Alabama Homecare of Gadsden

“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, and staff interview, it was determined the agency failed to ensure staff performed hand hygiene per agency policy. This did affect one of five home visits (HV) including HV # 1, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Hand Hygiene Policy Number: 8.004 Revised Date: 05/01/19 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 specific time points during, and following patient contact... Procedure: 1. Staff performs hand hygiene by handwashing with soap and water or using an alcohol based hand sanitizer: a. before direct contact with patients. b. before performing an aseptic task (ergo,...wound care). c. after contact with...wound dressings... 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...) in the immediate vicinity of the patient. f. before and after removal of personal protective equipment... 8. Other Aspects of Hand Hygiene: ...Change gloves during patient care if moving from a contaminated body site to a clean body site. HV # 1 was admitted to the agency on 6/6/25 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Skin Subcutaneously and Type Two Diabetes Mellitus with Diabetic Polyneuropathy. A HV was conducted on 8/26/25 at 1:38 PM with Employee Identifier (EI) # 2, Licensed Practical Nurse, to observe wound care provided. During the HV the following was observed: 1. EI # 2 failed to perform hand hygiene, after removing gloves, four times. 2. EI # 2 failed to perform hand hygiene prior to donning gloves three times, including prior to wound care. 3. During wound care, EI # 2 cleansed the wound with Vashe, patted dry with gauze, and reached into the clean supplies gathered at the patient’s feet to obtain a package of q-tips to use the wrapper to measure the wound. EI # 2, while wearing the same gloves, picked up the EMR to take a picture of the wound, obtained a pen from his/her pocket to write wound measurements on the wrapper, took a second picture of the wound, cut the Aquacel AG with scissors to fit into the wound, placed the used scissors on the patients blanket, placed the Aquacel AG into the wound, opened the Urgotul and used the same scissors to cut it to fit into the wound, all while wearing the same pair of gloves. EI # 2 appeared to have difficulty removing the back of the Urgotul and removed the dirty pair of gloves and without performing hand hygiene or donning gloves, inserted the Urgotul into the wound with his/her bare hands, covered the wound with gauze and wrapped the foot with kerlix and secured it with tape. The pen was obtained from his/her pocket and the tape was dated with the change of dressing. An interview was conducted on 8/27/25 at 3:28 PM with EI # 1, Interim Executive Director, who confirmed staff failed to perform hand hygiene 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 review of medical records (MR), policy and procedure, and staff interviews, it was determined the agency failed to ensure Visit Notes were completed within 24 hours according to policy. This affected MR # 2, MR # 3, MR # 4, MR # 7, Home Visit (HV) # 3, and MR # 8, in 6 of 13 MRs reviewed, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Date Revised: 9/1/24 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Policy: ...Identifying patient needs through assessment and communication with other health care providers. Procedure: ...5. d. Completed visit notes will be submitted to the agency via synchronization within 24 hours of visit for point of care agencies. e. Care planning information is available to all staff and contracted professionals providing care for the patient... 1. MR # 2 was admitted to the agency on 7/15/25 with diagnoses including Unspecified Fracture of Right Lower Leg, Subsequent for Closed Fracture with Routine Healing and Pain in Right Ankle and Joints of Right Foot. Review of the MR revealed the Visit Note Report (VNR) dated 7/29/25 was not signed by the Registered Nurse (RN) within 24 hours per the agency’s policy. An interview was conducted on 8/27/25 at 3:10 PM with Employee Identifier (EI) # 1, Interim Executive Director, who confirmed staff failed to sign the VNR within 24 hours per the agency’s policy. 2. MR # 3 was admitted to the agency on 12/5/24 with a diagnosis of Local Infection of Skin and Subcutaneous Tissue, unspecified. Review of the MR revealed the VNR dated 8/7/25 was not signed by the Licensed Practical Nurse (LPN) within 24 hours per the agency’s policy. An interview was conducted on 8/27/25 at 3:03 PM with EI # 1, who confirmed staff failed to sign the VNR within 24 hours per the agency’s policy. 3. MR # 4 was admitted to the agency on 7/22/25 with diagnosis of Encounter for Nonsurgical After Care Following Surgery on the Circulatory System. Review of the MR revealed VNRs dated 8/1/25, 8/6/25, 8/8/25, and 8/15/25 were not signed by the Physical Therapist (PT) within 24 hours per the agency’s policy. An interview was conducted on 8/27/25 at 3:05 PM with EI # 1, who confirmed staff failed to sign the VNRs within 24 hours per the agency’s policy. 4. MR # 7 was admitted to the agency on 12/20/25 with a diagnosis of Chronic Obstructive Pulmonary Disease. Review of the MR revealed the RN Oasis Admission dated 12/20/25 was not signed by the RN within 24 hours per the agency’s policy. Further review of the MR revealed the RN Discharge dated 1/9/25 was not signed by the RN within 24 hours per the agency’s policy. An interview was conducted on 8/27/25 at 3:18 PM with EI # 1, who confirmed staff failed to sign the Oasis Admission and RN Discharge within 24 hours per the agency’s policy. 5. HV # 3 was admitted to the agency on 7/11/25 with a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. Review of the MR revealed the RN Oasis Admission dated 7/11/25 was not signed by the RN within 24 hours per the agency’s policy. Further review of the MR revealed the VNR dated 7/16/25 was not signed by the LPN within 24 hours per the agency’s policy. An interview was conducted on 8/27/25 at 3:15 PM with EI # 1, who confirmed staff failed to sign the Oasis Admission and VNR within 24 hours per the agency’s policy. 6. MR # 8 was admitted to the agency on 8/19/24 with diagnoses including Obstructive and Reflux Uropathy, Unspecified and Type 2 Diabetes Mellitus with Hyperglycemia. Review of the MR revealed the VNR dated 9/5/24 was not signed by the PT within 24 hours per the agency’s policy.. An interview was conducted on 8/27/25 at 3:16 PM with EI # 1, who confirmed staff failed to sign the VNR within 24 hours per the agency’s policy.”

“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 observations, agency policies and procedures, medical record (MR) review, and staff interview, it was determined the agency failed to ensure staff followed the physician’s order for wound care. This affected one of three home visits (HV), including HV # 1, with wound care ordered and had the potential to negatively affect all patients with wounds serviced by the agency. Findings include: Agency Policy: Plan of Care Policy Number: 2.1.007 Revision Date: 4/1/25 Policy: Every patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff 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... f. Medications and treatments... i. Patient specific interventions... n. All patient care orders... 6. Physician/authorized practitioner’s orders are obtained to update the POC. 7. Medications, treatments, and interventions are provided by authorized agency staff as ordered by the physician or authorized prescriber. Agency Policy: Wound Assessment, Documentation, and Photography Policy Number: 2.2.001 Revision Date: 9/1/24 Procedure: ...2. Perform wound care according to LHC adopted clinical skills guidelines and physician orders. HV # 1 was admitted to the agency on 6/6/25 with diagnoses including Encounter for Surgical Aftercare Following Surgery in the Skin Subcutaneous and Type Two Diabetes Mellitus with Diabetic Polyneuropathy. A HV was conducted on 8/26/25 at 1:38 PM with Employee Identifier (EI ) # 2, Licensed Practical Nurse, to observe wound care provided. Review of Home Health Certification and Plan of Care dated 8/5/25 to 10/3/25 revealed an order for Skilled Nurse (SN) to visit two times a week for nine weeks. Review of the physician’s order dated 8/22/25 revealed SN to perform/instruct patient/caregiver procedure of wound care to wound # 2, right plantar foot, every SN visit and every other day by PT/CG on days Home Health does not visit. Cleanse with Vashe, Pat dry with clean gauze. Apply moisturizing lotion of patients choice to perimeter (peri) wound. Apply Prisma (wound dressing) moistened with normal saline. Apply Urgotul (wound dressing). Cover with gauze. Wrap right foot with Kerlix then Ace wrap using clean technique. EI # 2 failed to apply moisturizing lotion to peri wound, used Aquacel AG (wound dressing) and not Prisma, as ordered, and failed to wrap the right foot with an Ace wrap. EI # 2 failed to follow the physician’s order for wound care. An interview was conducted on 8/27/25 at 3:28 PM with EI # 1, Interim Executive Director, who confirmed staff failed to follow the physician’s order for wound care.”