Clay County Hospital Home Care, LLC

“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 policy and procedure, CDC (Centers for Disease Control) Hand Hygiene in Healthcare Settings Health Providers, and staff interviews, it was determined the agency failed to ensure staff performed hand hygiene per agency policy. This did affect two of three home visits (HV) including HV # 3 and HV # 1 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Hand Hygiene Policy Number: 8.004 Date Revised: 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: 1. Staff performs hand hygiene... a. Before contact with patients b. Before performing an aseptic task (... wound care). c. After contact with 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 in the immediate vicinity of the patient. 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, (ergo, when taking vital signs...)... 8. Other Aspects of Hand Hygiene: ... Change gloves during patient care if moving from a contaminated body site to a clean body site... CDC Hand Hygiene in Healthcare Settings Healthcare Providers Date: 1/18/23 Glove Use- When and How to Wear Gloves: Gloves are not a substitute for hand hygiene. ... perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves. 2. HV # 1 was admitted to the agency on 3/28/25 and recertified for care on 11/23/25 with a primary diagnosis of Varicose Veins of Right Lower Extremity with Both Ulcer of Ankle and Inflammation. A review of the Home Health Certification and POC revealed an order for SN visits two times a week for eight weeks. Further review of the MR revealed a physician’s order for wound care dated 12/2/25 for wound care to the right ankle daily, cleanse with wound cleanser and gauze, pat dry with gauze, apply Medi-honey to wound bed and cover with foam dressing, wrap with Coban. A HV was conducted on 12/16/25 at 11:00 AM with EI # 2, RN, to observe wound care provided. During the HV, EI # 2 failed to perform hand hygiene prior to entering the bag to obtain supplies two times, prior to donning gloves two times, obtained wound supplies from a box on the floor and while wearing the same pair of gloves, cleansed the wound with wound cleanser. After completing wound care and while wearing the same pair of dirty gloves, EI # 2 retrieved his/her pen to initial and date the dressing, removed the dirty gloves and did not perform hand hygiene. An interview was conducted on 12/17/25 at 1:21 PM with EI # 1, who confirmed the staff failed to perform hand hygiene per agency policy. 1. HV # 3 was admitted to the agency on 5/21/25 and recertified for continued care on 11/17/25 with a primary diagnosis of Type Two Diabetes Mellitus with Foot Ulcer. A review of the Home Health Certification and Plan of Care (POC) revealed an order for Skilled Nursing (SN) two times a week for nine weeks. Further review of the Medical Record (MR) revealed a physician’s order for wound care to the right plantar foot; cleanse with soap and water, Vashe wound cleanser, apply silver alginate dressing to the wound bed and then secure with gauze and tape three times weekly. Back wound: cleanse with soap and water, then Vashe wound cleanser, and pack with one quarter inch packing strips moistened with Vashe, cover with gauze and tape two times a day. An observation was conducted on 12/17/25 at 8:56 AM with Employee Identifier (EI) # 3, Registered Nurse (RN) to observe wound care. During the observation EI # 3 prepared supplies for wound care with clean gloves without performing hand hygiene prior to donning. EI # 3 obtained a basin of water for wound care. EI # 3 completed each task of the wound care to the rt foot and changed gloves throughout the wound care without performing hand hygiene prior to donning clean gloves. EI # 3 then began wound care on the back wound using the same basin of water to clean the back, that was used for foot wound. EI # 3 obtained new wound care orders for the back from the wound treatment center. Then EI # 3 continued each step of the wound care and changed gloves without performing hand hygiene. During the wound care EI # 1 touched the trash bag containing the used wound supplies with gloves on then discarded gloves and donned new gloves without performing hand hygiene. At the end of the visit EI # 3 cleaned the reusable equipment and placed the equipment in his/her bag without performing hand hygiene prior to entering the clean bag. An interview was conducted on 12/17/25 at 1:05 PM with EI # 1, Branch Director, who confirmed the staff member did not follow the agency’s hand hygiene 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 Chapter 610-x-6: Standards of Nursing Practice, and staff interview it was determined the agency failed to ensure the staff documented accurately and completely in the patient MR. This affected MR # 4, one of seven MRs reviewed, and had the potential to affect all patients served by this agency. Findings include: Alabama Board of Nursing Chapter 610-x-6: Standards of Nursing Practice 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 # 4 was admitted to the agency on 6/19/25, and discharged 7/14/25 with diagnoses of Pleural Effusion not Elsewhere Classified, Pressure Ulcer of Sacral Region. Stage Two. A review of the MR revealed a Home Health Certification and Plan of Care (POC) dated 6/19/25 with an order for Skilled Nursing (SN) two times a week for nine weeks and an order for Pleural catheter site care every time pleural fluid is drained. Cleanse the site with alcohol swab, tubing with alcohol swab and tubing cap with alcohol swab. Place foam split gauze around tubing site, coil tubing, cover with gauze and secure with a transparent dressing using sterile technique. A further review of the 6/19/25 POC revealed orders for the SN to perform/instruct patient/caregiver of wound care to stage two pressure ulcer coccyx two times weekly and as needed for soiled or dislodged dressing. Cleanse with wound cleanser and gauze, pat dry with gauze, apply foam dressing using clean technique. SN may perform on visit and caregiver to perform other days. Review of the Start of Care (SOC) documentation dated 6/19/25 revealed the SN documented there was no caregiver in the home that day and the patient was unable to drain the pleural catheter themself. There was no documentation of wound care performed. Further review of the MR revealed the Visit Note Report dated 6/26/25 and 7/11/25 had no documentation of the catheter site care performed. An interview was conducted on 12/17/25 at 12:47 PM with Employee Identifier (EI) # 1, Branch Director, who reported the patient was called from 6/20/25 to 6/26/25 to check if supplies were delivered to the home for the draining of the pleural catheter, but not documented in the MR. EI # 1 confirmed the patient refused the wound care on 6/26/25, and the SN failed to document in the MR, and there was no documentation the site care was performed, EI # 1 reported the site care was performed at the time, but was not documented.”

“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, agency policy and procedure, and interviews, it was determined the agency failed to update the medication profile. This did affect three of three home visits (HV) including HV # 2 , HV # 1, 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 Date 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: 1a. ...Compare medication list... to actual medications the patient is taking. 1b. Review all medications including over the counter (OTC) medications, vitamins, herbs, and herbal products, creams and topical creams. 3. HV # 3 was admitted to the agency on 5/21/25 and recertified for continued care on 11/17/25 with a primary diagnosis of Type Two Diabetes Mellitus with Foot Ulcer. An observation was conducted on 12/17/25 at 8:56 AM with EI # 3, RN to observe care provided. During the observation the home medications were compared to the current medication list given on 12/17/25 and the following discrepancies were noted. a. Hydrocodone 7.5 mg Acetaminophen 325 mg tablet one tablet twice a day with a start date of 10/30/25. HV # 3 reports they stopped taking this medication last month. b. Tizanidine 4 mg one capsule daily with a start date of 8/18/25. HV # 3 reports they stopped taking this medication two months ago at the direction of the physician. c. Albuterol 90 micrograms two puffs four times a day as needed, was not on the current medication list. HV # 3 reports they have been taking this medication for one year. d. Adipex 37.5 mg 1 tablet by mouth daily, was not on the current medication list. HV # 3 reports they have been taking this medication for three months. An interview was conducted on 12/17/25 at 1:05 PM with EI # 1, who confirmed the staff failed to keep the medication profile current per agency policy. 1. HV # 2 was admitted to the agency on 10/10/25 with a primary diagnosis of Fracture Unspecified Part of the Neck of the Femur, Subsequent Encounter for a Closed Fracture with Routine Healing. A HV was conducted on 12/16/25 at 12:17 PM with Employee Identifier (EI) # 4, LPTA (Licensed Physical Therapy Assistant) to observe care provided. During the HV, four OTC medications were noticed on the kitchen table and next to the patient’s recliner. A review of the medication profile revealed the four OTC medications were not on the medication profile. The patient stated he/she liked to buy OTC pain relief medications and does not always tell the LPTA when he/she makes the purchases because he/she does not use them regularly. The four OTC medications observed were: a. Volterin Arthritis Pain Topical Gel use as directed. b. Advil 200 mg (milligram) p.o. (by mouth) prn (as needed) for pain. c. Icy Hot Max Lidocaine 4% (percent) use as directed. d. Tylenol 325 mg per tablet prn use as directed. An interview was conducted on 12/17/25 at 1:15 PM with EI # 1, Branch Director, who confirmed staff failed to keep the medication profile current. 2. HV # 1 was admitted to the agency on 3/28/25 and recertified for care on 11/23/25 with a primary diagnosis of Varicose Veins of Right Lower Extremity with Both Ulcer of Ankle and Inflammation. A HV was conducted on 12/16/25 at 11:00 AM with EI # 2, Registered Nurse (RN) to observe wound care provided. During the HV, medications were reconciled with EI # 2 and HV # 1. Furosemide 40 mg tablet p.o. one daily, was listed on the current medication profile. HV # 1 stated he/she stopped taking this medication several months ago. An interview was conducted on 12/17/25 at 1:21 PM with EI # 1, who confirmed staff failed to keep the medication profile current.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on Medical Record (MR) review, agency policy, and staff interview it was determined the agency failed to ensure the staff followed the agency policy regarding physician orders. This affected two of seven MRs reviewed to include Home Visit (HV) # 1, MR # 2, and had the potential to affect all patients served by this agency. Findings include: Agency Policy: Physician Orders Policy number: 2.1.008 Revised date: 10/1/23 ...Policy: No medications, treatments, diagnostic studies or therapeutics will be administered without the order of a qualified physician or authorized practitioner, or as designated by State Practice Acts and that order be reduced to writing signed/dated by the ordering physician... 2. MR # 2 was admitted to the agency on 11/18/25 with a primary diagnosis of Encounter for Attention to Gastrostomy. Review of the Home Health Certification and POC dated 11/18/25 revealed orders for SN one visit per week for nine weeks. Review of the SN visit note dated 11/18/25 and 11/25/25 revealed the SN documented New Peg Tube Insertion...cleansed with sterile water, patted dry with gauze, applied 4 inches by 4 inches gauze and secured with tape. Further review of the Home Health Certification and POC dated 11/18/25 revealed no documentation of orders for Peg Tube site care. An interview was conducted on 12/17/25 at 1:25 PM with EI # 1, who confirmed there was no documentation of an order for site care of the gastrostomy tube and the agency failed to follow the agency policy regarding physician’s orders. 1. HV # 1 was admitted to the agency on 3/28/25 and recertified for continued care on 11/23/25 with a primary diagnosis of Varicose Veins of the Right Lower Extremity with Ulcer. A review of the MR revealed a Home Health Certification and Plan of Care (POC) dated 11/23/25 with an order for Skilled Nursing (SN) two times a week for eight weeks. Further review of the POC revealed an order for wound care to the right ankle daily; clean wound with wound cleanser, gauze and pat dry, apply Xeroform petrolatum gauze to the wound bed, cover and secure with a foam dressing. A review of the SN Visit Note Report dated 12/11/25 revealed the SN documented wound care to right lower extremity ankle as sterile saline, Prisma collagen dressing to wound covered with foam dressing secured with Coban self-adherent wrap. An interview was conducted on 12/17/25 at 12:56 PM with Employee Identifier # 1, Branch Director, who confirmed the staff failed to follow the agency policy and physician’s order.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on Medical Record (MR) review, and staff interview, it was determined the agency failed to ensure the staff followed the Plan of Care as ordered by the physician. This affected two of seven MRs reviewed to include MR # 1 and MR # 4 and had the potential to affect all patients served by this agency. Findings include: 1. MR # 1 was admitted to the agency on 11/28/25 with a primary diagnosis of Hypertensive Heart Disease with Heart Failure. A review of the Home Health Certification and Plan of Care (POC) dated 11/28/25 revealed an order for the Skilled Nurse (SN) one time a week for one week and two times a week for eight weeks. An order for the SN to obtain weights every visit and notify the physician of weight gain of three pounds within one day or five pounds within one week. Further review of the Nursing Progress Note dated 12/11/25 revealed an actual weight documented of 165 pounds. On the Visit Note Report dated 12/15/25, the SN documented the patient weight as 170 pounds. There was no documentation the physician was notified of the five-pound weight gain in four days. An interview was conducted on 12/17/25 at 12:45 PM with Employee Identifier (EI) # 1, Branch Director, who confirmed the staff failed to follow the physician’s order and notify the physician of the weight gain. 2. MR # 4 was admitted to the agency on 6/19/25 with a Primary Diagnosis of Pleural Effusion not Elsewhere Classified. A review of the POC dated 6/19/25 revealed an order for the SN two times a week for nine weeks and for the SN to obtain an ankle circumference every visit by measuring two inches above the stump site and notify the physician of an increase of two centimeters within one day. A review of the Visit Note Reports dated 6/24/25, 6/26/25, 7/2/25, and 7/11/25 revealed no documentation of the circumference two inches above the stump. An interview was conducted on 12/17/25 with EI # 1, who confirmed the staff failed to follow the physician’s orders for the measurement each visit.”