Concordia Home Health of Bethlen

“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 manufactures directions for use, observations (OBS) , review of agency policy and procedure, and staff (EMP) interview the agency failed to ensure that acceptable standards of practice for infection control/prevention were maintained for three (3) of five (5) OBS (OBS1, OBS4 and OBS5). Findings include: Review of the manufacture’s recommendation s for use on 7/25/2024 at approximately 1:03 PM revealed, “Review of manufacturer’s directions for use (on container) for disinfectant wipes “Micro-Kill One Germicidal Alcohol Wipes: ... Disinfecting: To disinfect hard, non-porous surfaces use one or more wipes, as necessary, to thoroughly wet the surface to be treated. Treated surface must be visibly wet for one (1) minute to achieve complete disinfection of all pathogens listed on this label...” Review of the manufacture’s recommendation s for use on 7/19/2024 at approximately 1:10 PM revealed, “MEDLINE MICROKILL AF2 DISINFECING, DEODORIZING, CLEANNING WIPES, ELIMINATES GERMS IN JUST 2 MINUTES…DIRECTIONS FOR USE…TO CLEAN AND DISINFECT/VIRUCIDAL DIRECTIONS: Wipe hard, nonporous surface with wipe until surface is visible wet. Allow surface to remain wet for 2 minutes…” Review of the agency policy on 7/19/2024 at approximately 1:10 PM revealed, “Skills: Supply Bag Technique (Home Health Care)- CE/NCPD…Preparing The Bag 1. Store hand hygiene supplies (i.e., antimicrobial soap, waterless handwashing gel, paper towels, and barrier) in the outermost pocket of the bag (sometimes referred to as the dirty section). 2. Create a dedicated area of the bag for clean, reusable items, such as blood pressure cuff. 3. Create a dedicated area of the bag for clean, sterile, nonreusable items, such as dressings and supplies. Anything removed from this section will not be returned to it following use…Using the Bag…3. When reentering the home, place the bag on clean, dry surface with a water resistant barrier placed between the bag and the surface…” During (OBS1) MR1 on 7/19/2024 at approximately 7:33 AM the following was observed: The surveyor confirmed the disinfectant being used was Medline Micro-Kill One Germicidal Alcohol Wipes. Observation of EMP8 revealed after direct patient care was completed reusable thermometer and blood pressure cuff was cleaned and placed directly into a see-through plastic bag without dry time being observed. During (OBS4) MR3 on 7/19/2024 at approximately 10:00 AM the following was observed: EMP9 placed a chuck/barrier on a table with the nursing/supply bag on top of the chuck/barrier. Part of the strap from the nursing/supply bag was laying off the side of the chuck/barrier against the top section of a chair. During (OBS5) MR4 on 7/19/2024 at approximately 11:53 AM the following was observed: The surveyor confirmed the disinfectant being used was Medline Micro-Kill One Germicidal Alcohol Wipes. Observation of EMP10 revealed after direct patient care was completed the reusable stethoscope, pulse oximeter, thermometer and blood pressure cuff was cleaned and placed directly into the supply bag with no dry time observed. An exit interview conducted with the administrator, manager quality and intake, director of compliance and education and private care manager on 7/19/2024 at approximately 1:30 PM which confirmed the above findings.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on review of policies and procedures, medical records (MR) and staff (EMP) interview the agency failed to ensure the plan of care contained all patient care orders and referred services for one (1) of thirteen MR reviewed MR5. Findings Included: Review of the agency admission packet on 7/16/2024 at approximately 12:02 PM revealed, “Patient Information for Home Health Care…Plan of care and treatment-you have the right to…Quality of care-you have a right to…*Be admitted by the agency only if we have the resources needed to provide your care safely and at a required level of intensity as determined by a professional assessment…” Review of the agency policy on 7/19/2024 at approximately 1:10 PM revealed, “SUBJECT Policy VII-1, I. Policy (Agency) accepts referrals on adult patients who are essentially homebound and in need of home care visits by nurses, physical therapists, occupation al therapists, speech language pathologist, medical social workers, dietitians, and home health aides…II. Procedure…D. All patients will be evaluated to ensure they meet the criteria for home health services such as payer criteria, medical necessity and need for intermittent skilled care…E. The Home Care personnel may confer with any or all of the following to evaluate the patient’s status: the attending physician, support physician(s), clinic staff, supervisors, patient, family, and significant other (s) with references to the following items: 1. The adequacy and suitability of personnel to provide the skilled services in the home, as ordered by the physician, in accordance with the established plan of care…F. The patient will be referred to alternate resources as appropriate, and the referring physician is notified, when the organization is unable to meet identified patient needs or the patient does not meet eligibility criteria for home health services. Reviews of MR5 was conducted on 7/18/2024 at approximately 11:50 AM, start of care was 6/25/2024 with a certification period of 6/25/2024 to 8/23/2024 with a primary diagnosis of urinary tract infection site not specified. A review of the documentation provided the following information: “(Agency) DOCUMENTATION OF FACE TO FACE ENCOUNTER AND CERTIFICATION…4. I certify that, based on my findings, the following services are medically necessary home health services (Check all that apply): Nursing, Physical Therapy, Speech language Pathology, Occupational Therapy, Medical Social Worker, HHA (Home Health Aide), Psych Nurse (written).” The following services were marked with an “X” “Nursing, Physical Therapy, Occupational Therapy, Medical Social Worker, HHA, Psych Nurse.” During review of the MR the surveyor could not confirm medical social worker or Psych nurse evaluation were conducted or that the patient declined services. An exit interview conducted with the administrator, manager quality and intake, director of compliance and education and private care manager on 7/19/2024 at approximately 1:30 PM which confirmed the above findings.”