Community Home Health Services

“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 review of the Home Health Agency (HHA)’s Policy and Procedure, record review, interview and observation, the HHA failed to maintain infection control measures to prevent potentially cross contamination during wound care for 1 of 1 sampled patients (Patient #3) and a PICC (Peripherally Inserted Central Catheter) care dressing change for 2 of 2 sampled patients (Patient #2 and #4). The findings included: 1) Review of the HHA’s Policy titled, “Bag Technique HH 4020” revised on 10/2024 documents, “…the bag should be placed on a barrier…in the patient’s home…skin cleansers…should be kept in an outside pocket for available access…prior to administering care, alcohol-based hand rub or skin cleansers…will be removed from the bag…” Review of the HHA’s Policy titled, “Central Venous Catheters and Midline Catheters” revised on 01/2025 documents under Changing catheter site dressing, “…apply mask and don non-sterile gloves. Remove old dressing…removed gloves and perform hand hygiene…open the central line dressing kit and don sterile gloves…open the package of one alcohol swab stick. Clean the area…open the povidone-iodine swab stick and clean the area using all three…” Review of Patient #3’s clinical record revealed a Start of Care assessment dated 02/14/25 and a “Home Health Certification and Plan of Care (POC)” certification period from 02/14/25 to 04/14/25 that documented, “Right and Left Buttock Stage 2 red pressure ulcer.” On 04/07/25 at 3:35 PM, a home visit was conducted with the Home Health Agency’s Administrator and Employee #1, Registered Nurse (RN) for Patient #3. During an interview, on 04/07/25 at 3:35 PM, Employee #1 stated they have been seeing the patient once a week, patient is bed bound, incontinent of bowel and uses the urinal, developed a Buttock wound, was using Desitin (ointment), did not improve and was recently ordered Silvadene (antibacterial) cream for the wound; stated the patient’s Spouse/Caregiver is doing the wound care daily. Observation, on 04/07/25 at 3:35 PM, revealed Employee #1 performed handwashing, donned gloves, checked the patient’s Blood Pressure (BP) with a wrist BP machine, wiped the machine pad with an alcohol pad and placed the machine back into his uniform pocket. Employee #1 then removed his pair of gloves, reached into his uniform pocket, pulled a hand sanitizer bottle from his pocket and performed hand hygiene. Employee #1 asked the patient’s caregiver to don gloves. Employee #1 then donned gloves, assessed the patient’s buttocks that revealed macerated, excoriated and open skin. Employee #1 proceeded to do wound care and the patient’s caregiver was next to him. Employee #1 cleansed the buttocks/wound area with Normal Saline solution and applied Silvadene cream, removed gloves and reached into his uniform pocket to retrieve a hand sanitizer bottle, performed hand hygiene. Employee #1 donned gloves, performed the patient’s assessment, removed gloves and reached to his uniform pocket again to retrieve a hand sanitizer bottle, performed hand hygiene, then retrieved an alcohol pad and disinfected the stethoscope bell. Further observation on 04/07/25 at 3:35 PM revealed Patient #3’s caregiver/spouse touched the patient’s buttock open skin with her gloved hand during the wound care and kept her gloves on throughout the visit. On 04/09/25 at 10:12 AM, an interview was conducted with the Administrator who was apprised of the concerns during Patient #1’s home visit and wound care performed by Employee #1 visit; the Administrator was apprised of the employee reaching into his uniform pocket many times to retrieve the hand sanitizer bottle after removing gloves; the Administrator stated she did not know why Employee #1 did not have the bottle outside on a field, added he should place the hand sanitizer bottle on a barrier with the supplies ... and the Administrator stated the staff/employee need retraining. On 04/09/25 at 12:04 PM, a telephone interview was conducted with Employee #1, RN who was apprised of the concerns during the home visit for Patient #3 such as reaching in and out of his uniform pocket after removal of their gloves to retrieve a bottle of hand sanitizer; the employee was apprised of the patient’s caregiver wearing soiled gloves throughout the visit. Employee #1 stated the patient’s caregiver does the wound care daily and was educated on infection control. 2) Review of Patient #2’s clinical record revealed a Start of Care Assessment dated 01/03/25 and a “Home Health Certification and Plan of Care (POC)” certification period from 03/04/25 to 05/02/25. The POC documented under SN (Skilled Nurse) interventions, “SN to perform PICC line site care: using sterile technique, cleanse with antiseptic scrub solution, apply bio patch, apply transparent, occlusive dressing with no gauze weekly…”. On 04/07/25 at 2:24 PM, a home visit was conducted with the Home Health Agency’s Administrator and Employee #3, RN for Patient #2. On 04/07/25 at 2:24 PM, an interview was conducted with Employee #3 who stated they have seen the patient once a week for PICC line site dressing change. Observation, on 04/07/25 at 2:24 PM revealed Employee #3 performed hand washing, donned gloves, placed a barrier on top of the kitchen table, removed supplies from the catheter care kit, donned a face mask, the patient donned a face mask. Employee #3 was maneuvering the site’s dressing and was unable to remove it. Employee #3 then removed her pair of gloves and without hand hygiene donned another pair of gloves, reached into her bag and retrieved a pair of scissors from her bag. Employee #3 then cut the PICC site dressing around the line and removed the dressing. Employee #3 removed her pair of gloves, performed hand washing and donned the sterile gloves from the kit. During the PICC line care, observation on 04/07/25 at 2:24 PM revealed Patient #2 touched the measurement tape located in the sterile/clean field three times during the care. Employee #3 cleansed with PICC line area with the alcohol swab stick and applied gauze under the PICC line and placed a Tegaderm dressing. Further observation, on 04/07/25 at 2:24 PM revealed Employee #3 did not clean the PICC line site with the povidone (Iodine) swab stick as per the HHA’s policy. On 04/09/25 at 10:12 AM, an interview and a side-by-side review of the HHA’s PICC line policy was conducted with the Administrator who was apprised of Patient #2 touching the clean field during Employee #3 PICC line dressing change, the employee failed to clean the PICC line site with povidone swab stick and failed to place her reusable equipment on a barrier; the Administrator confirmed the patient touched the clean/sterile field and that the employee did not place a barrier. On 04/09/25 at 11:19 AM, a telephone interview was conducted with the RN who stated she realized she did not use a barrier to place her reusable equipment during Patient #2’s home visit and that the patient touched her clean/sterile field. 3) Review of Patient #4’s clinical record revealed a Start of Care assessment dated 03/12/25 and a “Home Health Certification and Plan of Care (POC)” certification period from 03/12/25 to 05/10/25. The POC documented under SN (Skilled Nurse) interventions, “SN to instruct pt/CG (patient/caregiver) ... to clean PICC port with alcohol swab…” On 04/08/25 at 10:33 AM, a home visit was conducted with the Home Health Agency’s Administrator, and Employee #1, RN for Patient #4. On 04/08/25 at 10:33 AM, an interview was conducted with the patient who stated Employee #1 comes once a week to do the PICC line dressing change and that the patient and their spouse were doing the intravenous antibiotic with no problems. Observation, on 04/08/25 at 10:33 AM revealed Employee #1 performed hand washing, retrieved a BP wrist machine from his uniform pocket cleansed the BP wrist machine with an alcohol pad, checked the patient’s BP, retrieved an alcohol pad from his uniform pocket, wiped the machine and placed the machine back into his uniform pocket, retrieved a Pulse Oximeter (measures oxygen level in the blood) from his uniform pocket checked the patient’s Pulse Oximeter, cleansed the meter with an alcohol pad and placed it back into his pocket. Employee #1 then reached into his uniform pocket and retrieved a hand sanitizer bottle and performed hand hygiene, placed the bottle back to his pocket, donned gloves, performed the patient’s skin assessment, removed the patient’s socks, auscultated (listened to) the patient’s bowel sounds and then reached out to his uniform pocket with his gloved right hand, retrieved an alcohol pad and wiped the stethoscope bell, removed his pair of gloves, retrieved the hand sanitizer bottle from his pocket and performed hand hygiene, then placed the hand sanitizer bottle back to his pocket. Employee #1 donned gloves and then reached into the patients supplies bag, retrieved a catheter care kit and a 10 centimeter (cc) Normal Saline syringe. Employee #1 opened the kit; the kit had two face masks, alcohol and povidone swabs sticks. Employee #1 the donned one of face mask, donned a pair of gloves, opened the corner of the alcohol and povidone swabs packing, placed the second mask aside, placed a Normal Saline syringe retrieved from the supplies bag with its wrap on the clean/sterile field. Further observation on 04/08/25 at 10:33 AM revealed the employee proceeded to remove the patient’s PICC line dressing. During the care, the patient was not wearing a face mask and was talking to the employee and facing the exposed PICC site. The employee directed Patient #4 to turn their face to the other side of the PICC site and not to talk. Observation on 04/08/25 at 10:33 AM revealed the employee disinfected the PICC entry site with povidone swab stick first and then with an alcohol swab stick. The HHA ‘s policy documents, “…open the package of one alcohol swab stick. Clean the area…open the povidone-iodine swab stick and clean the area...” The employee did not follow the HHA’s policy. On 04/09/25 at 10:12 AM, an interview and a side-by-side review of the HHA PICC line policy was reviewed with the Administrator. who was apprised of infection control concerns during Patient #4’s home visit and Employee #1 reaching to his uniform pocket many times to retrieve the hand sanitizer bottle after removing gloves, and at one point reached his pocket with a gloved hand; the Administrator stated she did not know why Employee #1 did not have the bottle outside on a field, added they should place the hand sanitizer bottle on a barrier with the supplies and work of it; stated there was a second mask on the kit that the patient could use and did not provide it; the Administrator confirmed the employee getting items in and out of his pocket many times, added that this is a break in infection control and break down in the (HHA’s) policy and the Administrator stated the employees need retraining. On 04/09/25 at 12:04 PM, a telephone interview was conducted with the RN who was apprised of the concerns during the home visit reaching in and out of their uniform pocket, not providing Patient #4 with a face mask that was in the kit and using one pair of gloves for the whole procedure. Employee #1 stated the PICC dressing change is an aseptic procedure; recommended to wear a mask, makes it as close as he can to be sterile, is in the patient’s home not an operation room. Employee #1 stated the patient did not have a mask and usually he does not talk during the dressing change; Employee #1 appreciated the observation feedback and stated there is always room for improvement.”

“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: Based on review of the Home Health Agency (HHA)’s Policy and Procedure, record review and interview, the Home Health Agency failed to follow the physicians’ orders for drugs and treatments for 1of 13 sampled patients (Patient #9). The findings included: Review of the HHA’s Policy titled, “Vital Sign Parameters HH2019” revised on 03/2025 documents, “the home health agencies will adhere to industry standards for vital sign and reporting parameters unless specifically ordered by the physician…blood sugar: best practice: it is recommended clinician use ranges as outlined by physician orders upon patient admission to home health service…” Review of Patient #9’s clinical record reveals a Home Health Certification and Plan of Care (POC) for period 02/17/25 to 04/17/25 with diagnoses of Type 2 Diabetes with Diabetic Peripheral Angiopathy. Review of the POC orders included the following, Notify physician of…” Fasting blood sugar greater than (>) 130 or less than () 180 or less than ( Review of Patient #9’s clinical record revealed a Skilled Nurse (SN) visit note dated 02/20/25, 02/25/25 and 03/06/25 that documents a non-fasting blood sugar reading highlighted in red, greater than 180.Further review revealed SN visits dated 02/20/25, 02/25/25 and 03/06/25 with a lack of written evidence of notifying the physician or the Case Manager regarding the patient’s blood sugar level out of range, as ordered by the physician’s POC. On 04/09/25 at 1:59 PM, an interview and a side-by-side review of Patient #9’s SN notes was conducted with the Administrator who stated the SN was supposed to call the physician with out-of-range parameters for blood sugar readings and stated she did not see any communication from the SN with the Director of Professional Services or the physician.”