Albemarle Home Care and Hospice

“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 agency policy, observations, clinical record review, and staff interviews, the agency failed to include contact precautions in the plan of care for 1 of 1 patient requiring contact precautions (patient # 4) and failed to perform hand hygiene between glove changes for 1 of 2 registered nurse home visits (patient #10). Findings included: A policy, Exposure Control Plan (revised 05/2024) received on 04/29/2025 at 3:53 pm from the clinical manager stated, “Preventing and controlling occupational exposures is a shared responsibility of [Agency Name] and all employees…The following controls will be utilized at all [Agency Name] facilities…After removal of personal protective gloves, employees shall perform proper hand hygiene on hands and any other potentially contaminated skin area immediately or as soon as feasible with soap and water and or alcohol based hand rub/cleanser.” A policy, Infection Control Program (revised 06/2024) received on 04/29/2025 at 3:11 pm from the clinical manager stated, “[Agency Name] has established a comprehensive Infection Control Program to…improve patient outcomes by identifying and reducing the risk of infection in patients and [Agency Name] staff…[Agency Name] follows 6 core practices, identified by the CDC…hand hygiene…appropriate use of personal protective equipment”. A policy, Infection Control (revised 10/2024) received on 4/30/2025 at 10:14 am from the clinical manager stated, “To monitor and control the risk of healthcare associated infections throughout the patient population and staff by utilizing the following…hand hygiene before and after direct contact with the patient…before and after use of gloves…after handling potentially contaminated items…between different tasks or procedures on the same patient”. Patient #10 had an admission date of 4/17/2025 with a diagnosis of Vascular dementia with psychotic disturbances (a decline in cognitive function due to impaired blood flow to the brain affecting how a person perceives their environment and interacts with others) and Pressure ulcer of sacral region, stage 2 (partial thickness skin loss on the tail bone due to pressure). The plan of care for 4/17/2025 – 6/15/2025 included orders for skilled nurse (SN) visits 1 time a week for 9 weeks with 3 PRN (as needed) and “Clean wound with wound cleaner. Apply zinc oxide ointment daily and prn”. During a joint visit on 4/29/2025 at approximately 11:30 am with RN #14, it was observed that RN#14 did not perform hand hygiene after removing gloves soiled with feces and before putting on clean gloves to perform wound care. During a phone interview conducted on 04/30/2025 at approximately 2:05 pm, RN #14 stated, “If you say so I guess I didn’t clean my hands after removing gloves. Honestly, I do not normally wash my hands with glove changes.” During an interview conducted on 04/30/2025 at approximately 2:30 pm, the agency director stated, “she should have cleaned her hands” and agreed that hand hygiene between glove changes is the expectation of the agency. A policy, Nursing Standards (revised 10/2024) received on 04/30/2025 at 1:10 PM from the clinical manager stated, “The Home Health Nurse will develop a plan of nursing care… Implementation of nursing activities will include: … Implementation of nursing interventions and medical orders.” A policy, Procedures (revised 04/2024) received on 04/30/2025 at 12:45 PM from the clinical manager stated, “Table 31-1 Multidrug-Resistant Organisms (MDROs) Methicillin-resistant Staphylococcus aureus (MRSA)… Transmitted via direct and indirect contact… Prevention… Use of gloves and gowns for patient contact...” A policy, Infection Control Program (revised 06/2024) received on 04/29/2025 at 3:11 PM from the clinical manager stated, “[Agency Name] has established a comprehensive Infection Control Program to…. To reduce the risk of acquired and transmitted infections… [Agency Name] incorporates the following in a continuing cycle… Selection and implementation of best practices to minimize adverse outcomes.” Patient #4 was admitted on 10/01/2024 with a diagnosis of Cellulitis (bacterial skin infection) of the right lower limb. The plan of care for 03/30/2025-05/28/2025 included orders for skilled nurse (SN) visits 2 times a week for 8 weeks with 4 PRN (as needed), “Clean wound to right heel with normal saline, mupirocin 2% ointment [topical antibiotic] to cover wound with gauze wrap with kerlix [gauze bandage roll] secure with tape.” And “SN to do wound care to right heel 2 times a week…” Review of the clinical record revealed that on 03/31/2025 licensed practical nurse (LPN) #13 documented, “MRSA [Methicillin-resistant Staphylococcus aureus requiring contact precautions] positive due to lesions on arms and legs.” Further review revealed that there was no documentation in the plan of care for contact precautions.During an interview conducted on 04/30/2025 at approximately 2:30 PM LPN #13 stated, “We received a culture [of the wound as MRSA positive]. Yes, I would expect to see that [contact precautions] in the care plan. Well, I guess I would look at the policy and procedure. We would contact the doctor and get an order [for contact precautions] and add it to the plan of care.” During an interview conducted on 04/30/2025 at 2:37 PM the agency director stated, “They should have called the doctor and put an order in for contact precautions.””

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to obtain and document weekly wound measurements for 1 of 6 patients with wounds. (patient #14) Findings included: A policy Wound Care Standards (revised 08/2024) received on 04/29/2025 at 2:26 PM from the agency director stated, “Any patient with an open wound will have the sites measured weekly.” Patient #14 was admitted on 01/30/2025 with a diagnosis of cutaneous abscess of left lower limb (skin infection left lower leg). The plan of care for 03/31/2025-05/29/2025 included orders for skilled nurse (SN) visits 3 times a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks, and “SN to clean with normal saline insert iodoform to open wounds, cover with foam dressing. SN to do dressing change 3 times weekly and PRN.” Review of the documentation for the SN home visit on 03/31/2025 revealed that LPN (licensed practical nurse) #10 documented “N/A [not applicable]” for wound measurements. Review of the documentation for the registered nurse (RN) visit on 04/02/2025 revealed that RN #15 documented, “Size: Not Applicable.” Review of the documentation for the SN visit on 04/04/2025 revealed that LPN #4 documented, “Size: Not Applicable”. An interview conducted on 04/29/2025 at 2:05 PM with the Director of Professional Services (DOPS) revealed that the wounds were not measured during the week of 03/30/25. During an interview on 04/29/25 at 2:14 PM the DOPS stated, “The expectation is for the staff [nurses] to measure the wounds 1 time a week.””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on agency policy, direct observations, staff/patient/caregiver interviews, the Plan of Care failed to include all the current/correct medications for 3 of 6 patients who received home visits (#14,16,17). Findings included: The policy, Medication Monitoring (revised 04/2024), provided by the Director of Professional Services on 4/29/2025 at 3:11 pm stated, “Whenever new medications are added a medication reconciliation is completed. Medication reconciliation will also occur, at a minimum, with each OASIS [Outcome and Assessment Information Set] time point…in conjunction with RN [Registered Nurse] supervisory visits for aide or LPN [Licensed Practical Nurse], and with any change in medications to assess any potential adverse reactions.” 1. Patient #14 had a Start of Care date of 1/30/2025 with an admitting diagnosis of Cutaneous abscess of left lower limb (A localized collection of pus that develops within the skin and underlying tissues of the leg or foot). The Plan of Care for 3/31/2025-5/29/2025 included orders for SN (Skilled Nurse) visits 3 times a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks. During a home visit conducted on 4/29/2025 at approximately 11:30 am with LPN (Licensed practical nurse) #8, a medication review was performed and the following discrepancies were noted: The agency medication profile included Hydroxyzine HCL (used to treat anxiety) 10 mg every 12 hours, patient #14 stated that she was taking a 10mg and a 50mg tablet together for a total of 60mg 3 times per day as needed. The agency medication profile failed to include the following long term medications: Furosemide (used to treat fluid retention) 80mg, 1 tablet daily, Potassium (mineral supplement) 20meq 1 tab every other day PRN (as needed), PreserVision AREDS 2 (vitamin and mineral supplement that promotes eye health) 1 tablet daily and Calcium Citrate+D3 (vitamins that promote bone strength) 1 tablet daily. 2. Patient #16 had a Start of Care date of 3/25/2025 with an admitting diagnosis of Fracture of unspecified part of neck of left femur (left hip fracture). The Plan of Care for 3/25/2025-5/23/2025 included orders for SN 1 time a week for 7 weeks. During a home visit conducted on 4/29/2025 at approximately 1:30 pm with RN (Registered Nurse) # 6, a medication review was performed and the following discrepancies were noted: The agency medication profile included Warfarin Sodium (used to prevent blood clots) 7.5mg and 10mg to be taken together to equal a total of 17.5mg daily. The patient stated the dose was 17.5mg on Tuesdays, Thursdays, and Saturdays. 20mg on Mondays, Wednesdays, Fridays, and Sundays. The agency medication profile listed Insulin Glargine (injectable long-lasting insulin used to treat high blood sugar) 10 units at bedtime. The patient stated he no longer administers insulin and is now on Glipizide (oral tablet used to lower blood sugar) 10mg 2 times daily. The medication profile listed Gabapentin (used to treat nerve pain) 100mg 1 tablet 2 times a day, the frequency is 3 times a day. The medication profile included the following discontinued medications: Nephro-Vite (used to prevent vitamin deficiency) 0.8 mg, Iron (used to treat anemia) 325mg, and Fluticasone Propionate nasal spray (used to treat allergies)50mcg. 3. Patient #17 had a start of care date of 3/18/2025 with an admitting diagnosis of other complications of procedures (Patient has a non-healing wound on left foot). The Plan of Care (POC) for 3/8/2025-5/6/2025 included orders for SN (Skilled Nurse) 2 times a week for 8 weeks. During a home visit on 4/29/2025 at approximately 8:30 am with LPN #4 a comprehensive medication review revealed that patient #17 has been administering Insulin Lispro (used to treat high blood sugar) 6 units before meals if blood sugar is over 160. This medication was not listed on the medication profile. An interview conducted on 04/30/2025 at 2:28 pm with the Agency Director revealed that the expectation is that a comprehensive medication review is to be completed with all medication changes.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on agency policy, direct observations, and staff interviews, the nurse failed to include medication discrepancies in the visit documentation for 3 of 6 patients with home visits conducted (#14,16,17). Findings included: The policy, Medication Monitoring (revised 04/2024), provided by the Director of Professional Services on 4/29/2025 at 3:11 pm stated, “Whenever new medications are added, a medication reconciliation is completed…the findings, conclusions, and recommendations of medication monitoring are documented in the patient’s medical record”. Patient #14 had a Start of Care date of 1/30/2025 with an admitting diagnosis of Cutaneous abscess of left lower limb (A localized collection of pus that develops within the skin and underlying tissues of the leg or foot). The Plan of Care for 3/31/2025-5/29/2025 included orders for SN (Skilled Nurse) visits 3 times a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks. During a home visit conducted on 4/29/2025 at approximately 11:30 am with LPN (Licensed practical nurse) #8, a medication review was performed and 5 discrepancies were revealed. Review of the clinical record revealed that LPN #8 documented “no discrepancies” for the visit of 4/29/2025.Patient #16 had a Start of Care date of 3/25/2025 with an admitting diagnosis of Fracture of unspecified part of neck of left femur (left hip fracture). The Plan of Care for 3/25/2025-5/23/2025 included orders for SN 1 time a week for 7 weeks. During a home visit conducted on 4/29/2025 at approximately 1:30 pm with RN #6, a medication review was performed and 6 discrepancies were revealed. Review of the clinical record revealed that RN #6 documented “no discrepancies” for the visit on 4/29/2025.Patient #17 had a start of care date of 3/18/2025 with an admitting diagnosis of other complications of procedures (Patient has a non-healing wound on left foot). The Plan of Care for 3/8/2025-5/6/2025 included orders for SN 2 times a week for 8 weeks. During a home visit conducted on 4/29/2025 at approximately 8:30 am with LPN #4, a medication review was performed and 1 discrepancy was revealed. Review of the clinical record revealed that LPN #4 documented “no discrepancies” for the visit on 4/29/2025. An interview conducted on 04/30/2025 at 2:28 pm with the Agency Director revealed that the expectation is that medication discrepancies should be documented in the visit note.”