New Life Home Health Services

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to code and electronically transmit completed OASIS (Outcome and Assessment Information Set) assessments to the CMS (Center for Medicare and Medicaid) system within thirty days of completing the assessment of the beneficiary for 409 of 1438 (28.44%) records submitted. This failure prevented the patient’s data from being made available to Center for Medicare and Medicaid (CMS) for analysis to identify agency performance levels in the provision of patient care. The findings included: Record review of IQIES “Home Health Error Summary by Agency” report generated from the CMS national data system during presurvey preparation on 03/27/25 revealed Agency had submitted and processed 1438 assessments. The report also revealed the Agency had 409 assessments with error -3330 indicating those records were submitted after the 30th date of the M0090 (assessment) date, which equaled to 28.44% of the total assessments submitted in error. In an interview with DON and Adm on 04/04/24 at 11:00 a.m., DON stated she was responsible for submitting OASIS information to CMS. DON and Adm did not dispute the errors and stated “yes,” they did have several late submissions for the past year. Surveyor asked why they had late submissions for their Oasis. DON stated, “I had some difficulty with some nurses this past year. The nurses turn in the oasis late.” Surveyor further asked how late Oasis submissions can affect patient care. DON further stated, “Client care won’t be affected by this.” Adm stated, “When we start deviating from policy, we can affect client care.” Record review of the Agency’s policy manual contained a policy titled, “Timelines IM.35”, with a date of 10/25/24, quoted in part, “Purpose: To establish timely parameters for all medical record information. Policy: The agency will ensure timely provision of care and services to meet the patient’s/client’s needs in compliance with federal and state laws and regulations. Procedure…II. All completed and encoded OASIS date will be transmitted via electronic communication software…from the Agency or the Agency contractor to CMS collection site within 30 days of M0090 date. The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information. No additional information was presented to this surveyor upon exit on 04/04/25.”

“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 record review, observation, and interview the agency failed to enforce its written policy addressing infection control including the prevention of the spread of infectious and communicable disease for 3 of 7 active Patients (Patient #1, 2, and 3) reviewed for infection control in that: LVN A failed to follow proper procedures while conducting a home visit with patients #1 and #2: 1.) no use of a protective barrier for his nursing bag 2.) placed the bag on the floor 3.) no gloves used while assessing patient #1 vitals/body systems 4.) touched patient #2’s folder and his cellular phone with contaminated gloves 5.) did not properly clean equipment prior to placing it back into nursing bag 6.) missed opportunities for glove changes 7.) missed opportunities for hand hygiene. LVN B failed to follow proper procedures while conducting a home visit with patient #3: 1.) missed opportunities for glove changes. This deficient practice could place Patients, LVN A, and LVN B at risk for increased wound infections, and further deterioration of the patient’s wounds. The findings included: Record review of [Agency Name] Policy and Procedure Compliance Manual titled “Infection Control Program IC.10” with an revision date of 01/01/25, quoted in part...Purpose: “To outline the policies and procedures for an infection control program which applies to patients/clients, staff, and care provided. The program improves patient/client outcomes through risk reduction, prevention, identification, and control of infections and communicable diseases in patients/clients and staff…Policy: The Agency’s Infection Control Program will be based on the following criteria…C. Current scientific methods of surveillance and prevention or control of adverse outcomes related to infections. D. CDC guidelines…F. OSHA…G. Current federal, state, and local laws and regulations…Prevention and Control Activities 1. The agency will follow accepted standards of practice…use of standard precautions…transmission-based precautions with standard precautions, to prevent the transmission of infections and communicable diseases. 2. All employees will follow the Exposure Control Plan…3…hand hygiene, cleaning and management of Supplies and Equipment, Hazardous Materials and Waste, Disposal of Dressings, Personal Protective Equipment, Bag Technique…” Record review of [Agency Name] Policy and Procedure Compliance Manual titled “Hand Hygiene IC.15” with an revision date of 05/01/24, quoted in part, “Purpose: To ensure patient/client staff practice proper hand hygiene techniques in the prevention and spread of infection per CDC guidelines…Policy: B. All agency staff providing patient/client care will perform hand hygiene in accordance with CDC recommendations…D…Staff may use an alcohol-based …in the clinical situation described below…Prior to initial entry into supply bag 2. Immediately before touching a patient/client 3. Before an aseptic task…4. After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressing and used supplies (PPE)…5. Before moving from a contaminated site to a clean body site during patient/client care 6. After touching a patient/client or the patients/client’s immediate environment 7. After contact with blood, body fluids, or contaminated surfaces 8. After removing gloves…” Record review of [Agency Name] Policy and Procedure Compliance Manual titled “Bag Technique IC.60” with a revision date of 05/01/24, quoted in part, Purpose: To describe the procedure for maintaining a contaminate free home health bag and preventing cross-contamination. Policy: The principles in bag technique are developed and used to maximize the efficient use of the bag and to assure asepsis and infection control...II. Bag Technique A. In the patient/client home, a barrier (such as newspaper, paper towel, small trash bag, etc.) is to be placed under the bag. Bags should never be placed on the floor…C. After cleansing hand, the supplies and/or equipment are removed from the bag. D. When the visit is completed, reusable equipment is cleaned…hands are cleansed per CDC guidelines and supplies are returned to the bag. Equipment may be cleaned as follows: Stethoscope…” 1. Review of Patient #1 “Home Health certification and plan of care” documented a 52-year-old male with primary diagnosis of Type II Diabetes mellitus (DM) with foot ulcer (high blood sugar levels with open sore), non-pressure chronic ulcer of right heel and midfoot with necrosis muscle (open sore with dead tissue), non-pressure chronic ulcer left foot with necrosis of muscle (open sore with dead tissue), chronic osteomyelitis of left ankle and foot (infection in the bone), schizoaffective disorder (mental disorder-exhibits both symptoms of schizophrenia and bipolar), Bipolar (mental health condition associated with emotional highs and lows), Anxiety disorder (uncontrollable feelings of fear), Essential hypertension (when the force of blood pushing against your artery walls is consistently too high), hyperlipidemia (blood has too much fat), Peripheral vascular angioplasty (procedure to open blocked arteries in the legs), limitation of activities due to disability, long-term use of insulin (regulates blood sugars), anticoagulants (prevents blood clots), non-insulin antidiabetic drugs (regulate blood sugar levels), and other long term drug therapy. The form also documented a start of care as 01/31/25 and a “current episode” or certification period as 04/01/25-05/30/25 with skilled nurse visits once daily for 60 days and 3 as needed. Safety Measures: Standard precautions/Infection Control. Upon further review, “Orders and treatments” 7. SN using aseptic technique and sterile supplies to perform wound care every day to (wound #1) DM Ulcer (slow healing wound on the feet) to Lt Metatarsal (bones in the feet) and to (wound #2) DM Ulcer to Rt heel as follows: Cleanse with Anasept spray (treats skin and tissue infections), leave on for 30 seconds, pat dry with 4x4 gauze, apply puracol Plus Ag wound dressing (promotes natural healing with antimicrobial properties), cover with 4x4 gauze, wrap with kerlix and secure with tape until healed by SN/MD. An observation was made of LVN A performing wound care to wound #1 left metatarsal and wound #2 Right heel during a home visit to patient #1 on 04/02/25. Surveyor and LVN A arrived at patient #1’s home at 10:00 a.m. Brief introductions were made, and consent was signed by patient #1. Upon entrance of home, LVN A sanitized his hands with a sanitizer wipe before initial contact with patient #1. Surveyor and LVN A entered patient #1 room. Patient #1 observed lying in bed in a supine position. LVN A set his bag on the floor at the foot of the bed. No barrier between bag and floor. Trash bag opened and placed on floor. LVN A placed barrier on bed and set-up his supplies on clean field. LVN A assessed patients body systems and vitals with no gloves. LVN A placed a barrier under the patient’s feet. LVN A sanitized hands with sanitizer wipe. New gloves donned (put on) by LVN A. LVN A removed bandage to left foot. LVN A placed soiled dressing in trash. LVN A doffed (took off) gloves and placed in trash. LVN A donned new gloves. No handwashing nor use of hand sanitizer in between glove change. LVN A gathered more supplies and placed them on clean field. LVN A cleaned scissors with disinfectant. LVN A cut puracol to the size of wound. LVN A sprayed Left metatarsal (wound #1) with anasept and let it sit for 30 seconds. Cleansed left metatarsal with anasept and 4x4 gauze. LVN A threw the 4x4 gauze into trash. Applied puracol to wound, then 4x4 gauze, wrapped with kerlix, and secured with tape. LVN A did not change his gloves post cleansing wound #2. LVN A reached into to his nursing bag with same contaminated gloves and grabs disinfectant wipes with contaminated gloves to clean scissors. Throws away wipe in trash. LVN A proceeded to cut off the dressing off right heel, placing soiled dressing in trash. Doffs gloves and Donned new gloves. No handwashing nor use of hand sanitizer between glove change. LVN A sprays right heel (wound #2) with anasept and lets it sit for 30 seconds, cleanses wound with anasept and 4x4 gauze. Throws gauze in trash. Doffs gloves and places them in trash. Donned new gloves. No handwashing nor use of hand sanitizer in between glove change. LVN A cuts puracol to fit wound, places it on wound, applies 4x4 gauze, wraps with kerlix, and secures with tape. LVN A cleans up supplies and barriers, places them in trash. Doffs gloves. Cleans hand with disinfectant wipe. Then proceeds to grab his bag and trash. LVN A throws trash in outside trash bin. 2. Review of Patient #2 “Home Health certification and plan of care” documented a 68-year-old male with primary diagnosis of Non-pressure chronic ulcer to right lower leg with fat layer exposed (open wound), open wound to right lower leg, Chronic obstructive pulmonary disease (respiratory/airflow limitation), cirrhosis of liver (liver damaged with scar tissue), macular degeneration to left eye (affects the central part of the retina, leading to blurred or no vision in the center of the visual field), nicotine dependence, skin transplant status, problems related to living alone, acquired absence of right foot, acquired absence of left leg below knee amputation, presence of artificial left leg, personal history of other infectious and parasitic diseases, and long-term use of opiate analgesic (relieve pain). The form also documented a start of care as 04/01/24 and a “current episode” or certification period as 03/27/25-05/25/25 with skilled nurse visits once daily for 60 days and 3 as needed. Safety Measures: Standard precautions/Infection Control. Further review, “Orders and treatments” 7. SN using aseptic technique and sterile supplies to perform daily wound care to (wound #2) Arterial Ulcer to Rt Lateral Dorsal Foot and to (wound #7) Trauma wound to Rt Foot TMA as follows: Cleanse with vashe solution (combats bacteria and facilitates wound healing), pat dry with 4x4 gauze, apply Iodosorb Gel (helps clean and heal wounds) using cotton tip applicator, cover with 4x4 gauze, wrap with kerlix and secure with tape until healed by SN/MD. Apply Ammonium Lactate 12% lotion (used to treat dry, scaly, and itchy skin) to bilateral lower extremities for dryness every day. Upon further review a patient communication dated 03/27/25 revealed; findings: Patient with s/p MD appointment for wound evaluation, no new orders were given, SN to continue with same wound care… An observation was made of LVN A performing wound care to wound #2 Right dorsal foot and to wound #7 Right foot TMA during a home visit to patient #2 on 04/02/25. Surveyor and LVN A arrived at patient #2’s home at 11:30 a.m. Brief introductions were made, and consent was signed by patient #2. Upon entrance of home, LVN A sanitized his hands before initial contact with patient #2. Patient #2 was sitting up watching TV on his couch. LVN A sets his bag on the floor next to patient #2. No barrier placed under bag. Trash bag opened and placed on floor. LVN A donned new gloves, placed barrier on top of kitchen counter, cleaned supplies as he got them out of his nursing bag and placed them on top of clean barrier. Disinfectant wipe placed in trash. LVN A assessed patients body systems and vitals. LVN A then grabs patient’s folder, touches his cell phone with same gloves, places cell phone back into his pocket. LVN A places stethoscope that was used on the patient back into his nursing bag. (did not disinfect stethoscope before placing it in bag). Doffs contaminated gloves and places them in trash. LVN A places a barrier on a stool. Patient places right leg on stool/barrier. LVN A donned new gloves. No hand sanitizer or handwashing between glove change. LVN A opens package for gauze and applies vashe wound cleanser onto gauze, cleanses Rt foot TMA, pat dries with 4x4 gauze. Doffs contaminated gloves and places them into trash. Donned new gloves. No hand washing or use of hand sanitizer between glove change. Applies Gentamycin Ointment 0.1% to right TMA (wound #7). LVN A then starts to cleanse right lateral dorsal foot with vashe using 4x4 gauze, pat dries with 4x4 gauze. Doffs contaminated gloves and places them into trash. No glove change while moving to next wound. Dons’ new gloves. Applies iodosorb gel with cotton tip applicator to right lateral dorsal foot (wound #2). LVN A then proceeds to apply Ammonia Lactate to BLE. No glove change while moving sites. Doffs gloves and places them in trash. Dons’ new gloves. No handwashing or use of sanitizer between glove change. LVN A covers Right TMA and lateral dorsal foot with 4x4 gauzes, wraps foot with kerlix, and secures with tape. Cleans up supplies and barrier places in trash. Doffs gloves and places them in trash. Takes trash to outside trash bin. Sanitized hands. In an interview on 04/04/25 at 10:00 am with LVN A, surveyor presented the above findings during home visits for patient #1 and patient #2 which included the following: 1.) no use of a protective barrier for his nursing bag, 2.) placed the bag on the floor, 3.) no gloves used while assessing patient #1 vitals/body systems, 4.) touched patient #2’s folder and his cellular phone with contaminated gloves, 5.) did not properly clean equipment prior to placing it back into nursing bag, 6.) missed opportunities for glove changes, 7.) missed opportunities for hand hygiene. LVN A agreed to these infection control findings. LVN A confirmed employees were to use infection control precautions in every home. LVN A further confirmed he was trained upon hire and yearly for infection control precautions by the agency. LVN A confirmed the agency’s bag technique policy is to put a barrier under their bag in every home and the bag should not be placed on the floor. LVN A further confirmed that during home visit #1 and #2 he placed his bag on the floor with no barrier and patients #1 and #2 had dogs in their home. LVN A confirmed the bag to be contaminated by placing it on the floor. Surveyor asked why he placed the bag on the floor and why he didn’t place a barrier for home visits #1 and #2. LVN A stated, “I forgot and it’s a bad habit.” Surveyor asked how this can affect patient care LVN A stated, “It can cause infection or contamination which I could expose to other patients.” LVN A further confirmed that gloves and stethoscopes are considered contaminated once they have been used on a patient and it can cause cross-contamination if he touches other items in the home and infection to himself and other patients. Surveyor further asked, why he had missed opportunities for hand hygiene and glove changes at home visit #1 and #2. LVN A stated, “It’s a bad habit I formed but I wasn’t aware I needed to since I’m changing my gloves. I must have missed some steps from being nervous.” In further interview, surveyor further asked considering patient #1 and patient #2’s age, diagnosis, comorbidities, and wounds how can these infection control findings affect your patient. LVN A stated, “I can introduce bacteria and cause infection to the patient which could have a negative effect on the patient.” 3. Review of Patient # 3 “Home Health certification and plan of care” documented a 28-year-old male with primary diagnosis of Pressure ulcer of right hip stage 4 (open wound that extends into deep tissues, muscles), pressure ulcer of right buttock stage 2 (open ulcer with damage to underlying tissue), Urinary tract infection (infection in the urinary system), Neuromuscular dysfunction of bladder (injury in the nervous system that makes you lose control of your bladder), urinary device, anemia (lack of red blood cells), chronic pain, paraplegia (partial or complete paralysis of the lower body), cervical spine injury (fracture/dislocation of spine), morbid obesity (excessive body fat), depression (persistent feeling of sadness), cyst of kidney (fluid-filled sacs that form on or in kidneys), and skin transplant status. The form also documented a start of care as 10/24/23 and a “current episode” or certification period as 02/15/25-04/15/25 with skilled nurse visits once daily for 60 days and 3 as needed. Safety Measures: Standard precautions/Infection Control. Upon further review, “Physician order” dated 03/21/25 documented Clinical findings: Patient with s/p MD appointment for wound evaluation, MD gave new wound care orders as follows…effective date 03/22/25…Physician order: 1. SN using aseptic technique and sterile supple to perform wound care every day to (wound #1) stage 4 Pressure Ulcer to Rt (Posterior [back of body]/Superior [above]Hip as follows: Cleanse with Vashe solution, pat dry with 4x4 gauze, apply Hydrogel with collagen (treatment for wound healing), apply adaptic gauze, cover with 4x4 gauze, and secure with tape. 2. SN using aseptic technique and sterile supplies to perform wound care every day to (wound #2) Stage 2 Pressure Ulcer to Rt Medial (Interior) Buttock as follows: Cleanse with Vashe solution, pat dry with 4x4 gauze, apply Medihoney ointment (supports removal of necrotic tissue and promotes healing) with cotton tip applicator, apply hydrofera blue (aids wounds by debridement and kills bacteria), apply ABD pad, cover with 4x4 gauze, and secure with tape. An observation was made of LVN B performing wound care while performing a home visit to patient #3 on 04/02/25at 1:00 pm. Surveyor and LVN B arrived at patient #3’s home at 10:00 a.m. Brief introductions were made, and consent was signed by patient #3. Upon entrance of home, LVN B washed his hands for 20 seconds before initial contact with patient #3. Surveyor and LVN B entered patient #3 room. Patient #1 observed lying in a hospital bed with air mattress in a supine position. Brother assisted patient #3 and turned him to left side. LVN B placed barrier on stand and placed nursing bag. LVN B placed first barrier on mattress behind patient #3s back, 2nd on the front of patient, and 3rd barrier at the end of bed. LVN B washed hands, setup supplies on barriers. Trash bag secured with tape on bedside table. LVN B cleans scissors with disinfectant. Doffs gloves, trash. Hand sanitizer. Donned new gloves. Cleansed vashe spray bottle and places in on clean barrier. Doffs gloves, trash, hand sanitizer. New gloves. LVN B cuts hydrofera blue to wound size and places on clean barrier. Squeezes medihoney on to clean barrier with applicator. Doffs gloves. Trash. Hand sanitizer. Donned new gloves. Squeezes hydrogel and mixes with collagen on clean barrier with applicator. Doffs gloves, trash, hand sanitizer. Donned new gloves. LVN B removes dressing to right hip, trash, doffs gloves, hand sanitizes, donned new gloves. LVN B cleanses right hip with vashe cleanser and 4x4 gauze, pat dries with 4x4 gauze, applies hydrogel mix to right hip wound with applicator, trashes applicator, applies adaptic dressing, covers with 4x4 gauze, then abdominal pad, secures with tape. LVN B missed opportunity for glove change after cleansing the wound. LVN B doffs gloves, hand sanitizer, d onned new gloves. Cleanse right medial buttock with vashe cleanser, pat dries with 4x4 gauze, applies medihoney, then places hydrofera blue on wound, applies 4x4 gauze, covers with abdominal pad, and secures with tape. No glove change post cleansing of the wound. Doffs gloves, trash, hand sanitizer. Donned new gloves, places on dirty barrier, picks up barrier and places in the trash bag. Doffs gloves, hand sanitizer, new gloves. LVN B checks patient #3 vitals and assess body systems. Cleans up all barriers and places them in the trash bag. Doffs gloves. Hand sanitizes. Throws trash in the trash can outside. In an interview on 04/02/25 at 2:15 pm with LVN B, surveyor presented the above findings during home visits for patient #3 1.) missed opportunities for glove changes, LVN B agreed to these infection control findings. LVN B confirmed employees are to use infection control precautions in every home. LVN A further confirmed he was trained upon hire and yearly for infection control precautions by the agency. Surveyor further asked why he missed opportunities for glove changes during wound care. LVN B stated, “I thought it was ok to continue with the same gloves.” Surveyor further asked how cannot changing your gloves affect patient #3. LVN B stated, “It could contaminate the wound again and he can take longer to heal, or he may get an infection.” Further interview with Adm and DON on 04/04/25 at 11:00 a.m., the surveyor presented the findings of infection control for home visits with patients #1, #2, and #3. The Adm and DON confirmed the agency provided training to their nurses for infection control precautions upon hire and annually. Adm and DON confirmed the agency’s infection control policy was to be used at all times during a home visit and agrees that the findings are an infection control issue concerning transmission of disease . Surveyor asked how not using standard precautions/infection control precautions affect your patients that have wounds. DON stated, “It can create more infection; the client can go septic and end up in the hospital. As an agency we are trying to prevent infection and them going back into the hospital.” Adm stated, “It affects the patient from getting better.” Review of Lippincott Advisor & Lippincott Procedures (evidence-based practice information) “Wound dressing application, home care” revision date 02/19/24 contains the following in part: Implementation: Perform hand hygiene… put on gloves…remove old dressing…inspect soiled dressing…discard dressing. Remove and discard soiled gloves. Perform hand hygiene. Put on new gloves. Assess wound. Clean the wound…Discard soiled gauze…remove and discard your soiled gloves. Perform hand hygiene. Put on new gloves…Apply topical wound treatments to wound bed using a cotton-tipped applicator…Apply dressing…secure dressing…remove and discard your gloves. Perform hand hygiene”. Review of Lippincott Advisor & Lippincott Procedures (evidence-based practice information) “Hand Hygiene, home care” revision date 02/19/23 contains the following in part: “Washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids…Using an alcohol-based hand rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; before inserting an invasive device; after contact with a patient; when moving from a contaminated body site to a clean body site during patient care; after contact with body fluids, excretions, mucous membranes, nonintact skin, or wound dressings (if hands aren’t visibly soiled); after removing gloves; and after contact with inanimate objects in the patient’s environment. WHO simplifies points of hand hygiene into five key moments. 1. Before touching a patient 2. Before clean/aseptic procedure 3. After body fluid exposure 4. After touching a patient 5. After touching patient surrounding”. Review Lippincott Advisor & Lippincott Procedures (evidence-based practice information) “Standard precautions, home care” revised date 08/18/22 contains the following in part: “The Centers for Disease Control and Prevention (CDC) developed standard precautions to protect against the transmission of infection… Standard precautions include hand hygiene, appropriate use of personal protective equipment (PPE), and proper handling of potentially contaminated items, including patient equipment, items in the environment, sharps, and specimens…. Wear gloves if you may or will come into contact with blood…body fluids… contaminated surfaces or objects…. Change your gloves and perform hand hygiene if your gloves become…soiled and when moving from a contaminated to a clean site during patient care to avoid cross-contamination. Avoid touching your face, body, and other surfaces and items not needed for direct patient care with your gloved hands to reduce the risk of transmitting infectious organisms”. The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information. No additional information was presented to this surveyor upon exit on 04/04/25.”

“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: This is a continuing violation from survey dated 05/12/22 (38A36-H1) TAG: G0580 Based on record review, observation, and interview, the agency’s Supervising Nurse failed to ensure that treatments were performed only as ordered for 1 of 7 active patients (Patient #2) receiving licensed and certified services and whose clinical records were reviewed, in that: 1.) Patient #2 did not receive proper wound care treatment to right TMA (transmetatarsal amputation) as ordered in the Plan of Care conducted by LVN A. This failure could place the patients at risk of not receiving the necessary care and services and a worsening of patient #2’s wound. The findings included: Review of Patient #2 “Home Health certification and plan of care” documented a 68-year-old male with primary diagnosis of Non-pressure chronic ulcer to right lower leg with fat layer exposed (open wound), open wound to right lower leg, Chronic obstructive pulmonary disease (respiratory/airflow limitation), cirrhosis of liver (liver damaged with scar tissue), macular degeneration to left eye (affects the central part of the retina, leading to blurred or no vision in the center of the visual field), nicotine dependence, skin transplant status, problems related to living alone, acquired absence of right foot, acquired absence of left leg below knee amputation, presence of artificial left leg, personal history of other infectious and parasitic diseases, and long-term use of opiate analgesic (relieve pain). The form also documented a start of care as 04/01/24 and a “current episode” or certification period as 03/27/25-05/25/25 with skilled nurse visits once daily for 60 days and 3 as needed. Safety Measures: Standard precautions/Infection Control. Further review, “Orders and treatments” 7. SN using aseptic technique and sterile supplies to perform daily wound care to (wound #2) Arterial Ulcer to Rt Lateral Dorsal Foot and to (wound #7) Trauma wound to Rt Foot TMA as follows: Cleanse with vashe solution (combats bacteria and facilitates wound healing), pat dry with 4x4 gauze, apply Iodosorb Gel (helps clean and heal wounds) using cotton tip applicator, cover with 4x4 gauze, wrap with kerlix and secure with tape until healed by SN/MD. Apply Ammonium Lactate 12% lotion (used to treat dry, scaly, and itchy skin) to bilateral lower extremities for dryness every day. Upon further review a patient communication dated 03/27/25 revealed; findings: Patient with s/p MD appointment for wound evaluation, no new orders were given, SN to continue with same wound care… During a home visit observation with patient #2 on 04/02/25 at 11:30 a.m., LVN A donned new gloves. LVN A opens package for gauze and applies vashe wound cleanser onto 4x4 gauze, cleanses Rt foot TMA with 4x4 gauze, pat dries with 4x4 gauze. Doffs contaminated gloves and places them into trash. Donned new gloves. LVN A applies Gentamycin Ointment 0.1% (treats bacterial skin infections) to right TMA (wound #7). In an interview with LVN A on 04/04/25 at 10:00 am, surveyor presented the above findings. LVN A confirmed he did not perform the correct wound care for patient #2 by using gentamycin Ointment 0.1% to right TMA instead of following the correct order for Iodosorb gel. Surveyor asked why he did not perform the correct wound care order. LVN A stated, “I was really nervous and just forgot.” Surveyor further asked how cannot following the plan of care or physician’s orders affect patient care. LVN A stated, “We can miss something and if we use the wrong medication, it can cause an adverse reaction to the patient.” During an interview on 04/04/25 at 11:00 am conducted with DON/Supervising Nurse confirmed that she is responsible for ensuring that patient #2’s plan of care and any physician orders are followed. DON/Supervising Nurse further confirmed that the current order for patient #2 wound to right TMA is Iodosorb Gel and not Gentamycin Ointment 0.1%. and LVN A did not perform the correct wound care. Surveyor asked how cannot following physician’s orders or the plan of care affect patients. DON/supervising nurse stated, “There wounds may not improve, or they may have an adverse effect.” Review of the agency’s policy titled, “Plan of Care PC.25,” dated 05/02/24 revealed in part, “...V. Each patient/client must receive the home health services that are written in a individualized Plan of care…” Review of the agency’s policy titles, “Orders for Care PC.30”, dated 05/01/24 revealed in part, “Purpose to ensure patient/client care is provided in accordance with a physician and/or non-physician practitioner order and federal and state laws and regulations. Policy The Agency will obtain orders and provide care in accordance with physician’s orders…” The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information. No additional information was presented to this surveyor upon exit on 04/04/25.”