Beacon 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 policy review, observation, and interview, the facility failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases when 1 of 7 (Patient #2) employee failed to change gloves and perform hand hygiene after removing a soiled dressing. The findings included: Review of the agency’s policy “Application of a Wound Care Dressing,” dated 4/30/2024, revealed “…Hold soiled dressing in hand and remove glove to wrap inside out around dressing. Repeat with second glove and discard in disposable bag…Perform hand hygiene. Don non-sterile gloves…” Review of the agency’s policy “Hand Hygiene,” dated 6/26/2024, revealed “…Perform hand hygiene as follows: ...After contact with…wound dressings…” Review of the medical record revealed Patient #2’s was admitted to the agency Start of Care (SOC) on 10/18/2024 with diagnoses including Pressure Ulcers to right and left heel, Hypertensive Chronic Kidney Disease, and Emphysema. Review of the Home Health Certification and Plan of Care dated 2/15/2025 to 4/15/2025, revealed “…RN [Registered Nurse]/LPN [Licensed Practical Nurse]/ LVN [Licensed Vocational Nurse] to perform/ teach patient/ caregiver wound care pressure injury to…[both heels]…cleanse with wound cleanser[,] apply…[Named petroleum gauze] with foam dressing wrap with [Named gauze wrap]…[Named adhesive wrap] Change dressing 2 X [twice] a week and PRN [as needed] for dislodgement…” Observation in Patient #2’s home on 2/24/2025 at 2:00 PM, revealed that after removing the soiled dressing from Patient #2’s left heel, the LPN threw the soiled dressing in the trash. Patient #2 requested to see the soiled dressing. The LPN reached into the trash with both hands to retrieve the soiled dressing and showed it to Patient #2. The LPN returned the soiled dressing to the trash, grabbed a bag of gauze pads, and removed the scissors from the clean drape to cut the bag. The LPN then applied a clean dressing to Patient #2’s left heel. The LPN did not change her soiled gloves and did not perform hand hygiene prior to applying a clean dressing. During an interview on 2/24/2025 at 2:46 PM, Clinical Manager #2 confirmed that the LPN should have removed the soiled gloves, performed hand hygiene, and donned a pair of clean gloves before returning to Patient #2’s dressing change.”

“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 policy review, medical record review, and interview, the agency failed to update the medication profile for 5 of 7 (Patient #1, #2, #3, #4, and #6) patients reviewed. The findings included: 1. Review of the agencies “Drug Regimen Review,” policy last revised 12/9/2024, revealed “...Purpose: To identify appropriateness, inconsistencies, and/or significant drug interactions in the patient’s current medication regimen, as well as ensure the comprehensive list of medications are updated any time there is a medication change including dose changes, new medications, and any medications discontinued…” 2. Review of the medical record revealed Patient #1 was admitted to the agency Start of Care (SOC) on 2/11/2025, with diagnoses of Pulmonary Fibrosis, Chronic Kidney Disease, Atrial Fibrillation, and History of Falling. Observations in Patient #2’s home 2/24/2025 amlodipine (treats high blood pressure) 5 mg (milligram) by mouth daily, alprazolam (treats anxiety) 1 mg 2 times a day as needed for anxiety/sleep, levocetirizine (treats allergy symptoms) 5 mg by mouth at bedtime, over the counter (OTC) acetaminophen extra strength 500 mg by mouth every 4- 6 hours as needed, and OTC Nasacort (treats nasal allergies) nasal spray, 55 micrograms (mcg)/ spray, 2 sprays in each nostril twice daily. During an interview on 2/24/2025 at 1:45 PM, Patient #1 stated he didn’t take amlodipine because it caused swelling, and he used 1 spray of Nasacort at bedtime. During an interview on 2/24/2025 at 2:15 PM, Clinical Manager #1 confirmed Patient #1’s medications needed to be reconciled. 3. Review of the medical record revealed Patient #2 was admitted to the agency SOC on 10/18/2024, with diagnoses including Pressure Ulcers to right and left heel, Hypertensive Chronic Kidney Disease, and Emphysema. Review of the Home Health Certification and Plan of Care dated 2/15/2025 to 4/15/2025, revealed there were no orders for loperamide (treats diarrhea) 2 mg, twice daily and trazadone (treats insomnia) 50 mg. 0.5 tablet at bedtime. Observations in Patient #2’s home on 2/24/2025 at 1:32 PM, revealed trazadone (treats insomnia) 50 mg. 0.5 tablet at bedtime and loperamide hcl (hydrochloride) 2 mg, twice daily. Loperamide was not listed on the medication profile. During an interview on 2/24/2025 at 2:45 PM, Patient #2’s son stated that his father had been taking loperamide hcl for about 3 or 4 months, and his father stopped taking trazadone about 2 or 3 months ago. 4. Review of the medical record revealed Patient #3 was admitted to the agency SOC on 11/18/2023, with diagnoses of Pressure Ulcer of Sacral Region, Hypertension, and Alzheimer’s Disease. Review of the Home Health Certification and Plan of Care dated 1/11/2025 to 3/11/2025, revealed “…memantine [helps with cognition] 5 mg…2 times daily; Nystatin [treats fungal infections] 100,000 unit/gram topical cream…as directed…” During an interview on 2/25/2025 at 11:42 PM, Patient #3’s wife stated the memantine was increased from 5 mg to 10 mg several months ago and Nystatin had not been used since June 2024. During an interview on 2/24/2025 at 11:43 PM, Clinical Manager #2 confirmed Patient #3’s medications needed to be reconciled. 5. Review of the medical record revealed Patient #4 was admitted to the agency SOC on 2/13/2025, with a diagnosis of Nonrheumatic Aortic (Valve) Stenosis. Review of the Home Health Certification and Plan of Care dated 2/13/2025- 4/13/2025, revealed no order for lidocaine patches. Observations in Patient #4’s home on 1/7/2025 at 12:27 PM, revealed a box of over the counter (OTC) lidocaine 4% patches (treats pain), apply 1 patch to affected area for 12 hours and remove after 12 hours, was not listed on the medication profile. During an interview on 2/25/2025 at 11:35 AM, Patient #4’s wife reported that Patient #4 was using the patches once a week, and he had been using them prior to receiving home health services on 2/13/2025. During an interview on 2/24/2025 at 2:46 PM, Clinical Manager (CM) #2 confirmed that all medications were to be listed in the patient’s chart. CM #2 stated nursing was to contact the patient’s physician to review the medication list. 6. Review of the medical record revealed Patient #6 was admitted to the agency SOC on 2/1/2025, with diagnoses of Displaced Oblique Fracture of Right Femur, Pressure Ulcer of Right Heel, Hypertension, Diabetes Mellitus, and Prostate Cancer. Review of the Home Health Certification and Plan of Care dated 2/1/2025 to 4/1/2025, revealed “…baclofen [muscle relaxer] 5 mg …oral…3 times daily/prn [as needed]; folic acid [supplement] 1 mg…oral…daily; lidocaine [treats pain] 5% topical Patch daily; melatonin [helps with sleep]…1 tablet…oral…bedtime; Miralax [helps with constipation] 17 gram/ dose oral powder…prn…” Observations in Patient #6’s home on 2/26/2025 at 9:15 PM, revealed Humalog insulin (treats high blood sugar) 3 units twice daily for glucose greater than 150. During an interview on 2/26/2025 at 9:20 AM, Patient #6’s wife stated “…A nurse came out last Tuesday to change his [Patient #6] dressing on his foot…He has been checking his blood sugars and taking his insulin since he was diagnosed with Cancer…” Patient #6’s wife confirmed he was no longer taking Baclofen, folic acid, melatonin, Miralax, or using the lidocaine patch. During an interview on 2/26/2025 at 9:40 AM, the Registered Nurse (RN) confirmed that Patient #6’s medications were not updated. The RN explained to Patient #6 that he would receive an updated medication list in the mail, and she had deleted the medications that he was no longer taking.”