Prime Home Care

“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, the observation of the provision of cares, and staff interview, the 2 of 3 staff (Staff D and Staff E) observed during the provision of cares to 2 of 3 patients (Patient 5 and Patient 2 respectively) failed to perform proper hand hygiene, bag technique, reusable equipment care, and/or glove use according to the agency’s policies and procedures and the agency failed to have a complete bag technique policy and procedure for the cleaning and disinfecting of reusable equipment. The total sample size was 7. The census was 59. Findings are: A. Review of the agency policy and procedure titled Handwashing, no date indicated, revealed: 1. All direct caregivers will observe proper hand hygiene techniques. 2. Hand hygiene is to be performed alcohol-based hand rub or soap and water. 3. Hand hygiene is to be performed prior to initial entry into supply bag, before providing direct care, following each patient contact, after touching soiled items, before and after performance of an invasive procedure or wound care, and after contact with bodily fluids. B. Review of the agency policy and procedure titled Standard Precautions, no date indicated, revealed: 1. Standard precautions will be followed by all employees to reduce risk of transmission of microorganisms and to protect both patients and employees. 2. Handwashing is the single most important means of reducing the risks of transmitting microorganisms. 3. Even if gloves are worn, hands may become contaminated during glove removal. 4. Wearing gloves does not replace the need for handwashing because gloves may have defects. 5. Hands are to be washed after glove removal. C. Review of the agency policy and procedure titled Bag Technique, undated, revealed staff are to: 1. Identify a clean and safe area to place the bag, never on the floor. 2. Place an impervious barrier on the surface, then place the bag on the barrier. 3. Remove any items needed for patient care, including personal protective equipment from the bag. 4. Close the bag before providing patient care. 5. Rewash hands again if needing to re-enter the bag for additional supplies. 6. This policy does not discuss cleaning/disinfecting reusable equipment prior to placing back in the supply bag. 7. The policy does not address where to place the supplies needed during patient care once they are removed from the supply bag. D. Review of the agency policy and procedure titled Cleaning and Management of Supplies and Equipment, undated, revealed: 1. Staff are to follow agency procedure for the cleaning and management of supplies and equipment according to federal/state laws and regulations, and appropriate manufacturers’ recommendations. 2. Some items, but not all inclusive, include the nurse/supply bag, stethoscope, blood pressure cuff, clippers, physical and occupational therapy equipment, and more. 3. Depending on the item, staff are to wipe items with detergent solutions, antiseptic wipes, or an approved solution per manufacturer recommendations and then allowed to air dry. 4. Contaminated supplies are not placed back inside the supply bag. E. Review of Patient 2’s clinical record revealed the Plan of Care for the certification period of 7/10/26 through 9/7/26 included orders for Skilled Nurse (SN) 1 time a week for 1 week, then 3 times a week for 8 weeks for hands on wound care, monitoring, instruction, education, intervention of disease process, medication education, and safety. F. During the observation of wound care to Patient 2 on 8/12/26 at 1:00 PM, the SN (Staff- E) failed to: 1. Sanitize scissors used to cut soiled gauze dressing from patients leg wound and prior to using those same scissors to cut primary dressings on 3 separate occasions during wound care. 2. Sanitize the cell phone used to take pictures of the patients wound, after removing soiled gauze dressing and prior to placing the cell phone in [gender] uniform pocket. 3. Sanitize hands after completing wound care, and prior to putting new gloves on to place unused portions of the clean dressing supplies back in the packages for later use. 4. Sanitize bottles of wound wash and hand sanitizer, which had been placed on a pet step stool, prior to placing those items back in the supply bag. 5. Close the supply bag after supplies were removed. G. Review of Patient 5’s clinical record revealed: 1. The Plan of Care for the certification period of 7/2/26 through 8/30/26 included orders for Physical Therapy (PT) to evaluate and treat for weakness, deconditioning, and right sided hemiparesis. 2. The PT Evaluation dated 7/10/26 included additional orders for PT 1 time a week for 1 week, then 2 times a week for 7 weeks. H. During the observation of the provision of PT services to Patient 5 on 8/12/26 at 11:00 AM, PT-(Staff-D) failed to: 1. Place the supply bag on a barrier. 2. Place the computer tablet on a barrier. 3. Sanitize the TheraBand (a stretchy elastic band used for exercises) after use with the patient and prior to placing the TheraBand back in the supply bag. I. During an interview on 8/12/26 at 2:50 PM, the Administrator and the Clinical Manager confirmed that Staff-D, and Staff-E failed to follow agency policies and procedures for proper hand hygiene, bag technique, equipment care, and/or glove use during the provision of cares to Patient 5 and Patient 2, respectively.”