Perry County Health Department

“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, document review, and interview, it was determined for 3 of 3 (Pt #1, Pt #5, Pt #6), patient home visits, the Agency failed to ensure infection control measures were implemented to prevent the potential for cross-contamination. 1. Pt # 6 - SOC: 4/05/24 Diagnosis: Joint Replacement. A home visit was conducted on 4/10/24 at approximately 10:30 am with the HHA RN Supervisor (E #1). E #1 laid a protective barrier on the couch and placed HHA supply bag on the barrier. E #1 removed a stethoscope, pulse oximeter, blood pressure cuff and stethoscope from the bag. E #1 obtained Pt #6’s vital signs and then immediately replaced the equipment back into the bag. E #1 removed Pt #6’s sock, assessed the Pt’s foot and then replaced the sock. E #1 performed hand hygiene with hand sanitizer one time (after replacing Pt #6’s sock). E #1 completed the visit, went to E #1’s car, placed a protective barrier on the seat, removed the equipment from the bag and cleaned with a Clorox wipe, then placed the equipment on the barrier. 2. Pt #5 - SOC: 04/05/24 Diagnosis: Metabolic encephalopathy. A home visit was conducted on 04/10/24 at approximately 1:00 PM with the HHA RN Supervisor (E #1). E #1 was observed to remove a protective barrier from her nursing bag and placed it on Pt #5’s recliner. E #1 placed her bag on the barrier, sat on the barrier, laid her cell phone on the barrier, and dumped E#1’s medication bottles onto the barrier. During the course of the home visit, E#1 removed a stethoscope, pulse oximeter, blood pressure cuff, and stethoscope from her bag and took Pt #5’s vitals without first sanitizing the equipment. E #1 then placed these items directly back into the bag again without cleaning the equipment. E #1 did not wear gloves during the home visit, and only sanitized her hands one time with alcohol-based gel after patient care and prior to exiting the home. E#1 then was observed to place her bag in the back seat of E #1’s car, remove the vital sign equipment and cleaned the equipment with a Clorox alcohol wipe. E #1 then immediately placed the equipment back in the bag (which did not allow for the manufacturer’s recommend 4-minute dry time). 3. Pt # 1 - SOC: 03/12/24 Diagnosis: Parkinson’s Disease. A home visit was conducted on 04/10/24 at approximately 4:30 PM with Occupational Therapy Assistant (E #2). E #2 conducted the home visit (home therapy exercises which included E #2 touching/assisting Pt #1 to complete the exercises) without completing any hand hygiene. 4. An Agency policy titled; “Infection Prevention/Control” Reviewed July 2023 contains the following. “… Standard Precautions – Tier One: 1. Standard precautions apply to blood, all bodily fluids, secretions, excretions, non-intact skin, … 2. Hands are washed if contaminated with blood or body fluids, immediately after gloves are removed, between client contacts, and when indicated to prevent transfer or microorganism between other clients or the environment. 3. Gloves are worn when touching blood, body fluids, secretions, excretions, non-intact skin, … 6. Equipment used for client care is properly cleaned …” 5. The manufacturer guidelines for Clorox Disinfecting Wipes includes, “ ... How to Use Disinfecting Wipes: To disinfect and sanitize hard, nonporous, non-food contact surfaces: 1) Wipe surface with enough wipes for treated surface to remain visibly wet for 4 minutes (disinfecting) or 10 seconds (sanitizing). 2) Let the surface dry ... To spot sanitize and deodorize soft surfaces or fabrics: ... 2) Wipe surface; use enough wipes for treated surfaces to remain visibly wet for 4 minutes. 3) Let air dry ... “ 6. An interview was conducted with E #1 on 4/11/24 at approximately 1:00 PM. E #1, stated, “I usually clean the equipment at my car and lay it to dry between patients. I do not clean at the house, but I will start cleaning at the house. I wear gloves when I draw blood and or if I’m doing a procedure like catheter care. We should be utilizing hand sanitizer.””

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on document review and staff interview, it was determined for 2 of 7 (Pt #3 and Pt #4) patients records reviewed, the Agency failed to ensure the initial assessment was conducted within 48 hours of referral. This has the potential to affect all patients receiving services. 1. Pt #3 Start of Care: 03/28/2024 Diagnoses: Status post Joint Replacement. Pt #3’s record was reviewed. Pt #3 was referred to the HHA on 03/25/2024. The Plan of Care for certification period 03/28/2024 to 05/26/2024 indicated the initial assessment was conducted on 03/28/2024,72 hours after referral. There was no physician order changing the start of care date. 2. Pt #4 Start of Care: 03/13/2024 Diagnoses: Calculus of bile duct with cholangitis and obstruction. Pt #4’s record was reviewed. Pt #4 was referred to the HHA on 03/10/2024. The Plan of Care for certification period 03/13/2024 to 05/11/2024 indicated the initial assessment was conducted on 03/13/2024, 72 hours after referral. There was no physician order changing the start of care date. 3. On 04/10/2024 at approximately 2:30 PM, an interview with the HHA RN Supervisor (E #1) was conducted. E #1 reviewed the records of Pt #3 and Pt #4. E #1 confirmed the initial assessments were conducted more than 48 hours after the referral. E #1 stated “At times start of care is delayed because therapy is unable to complete their assessment in a timely manner. We let the physician know, but we do not get an order to change the start of care date.””

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on document review and staff interview, it was determined for 1 of 2 (Pt #7), discharged records reviewed from the agency, the physical therapist (PT) failed to complete visit documentation as required. This failure has the potential to affect all patients receiving services. 1 The Agency policy titled, “Therapy Notes Policy (revised 7/26/23)” was reviewed on 4/11/24. The policy stated, “All therapy notes must be in the (Home Health Agency) office within seven days of the visit.” 2. Pt #7 SOC: 3/4/24, Diagnosis: Long-standing atrial fibrillation. Pt #7’s record was reviewed. Pt #7’s record indicated, a Physical therapy (PT) visit was conducted on 3/20/24 and 3/27/24. Both visit notes only indicated the time of the visit. The records lacked documentation of the visit details. 3. An interview with the HHA RN Supervisor (E #1) was conducted on 4/10/24 at approximately 2:30 PM. E#1 reviewed the notes and verbally agreed the PT visit notes were incomplete. E#1 stated, “We have had problems with getting this physical therapist to complete notes within the required timeframe.””