UNC Home Health

“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 registered nurses failed to perform glove changes and hand hygiene during wound care for 2 of 2 patients with registered nurse (RN) home visits conducted (#’s 16 & 19), failed to disinfect equipment for 1 of 2 RN home visits conducted (#19), and failed to disinfect a wash basin, obtain clean water and washcloth during wound care for 1 of 2 RN (#19) with home visits conducted. Findings included: A policy, Home Health Standard Precautions (revised 03/2026) received on 03/04/2026 at 9:44 AM from the administrator stated, “Gloves are to be changed: Between task and procedures on the same patient… After removing an old dressing…” A policy, Wound Assessment, Home Care (revised 02/24/2024) received on 03/05/2026 at 9:45 AM from the administrator stated, “Remove the old dressing carefully… Discard the soiled dressing in the waterproof trash bag. Remove and discard your soiled gloves. Perform hand hygiene…” 1. Patient #16 was admitted on 02/11/2026 with diagnoses of unspecified open wound, right lower leg and unspecified open wound, left lower leg. The plan of care for 02/11/2026-04/11/2026 included orders for skilled nurse (SN) visits 1 time a day for 1 day, 1 time a week for 1 week, 1 time a week for 8 weeks, with 3 PRN (as needed), “SN to perform wound care as follows: RLE [right lower extremity] Wash wound with soap and water… apply Dakin’s [topical antiseptic] moist to dry… Apply ABD [absorbent dressing] & Kerlix [rolled gauze], secure with _____ [brand name] tape, Change 1-2x/Day [1-2 times a day], Wear 1-2 layer tubigrip [compression bandage] 24/7 [continuously] size G… to be worn from just below the knee and down over the toes,” and “SN to perform wound care as follows: LLE [Left lower extremity] Wash wound with soap and water… apply Dakin’s [topical antiseptic] moist to dry… Apply ABD [absorbent dressing] & Kerlix [rolled gauze], secure with _____ [brand name] tape, Change 1-2x/Day [1-2 times a day], Wear 1-2 layer tubigrip [compression bandage] 24/7 [continuously] size G… to be worn from just below the knee and down over the toes.” During a home visit conducted on 03/03/2026 at 9:30 AM while wearing clean gloves, registered nurse #7 removed supplies from the clinical bag, repositioned the patient’s personal bath towel on the floor and failed to remove the gloves and perform hand hygiene before removing the wound dressing from the right leg. RN #7 failed to remove the gloves after removing the soiled dressing and proceeded to begin the dressing change on the left leg. RN #7 used soap, water and a washcloth to cleanse the left leg and failed to remove the gloves, perform hand hygiene, disinfect the wash basin and obtain clean water before cleansing the right leg. RN #7 applied the Dakins soaked gauze to the right leg and failed to remove the gloves and perform hand hygiene before treating the left leg. An interview conducted on 03/05/2026 at 8:47 AM with RN #7 revealed that they were not aware that hand hygiene and new gloves were required after handling the patient’s personal bath towel and removing a wound dressing, was not aware that each wound should have been treated separately with glove changes and hand hygiene in-between each wound. During an interview conducted on 03/04/2026 at 12:05 PM the nurse educator stated, “They [nurses] should treat 1 wound at a time.” During an interview conducted on 03/05/2026 at 8:57 AM nurse manager #15 stated, “Hand hygiene should be performed every time you move from dirty to clean, every time you take off or put on your gloves, they should use individual cleanser for each wound and should done one wound at a time.” 2. Patient #19 was admitted on 11/24/2025 with a diagnosis of non-pressure chronic (long term) ulcer (wound) of right heel with fat layer exposed. The plan of care for 01/23/2026-03/23/2026 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 3 times a week for 2 weeks with 1 PRN visit and “SN to cleanse wound with Vashe [wound cleanser], apply collagen to the center of the wound, cover with bordered gauze/band-aid, and gentle 1-layer compression -8-15 [amount of compression] compression sock each visit.” During a home visit conducted on 03/02/2025 at 1:45 PM while wearing clean gloves RN #5 failed to remove the gloves and perform hand hygiene after removing bandage scissors from the patients personal supply box and failed to disinfect the scissors before cutting the collogen dressing and placing it on the wound. During an interview conducted on 03/05/2026 at 9:14 AM RN #5 stated, “Yes [would normally clean the scissor]” and agreed that she should have sanitized the scissors, removed gloves, performed hand hygiene and donned new gloves.” 9:18 AM 03/05, “Our expectation is that once she reached in the get the scissor, she should have removed the gloves, performed hand hygiene and put on clean gloves….””

“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, observation, clinical record review, and staff interviews, the agency registered nurses failed to notify the physician of treatments that were not completed as ordered for 2 of 7 patients with orders for wound care (patients #12 & 16). Findings included: A policy, Home Health Monitoring Patient’s Response/Reporting to Physician or other Licensed Practitioner, received on 03/04/2026 at 1:26 PM from the administrator stated, “During each home visit, the clinician will assess the patient and communicate any change in the patient’s condition or established plan of care, including… Changes that have occurred regarding … treatment (including procedures…) When there is a problem implementing the plan of care.” 1. Patient #12 was admitted on 01/29/2026 with “No primary diagnosis documented.” The plan of care for 01/29/2026-03/29/2026 included orders for skilled nurse (SN) visits 1 time a week for 5 weeks with 5 PRN (as needed) and “SN to assess wound and measure weekly.” Review of the clinical record revealed that during the SN visits on 02/06/2026 and 02/13/2026 registered nurse (RN) #17 documented, “Dressing status Intact/not removed.” Further review revealed that there was no documentation of the physician not being notified that the wound was not assessed or measured as ordered. During an interview conducted on 03/05/2026 at 9:19 AM RN #17 stated, “I don’t believe that I did [notify the physician], normally yes [would notify the physician], it was just missed.” During an interview conducted on 03/05/2026 at 9:21 AM nurse supervisor #18 stated, “They [nurses] should notify the physician or provider.” 2. Patient #16 was admitted on 02/11/2026 with diagnoses of unspecified open wound, right lower leg and unspecified open wound, left lower leg. The plan of care for 02/11/2026-04/11/2026 included orders for skilled nurse (SN) visits 1 time a day for 1 day, 1 time a week for 1 week, 1 time a week for 8 weeks, with 3 PRN (as needed), “SN to perform wound care as follows: RLE [right lower extremity] Wash wound with soap and water… apply Dakin’s [topical antiseptic] moist to dry… Apply ABD [absorbent dressing] & Kerlix [rolled gauze], secure with _____ [brand name] tape, Change 1-2x/Day [1-2 times a day], Wear 1-2 layer tubigrip [compression bandage] 24/7 [continuously] size G… to be worn from just below the knee and down over the toes,” and “SN to perform wound care as follows: LLE [Left lower extremity] Wash wound with soap and water… apply Dakin’s [topical antiseptic] moist to dry… Apply ABD [absorbent dressing] & Kerlix [rolled gauze], secure with _____ [brand name] tape, Change 1-2x/Day [1-2 times a day], Wear 1-2 layer tubigrip [compression bandage] 24/7 [continuously] size G… to be worn from just below the knee and down over the toes.” During a home visit conducted on 03/03/2026 at 9:30 AM patient #16 requested that the tubigrip not be applied to his legs. RN #7 completed the wound care to both legs and did not apply the tubigrip as requested. A review of the clinical record revealed that there was no documentation of the physician being notified that the treatment was not provided as ordered. An interview conducted on 03/05/2026 at 8:47 AM with RN #8 revealed that they would normally notify the physician and document it. An interview conducted on 03/05/2026 at 9:00 AM with nurse manager #15 revealed that the nurse should have notified the physician and documented it.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency occupational therapist failed to include an order for a social worker (SW) visit in the plan of care for 1 of 3 patients with an order for SW visits (patient #15). Findings included: A policy, Home Health Monitoring Patient’s Response/Reporting to Physician or other Licensed Practitioner (revised 03/2026), received on 03/04/2026 at 1:26 PM from the administrator stated, “Based on communication with the physician or licensed practitioner, a verbal order will be obtained for any change in the plan of care and communicated to all appropriate team members to ensure that care is provided according to the revised plan of care.” Patient #15 was admitted on 02/02/2026 with a diagnosis of other sequelae of cerebral infarction (long term, post-acute, impairments following a stroke). The plan of care (POC) for 02/02/2026-04/02/2026 included orders for occupational therapy (OT) visits 1 time a week for 1 week, 2 times a week for 3 weeks and 2 times a week for 2 weeks. Review of the clinical record revealed that on 02/04/2026 OT #19 documented, “Disciplines ordered per referral and patient in agreement with the following evals [evaluations]: PT [physical therapy], OT, adding SW [social worker] …” OT #19 documented a communication with the physician requesting approval to the change in the POC including a request for the SW. The physician responded, “I agree with the POC.” Further review revealed that an order for a SW evaluation was not added to the POC. Patient #15 did not receive a SW visit. During an interview conducted on 03/05/2026 at 8:34 AM OT #19 stated, “I don’t think that was something that I was really attune too… What I would do would be to definitely let the care manager know that it was requested … for follow-up… the ball got dropped on this.” During an interview conducted on 03/05/2026 at 8:43 the therapy manager stated, “As soon as she received that communication from the doctor she should have put a one-time order in [the plan of care].””

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on clinical record review and staff interviews, the agency registered nurse documented inaccurate information in the clinical record for 1 of 2 patients with registered nurse home visits conducted. (#16) Findings included: Patient #16 was admitted on 02/11/2026 with diagnoses of unspecified open wound, right lower leg and unspecified open wound, left lower leg. The plan of care for 02/11/2026-04/11/2026 included orders for skilled nurse (SN) visits 1 time a day for 1 day, 1 time a week for 1 week, 1 time a week for 8 weeks, with 3 PRN (as needed), “SN to perform wound care as follows: RLE [right lower extremity] Wash wound with soap and water… apply Dakin’s [topical antiseptic] moist to dry… Apply ABD [absorbent dressing] & Kerlix [rolled gauze], secure with _____ [brand name] tape, Change 1-2x/Day [1-2 times a day], Wear 1-2 layer tubigrip [compression bandage] 24/7 [continuously] size G… to be worn from just below the knee and down over the toes,” and “SN to perform wound care as follows: LLE [Left lower extremity] Wash wound with soap and water… apply Dakin’s [topical antiseptic] moist to dry… Apply ABD [absorbent dressing] & Kerlix [rolled gauze], secure with _____ [brand name] tape, Change 1-2x/Day [1-2 times a day], Wear 1-2 layer tubigrip [compression bandage] 24/7 [continuously] size G… to be worn from just below the knee and down over the toes.” During a home visit conducted on 03/03/2026 at 9:30 AM patient #16 requested that the tubigrip not be applied to his legs. RN #7 completed the wound care to both legs and did not apply the tubigrip as requested. A review of the clinical record revealed that on 03/03/2026 RN #7 documented for the right and left lower extremity wounds that the wound care was provided as ordered. Further review revealed no documentation that the tubigrip was not applied. An interview conducted on 03/05/2026 at 8:47 AM with RN #7 revealed that because they had documented the patient’s refusal of the tubigrip at a prior visit they didn’t need to document it again. An interview conducted on 03/05/2026 at 9:00 AM with nurse manager #15 revealed that the expectation is for the nurses to document only the care that is provided, document any deviation from the physician’s order, and notify the physician.”

“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 agency policy, clinical record review, and staff interviews the agency failed to follow the physician’s orders related to visit frequency for 1 of 2 patients with occupational therapy services orders [#3]. The findings included: On 6/3/24 at approximately 3:25 pm, the policy, Home Health Care Coordination, was provided by the Director of Home Health. The policy stated, “...integrate orders from all physicians involved in the plan of care so that all services and interventions are coordinated...” Patient #3 was admitted on 2/16/24 with diagnoses of pressure ulcer of sacral region (below the lumbar spine and above the tailbone, which is known as the coccyx), stage 4 (extending below the subcutaneous fat into deep tissues, including muscle, tendons, and ligaments) left heel pressure ulcer, infection and inflammatory reaction due to nephrostomy catheter (a tube that lets urine drain from the kidney through an opening in the skin on the back), Klebsiella pneumoniae (type of bacteria), malignant neoplasm of head of pancreas, secondary malignant neoplasm of other urinary organs, in addition to other comorbidities. The plan of care orders for the certification period 2/16/24 to 4/15/24 included orders for skilled nursing three times a week for wound care, physical therapy two times a week, and an occupational therapy [OT] evaluation. A supplemental order for OT was written on 2/20/24 for 2 times a week for 3 weeks. During the record review on 6/3/24, there were no occupational therapy visits done after the initial assessment on 2/20/24 and no documentation stating why the visits were not completed. During an interview with employee #1 on 6/3/24 at approximately 3:10 pm, employee #1 confirmed there was no evidence the patient received any OT visits after the initial evaluation on 2/20/24 and the agency failed to follow the physician’s orders related to visit frequencies.”