Bellestar Home Health Care, Inc.

“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 and interview the agency failed to ensure infection control practices were followed for 1 of 10 sampled patients (Patient 7) when a Skilled Nurse (SN 1) did not consistently perform hand hygiene during direct patient care and did not sanitize equipment after use. This failure had the potential to spread infections to Patient 7. Patient 3’s Start of Care (SOC) dated 1/6/26 indicated a diagnosis of Hypertension (high blood pressure). During an observation on 1/13/26 at 10:40 a.m. with SN 1 in Patient 7’s room, SN 1 was observed grabbing scissors from his supplies bag, used the scissors to cut Patent 7’s dressing and directly placed the scissors back into the bag. SN 1 did not sanitize the scissors before and after patient use. During a continued observation on 1/13/26 with SN 1 during Patient 7’s home visit, SN 1 was observed not performing hand hygiene after doffing gloves at 10:31 a.m.,10:33 a.m., 10:35 a.m., 10:38 a.m., and 10:41 a.m. During a follow up interview on 1/13/26 at 11:21 a.m. SN 1 confirmed he did not perform hand hygiene when changing gloves during direct patient care and did not sanitize his scissors, used to cut Patient 7’s dressing after wound care treatment. SN 1 further acknowledged that the clean and dirty areas set aside for equipment were not clearly separated for clean and dirty items. During an interview on 1/14/26 at 10:37 a.m. with Administrator/Director of Patient Care Services (Admin/DPCS), the Admin/DPCS stated the expectation for agency staff is to perform hand hygiene as they enter the home for home visits, as they bring out their supplies, and as the staff changes gloves during direct patient care. Admin/DPCS further stated that equipment is to be sanitized after each use and prior to returning it to the bag and that hand hygiene was to be performed between change of gloves. A review of the agency’s policy and procedure (P&P) titled “… Hand Hygiene”, dated November 2021, indicated, “… Hand decontamination using an alcohol-based hand rub should be performed … before having direct contact with patients … after contact with a patient intact skin… After contact with inanimate objects (including medical equipment) … After removing gloves …” A review of the agency’s P&P titled, “… Bag Technique”, dated November 2021, indicated, “… The bag will contain a designated clean and dirty area. The clean area contains unused or cleaned supplies/equipment, and the dirty area is designated for contaminated materials … When the visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solutions, hands will be washed, and equipment and supplies will be returned to the bag…””

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure 1 of 10 sampled patients (Patient 3) comprehensive assessment was completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care (SOC). This failure had the potential to delay Patient 3’s plan of care. Patient 3’s SOC date was 1/1/26 and diagnoses included hypertension (high blood pressure). Review of Patient 3’s initial comprehensive assessment for the SOC 1/1/26 was incomplete from page 11 through page 22. During an interview on 1/12/26 at 2:38 p.m. with the Administrator/Director of Patient Care Services (Admin/DPCS) she confirmed Patient 3’s initial comprehensive assessment for the SOC 1/1/26 was not completed within 5 days. The Admin/DPCS stated the assessment should have been completed within 5 days. During a review of the agency’s policy and procedure titled, “Initial and Comprehensive Assessment,” revised November 2021, indicated, “A comprehensive patient assessment will be completed within five (5) calendar days of the patient’s start of care.””

“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 interview and record review the agency failed to 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 for 1 of 10 sampled patients (Patient 3). This failure had the potential to delay care and services for Patient 3. Patient 3’s start of care date (SOC) was 1/1/26 and diagnoses included hypertension (high blood pressure). Review of a Physician’s Order dated 1/1/26 indicated Patient 3 was to receive an Occupational Therapy (OT) evaluation. There was no documentation an OT evaluation was completed as of 1/12/26. During an interview on 1/12/26 at 11:46 a.m. with the Administrator/Director of Patient Care Services (Admin/DPCS) she confirmed Patient 3’s OT evaluation had not been completed. The Admin/DPCS confirmed OT evaluation was to be completed within 48 hours of referral. During a review of the agency’s policy and procedure titled, “Initial and Comprehensive Assessment,” revised November 2021, indicated, “An initial patient assessment will be performed and documented in the patient’s clinical record by a registered nurse, physical therapist, occupational therapists, or speech therapist. The initial assessment visit must be performed either within forty-eight (48) hours of the referral….””