E & V Health Care Inc.

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on observation and interview the agency failed to provide infection control in 1 out of 3 Sampled Patient’s (SP) during home visits. SP #1. Findings Include: A home visit of Sample Patient (SP) #1 was conducted on 07/08/2025 with the agency Administrator and field LPN Staff A. Upon this visit staff A will be preforming wound care on 3 separate wounds, Wound #1, #2, and #3. The wound care took place between 04:21pm and 04:46pm. With each dressing a clean barrier was placed near the patient and supplies for the wound care placed on top. Staff sanitized hands and placed gloves on before removing each dressing and then placed gloves in garbage, sanitized hands and put on new gloves. He prepared supplies and cleaned each wound, then once each wound was cleaned, he placed unsoiled dressings on top and then placed cover and then removed gloves and sanitized hands and placed new gloves before starting to remove next old dressing. However, what was observed is that the nurse for all 3 dressings did not change his gloves after cleaning the wounds before he placed “new clean dressing on top of the cleansed wounds”. On all 3 dressings the gloves were removed after he placed a dressing/barrier on top of each wound and before he would begin with the next wound, however, after removing the old dressing and changing into new gloves no gloved changed until done with dressing. Interview with the Administrator and Alternate Administrator/Director of Nursing on 07/10/2025 at 12:20pm, they both stated that with this behavior infection control was not being followed.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on observation and interview the Home Health Agency Staff C LPN failed to be in accordance with current clinical practice to prevent a needle stick, by not using the scoop method on a counter surface to prevent a needle stick after giving an insulin injection with a pen needle. Findings Include: Home visit of Sample Patient (SP) #3 observed Staff C LPN on 07/09/2025 at 05:08pm giving SP #3 and insulin injection with a pen needle syringe, the nurse after used his ungloved hands and unscrewed the pen needle from the syringe in open air and then put the pen needle into the sharps container, he should have used the scoop method on a counter service to prevent a needle stick and use the cop of the pen needle to cover the needle and then remove it from the syringe. Interview with the Administrator and Alternate Administrator/Director of Nursing on 07/10/2025 at 12:20pm they confirmed that is not the standard practice and this particular nurse has been observed before and does not normally do it this way.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the home health agency is unable to demonstrate a completed termination summary including the reason for admission to home health agency services, the type of service and frequency, Patient’s outcomes in meeting the goals in the plan of care for 2 out of 5 Sampled Patients (SP). SP#4 and SP#5. Findings Include: Closed record reviews of Sampled Patient (SP) #4 and #5 were conducted on 07/07/2025 to 07/10/2025. The clinical record for SP #4contained a discharge summary from the agency with a discharge date of 02/26/2025: and SP #5 contained a discharge summary from the agency with a discharge date of 06/07/2025. The discharge summaries for SP #4 and #5 omitted information such as reason for admission to home health services, the type of service, frequency and duration of services at time of discharge, patient outcomes in meeting the goals of the plan of care. Interview was conducted with the Administrator and Alternate Administrator/Director of Nursing on 07/10/2025 at 12:20pm, acknowledged that the summaries for SP #4 and #5 were incomplete, missing the required notations as previously mentioned.”