Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 017050	(X3) Date Survey Completed 01/06/2023
Name of Provider or Supplier Central North Alabama Health Services, Inc.	Street Address, City, State 1310 Pulaski Pike, Unit A, Huntsville, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag	Summary Statement of Deficiencies (Each deficiency should be preceded by full regulatory or LSC identifying information)
E0000	A recertification survey was conducted 1/4/23 to 1/6/23 at Spectrum Home Health Agency. Standard level deficiencies were cited for Emergency Preparedness and will require a plan of correction.
G0000	A recertification survey was conducted 1/4/23 to 1/6/23 at Spectrum Home Health Agency. Standard level deficiencies were cited and will require a plan of correction.
E0004	Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness (EP) Program, and agency staff interview, it was determined the home health agency failed to review and/or update the EP plan every two years. Findings include: Review of the agency EP program on 1/6/23 revealed the facility's Emergency Plan was last reviewed by the Board of Directors on 11/1/16, which was six years prior. An interview conducted on 1/6/23 at 12:45 PM with Employee Identifier (EI) # 3, Operations Manager, confirmed the Emergency Plan was not reviewed every two years as required.
E0024	Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. [For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. [For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness (EP) Program, list of current agency personnel, and staff interview it was determined the agency failed to develop policies and procedures for emergency staffing strategies during an emergency. Findings include: Review of the agency EP program revealed there were no policies or procedures for emergency staffing strategies during an emergency in the event the RN was unavailable. Review of the list of current personnel provided by the agency on 1/6/23 revealed: One Full Time (FT) RN One Part Time (PT) LPN One FT Physical Therapist One FT Occupational Therapist Two contract Occupational Therapy Assistants One contract Speech Pathologist There was only one SN to make all ordered/needed nursing visits for the agency. An interview was conducted on 1/4/23 with Employee Identifier (EI) # 1, Registered Nurse (RN) Administrator regarding the agency's processes of operation. During the interview, EI # 1 confirmed he/she was the only Skilled Nurse (SN) that made Home Visits (HV) for the agency, and there was a Licensed Practical Nurse (LPN) that worked elsewhere during the day and did not make HV's for patients. During the review of the agency's EP program on 1/6/23 at 12:45 PM with EI # 3, Operations Manager, EI # 3 confirmed the agency had no emergency staffing policies and procedures.
E0039	EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). [For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. [For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. [For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. [For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. [For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. [For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. [For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. [For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness (EP) Program and staff interview it was determined the agency failed to conduct a Full Scale Community or Facility Based Testing Exercise in 2021. Findings include: Review of the agency EP program revealed the facility conducted a Facility Based Exercise Fire Drill on 2/3/22 which included documentation of staff who participated, and an analysis of the exercise. There was no documentation of an actual event or testing exercise for 2021. An interview conducted on 1/6/23 at 12:45 PM with Employee Identifier (EI) # 3, Operations Manager, confirmed there was no documentation of an Actual Event, Full Scale Testing or Table Top Exercise for 2021.
G0536	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 review of medical records (MR), agency policy and procedure, observation, and interviews, it was determined the agency failed to ensure the Medicine Profile (MP) was current and accurate for all patients. This affected one of two Home Visits (HV) conducted, and did affect HV # 1, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Medication Reconciliation Policy Number: None Revision/Review Date: None Policy: The agency will reconcile patient's medications at time of admission and on an ongoing basis. Procedure: ...2. ...The medication list/profile will be updated with each new or changed medication. 1. HV # 1 was admitted to the agency on 11/10/22 with diagnoses including Lymphedema, Not Elsewhere Classified, and Unspecified Open Wound Abdominal Wall, Unspecified Quadrant Without Penetration Peritoneal Cavity Initially. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 11/10/22 to 1/8/23 revealed orders for a Skilled Nurse (SN) visit frequency of one time a week for one week, then two times a week for eight weeks. A HV was conducted on 1/4/23 at 1:37 PM to observe care provided by Employee Identifier (EI) # 1, Registered Nurse (RN). During the HV, a comparison was made between medications observed in the home and the MP provided to the surveyor on 1/4/23. The following discrepancies were observed: a. Folic Acid one milligram (MG), one tablet every day was listed on the MP. The patient stated his/her physician stopped the folic acid in December 2022. b. Furosemide 40 MG, one tablet once a day was listed on the MP. The patient stated he/she had not taken a dose of furosemide in a month. c. Two bottles of Levothyroxine 50 micrograms (MCG), one with fill date 11/15/22, the second with fill date 12/22/22 were observed in the home. Levothyroxine was not on the ML. The patient stated he/she took the Levothyroxine daily. d. Nystatin Cream 100,000 units with fill date 12/20/22 was observed in the home and not on the ML. The patient stated he/she currently used the Nystatin Cream as needed, and had used it as needed for years. e. Nystatin Powder 100,000 units with fill date 12/20/22 was observed in the home and not on the ML. The patient stated he/she currently used the Nystatin Powder as needed, and had used it as needed for years. An interview with EI # 1 on 1/6/23 at 3:32 PM confirmed the ML was not current and accurate for HV # 1.
G0578	Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on Medical Record (MR) review, agency policy and procedure, and interview, it was determined the agency failed to notify the physician when unable to obtain ordered labs. This deficient practice affected one of seven records reviewed, including MR # 4, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Physician Communication Policy Number: HHS.030 Review Date: 11/16 Policy: The agency will establish and maintain communication with the physician to ensure safe and appropriate care for the patient /client. Standard Operating Procedures: 1. Professional agency personnel contact the patient's /client's physician: ...F. When there is any problem implementing the plan of care. 2. All conferences or attempt to communicate with physician will be documented in the clinical record. 1. MR # 4 was admitted to the agency on 3/18/22 with diagnoses including Pressure Ulcer of Sacral Region, Stage 3, Pressure Ulcer of Right Buttock, Stage 3, and End Stage Renal Disease. Review of the Home Health Certification and Plan of Care dated 3/18/22 to 5/16/22 revealed an ordered Skilled Nurse (SN) visit frequency of one time a week for eight weeks, and two as needed (PRN) visits for cardiopulmonary or wound complications. Review of physician order dated 3/23/22 revealed an order for the SN to perform venipuncture for monthly dialysis lab work using needle of choice beginning month of March 2022. Review of the 3/23/22 SN visit Interventions revealed the SN documented he/she attempted to obtain the dialysis labs times four attempts. There was no documentation the SN notified the physician he/she was unable to obtain the ordered labs. Review of the 3/29/22 and 4/5/22 SN visits revealed no documentation the ordered labs were obtained. An interview conducted 1/6/23 at 3:13 PM with Employee Identifier (EI) # 1, Registered Nurse Administrator confirmed the ordered dialysis labs were not obtained, and the physician was not notified.
G0658	Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on review of the facility's Quality Assessment, Performance Improvement (QAPI) program, and interview, it was determined the facility failed to conduct a performance improvement project (PIP) annually. Findings include: A review of the facility's QAPI program was conducted 1/6/23 at 1:56 PM with Employee Identifier (EI) # 1, Registered Nurse Administrator, and EI # 2, Compliance Officer. Review of the PIP documentation revealed there was no current agency PIP, and the last PIP initiated was on 5/6/19, which was three years prior to the current review. During the QAPI program review on 1/6/23, EI # 2 confirmed at 2:21 PM there was no other documentation of PIPs initiated by the agency.
G0682	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 observation, review of agency policy and procedure, Centers for Disease Control (CDC) guidance for hand hygiene in healthcare settings, and interviews, it was determined the agency failed to ensure staff performed hand hygiene and followed accepted standards of practice to prevent the transmission of infections. This affected Home Visit (HV) # 1, one of two HV's conducted, and had the potential to negatively affect all patients admitted to the agency. Findings include: Agency Policy: Hand Hygiene Policy and Compliance Program Policy Number: None Revision/Review Date: None Purpose: To prevent transfer of germs and transmission of infections to patients and caregivers, and to implement a hand hygiene compliance program. Procedure: 1. Indications for staff performing hand hygiene are: ...After any contact with contaminated materials... CDC Hand Hygiene in Healthcare Settings: January 2020 The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: a. Immediately before touching a patient b. Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices c. Before moving from work on a soiled body site to a clean body site on the same patient d. After touching a patient or the patient’s immediate environment e. After contact with blood, body fluids, or contaminated surfaces f. Immediately after glove removal 1. HV # 1 was admitted to the agency on 11/10/22 with diagnoses including Lymphedema, Not Elsewhere Classified, and Unspecified Open Wound Abdominal Wall, Unspecified Quadrant Without Penetration Peritoneal Cavity Initially. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 11/10/22 to 1/8/23 revealed a Skilled Nurse (SN) visit frequency of one time a week for one week, then two times a week for eight weeks, and orders for wound # 1, a stage 2 (open) pressure ulcer to the left lower quadrant of the abdomen as follows: SN to perform wound care to wound # 1, Lower Abdominal. Cleanse wound with wound cleanser solution, pat dry, cover with abdominal pad and secure with tape, using aseptic technique. SN to teach patient/caregiver to perform wound care when SN is not in the home. Wound care to be performed once a day. A HV was conducted on 1/4/23 at 1:37 PM to observe wound care provided by Employee Identifier (EI) # 1, Registered Nurse (RN). While wearing gloves, EI # 1 removed the old contaminated dressing to the left lower abdomen, then without changing gloves, cleansed the wound with wound cleanser and gauze. EI # 1 then removed the gloves, donned a new pair of gloves without performing hand hygiene, and placed an abdominal pad over the wound. EI # 1 did not perform hand hygiene after contact with the contaminated dressing per policy. An interview with EI # 1 on 1/6/23 at 3:32 PM confirmed hand hygiene was not performed per policy.