Chi Health Health at Home Plainview

“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 record review, policy and procedure review, observation of the provision of care, and staff interview, the agency failed to ensure 1 of 3 staff (Staff C), observed during the provision of care for 1 of 3 patients (Patient 1), performed proper hand hygiene and bag technique according to the agency’s policies and procedures. The total sample size was 7. The census was 39. A. Review of the agency’s policy and procedure titled Bag Technique, reviewed/revised 5/7/24, revealed: 1. Hand hygiene was to be performed before entering/re-entering the clinician bag, and before, and after patient and/or equipment contact. 2. Equipment was to be cleaned prior to returning to the clinician bag. 3. The hard-shell case and the laminated screen protector of the tablet was to be cleaned after patient and caregiver use with a lightly moist sanitizing or alcohol wipe prior to returning it to the clinician bag. B. Review of the agency’s policy and procedure titled Hand Hygiene, revised 8/10/22, revealed hand hygiene was to be performed before re-entering the clinician bag and/or handling clinician or patient’s clean supplies, such as, clinician bag, tablet, and clean supplies. C. Review of Patient 1’s Home Health Certification and Plan of Care (POC), for the certification period of 5/20/25 through 7/18/25, included orders for Skilled Nurse (SN) every 2 weeks for Home Health Aide supervision, prefill medication planner, and provide education regarding safety issues, proper oxygen use, preventing falls and provide interventions to reduce fall risk. D. The observation of the provision of care, for Patient 1 on 6/10/25 at 11:00 AM, revealed Staff C: 1. Failed to perform hand hygiene on one occasion prior to entering the clinician bag. 2. Failed to provide cleaning of the tablet prior to returning it to the clinician bag after use by the SN and patient. E. During an interview on 6/10/25 at 1:00 PM, the Home Health Supervisor confirmed Staff C failed to follow the agency’s policy and procedure for hand hygiene and bag technique during the provision of care for Patient 1.”

“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, policy and procedure review, and staff interview, the agency failed to follow their policy and procedure to ensure transfer information was sent to the receiving facility for 2 of 2 patients who had a transfer (Patients 3 and 5). The total sample size was 7. The census was 39. A. Review of the agency policy and procedure titled Transfer and Discharge-Home Health, revised 10/20/23, revealed the agency was to: 1. Send a transfer summary within two (2) business days of becoming aware of an unplanned transfer to the receiving provider. 2. Maintain a copy in the patient’s clinical record of the Transfer or Discharge Summary provided to the receiving provider. B. Review of Patient 3’s clinical record revealed: 1. A Home Health Certification and Plan of Care with a start of care date of 10/31/24. 2. A Care Summary - Transfer Client Coordination Note Report, dated 5/12/25, showing Patient 3 was admitted to the hospital on 5/9/25. 3. There was no documentation in the clinical record that a transfer or discharge summary was provided by the agency to the receiving facility. C. Review of Patient 5’s clinical record revealed: 1. A Home Health Certification and Plan of Care with a start of care date of 5/8/25. 2. A Care Summary - Transfer Client Coordination Note Report, dated 5/20/25, showing Patient 5 was admitted to the hospital on 5/19/25. 3. There was no documentation in the clinical record that a transfer or discharge summary was provided by the agency to the receiving facility. D. During an interview on 6/11/25 at 2:15 PM, the Home Health Supervisor and the Regional Director of Clinical Services confirmed: 1. There was no documentation in the clinical record that a Patient Transfer Form or Transfer Summary was completed or provided to the receiving facility when Patient 3 and Patient 5 were transferred to the hospital on 5/9/25 and 5/19/25, respectively. 2. The Agency staff failed to follow the agency’s policy and procedure to ensure transfer information was sent to the receiving facility for 2 of 2 patients who had a transfer (Patient 3 and 5).”