Carter Healthcare

“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 ensure that accepted standards of practice were followed, including the use of standard precautions, to prevent the transmission of infections and communicable diseases, in that: for one (Patient # 5) of three records reviewed in which the patients received a home visit; the (Admin/DON) failed to provide wound care using clean and aseptic technique (techniques utilized to reduce the number of microorganisms and decrease to risk of infections) in accordance with the agency’s policies. The failure caused the patient to not receive wound care in accordance with the agency’s infection control policies. The failure placed the patient at increased risk of skin infections. Findings include: Patient Record Review # 5: Review of Patient # 5’s EHR revealed a POC with a start of care date of 07/29/2025 for certification period of 01/25/2026 to 03/25/2026. Review of the POC revealed that the Admin/DON signed and dated it on 01/25/2026; it contained a primary diagnosis of encounter for change or removal of non-surgical wound dressing; it included orders for SN visits two times per week for eight weeks and one time per week for one week. Continued review of Patient # 5’s record revealed a physician’s order addressed to nurse practitioner (NP # 100) dated 02/10/2026. Review of the physician’s order revealed the Admin/DON signed and dated the order on 02/10/2026. Further review of the physician’s order revealed the following: “…Interventions added [:] SN Performed 3 times weekly wound care to [right upper quadrant abdomen] and right upper forearm wounds using aseptic technique with wound cleanser and covered with silicone foam dressing (wound dressing with many layers to absorb moderate to high levels of drainage)…SN preformed 3 times weekly wound care to right pelvic fold using aseptic technique cleansed with wound cleanser, applied [normal saline] soaked alginate to wound bed, applied silver cloth over alginate pad, applied Nystatin powder along intact skin within fold and folded skin to secure…SN performed 3 times weekly wound preventive care to former wound sites including both forehead temples, inner thigh and both axilla using clean technique, cleansed area with wound cleanser and applied [antibacterial medicated] gel twice weekly…” During a home visit, interview, and observation with Patient # 5, Admin/DON, and Surveyor B on 02/18/2026 at approximately 11:00 a.m., the surveyors observed: the Admin/DON use hand sanitizer upon entry to the patient’s residence, don (put on) gloves, lay out a reuseable agency protective liner on Patient # 5’s bed, lay out wound care supplies on the liner, assess and listen to Patient # 5’s heart, lungs, assess (Patient # 5’s) blood pressure, and measure the wound to the right pelvic fold (lower abdomen). The surveyors observed the Admin/DON cleanse Patient # 5 wounds while gloved; gloves were never changed when going from wound to wound; Admin/DON used a disinfectant wipe to cleanse gloves between three wounds. The Admin/DON cleansed the two wounds on Patient # 5’s temple areas with normal saline wound cleanser (sterile salt water) and immediately applied antibacterial medicated ointment with the same gloves; cleansed left and right arm pits and immediately applied antibacterial medicated ointment with the same gloves; immediately moved to the right pelvic fold, cleansed it, and applied dressing without changing gloves or wiping off with the wipe. The surveyors observed the Admin/DON use the same wipe to cleanse gloves throughout the wound care. When wound care was completed the Admin/DON used the same wipe to cleanse his gloves and help Patient 5 dress. The surveyors observed the Admin/DON used a wipe that he previously used to clean his equipment, to clean his equipment and the reuseable liner. Then he cleansed his tablet with the same wipe that he used to cleanse his gloves. The Admin/DON used the same pair of gloves during the entire visit. During an interview with the Admin/DON, on 02/20/2026 at approximately 12:30 p.m. the surveyor asked who was responsible for ensuring that the agency’s patients received services as outlined in the plan of care. The Admin/DON stated that (Admin/DON) was responsible. The surveyor asked what the agency’s processes were for providing wound care as outlined in the plan of care. The Admin/DON stated that the process was to provide wound care as written in the physician’s orders. The survey asked the Admin/DON to describe the process for clean and aseptic technique. The Admin/DON stated that all tools and equipment that were used should be on a clean area or barrier (liner) so that they were not contaminated. The Admin/DON stated that gloves should be changed anytime visibly soiled or compromised (torn) and especially when going from one area to another or gloves should be changed when in doubt. He stated that hands should be sanitized or washed before going into the home, when touching surfaces in the patient’s home, or after touching the patient. He stated that when going from one wound area to another aseptic technique should be maintained and gloves should be sanitized and changed if soiled. The surveyor reviewed the findings and asked why wound care was not provided as outlined in the plan of care and as order by the physician (with clean and aseptic technique). The Admin/DON that he was “pretty nervous.” He stated that he lost track of which wipe he used. The surveyor asked what could have been done differently to ensure that wound care was provided as outlined in the plan of care and agency policy. The Admin/DON stated that if he had any concerns that gloves might be contaminated he would change them. Review of agency policy titled, “Standard Precautions (foundational or minimum practices, i.e., hand washing, used for all patient care to prevent infections)” last reviewed on 12/2024 revealed the following: “Purpose [:] To reduce the risk of exposure and transmission of infections when caring for patients. Policy [:] Organization personnel will adhere to the following precautions…Procedure…Gloves are to be worn when…xi. Performing wound care…C. Gloves are to be changed: i. Between tasks and procedures on the same patient i. After removing an old dressing…D. Gloves should never be washed or disinfected for reuse…” Review of agency policy titled, “Clean vs. Aseptic Technique” last reviewed on 12/2024 revealed the following, “Purpose [:] To define the difference between aseptic (near sterile) and clean environment for patient- care-related procedures. Policy [:] All home health personnel will use the appropriate technique for the procedure being performed. Procedure [:] Clean technique refers- to the infection control strategies utilized to reduce the number of microorganisms or to reduce or prevent the transmission of microorganism (bacteria or viruses) from one person to another. Clean technique includes the following strategies… keep the work area clean with an appropriate disinfectant or cleaning solution… Wipe the area with alcohol or the disinfectant solution prior to performing the procedure… Decontaminate hands using an alcohol-based hand rub before and after the procedure… 1. Aseptic, or Near-Sterile, Technique- refers to infection control Strategies used to render and maintain objects in areas maximally free of microorganisms. Aseptic technique includes the following strategies… wash hands thoroughly with antimicrobial soap and warm water… Establish a sterile field to prevent transmission of microorganisms from the environment or from the clinician to the patient… Use sterile gloves to perform the procedure… Maintain all equipment used in a sterile condition or use disposable, one-time-use sterile equipment.””

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on record review, observation, and interview, the agency failed to ensure that the patient received all services as outlined in the plan of care in one (Patient # 5) of three records reviewed in which the patients received a home visit. The (Admin/DON) failed to provide wound care using clean and aseptic technique (techniques utilized to reduce the number of microorganisms and decrease to risk of infections) as written in the plan of care (physician’s orders). The failure caused the patient to not receive wound care as ordered on the POC and addendum orders. The failure placed the patient at increased risk of skin infections. Findings include: Patient Record Review # 5: Review of Patient # 5’s EHR revealed a POC with a start of care date of 07/29/2025 for certification period of 01/25/2026 to 03/25/2026. Review of the POC revealed that the Admin/DON signed and dated it on 01/25/2026; it contained a primary diagnosis of encounter for change or removal of non-surgical wound dressing; it included orders for SN visits two times per week for eight weeks and one time per week for one week. Continued review of Patient # 5’s record revealed a physician’s order addressed to nurse practitioner (NP # 100) dated 02/10/2026. Review of the physician’s order revealed the Admin/DON signed and dated the order on 02/10/2026. Further review of the physician’s order revealed the following: “…Interventions added [:] SN Performed 3 times weekly wound care to [right upper quadrant abdomen] and right upper forearm wounds using aseptic technique with wound cleanser and covered with silicone foam dressing (wound dressing with many layers to absorb moderate to high levels of drainage)…SN preformed 3 times weekly wound care to right pelvic fold using aseptic technique cleansed with wound cleanser, applied [normal saline] soaked alginate to wound bed, applied silver cloth over alginate pad, applied Nystatin powder along intact skin within fold and folded skin to secure…SN performed 3 times weekly wound preventive care to former wound sites including both forehead temples, inner thigh and both axilla using clean technique, cleansed area with wound cleanser and applied [antibacterial medicated] gel twice weekly…” During a home visit, interview, and observation with Patient # 5, Admin/DON, and Surveyor B on 02/18/2026 at approximately 11:00 a.m., the surveyors observed: the Admin/DON use hand sanitizer upon entry to the patient’s residence, don (put on) gloves, lay out a reuseable agency protective liner on Patient # 5’s bed, lay out wound care supplies on the liner, assess and listen to Patient # 5’s heart, lungs, assess (Patient # 5’s) blood pressure, and measure the wound to the right pelvic fold (lower abdomen). The surveyors observed the Admin/DON cleanse Patient # 5 wounds while gloved; gloves were never changed when going from wound to wound; Admin/DON used a disinfectant wipe to cleanse gloves between three wounds. The Admin/DON cleansed the two wounds on Patient # 5’s temple areas with normal saline wound cleanser (sterile salt water) and immediately applied antibacterial medicated ointment with the same gloves; cleansed left and right arm pits and immediately applied antibacterial medicated ointment with the same gloves; immediately moved to the right pelvic fold, cleansed it, and applied dressing without changing gloves or wiping off with the wipe. The surveyors observed the Admin/DON use the same wipe to cleanse gloves throughout the wound care. When wound care was completed the Admin/DON used the same wipe to cleanse his gloves and help Patient 5 dress. The surveyors observed the Admin/DON used a wipe that he previously used to clean his equipment, to clean his equipment and the reusable liner. Then he cleansed his tablet with the same wipe that he used to cleanse his gloves. The Admin/DON used the same pair of gloves during the entire visit. During an interview with the Admin/DON, on 02/20/2026 at approximately 12:30 p.m. the surveyor asked who was responsible for ensuring that the agency’s patients received services as outlined in the plan of care. The Admin/DON stated that (Admin/DON) was responsible. The surveyor asked what the agency’s processes were for providing wound care as outlined in the plan of care. The Admin/DON stated that the process was to provide wound care as written in the physician’s orders. The survey asked the Admin/DON to describe the process for clean and aseptic technique. The Admin/DON stated that all tools and equipment that were used should be on a clean area or barrier (liner) so that they were not contaminated. The Admin/DON stated that gloves should be changed anytime visibly soiled or compromised (torn) and especially when going from one area to another or gloves should be changed when in doubt. He stated that hands should be sanitized or washed before going into the home, when touching surfaces in the patient’s home, or after touching the patient. He stated that when going from one wound area to another aseptic technique should be maintained and gloves should be sanitized and changed if soiled. The surveyor reviewed the findings and asked why wound care was not provided as outlined in the plan of care and as order by the physician (with clean and aseptic technique). The Admin/DON that he was “pretty nervous.” He stated that he lost track of which wipe he used. The surveyor asked what could have been done differently to ensure that wound care was provided as outlined in the plan of care and agency policy. The Admin/DON stated that if he had any concerns that gloves might be contaminated he would change them. Review of agency policy titled, “Standard Precautions (foundational or minimum practices, i.e., hand washing, used for all patient care to prevent infections)” last reviewed on 12/2024 revealed the following: “Purpose [:] To reduce the risk of exposure and transmission of infections when caring for patients. Policy [:] Organization personnel will adhere to the following precautions…Procedure…Gloves are to be worn when…xi. Performing wound care…C. Gloves are to be changed: i. Between tasks and procedures on the same patient i. After removing an old dressing…D. Gloves should never be washed or disinfected for reuse…” Review of agency policy titled, “Clean vs. Aseptic Technique” last reviewed on 12/2024 revealed the following, “Purpose [:] To define the difference between aseptic (near sterile) and clean environment for patient- care-related procedures. Policy [:] All home health personnel will use the appropriate technique for the procedure being performed. Procedure [:] Clean technique refers- to the infection control strategies utilized to reduce the number of microorganisms or to reduce or prevent the transmission of microorganism (bacteria or viruses) from one person to another. Clean technique includes the following strategies… keep the work area clean with an appropriate disinfectant or cleaning solution… Wipe the area with alcohol or the disinfectant solution prior to performing the procedure… Decontaminate hands using an alcohol-based hand rub before and after the procedure… 1. Aseptic, or Near-Sterile, Technique- refers to infection control Strategies used to render and maintain objects in areas maximally free of microorganisms. Aseptic technique includes the following strategies… wash hands thoroughly with antimicrobial soap and warm water… Establish a sterile field to prevent transmission of microorganisms from the environment or from the clinician to the patient… Use sterile gloves to perform the procedure… Maintain all equipment used in a sterile condition or use disposable, one-time-use sterile equipment.””