Home Health of Wilson

“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, observation, and staff interviews, the agency failed to take precautions to prevent the spread of infection for 1 of 2 patients who received a skilled nurse home visit (patient #7). Findings included: A policy, Hand Hygiene (revised 05/01/2019), received on 03/24/2025 at 4:30 PM from the agency director stated, “Staff performs hand hygiene by handwashing with soap and water or an alcohol- based hand sanitizer [3] after contact with blood, body fluids or excretions, mucous membranes, non-intact skin, wound dressings, or contaminated surfaces.” Patient # 7 was admitted on 11/11/2024 with a diagnosis of type 2 diabetes mellitus (a disease of inadequate control of blood levels of glucose) with foot ulcer. The plan of care for 03/11/2025- 05/09/2025 included orders for skilled nurse (SN) visits 2 times a week for a week, 3 times a week for 8 weeks, and 2 PRN (as needed) and “Wound care to left dorsal foot cleanse with vashe, apply calcium alginate with silver ( apply to anterior and lateral foot areas), cover with ABD pad, 4x4, wrap in kerlix, secure with tape. To be changed daily. Patient/ CG (Caregiver) may perform in SN absence. Left great toe cleanse with wound cleanser, apply calcium alginate, cover with dry gauze, wrap in kerlix, secure with tape. To be changed daily. Patient/ CG may perform in SN absence.” A home visit was conducted on 3/24/2025 at approximately 2:30PM with registered nurse (RN) 9. RN #9 performed hand hygiene, donned clean gloves, removed the soiled dressing, cleansed the wound, retrieved extra 4x4’s, and applied a clean dressing. RN #9 failed to remove contaminated gloves and perform hand hygiene after removing the soiled dressing, before retrieving supplies, and before applying the clean dressing. During an interview conducted on 03/25/2025 at 2:26 PM RN #9 stated, “Yes, I reached in supply box; and did not replace gloves; there was a few times that hand hygiene was missed”. An interview on 03/25/2025 at 2:30 PM with the agency director revealed that the expectation is for the nurses to “Sanitize their hands, don clean gloves, remove the soiled dressing, remove soiled gloves, perform hand hygiene, cleanse the wound, remove gloves, perform hand hygiene, apply clean gloves and apply clean dressing. Never retrieve any supplies from boxes or bags with contaminated gloves.””

“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, clinical record review, observation, and staff interviews, the agency failed to include a complete list of medications for 2 of 4 patients with home visits conducted. (#7 and # 8) Findings included: 2. Patient #8 was admitted on 03/05/2025 with a diagnosis of atherosclerosis of the native arteries of the left leg with ulcer (plaque buildup inside the arteries of the leg resulting in a wound). The plan of care for 03/05/2025-05/03/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 1 week, 3 times a week for 7 weeks with 2 PRN (as needed), physical therapy 1 time a week for 9 weeks and “Skilled nurse to instruct on new and changed medication.” During a home visit that was conducted on 03/24/2025 at approximately 3:00 PM physical therapy assistant (PTA) #6 conducted a complete medication review. The medication review found the following medications were not included in the plan of care: Clopidogrel (prevents blood clots) 25 mg take by mouth daily. Furosemide (treats fluid retention) 20mg take by mouth daily. Linzess (treats constipation) 72 mcg take by mouth daily. A review of the clinical record revealed that registered nurse (RN) #9 documented that a medication review was completed on 03/24/2025 prior to the PTA visit. During an interview conducted on 03/25/2025 at approximately 9:40 AM PTA #6 stated, “Every visit I ask about medications and reconcile. I do [update the medication list] if there is something new. Yes, I look at all of the bottles periodically.” During an interview on 03/25/2025 at approximately 2:22 PM RN #9 stated, “I look at whatever the referral says [at admission] and I only put the medication on from that. I asked for an updated med rec [medication reconciliation] sheet from PCP [primary care physician]. Agency policy is to only use med from the discharge list.” During an interview conducted on 03/25/2025 at approximately 2:27 PM when asked about the expectation for medication reconciliation the agency director stated, “Should be reviewed entirely at least once a week and ask every visit and make changes as necessary.” During an interview conducted on 03/25/2025 at approximately 2:30 PM the clinical manager stated, “They [clinical staff] are comparing the list [medication] in [documentation software name] and the bottles.” A policy, Monitoring Medications (revised 07/01/2024), received on 03/25/2025 at 4:30 PM from the agency director stated, “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.” Patient #7 was admitted on 11/11/24 with a diagnosis of type 2 diabetes mellitus with foot ulcer (is a disease of inadequate control of blood levels of glucose). The plan of care for 03/11/2025-05/09/2025 included orders for skilled nurse visits (SN) 2 times a week for a week, 3 times a week for 8 weeks, and 2 PRN (as needed) and “Skilled nurse to instruct on new and changed medication.” During a home visit that was conducted on 03/24/2025 at approximately 2:30 PM registered nurse (RN) # 9 conducted a complete medication review. The medication review found the following medications were not included in the plan of care: Folic Acid (electrolyte balance) 400mg take by mouth daily. Hydralazine (treats fluid retention) 25mg take by mouth three times daily. Xarelto (prevention of blood clots) 2.5mg take by mouth twice daily. Carvedilol (treats high blood pressure and heart failure) 6.25mg twice daily. Valsartan (treats high blood pressure and heart failure) 160mg twice daily. During an interview on 03/25/2025 at approximately 2:22 PM RN #9 stated, “I look at whatever the referral says [at admission] and I only put the medication on from that. I asked for an updated med rec [medication reconciliation] sheet from PCP [primary care physician]. Agency policy is to only use from the discharge list.” During an interview conducted on 03/25/2025 at approximately 2:27 PM the agency director stated, “The medication reconciliation should be reviewed entirely at least once a week and at every visit ask a about medication changes and make changes as necessary.””

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to alert the physician of a change of condition for 2 of 2 patients with a documented change of condition (#3 and 4). Findings included: A policy Coordination of Care, From Admit through Discharge (revised on 09/01/2024), received on 03/25/2025 at 4:30 PM from the agency director stated, “Coordination of care with physician/ authorized practitioner at admission throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician when changes occur in the patient’s condition or response to treatment”. 1. Patient #3 was admitted on 11/22/2024 with diagnoses of Non-PRS (non- pressure) chronic ulcer to left lower leg with fat later exposed and heart failure (a chronic condition in which the heart doesn’t pump blood as well as it should). The plan of care for 11/22/2024- 01/20/2025 included orders for skilled nurse visits 1 time a week for two weeks, 2 times a week for 7 weeks with 2 PRN (as needed) and “Skilled nurse to obtain weight every day and notify MD (medical doctor) of weight gain or loss 2- 3lbs (pounds/weight) within 1 day or 5 lbs in 1 week.” Review of the clinical record revealed the following information on 11/29/2024 Patient # 3 had a 7 lb weight gain compared to the weight documented on 11/27/2024. There was no evidence that the LPN (licensed practical nurse) notified the physician. During an interview conducted on 03/25/2025 at 1:19 PM, LPN# 11 stated, “I normally would call and notify the MD, and assess for heart failure.” An interview conducted on 03/25/2025 at 1:20 PM with the clinical manager revealed that the expectation is for the nurses to notify the physician, assess for heart failure symptoms, and follow up. 2. Patient #4 was admitted on 02/18/2025 with diagnoses of necrotizing fasciitis (flesh- eating disease occurs when bacteria enter the body through a break in skin), Type 2 diabetes mellitus with hyperglycemia (a disease of inadequate control of blood levels of glucose) and heart failure (a chronic condition in which the heart doesn’t pump blood as well as it should). The plan of care for 02/18/2025-04/18/2025 included for skilled nurse (SN) visits 2 a week for a week, and 3 times a week for 8 weeks with 3 PRN (as needed). Review of the clinical record revealed RN (registered nurse) # 12 made a routine visit on 3/10/25 and documented the following information, “patient had diminished lung sounds, elevated blood pressure, and complaints of dizziness and vomiting.” Further review revealed no evidence that RN#10 notified the physician. An interview was conducted on 3/25/25 at 1:26PM with RN #12 stated “That she is pretty new to home health not sure what is needed to be done versus what she feels needs to be done.” RN #12 felt the decision was appropriate and was not aware of the previous visit findings from the prior visit. During an interview on 3/25/25 at 1:34PM the clinical manager stated, “the RN should review prior visits… and the event should’ve been reported to MD.””

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to document blood glucose levels for 1 of 5 patients with diabetes mellitus (disease resulting in too much sugar in the blood). (patient # 9) Findings included: A policy Home Care Record (revised 10/01/2023) received on 03/25/2025 at 2:44 PM from the agency director stated, “The patient home care record shall contain the following clinical information… Diagnostic and therapeutic test, procedures, and treatments and their results.” Patient #9 was admitted on 01/17/2025 with a diagnosis of Type 2 Diabetes Mellitus with foot ulcer. The plan of care for 01/17/2025- 03/17/2025 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 3 times a week for 3 weeks, 2 times a week for 5 weeks, and 2 PRN (as needed). Review of the clinical record revealed that during the SN visits on 02/14/2025 and 02/21/2025 licensed practical nurse (LPN) #10 documented, “Patient- CBG [capillary blood glucose] documented in vital sign section.” Further review revealed that the CBG was not documented in the clinical record. LPN #10 was not available for an interview. An interview conducted on 03/25/25 at 10:52 AM with the agency director revealed that the expectation is for the CBG to be documented at every visit.”