Divinity Home Health Services, LLC

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure the agency maintained a coordinated program for the surveillance and identification of infections for 5 (Patient #2, Patient #5, Patient #8, Patient #12, Patient #15) of 12 sampled patients reviewed for infection control investigations. Patient #2 Review of Patient #2’s Patient Medication Record revealed in part, Patient #2 received metronidazole (antibiotic used to treat stomach/intestinal infections) 500 milligrams (mg) one tablet by mouth twice a day for seven days, with a start date of 12/18/2025. Patient #5 Review of Patient #5’s Patient Medication Record revealed in part, Patient #5 received Zithromax (antibiotic, used to treat respiratory infections) 500 mg one tablet by mouth twice a day for 5 days for cough and congestion, with a start date of 11/18/2025. Patient #8 Review of Patient #8’s Patient Medication Record, revealed in part, Patient #8 received Macrobid (antibiotic, used to treat infections) 100 mg one capsule by mouth twice a day for five days, with a start date of 09/02/2025; Bactrim Double Strength (antibiotic, used to treat infections) 800-160 mg by mouth daily for 10 days, with a start date of 11/22/2025; and, Cephalexin (antibiotic, used to treat infections) 500 mg one capsule by mouth three times a day, with a start date of 11/24/2025. Patient #12 Review of Patient #12’s Patient Medication Record revealed, in part, Patient #12 received Cephalexin 500 mg one capsule twice a day with a start date of 03/31/2025; and, Cephalexin 500 mg one capsule every 6 hours for 10 days, with a start date of 10/29/2025. Patient #15 Review of Patient #15’s Patient Medication Records revealed, in part, Patient #15 received Ampicillin (antibiotic, used to treat infections) 500 mg one capsule twice a day for 7 days, with a start date of 08/18/2025; and, Fosfomycin Tromethamine (antibiotic, used to treat infections) 3 grams one packet daily for 5 days, with a start date of 08/18/2025. In an interview on 01/14/2026 at 10:55AM, S1Administrator/Director of Nursing (DON) indicated once a skilled nurse or clinician identifies signs and symptoms of an infection and/or a new antibiotic in the home, used to treat an infection, the clinician was to initiate an infection control report for the patient within the note. S1Administrator/DON further indicated the infection control report then would be automatically be sent to myself (S1Administrator/DON) and S2Case Manager for any reviews. S1Administrator/DON further indicated the agency then would use the infection control reports to create a log which would be used to track and trend all patient infections and/or contagious disease, and look for trends which would require intervention by the agency. Review of agency’s Infection Control Log for 01/01/2025 thorough 12/31/2025 revealed, in part, the above mentioned infections/antibiotic usage was not captured on the infection control log. In an interview on 01/14/2026 at 10:57AM, S3Regional Clinical Director of Operations indicated all infections and antibiotic usage, unless used for prophylaxis, should be captured on the infection control log. In an interview on 01/14/2026 at 11:27AM, S1Administrator/DON indicated she had reviewed the above mentioned antibiotic usage/infections and had no further evidence to present that the above mentioned infections/antibiotic usage was captured on the agency’s infection control log; therefore, the agency had no evidence the above mentioned infections were used to trend and identify infections, as required.”

“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 observation, interviews, and record reviews, the agency failed to ensure an accurate review of all medications that were prescribed for 1 (Patient #7) of 7 sampled patients observed for medication reconciliation during home visits. Findings: Review of Patient #7’s Resumption of Care Orders dated 12/18/2025 revealed Patient #7 was to receive skilled nursing services once a week for four weeks. Review of Patient #7’s record revealed Patient #7 received skilled nursing services on 12/18/2025, 12/26/2025, and 01/07/2026. Review of Patient #7’s medication profile, presented by S1Administrator/Director of Nursing (DON) as the most current copy of Patient #7’s medication, revealed Patient #7 was documented as receiving, in part, Metoprolol Succinate Extended Release (medication used to treat high blood pressure) 25 milligrams, one tablet by mouth twice a day with a start date of 12/18/2025; and, no evidence of Trazadone (medication used to treat depression) 50 milligrams one tablet by mouth at bedtime was listed as a current medication. Observation on 01/13/2026 at 9:15AM revealed the following medications were presented as current medications, in part, Metoprolol Succinate Extended Release 25 milligrams, administer one half of a tablet twice a day with a prescription filled date of 12/17/2025; and, Trazadone 50 milligrams one tablet by mouth at bedtime with a prescription filled date of 12/18/2025. In an interview on 01/13/2026 at 9:15AM, Patient #7 and Patient #7’s caregiver confirmed Patient #7 was currently taking Metoprolol Succinate Extended Release 25 milligrams administer one half of a tablet twice a day; and, Trazadone 50 milligrams one tablet by mouth at bedtime. Review of Patient #7’s Discharge Summary Report dated 12/17/2025 revealed, in part, Patient #7 was ordered Metoprolol Tartrate 25 milligrams administer 12.5 milligrams by mouth twice a day. Review of Patient #7’s Nurse Report Communication dated 12/18/2025 revealed, in part, Patient #7 had requested a prescription of Trazadone, which was given to Patient #7 in the hospital. Further review revealed Patient #7’s physician office was notified and a prescription was sent to the pharmacy. In an interview on 01/14/2026 at 12:07PM, S1Administrator/Director of Nursing indicated the skilled nurse should have identified the above mentioned medications and incorporated the medication changes into the medication profile.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on interview and record reviews, the agency failed to ensure the registered nurse measured a patient’s wound weekly to assess for wound healing status for 1 (Patient #12) of 15 sampled patients reviewed for weekly wound care assessments. Findings: Review of the Wound Ostomy and Continence Nurses Society’s Guidelines revealed the assessment and documentation of wound status included comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment included: dimensions and depth, presence, location and depth of any sinus tracts or undermining areas, status and characteristics of the wound bed, volume, color, and odor of exudates, and evidence of infection in surrounding tissues. Further review revealed when recorded over time, this information can be used to track the progress of wound healing. Review of Patient #12’s physician order dated 12/05/2025 revealed, in part, the skilled nurse was to evaluate and assess Patient #12’s wounds at each dressing change and as needed, and notify the physician if any signs and symptoms of infection were noted. Review of Patient #12’s Registered Nurse (RN) Skilled Nursing Visit dated 12/05/2025, 12/09/2025, and 12/18/2025 and revealed the following wounds, in part: -left buttock stage 1 pressure injury (a red non-blanchable skin, condition when skin is intact, red and does not turn white when pressure applied) with no documentation of the size of the wound; -left lower leg venous ulcer (wound caused by poor circulation) with a minimal amount of serous (clear fluid coming from the wound) drainage, with 100 percent pink/red wound tissue, with no documentation of the size of the wound; and, -right lower leg venous ulcer with a minimal amount of serous drainage, with 100 percent pink/red tissues, with no documentation of the size of the wound. Review of Patient #12’s RN Skilled Nursing Visit dated 01/05/2026 revealed the following wounds, in part: -left buttock stage 1 pressure injury with no documentation of the size of the wound; -left lower leg venous ulcer with a minimal amount of serous drainage, with 100 percent pink/red wound tissue, with no documentation of the size of the wound; and, -right lower leg venous ulcer with a moderate amount of serous drainage, with 100 percent pink/red tissues, with no documentation of the size of the wound. Review of Patient #12’s RN Skilled Nursing Visit dated 01/12/2026 revealed the following wounds, in part: -left buttock stage 1 pressure injury with no documentation of the size of the wound; -left lower leg venous ulcer with a moderate amount of serous drainage, with 100 percent pink/red wound tissue, with no documentation of the size of the wound; and, -right lower leg venous ulcer with a moderate amount of serous drainage, with 100 percent pink/red tissues, with no documentation of the size of the wound. In an interview on 01/14/2026 at 12:53PM, S1Administrator/Director of Nursing (DON) indicated the skilled nurse should have measured the open areas on Patient #12’s bilateral lower legs, and should have measured the red non-blanch able area to Patient #12’s left buttock.”