Pathfinder Home Health

“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, interview, and record review, the agency failed to follow accepted standards of practice to prevent the transmission of infections for 1 of 3 patients observed during a home visit. (Patient #2) RN D did not sanitize or wash her hands after removing gloves during patient wound care. This failure could result in the spread of infections to patients. Findings included: Review of an agency policy dated 5/1/2024 and titled, “Hand Hygiene”, indicated, “Policy All Agency staff providing client/patient care will perform hand hygiene in accordance with the Centers for Disease Control and Prevention (CDC) recommendations. Procedure 1. Hand hygiene with Soap and Water…II. Hand Hygiene with an Alcohol-based Hand Rub…4. After contact with…used supplies (PPE)…6. After touching a client/patient…7. After contact with blood, body fluids, or contaminated surfaces 8. After removing gloves. Review of a plan of care dated 5/28/2026 to 7/26/2026 indicated Patient #2 was 77 years old and admitted to the agency on 5/28/26 with diagnoses that included venous insufficiency (leg veins struggle to send blood back to the heart causing blood to pool in the lower legs) and chronic ulcer (an open wound that is slow healing) to left foot. Safety measures included standard precautions and infection control. The plan of care indicated wound care was to be provided three days a week. During an observation on 7/15/26 at 9:00 a.m. in the home of Patient #2 the surveyor observed RN D cleanse Patient #2s left open foot wound with wound care wash and gauze while wearing gloves, RN D removed her gloves but did not wash or sanitize her hands, RN D then touched her electronic device, re-gloved her hands without sanitizing her hands and continued to provide wound care to Patient #2’s left foot. During an interview on 7/15/26 at 9:30 am RN D said she had been employed with the agency for about three years and had received training on infection control and standard precautions. She could not remember the exact date of her last infection control and hand hygiene training but knew it had been within the last six months. RN D said she performed hand hygiene upon entry of the patient’s home, before and after wound care, after taking vital signs and before leaving their home. RN D said she was supposed to sanitize her hands after removing gloves then said she had cleaned her electronic device at the start of the visit. During an interview on 7/15/26 at 11:15 am RN D said she had not sanitized her hands during patient #2’s visit after removing her gloves because she was nervous. RN D said she should have sanitized her hands after she removed her gloves and after touching the electronic device. During an interview on 7/15/26 at approximately 3:00 pm the Administrator said the staff were emailed training material on 5/28/26 on infection control and prevention and it included hand hygiene. The Administrator said she would provide a copy of the training material. Review of an email dated 5/28/26 with the subject line: Reminder-CDC Guide to infection for Outpatient Settings-Minimum expectations indicated it was sent to RN D and included an attachment titled Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care and Infection Prevention Checklist for Outpatient Settings. Page 10 indicated, “key recommendations for hand hygiene in outpatient settings: 1. Key situations where hand hygiene should be performed include:…c. After contact with a patient. d. After contact with blood, body fluids or contaminated surfaces…f. After removal of personal protective equipment (PPE). During a telephone interview on 7/15/26 at 4:00 pm the Clinical Supervisor who is also the Alternate Administrator said nurses should sanitize their hands upon entry into the home, before reaching into their bag, before and after wound care. The Clinical Supervisor said she did not know if they should sanitize their hands after removing gloves and she would have to look at the policy. After reviewing the agency’s hand hygiene policy the Clinical Supervisor said RN D should have sanitized her hands after removing her gloves. Clinical Supervisor said RN D did not follow the agency policy when she did not sanitize her hands after removing her gloves. The Clinical Supervisor said not following the agency’s hand hygiene policy could cause infections in patients and gloves do not replace hand hygiene. The Clinical Supervisor said not sanitizing hands after glove removal is not an accepted standard of practice. During record review of an article on 7/15/26 at https://www.cdc.gov/infection-control/hcp/core-practices/?CDC%20AAref%20Val=https://www.cdc.gov/infectioncontrol/guidelines/core-practies/index.html#print dated 4/12/24 titled, “CDC’s Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings” indicated, “PPE includes gloves…hand hygiene should be performed…after touching a patient or the patient’s immediate environment, after contact with blood, body fluids or contaminated surfaces and immediately after glove removal.””