not on the agency ML. HV # 1 said he/she was taking, but couldn’t remember when she had started and date on the prescription bottle was unreadable. An interview was conducted on 11/20/25 at 10:25 AM with EI # 1, Executive Director who confirmed the staff failed to reconcile the patient medications per the agency policy. 2. HV # 4 was admitted on 8/12/25 and recertified for continued care on 10/11/25 to 12/9/25 with a primary diagnosis of Encounter for Orthopedic Aftercare following Surgical Amputation. A HV was conducted on 11/19/25 at 8:37 AM to observe care provided by EI # 6, SN. During the HV, EI # 6 reviewed the medications with HV # 4 and compared the medications with the agency ML dated 11/18/25. The following is a list of the discrepancies: Aspirin 81 mg tablet, delayed release one tablet daily was on the agency ML and was not in the home. HV # 4 said he/she had not taken in about two months. Biotin10,000 micrograms (mcg) capsule once daily was on the agency ML and was not in the home. HV # 4 stated, “I have not taken that since last year.” Calcitrol 6.25 mg one capsule three times a week was on the agency ML and was not in the home. HV # 4 said he/she had not taken for approximately one month. Losartan 50 mg one tablet daily was on the agency ML. Losartan 100 mg one tablet daily was found in the home dated 11/14/25 on the prescription bottle. HV # 4 stated he/she was currently taking Losartan 100 mg one tablet daily. Metformin 500 mg one tablet daily was on the ML. Metformin 500 mg one tablet twice a day was in the home and prescription was dated 11/14/25. HV # 4 stated he/she was taking Metformin 500 mg one tablet twice daily. There were two nursing visits which were made on 11/15/25 and 11/17/25 prior to HV on 11/19/25. Proair Respiclick 90 mcg/Actuation Breath Activated-Inhalation was on the agency ML and was not in the home. HV # 4 stated he/she had not taken for years and years. Sulfamethoxazole 800 mg-Trimethoprim 160 mg tablet two times daily was on the agency ML and was not in home. HV # 4 stated this medication was discontinued on 11/14/25. There were two nursing visits which were made on 11/15/25 and 11/17/25 prior to HV on 11/19/25. Clopidogrel 75 mg one tablet daily was found in the home, dated 10/15/25 on the prescription bottle. There was no documentation of Clopidogrel on the agency ML. HV # 4 stated he/she was taking Clopidogrel 75 mg one tablet daily. An interview was conducted on 11/20/25 at 10:30 AM with EI # 1, who confirmed the staff failed to reconcile the patient medications per the agency policy. 3. HV # 6 was admitted on 1/7/25 and recertified for continued care on 11/3/15 to 1/1/26 with a primary diagnosis of Pressure Ulcer of Sacral Region, Stage 4. A HV was conducted on 11/20/25 at 8:03 AM to observe care provided by EI # 7, SN. During the HV, EI # 7 reviewed the medications with HV # 6 and compared the medications with the agency ML dated 11/19/25. The following is a list of discrepancies: Triad Wound Dressing Paste apply one centimeter around wound edges with wound care at least daily. May use twice a day if dressing requires changing twice due to urine saturation. Triad Wound Dressing Paste, dated 10/21/25 was on the agency ML, and was not in the home. An interview was conducted on 11/20/25 at 10:30 AM with EI # 1, who confirmed the staff failed to reconcile the patient medications per the agency policy.”

“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 a review of the medical record (MR), agency policy and procedure, and staff interview, it was determined the agency failed to ensure the staff notified the physician of any significant changes in measurement of the length of the peripherally inserted central catheter (PICC) as this may indicate migration of catheter, per agency policy. This deficient practice affected 2 of 2 MRs with PICCs reviewed including HV # 7 and MR # 1, and has the potential to negatively affect all the patients with PICCs served by the agency. Findings include: Agency policy: Dressing Change Procedure for Central Venous, Midline, and Peripherally Inserted Central Catheters. Policy Number: 10.027 Date Revised: 10/01/2016 Procedure: 8. Inspect catheter, catheter exit site, and surrounding skin and patient’s arm, chest, and neck area …d. Measure external length of catheter from the insertion site to the catheter hub. Notify Physician of any significant findings in measurement as this may indicate migration of catheter… 2. MR # 1 was admitted to the agency on 6/5/25 with a primary diagnosis of Type Two Diabetes Mellitus with Foot Ulcer. A review of the SN Visit dated 10/13/25 revealed the staff documented a PICC in the right upper extremity with an external catheter measurement of 1 CM. A review of the SN Visit dated 10/15/25 revealed the staff documented the external catheter measurement of 11.5 CM. There was no documentation the physician was notified of the 10.5 CM increase in the external catheter measurement. An interview was conducted on 11/20/25 at 11:05 AM with EI # 1, who confirmed there was no documentation the SN notified the physician of the significant change to the PICC measurement per policy 1. HV # 7 was admitted to the agency on 4/30/25 with a primary diagnoses of Chronic Venous Hypertension with Ulcer and Inflammation of the Left Lower Extremity. Review of the Skilled Nurse (SN) Visit dated 10/29/25 revealed an external left upper arm PICC measurement of 1.5 centimeters (CM). Review of the SN Visit dated 11/8/25 revealed an external left upper arm PICC measurement of 0 cm. There was no documentation found in the medical record of the provider being notified of the change in the external PICC length by the SN. Review of the SN visit dated 11/12/25 revealed an external left upper arm PICC measurement of 5 cm. There was no documentation found in the medical record of the physician being notified of the change in the external PICC length by the SN. An interview was conducted on 11/20/25 at 10:40 am with the EI # 1, Executive Director, who confirmed there was no documentation the SN notified the physician of the significant change to the PICC measurement per policy.”