Troy Regional Medical Center 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 observations, agency policies and procedures, and staff interviews, it was determined the agency failed to ensure staff: 1. Maintained sterility throughout the Peripherally Inserted Central Catheter (PICC) Line dressing change. 2. Followed agency policy for cleaning the PICC Line site. 3. Performed hand hygiene per agency policy. This did affect two out of five home visits (HV), including HV # 1, HV # 5, and had the potential to affect all persons served by this agency. Findings Include: Policy: Dressing Change Procedure For central Venous, Midline, And Peripherally Inserted central Catheters Policy Number: 10.027 Revised Date: 03/01/26 Purpose: To keep insertion sites clean, stabilize catheters and minimize the risk of infection. Policy: ...Sterility will be maintained throughout this procedure... Procedure: ...6. Remove old dressing... b. Remove catheter securement device and chlorhexidine-impregnated sponge... 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, moving from the catheter insertion site outward in concentric circles... 12. Secure the catheter in place. The use of a sutureless stabilization device is preferred to tape and sutures. Agency Policy: Hand Hygiene Policy Number: 8.004 Revised Date: 5/01/19 Purpose To help prevent the spread of microorganisms and infection by cross-contamination and to provide practice guidelines. Policy: Staff are required to perform hand hygiene prior to, at specified time points during, and following patient contact. Hand hygiene will be performed using soap and water or an alcohol-based hand sanitizer. Procedure: 1. Staff performs hand hygiene... b. Before performing an aseptic task ( ergo [e.g.], insertion of invasive devices, wound care). c. after contact with blood, body fluids or excretions, mucous membranes, non-intact skin, wound dressings, or contaminated surfaces. d. if moving from a contaminated body site to a clean body site during patient care. e. After contact with inanimate objects (including medical equipment... f. Before and after removal of personal protective equipment (PPE). g. At the conclusion of the visit after contact with a patient’s intact skin, ( e.g., when taking vital signs, and lifting a patient)... Other aspects of Hand Hygiene: a. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin could occur... c. Change gloves during patient care if moving from a contaminated body site to a clean body site. 2. HV # 5 was admitted to the agency on 3/19/26 with diagnoses including Pressure Ulcer Left Buttock, Unstageable and Encounter for Surgical Aftercare Following Surgery on the Skin Subcutaneous tissue. A review of the POC revealed SN visits once a week for nine weeks. A HV was conducted on 4/8/26 at 9:40 AM to observe EI # 2, Registered Nurse (RN), provide wound care. During the HV, the following was observed: a. EI # 2, failed to perform hand hygiene three times when performing wound care. b. EI # 2 cleaned the wound with wound cleanser and gauze then removed gloves. EI # 2 failed to perform hand hygiene after removing gloves. EI # 2 then donned clean gloves, measured the wound, obtained clean wound care supplies, performed wound care, then returned the unused wound care supplies to area where the clean wound care supplies were stored. EI # 2 removed gloves and without performing hand hygiene initialed and dated the wound dressing, measured the patients ankles, obtained cleaned equipment used during the visit and placed the clean equipment in the agency bag which contaminated the clean equipment. An interview was conducted on 4/9/26 at 2:37 PM with EI # 5, who confirmed staff did not perform hand hygiene per agency policy. 1. HV # 1 was admitted to the agency on 10/26/26 with diagnoses including Pressure Ulcer of Sacral Region Stage 4 and Pressure Ulcer of Left Buttock, Stage 3. A review of the Plan of Care (POC) for the certification period of 2/1/26 to 4/18/26 revealed skilled nurse (SN) visits were ordered one visit weekly for eight weeks, two visits every week for one week, and lastly one visit every week for one week. A HV was conducted on 4/7/26 at 1:08 PM with Employee Identifier (EI) # 6, Dothan Executive Director (ED) to observe the care provided by EI # 1, Registered Nurse. During the HV the following was observed: a. EI # 1 was observed to contaminate the sterile field during PICC line dressing change set up by opening a nonsterile normal saline flush labeled “do not place on a sterile field,” on to the sterile field. b. EI # 1 failed to clean under the sutureless stabilizing device during the PICC line dressing change. A interview was conducted with EI # 5, Troy ED on 4/9/26 at 3:04 PM who confirmed that sterility was not maintained throughout the PICC line dressing changed, and proper cleaning techniques were not used while cleaning PICC line site.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on medical record (MR) review, agency policy and procedure, and interviews it was determined the agency failed to ensure the comprehensive assessments were completed within five days of the Start of Care (SOC). This deficient practice affected two of three MR’s reviewed including, home visit (HV) # 3, and MR # 4 and had the potential to negatively affect all patients admitted to this agency. Findings include: Agency Policy: Patient Assessment, Initial and Reassessment Policy Number: 2.1.002 Revised: 9/1/24 ...Policy: All patients admitted to the agency will receive an initial assessment...by a staff Registered Nurse, Speech Therapist, Physical Therapist, or Occupational Therapist...OASIS (Outcome and Assessment Information Set) comprehensive assessments are completed at patient admission... Procedure: ...d. Physical Therapist, Speech Therapist, Occupational Therapist, ...may make initial evaluations of the patient status to determine the need for specific therapies. This initial discipline specific evaluation(s) will occur within 5 days from the SOC date... 1. HV # 3 was admitted on 1/15/26 and recertified for continued care from 3/16/26 to 5/14/26 with diagnoses including Hypertensive Heart Disease with Heart Failure and Acute Systolic (Congestive) Heart Failure. A review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/11/26 revealed physician’s orders for Occupational Therapy (OT) one visit a week for one week, and Physical Therapy (PT) to evaluate/assess and develop Physical Therapy plan of care that will be approved by the physician prior to implementation. A review of the MR revealed no documentation the OT or PT assessments were performed within the five days of SOC. An interview was conducted on 4/9/26 at 2:39 PM with Employee Identifier (EI) # 5, Executive Director, who confirmed the agency failed to ensure all comprehensive assessments were completed within five days of the SOC. 2. MR # 4 was admitted on 1/24/26 with diagnoses including Aftercare Following Joint Replacement Surgery and Prescence of Artificial Knee Joint, Bilateral. A review of the HHC and POC dated 1/24/26 revealed physician’s orders for OT one visit a week for one week. A review of the OT Add-On-Evaluation Visit Note Report dated 2/23/26 revealed the OT initial assessment was completed thirty days after the SOC. An interview was conducted on 4/9/26 at 2:40 PM with EI # 5, who confirmed the agency failed to ensure all comprehensive assessments were completed within five days of the SOC.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, observations, and staff interviews, it was determined the agency failed to ensure patient medication profiles were accurate. This deficient practice affected five of five home visits (HV) including HV # 1, HV # 4, HV # 2, HV # 5, and HV # 3, and had the potential to affect all persons served by the agency. Findings include: Agency Policy: Monitoring Medications Policy Number:10.008 Revised Date: 4/01/26 Purpose: To provide a process to ensure continuous monitoring of all medications the patient is currently taking. Policy: A drug regimen 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: 1. The discipline responsible for the drug regimen review will: a. Compare medication list obtained from the facility from which the patient was transferred and/or physician orders to actual medications patient is taking. b. Review all medications including over the counter (OTC) medications, vitamins, ... 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... 5. HV # 3 was admitted on 1/15/26 and recertified for continued care from 3/16/26 to 5/14/26 with diagnoses including Hypertensive Heart Disease with Heart Failure and Acute Systolic (Congestive) Heart Failure. A review of the POC dated 3/11/26 revealed physician’s orders for SN one visit a week for nine weeks, OT one visit a week for one week, and Physical Therapy (PT) to evaluate/assess and develop Physical Therapy plan of care that will be approved by the physician prior to implementation A HV was conducted on 4/7/26 at 2:03 PM to observe care provided by EI # 4, Physical Therapy Assistant. During the HV, a review of the CMR revealed the following discrepancies: a. Benzonate 200 MG capsule, take three times a day was noted on the CMR. Benzonate 100 MG capsule, take 3 three times daily as needed was in the home dated 10/29/25. b. Hydrocodone-Acetaminophen 5-325 MG one tablet every six hours as needed for pain was found in home with a fill date of 3/27/26. There was no documentation of the Hydrocodone-Acetaminophen on the agency CMR. c. Megestrol 400 MG/10 ML oral suspension, take 3 ML two times daily as needed was on the CMR. Megestrol 5 ML take two times daily was in the home dated 3/31/26. d. Quetiapine 150 MG tablet, one tablet daily was listed on the CMR. Quetiapine 25 MG tablet, take one tablet daily was in the home dated 2/20/26. e. Terbinafine Hydrochloric Acid 250 MG tablet, take one tablet every twelve hours was listed on the CMR. Terbinafine HCL 250 MG tablet, take one tablet daily was in the home dated 3/8/26. f. Albuterol 0.083% Nebulizer, use one vial in nebulizer three times a day was in the home with a fill date of 3/8/26. There was no documentation of the Albuterol on the agency CMR. An interview was conducted on 4/9/26 at 2:39 PM with EI # 5, who confirmed staff failed to keep the medication profile current. 3. HV # 2 was admitted to the agency on 1/29/26 with diagnoses including Aftercare Following Joint Replacement Surgery and Complete Rotator Cuff Tear/Rupture of Right Shoulder, not Trauma. A review of the POC for the certification period dated 3/30/26 to 5/28/26 revealed Occupational Therapy (OT) visits were ordered two times a week for four weeks. A HV was conducted on 4/7/26 at 1:26 PM to observe care provided by EI # 7, OT. During the HV, a review of the CMR revealed the following discrepancies: a. Duloxetine 30 MG delayed release capsule, take one daily by mouth as needed. HV # 2 stated she/he “does not recognize this medication” and it is not present in the home. b. People’s Choice Women’s Daily Vitamin with Iron, take one tablet as needed daily. HV # 2 stated she/he has taken this vitamin for a while. An interview was conducted on 4/9/26 at 2:27 PM with EI # 5, who confirmed staff failed to keep the medication profile current. 4. HV # 5 was admitted to the agency on 3/19/26 with diagnoses including Pressure Ulcer Left Buttock, Unstageable and Encounter for Surgical Aftercare following Surgery on the Skin and Subcutaneous Tissue. A review of the POC for the certification period 3/19/26 to 5/17/26 revealed SN visits were ordered once a week for nine weeks. A HV was conducted on 4/8/26 at 9:40 AM to observe wound care provided by EI # 2, RN and accompanied by EI # 6. During the HV, a review of the CMR revealed the following discrepancies: a. Vitamin C, take one a day, was not listed on the CMR and was in the home with a fill date of 3/19/26. b. Vitamin D, take one a day, was not listed on the CMR and was in the home with a fill date of 3/19/26. An interview was conducted on 4/9/26 at 2:37 PM with EI # 5 who confirmed staff failed to keep the medication profile current. 1. HV # 1 was admitted to the agency on 10/26/26 with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 and Pressure Ulcer of Left Buttock, Stage 3. A review of the Plan of Care (POC) for the certification period of 2/1/26 to 4/18/26 revealed skilled nurse (SN) visits were ordered one visit weekly for eight weeks, two visits every week for one week, and lastly one visit every week for one week. A HV was conducted on 4/7/26 at 1:08 PM with Employee Identifier (EI) # 6, Dothan Executive Director (ED) to observe care provided by EI # 1, Registered Nurse (RN). During the HV, A review of the Client Medication Report (CMR) revealed the following discrepancies: a. Amitriptyline 10 milligrams (MG) take one tablet by mouth three times daily, was not listed on the CMR and was found in the home with a fill date of 1/15/26. b. Verapamil 80 MG take one tablet by mouth three times daily, was listed on the CMR as 40 MG. Verapamil 80 MG was found in the home with a fill date of 1/15/26. c. Clindamycin 400 MG one scoop in 30 milliliters (ML) of solution. Shake and spray wound1-2 times daily during dressing change, was not listed on the CMR and was found in home with a filled date of 2/25/26. d. Levofloxacin 750 MG one scoop in 30 ML of solution. Shake and spray wound 1-2 times daily during dressing change, was not listed on the CMR and was found in home with a filled date of 2/25/26. An interview was conducted on 4/9/26 at 3:04 PM with EI # 5, Troy ED who confirmed staff failed to keep the medication profile current. 2. HV # 4 was admitted to the agency on 4/4/26 with a diagnosis of Hypertensive Chronic Kidney Disease with Stage 1-4, Unspecified Chronic Kidney. A review of the POC for the certification period of 4/4/26 to 6/2/26 revealed SN visits were ordered two visits a week for one week, three visits a weeks for one week, and finally one visit a week for eight weeks. A HV was conducted on 4/8/26 at 10:33 AM to observe care provided by EI # 3, RN. During the HV, a review of the CMR revealed the following discrepancies: Dilt-XR 120 MG capsule take one capsule by mouth daily, was listed on the CMR and was not found in the home. HV # 4 stated he/she did not know anything about that medication and did not know when he/she had last taken the medication. An interview was conducted on 4/9/26 at 2:22 PM with EI # 5 who confirmed staff failed to keep the medication profile current.”