Seymour Hospital 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 staff failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases for 1 of 3 (Patient #2) patients for whom care by agency staff was observed. This failure could result in the spread of infectious agents. The findings included: During an observation conducted on 06/11/25 at 9:50 a.m., with Patient #2 and RN I, the surveyor observed RN I provide tracheostomy (a medical tube inserted through a surgical opening in the airway between the mouth and the lungs) site care to Patient #2. RN I was observed to place soiled supplies, including the soiled tracheostomy dressing, which had visible mucus (a type of body fluid secreted by membranes in the nose, mouth, throat, sinuses, and linings of some organs) on the surface, the gauze used to clean the site, and the cotton-tip applicators (a type of medical swab) used to clean the site, on top of a soiled glove, which was sitting directly on top of the patient’s kitchen counter. RN I failed to place a barrier between the soiled supplies and the counter or to place the soiled items in a container for disposal. Record review of the clinical record for Patient #2 included a plan of care, for the certification period of 05/31/25 – 07/29/25, which indicated the patient had a start of care date of 05/31/25 and diagnoses of carcinoma (a type of cancer or abnormal cell growth which can spread to other tissues in the body and cause harm) of tongue, malignant neoplasm (cancer or abnormal cell growth that can spread to other tissues in the body and cause harm), secondary malignant neoplasms of other sites (cancerous cells that spread to other areas of the body from an original or primary site), and tracheostomy. The plan of care indicated the patient was to receive skilled nurse visits once a week for one week, seven times a week for one week, four times a week for one week, three times a week for two weeks, twice a week for two weeks, and once a week for two weeks. The plan of care indicated agency staff were to follow standard precautions and infection control precautions. The plan of care indicated, “SN to perform tracheostomy care PRN [as needed],” and indicated the patient had a “Recent tracheostomy placed on 5/23/25.” During an interview conducted on 06/11/25 at 9:50 a.m., Patient #2 did not report any complaints or concerns regarding the care provided by the agency. During an interview conducted on 06/11/25 at 11:38 a.m., RN I said she would usually use a barrier between dirty supplies and the patient’s counter/work surface in the patient’s home and said usually she would just use the trashcan directly. RN I said she was flustered with the surveyor being present and realized after she started providing the tracheostomy care and had the dirty supplies in her hands that she did not have a barrier or trashcan available to place or dispose of the supplies. During an interview conducted on 06/11/25 at 12:15 p.m., with the Alternate Administrator/Alternate Supervising Nurse, when asked regarding the agency’s expectation for use of a barrier between dirty supplies and work surfaces in a patient’s home, the Alternate Administrator/Alternate Supervising Nurse said the staff would usually have a barrier between the work surface in the patient’s home and dirty supplies, such as a blue pad or trash bag. The Alternate Administrator/Alternate Supervising Nurse said the agency staff did not want to get the patient’s home dirty or spread infectious agents and said infection control was the main concern. The Alternate Administrator/Alternate Supervising Nurse said a potential adverse outcome of not using a barrier would be the spread of infectious agents. During an interview conducted on 06/13/25 at 9:30 a.m., the Administrator/Supervising Nurse said the agency’s expectation was that the nurse should have a barrier between dirty supplies and the work surface in a patient’s home. The Administrator/Supervising nurse said that they would usually use a trash can but if not available, they would place a barrier between the soiled supplies and the work surface. The Administrator/Supervising Nurse said RN L was flustered with having the surveyor observing and just forgot to place it. The Administrator/Supervising Nurse said RN L notified her after the visit that she had forgotten it. The Administrator/Supervising Nurse said infection control was everyone’s responsibility, but it would be the responsibility of the nurse to ensure she had the necessary supplies and set up appropriately when providing care to ensure there was a barrier in place. The Administrator/Supervising Nurse said RN L was provided with training regarding infection control upon hire and she just forgot as she was flustered during the visit. Record review of the personnel record for RN I indicated this individual had a date of employment of 08/13/11. The personnel record for RN I indicated this employee received training on infection control, including bloodborne pathogens, on hire and annually for the years of 2023 and 2024. Record review of the Occupational Safety and Health Administration regulations relating to Bloodborne Pathogens at 29 CFR Part 1910.1030 and Appendix A to that section, on 06/17/25 at 3:04 p.m., indicated, “Contaminated means the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface … Other Potentially Infectious Materials means all body fluids in situations where it is difficult or impossible to differentiate between body fluids … Regulated Waste means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling … Universal Precautions is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious … Universal precautions shall be observed to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials … Employers shall ensure that the worksite is maintained in a clean and sanitary condition.” Record review of an agency policy titled, “Infection Control Program,” dated 01/01/25, indicated, “The Agency’s Infection Control Program will be based on the following criteria … The Occupational Safety and Health Administration (OSHA), 29 CFR Part 1910.1030 and Appendix A relating to Bloodborne Pathogens … Prevention and Control Activities … The Agency will follow accepted standards of practice, including the use of standard precautions and as needed, transmission-based precautions with standard precautions, to prevent the transmission of infections and communicable diseases …””

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on interview and record review, the agency failed to provide infection control education to staff for 1 of 10 (PT F) current employees reviewed in that the agency failed to provide education regarding bloodborne pathogens annually for the years of 2023 and 2024. This failure could result in adverse outcomes to patients in that the employee might not be aware of the most up to date information regarding bloodborne pathogens and infection control which could result in the spread of infections. The findings included: Record review of the personnel record for PT F indicated this individual had a date of employment of 07/27/20. The personnel record did not include documentation of annual training on bloodborne pathogens for the years of 2023 and/or 2024. Record review of the additional personnel record documentation maintained at the hospital which the agency was affiliated with for PT F did not include documentation of annual training on bloodborne pathogens for the years of 2023 and/or 2024. During an interview conducted on 06/10/25 at 3:05 p.m., the HR director said PT F had never been registered in the agency’s electronic education/training system and therefore had not received the annual training in bloodborne pathogens for the years of 2023 or 2024. During an interview conducted on 06/12/25 at 9:25 a.m., with PT F, when asked if she had received the annual bloodborne pathogens training for the years of 2023 and 2024, PT F said she could not recall if she had received that training from the agency. When asked if she had received the training elsewhere outside of the agency for the years of 2023 and 2024, PT F said, no. PT F said she did not receive the training from another healthcare agency/facility because she did not work at another agency/facility that would require that training. During an interview conducted on 06/13/25 at 9:30 a.m., the Administrator/Supervising Nurse said the HR director was responsible for assigning employees to the agency’s electronic education/training system to ensure the bloodborne pathogen trainings were completed annually, and she was not sure why it was not completed for PT F, but it must have been overlooked and PT F was never assigned the trainings. The Administrator/Supervising Nurse said there was potential for an adverse outcome to clients in that the employee might not be aware of the most up to date information regarding bloodborne pathogens and infection control. The Administrator/Supervising Nurse said the training should be completed annually and said the documentation of that training should be included in the employee’s personnel record. Record review of the Occupational Safety and Health Administration regulations relating to Bloodborne Pathogens at 29 CFR Part 1910.1030 and Appendix A to that section, on 06/17/25 at 3:04 p.m., indicated, “The employer shall train each employee with occupational exposure in accordance with the requirements of this section … The employer shall institute a training program and ensure employee participation in the program. Training shall be provided as follows … At the time of initial assignment to tasks where occupational exposure may take place … At least annually thereafter. Annual training for all employees shall be provided within one year of their previous training.” Record review of an agency policy titled, “Infection Control Program,” dated 01/01/25, indicated, “The Agency’s Infection Control Program will be based on the following criteria … The Occupational Safety and Health Administration (OSHA), 29 CFR Part 1910.1030 and Appendix A relating to Bloodborne Pathogens … Prevention and Control Activities … Education … Employees … Upon hire and annually thereafter, all Agency employees will be educated regarding the policies and procedures related to Bloodborne … Pathogen Program …””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patient’s individualized plan of care included all medications and treatments for 1 of 7 (Patient #4) patients reviewed in that the agency failed to include physician orders to flush the patient’s PICC line (a medical tube inserted through a blood vessel closer to the surface of the skin and advanced into a large blood vessel near the heart used to administer medication directly into the blood stream) with 10 ml of NS (a solution of salt and water) and 2.5 ml of Heparin (a medication used to prevent or reduce blood clotting) each skilled nurse visit. This failure could result in a nurse failing to realize the patient’s PICC line needed to be flushed during skilled nurse visits and could result in the line becoming obstructed and unusable requiring the patient to have another line placed which could result in discomfort or an inability to obtain IV access (a medical tube is inserted into a blood vessel to administer medications or fluids) in a timely manner. The findings included: Record review of the clinical record for Patient #4 included a plan of care, for the certification period of 04/16/25 – 06/14/25, which indicated the patient had a start of care date of 04/16/25 and diagnoses of cellulitis (an infection of the skin and underlying tissues) of right lower leg, chronic kidney disease (a progressive disorder in which the kidneys lose the ability to filter waste from the blood), and hypertensive heart disease with heart failure (a medical condition in which the heart cannot pump effectively which can result in buildup of fluid in the tissues). The plan of care indicated the patient was to receive skilled nurse visits twice a week for one week, three times a week for three weeks, and then once a week for five weeks. Record review of the clinical record for Patient #4 included a Resumption of Care Plan of Care update order, dated 05/03/25, which indicated the patient’s care was resumed by the agency on this date after a hospitalization and indicated the patient had a PICC line to the left arm. The Resumption of Care Plan of Care update order did not include orders for the skilled nurse to flush the PICC line with 10 ml of NS or 2.5 ml of Heparin. Record review of a skilled nurse’s note, dated 05/07/25, signed by LVN H, indicated the nurse flushed the patient’s PICC line with 10 ml NS and 2.5 ml Heparin during this visit. Record review of a skilled nurse’s note, dated 05/09/25, signed by the Administrator/Supervising Nurse, indicated the nurse flushed the patient’s PICC line with 10 ml NS and 2.5 ml Heparin during this visit. Record review of a skilled nurse’s note, dated 05/12/25, signed by the Administrator/Supervising Nurse, indicated the nurse flushed the patient’s PICC line. The note did not indicate what the PICC line was flushed with during this visit. Record review of a skilled nurse’s note, dated 05/16/25, signed by LVN H, indicated the nurse flushed the patient’s PICC line with 10 ml NS and 2.5 ml Heparin during this visit. Record review of a skilled nurse’s note, dated 05/19/25, signed by LVN H, indicated the nurse flushed the patient’s PICC line with 10 ml NS and 2.5 ml Heparin during this visit. Record review of a skilled nurse’s note, dated 05/21/25, signed by LVN M, indicated the nurse flushed the patient’s PICC line with 10 ml NS and 2.5 ml Heparin during this visit. Record review of a skilled nurse’s note, dated 05/23/25, signed by LVN M, indicated the nurse flushed the patient’s PICC line with 10 ml NS and 2.5 ml Heparin during this visit. Record review of a skilled nurse’s note, dated 05/26/25, signed by the Administrator/Supervising Nurse, did not indicate the nurse flushed the patient’s PICC line during this visit. Record review of a skilled nurse’s note, dated 05/30/25, signed by LVN M, did not indicate the nurse flushed the patient’s PICC line during this visit. Record review of a skilled nurse’s note, dated 06/02/25, signed by LVN H, did not indicate the nurse flushed the patient’s PICC line during this visit. Record review of a skilled nurse’s note, dated 06/04/25, signed by LVN H, indicated the PICC line was flushing well but did not indicate what the PICC line was flushed with during this visit. Record review of a skilled nurse’s note, dated 06/06/25, signed by LVN M, did not indicate the nurse flushed the patient’s PICC line during this visit. Record review of a skilled nurse’s note, dated 06/09/25, signed by RN L, did not indicate the skilled nurse flushed the patient’s PICC line during this visit. Record review of the clinical record for Patient #4, for the certification period of 04/16/25 – 06/14/25, did not include physician orders for the skilled nurse to flush Patient #4’s PICC line with 10 ml NS or 2.5 ml of Heparin. During an interview conducted on 06/11/25 at 9:00 a.m., Patient #4 said she had no complaints or concerns and was satisfied with the services provided by the agency. During an interview conducted on 06/11/25 at 9:35 a.m., with Caregiver #1 from ALF #1, where Patient #4 resided, when asked if she had been satisfied with the agency’s services, Caregiver #1 said, yes. Caregiver #1 said she had no concerns or complaints regarding the care and services provided by the agency. During an interview on 06/13/25 at 9:00 a.m., the Administrator/Supervising Nurse provided an agency form, titled, “Plan of Care Profile,” not dated, and said this was the agency’s PICC line care protocol template. Record review of an agency form, titled, “Plan of Care Profile,” not dated, included a section labeled, “IV … Therapy,” which included a section where the nurse creating the plan of care could enter orders for care of an IV. The form did not include orders to flush the PICC line with 10 ml NS or 2.5 ml Heparin. During an interview conducted on 06/13/25 at 9:09 a.m., RN L said she had taken over as the RN case manager for Patient #4 as of the week of 06/08/25 – 06/14/25 and said Patient #4 had a PICC line in place to the left arm. RN L said that the nurses continued to flush the PICC line each skilled nurse visit. RN L said the patient was difficult to get IV access on and the PICC line was left in place after her hospitalization in case she developed complications that would require IV antibiotics (a type of medication used to treat infections). RN L confirmed that the agency nurses flushed the patient’s PICC line with 10 ml NS and 2.5 ml Heparin each skilled nurse visit. RN L reviewed the PICC line care protocol provided by the administrator/supervising nurse on 06/13/25 at 9:00 a.m. and said this was the written protocol the nurses used for provision of PICC line care and said the protocol on the plan of care orders for Patient #4 should have included information regarding flushing the PICC line. RN L said usually when a patient had a PICC line in place they were also receiving IV medications, such as antibiotics, and the orders for the flushes were included with the IV medication orders. RN L said the orders for the flushes might have been missed as the patient was not currently receiving IV medication and the PICC line was just being left in place as a precaution. During an interview conducted on 06/13/25 at 9:17 a.m., LVN M confirmed she flushed Patient #4’s PICC line with 2.5 ml of Heparin and 10 ml of NS each skilled nurse visit and said she knew to do this from the written PICC line care protocol included on the patient’s plan of care orders. The surveyor provided a copy of the PICC line care protocol provided to the surveyor by the administrator/supervising nurse on 06/13/25 at 9:00 a.m., and after reviewing the protocol, LVN M said the protocol should have included documentation regarding the PICC line flushes and said when the patient first had the PICC placed she was receiving IV medication and when the IV medication was discontinued the PICC line flushes may have been inadvertently discontinued as well. LVN M said the PICC line flushes should have been included under the PICC line care protocol on the patient’s plan of care orders. LVN M said she flushed the PICC line with NS and Heparin every skilled nurse visit, including on 05/30/25, and said if she did not document the PICC line flushes on the skilled nurse’s note, she just forgot to document that she had done so. During an interview conducted on 06/13/25 at 9:23 a.m., LVN H confirmed she flushed Patient #4’s PICC line with 2.5 ml of Heparin and 10 ml NS during each skilled nurse visit and said she knew to do this from the PICC line care protocol. After reviewing the protocol provided by the administrator/supervising nurse on 06/13/25 at 9:00 a.m., LVN H said the patient was previously receiving an IV antibiotic when the PICC line was first placed and at that time the patient was also receiving the 2.5 ml Heparin and 10 ml NS flushes of the PICC line. LVN H said she could not recall when the IV antibiotic had been discontinued. LVN H said the PICC line was left in place after the IV medication was discontinued as a precaution. LVN H said she did flush the PICC line with 2.5 ml of Heparin and 10 ml of NS each skilled nurse visit, including 06/02/25 and 06/04/25, and said she had just failed to document this and said she just forgot. LVN H said the flushes would usually be included on the plan of care. During an interview conducted on 06/13/25 at 9:30 a.m., with the Administrator/Supervising Nurse, when asked about the PICC line care protocol provided on 06/13/25 at 9:00 a.m., the Administrator/Supervising Nurse said this was a template in the agency’s electronic medical records system used to create the plan of care/physician’s orders for PICC line care and said the nurse would fill the section in with the care to be provided. The Administrator/Supervising Nurse said she just never thought about adding the PICC line flushes into the template. The Administrator/Supervising Nurse said usually when a patient had a PICC line in place the patient was also receiving IV medication and the flushes would be included with the orders for the IV medication. The Administrator/Supervising Nurse said when Patient #4 was discharged home with the PICC line in place they were hoping to be able to remove it, but the patient had some unstable edema (swelling/excess fluid in the body’s tissues) and wound issues and the PICC line was left in place as a precaution. The Administrator/Supervising Nurse said as the patient resided in a rural area it could be difficult to get PICC line placement and it was considered best to leave the line in as a precaution as the line was still functioning. The Administrator/Supervising Nurse said she flushed the PICC line with 2.5 ml Heparin and 10 ml NS during each skilled nurse visit she completed with the patient and if it was not documented in her skilled nurse’s note for the visit, she had forgotten to document it. The Administrator/Supervising Nurse said the PICC line had been in place since the patient’s resumption of care on 05/03/25. The Administrator/Supervising Nurse said the PICC line flushes would usually be documented on the plan of care/physician’s orders. The Administrator/Supervising Nurse said there was potential for an adverse outcome related to not having the order regarding the PICC line flushes included in the plan of care in that if a nurse made a visit and did not know the PICC line needed to be flushed she might fail to flush it and that could result in them losing the line. The Administrator/Supervising Nurse said the order for the PICC line flushes should have been included on the resumption of care plan of care update order as soon as the patient’s care was resumed by the agency after the hospitalization, and it was noted she has a PICC line in place on 05/03/25. Record review of an agency policy titled, “Plan of Care,” dated 05/02/24, indicated, “The individualized Plan of Care must include the following … All medications and treatments …””

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the registered nurse or other appropriate skilled professional completed a supervisory assessment of the aide services being provided no less frequently than every 14 days for 1 of 3 (Patient #4) patients reviewed who received HHA services from agency staff. This failure could result in the agency failing to identify and address issues or complaints with the HHA’s services. The findings included: Record review of the clinical record for Patient #4 included a plan of care, for the certification period of 04/16/25 – 06/14/25, which indicated the patient had a start of care date of 04/16/25 and diagnoses of cellulitis (an infection of the skin and underlying tissues) of right lower leg, chronic kidney disease (a progressive disorder in which the kidneys lose the ability to filter waste from the blood), and hypertensive heart disease with heart failure (a medical condition in which the heart cannot pump effectively which can result in buildup of fluid in the tissues). The plan of care indicated the patient was to receive skilled nurse visits twice a week for one week, three times a week for three weeks, then once a week for five weeks and HHA visits once a week for one week, and then three times a week for eight weeks. Record review of the clinical record for Patient #4, for the time-period of 05/05/15 – 06/11/25, indicated HHA visits were conducted on 05/05/25, 05/07/25, 05/09/25, 05/12/25, 05/14/25, 05/16/25, 05/19/25, 05/21/25, 05/23/25, 05/30/25, 06/04/25, 06/06/25, 06/09/25, and 06/11/25. Record review of the clinical record for Patient #4, for the time-period of 05/05/25 – 06/11/25, did not include documentation of HHA supervisory assessments completed during this time-period. During an observation conducted on 06/11/25 at 9:00 a.m., with Patient #4, and HHA D, the surveyor observed care provided to the patient by HHA D. There were no concerns identified during the observation. During an interview conducted on 06/11/25 at 9:00 a.m., Patient #4 said she liked all the staff from the agency, had no complaints or concerns, and was satisfied with the services provided by the agency. During an interview conducted on 06/11/25 at 9:35 a.m., with Caregiver #1 from ALF #1, where Patient #4 resided, when asked if she had been satisfied with the agency’s services, Caregiver #1 said, yes. Caregiver #1 said she had no concerns or complaints regarding the care and services provided by the agency. During an interview conducted on 06/13/25 at 9:09 a.m., RN L said that she had taken over as the RN case manager for Patient #4 as of the week of 06/08/25 – 06/14/25. RN L said HHA supervisory assessments were to be completed every other week and said she did not do one on 06/09/25 as the HHA supervisory assessment was to be completed on 06/13/25. During an interview conducted on 06/13/25 at 9:30 a.m., the Administrator/Supervising Nurse said the HHA supervisory assessments for Patient #4 were missed because the patient had physician appointments the dates that they were scheduled to be completed. The Administrator/Supervising Nurse said if the HHA supervisory assessment was missed the RN should have identified that the supervisory assessment needed to be moved to another day or completed prior to the date of the physician visit to ensure they were completed on time. The Administrator/Supervising Nurse said it was just not identified by the agency that the HHA supervisory assessments were missed. The Administrator/Supervising Nurse said it would be the responsibility of the RN making the visits to ensure the HHA supervisory assessments were completed but it would also be her responsibility as she was the QAPI coordinator to identify that they had been missed and to reschedule them. The Administrator/Supervising Nurse said she was the RN overseeing the patient’s care until the week of 06/08/25 – 06/14/25 when RN L took over as the patient’s RN case manager. The Administrator/Supervising Nurse said if the HHA supervisory assessments were not completed every 14 days as required the agency might fail to identify and address issues or complaints with the HHA’s services. During an interview conducted on 06/13/25 at 10:37 a.m., the Administrator/Supervising Nurse provided a HHA supervisory assessment note for Patient #4, dated 05/26/25. Record review of the clinical record and additional documentation provided for Patient #4 indicated no HHA supervisory assessment was completed between 05/05/25 and 05/26/25, indicating 21 days passed between HHA supervisory assessments, and indicated no HHA supervisory assessment was completed between 05/26/25 and 06/12/25 (indicating 17 days had passed between HHA supervisory assessments). Record review of an agency policy titled, “Employee Supervision,” dated 05/02/24, indicated, “If home health aide services are provided to a patient/client who is receiving skilled nursing … services … A registered nurse (RN) or other appropriate skilled profession who is familiar with the patient/client … must … make an onsite visit to the patient’s/client’s home no less frequently than every 14 days …””