Iph Home Health Care Inc.

“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, observation and interview, the Agency failed to follow accepted standards of practice, including the use of standard precautions to prevent the transmission of infections and communicable diseases for 3 (Patient #9, Patient #11, and Patient #12) of 13 active patients whose records were reviewed for infection control in that: 1. LVN C failed to wash hands for at least 20 seconds as required by Agency policy to ensure thorough cleaning of hands prior to and after providing wound care to Patient #9 and Patient #12. 2. LVN C failed to follow aseptic technique (a set of practices used in healthcare to prevent the spread of germs and infection) while performing wound care to Patient #9. 3. LVN C failed to follow aseptic technique and minimize exposure of infections and bloodborne pathogens to herself, Patient #12 and other family members in the home setting while performing a glucometer check. 4. LVN D failed to wash hands for at least 20 seconds as required by Agency policy to ensure thorough cleaning of hands prior to and after providing wound care to Patient #11. 5. LVN D failed to follow aseptic technique while performing wound care to Patient #11. These deficient practices could place active patients at risk of exposure and infection and inadequate care when infection control practices are not applied. These deficient practices could place active patients at risk of exposure and infection and inadequate care when infection control practices are not applied. The findings included: Record review of Patient #9’s electronic medical record (EMR) included a “Home Health Certification and Plan of Care” (POC) signed and dated 05/27/25 that documented a start of care (SOC) date of 03/07/25 and a certification period of 05/06/25 through 07/04/15. Furthermore, the POC documented a principal diagnosis of pressure ulcer of left heel, unstageable (ulcer of the left heel caused by pressure and in which cannot determine how deep it has affected the surrounding tissues). The POC documented the following orders for disciplines and treatment: · SN (skilled nurse) frequency: one day for 60 days (1d60) and 3 as needed (prn) visits for falls, disease exacerbation or post hospitalization. · SN using aseptic technique and sterile supplies cleansed unstageable PU (pressure ulcer) to left heel using NS (normal saline), pat dry, cover with dry dressing and secure with hypofix tape (flexible, self-adhesive tape designed for secure dressing fixation) QD (every day) and prn (as needed). During a home visit to Patient #9 on 06/10/25 at 01:05 p.m., an observation was made of LVN C performing wound care. Upon arrival to the home visit, LVN C and the surveyor arrived at an assisted living facility and walked to Patient #9’s single living unit. LVN C knocked on the door, and both LVN C and the surveyor entered the living quarters where Patient #9 was sitting comfortably on a recliner in a small, clean, clutter free living area. After introductions were briefly made, LVN C washed her hands for 12 seconds timed, donned (put on) gloves, set an impermeable pad on a small table behind Patient #9 and her bag down on top of it. LVN C continued to assess Patient #9’s vital signs and all body systems. LVN C doffed (take off) her gloves, washed her hands for 8 seconds timed and donned new clean gloves. Patient #9’s recliner was positioned with the footrest up (no barrier was placed under Patient #9 or wound care supplies). LVN C gathered a plastic bag that contained dressing supplies near Patient #9 and a plastic bag from her nursing back to be used for trash and placed it next to Patient #9’s footrest. LVN C proceeded to assess Patient #9’s left heel pressure ulcer. LVN C reached into the plastic bag that contained supplies, took gauze, tape, and normal saline, and placed them on the footrest next to Patient #9’s foot. LVN C cleansed the wound to Patient #9’s left heel using normal saline and a dry 4x4 gauze. LVN C discarded the soiled gauze in the trash bag. LVN C then used a new gauze to pat dry and discarded that gauze in the trash bag (LVN C did not change her gloves or sanitize her hands). LVN C covered the left heel wound with a new, clean, dry 4x4 gauze and as she reached for the tape to secure the dressing, the tape rolled to the floor. LVN C reached down to pick up the tape from the floor with one hand while the other hand was holding the dressing over the wound. LVN C proceeded to secure the dressing over the left heel using the same tape that had touched the floor. LVN C placed the remaining roll of tape and normal saline back into the plastic bag with clean supplies. LVN C folded the remaining trash that included gauze wrappers into her soiled gloves while she doffed her gloves and discarded all of this and the barrier into the trash bag. LVN C then discarded the plastic trash bag into Patient #9’s waste can. LVN C proceeded to wash her hands for 8 seconds timed. LVN C donned new gloves, used a bleach wipe to sterilize her supplies and place them back in her nursing bag. LVN C doffed her gloves, picked up her nursing bag, discarded the pad and gloves into the waste can and washed her hands once again (not timed). LVN C then concluded her visit with Patient #9. In an observation and interview on 06/10/25 at 01:10 p.m., Patient #9 was sitting comfortably in his recliner, dressed appropriately, clean, and making pleasant conversations about his son and weekend plans. Patient #9 was aware of his surroundings and the reason why the nurse came to visit him. Patient #9 stated nurses came to his home to provide wound care but seemed confused about how often and when the nurses came to visit. Patient #9 stated he did not recall the wound ever being infected. Patient #9 turned to LVN C and stated, “really you all come every day?” LVN C failed to wash hands for at least 20 seconds prior to and after performing wound care to Patient #9. LVN C failed to place a barrier under Patient #9 or wound care supplies to prevent soilage and cross contamination. LVN C failed maintain aseptic technique after picking up tape from floor and securing clean dressing with contaminated dressing supplies. LVN C failed to maintain supplies clean and/or sterile by placing contaminated supplies in with clean supplies. Record review of Patient #12’s EMR included a POC not signed or dated that documented a SOC date of 05/29/25 and a certification period of 05/29/25 through 07/27/25. Furthermore, the POC documented a principal diagnosis of encounter for other orthopedic (bone) aftercare (period after surgery that focuses on wound care, pain management, monitoring of complications, etc. following orthopedic surgery) The POC documented the following orders for disciplines and treatment: · SN frequency: 2 times a week for 1 week (2w1), 7 times a week for 2 weeks (7w2), 6 times a week for 1 week (6w1), 3 times a week for 5 weeks (3w5) and 3 prn visits for disease exacerbation, fall, post-hospital, and soiled or dislodged wound dressing. · SN using aseptic technique and sterile supplies to cleanse pin sites to LLE (left lower extremity) external fixator using NS, place betadine cast (4x4 gauze soaked in antiseptic topical solution used to treat or prevent skin infections in minor cuts, scrapes or burns or to sanitize the skin before surgical procedures and wrapped around the pin sites) to pin sites, wrap with kerlix (type of dressing) and secure with tape QD. During a home visit to Patient #12 on 06/10/25 at 01:50 p.m., an observation was made of LVN C performing a blood glucometer test (a bedside machine that provides the amount of blood sugar/glucose) and wound care. Upon arrival to the home visit, LVN C and the surveyor arrived to a single-family home and was greeted by a male family member at the door. LVN C and the surveyor were escorted through a small hallway into a living room filled with large furniture. Patient #12 was escorted through an opposite hallway in a wheelchair by the same male family member. The visit started in the adjacent dining room table. LVN C placed a pad down on a sofa and her nursing bag down on top of the pad. LVN C walked into the adjacent kitchen where she washed her hands for 11 seconds timed. LVN C walked back to her supplies and donned clean gloves. LVN C assessed Patient #12 vital signs and all body systems. LVN C took a plastic bag from her nursing bag to be used for trash and placed it next to her. LVN C then prepared a glucometer also taken from her nursing bag. LVN C placed a new blood glucose test strip in the glucometer, wiped Patient #12’s 2nd right digit using an alcohol wipe, and pricked the finger using a new single use lancet (small blade with a sharp point) taken from the glucometer bag. LVN C then collected the blood sample with the glucose test strip. After a few seconds of analyzing the blood, the glucometer produced a glucose reading and LVN C removed the glucose test strip from the glucometer. LVN C then disposed of the lancet and the glucose test strip in the trash bag next to her. LVN C doffed her gloves, walked back to the kitchen where she washed her hands for 8 seconds timed and walked back to the living area. LVN C donned new clean gloves, placed a pad over a chair, and assisted Patient #12 in positioning her lower extremity (leg) over the chair. LVN C gathered and placed sterile dressing supplies near the patient and positioned the trash bag to be hanging from Patient #12’s wheelchair. LVN C took scissors from her nursing bag and wiped them with a sanitizing wipe. LVN C cut through the soiled kerlix (bandage) dressing between the external fixator (medical device that may be used to keep fractured bones stable and in place after a surgical procedure), unwrapped the lower extremity carefully and disposed the soiled dressing in the trash bag. LVN C assessed 8 pin sites to the lower extremity. LVN C removed each individual soiled betadine-soaked cast (4x4 gauzes) from each pin site by unwrapping the gauze and working her way upward discarded each one as she went into the trash bag. LVN C doffed her soiled gloves, sanitized her hands, and donned clean gloves. LVN C cleansed each individual pin site using normal saline and a dry 4x4 gauze and discarding each gauze in the trash bag. LVN C proceeded to dry each pin site using a dry 4x4 gauze and discarded each gauze in the trash bag. LVN C doffed her gloves (LVN C did not sanitize her hands), donned new clean gloves, opened several packages of sterile dry 4x4 gauzes, soaked each one with betadine and wrapped each individual pin with the betadine-soaked gauze. LVN C doffed her soiled gloves, sanitized her hands, donned new clean gloves, wrapped each section of pins (lower and upper) individually with kerlix, and secured with tape. LVN C placed unused supplies including tape, betadine, and NS back into the Patient #12’s clean supplies. LVN C disposed of used gauze wrappers, pad, and other trash in the plastic trash bag. LVN C doffed her gloves, sanitized her hands, and donned new gloves. Using a sanitizing wipe, LVN C sanitized all her nursing supplies including scissors, glucometer, and stethoscope and placed them back in her nursing bag. LVN C doffed and disposed of her gloves in the plastic trash bag. LVN C disposed of the plastic trash bag in Patient #12’s trash container and washed her hands for 10 seconds timed. LVN C then concluded her visit with Patient #12. In an observation and interview on 06/10/25 at 02:00 p.m., Patient #12 was observed sitting comfortably in a wheelchair, dressed appropriately, clean and making pleasant conversations about her recuperation. Patient #12 stated she had been referred to the Agency approximately 2 weeks prior to the visit by her physician for wound care. Patient #12 stated she received dialysis Monday, Wednesday and Friday and would schedule nurse visits around this because the nurses came daily to visit her. Patient #12 stated she was happy with services provided by Agency and staff. LVN C failed to wash hands for at least 20 seconds prior to and after performing wound care to Patient #12. LVN C failed to minimize exposure of infections and bloodborne pathogens to herself, Patient #12 and other family members in the home setting while performing a glucometer check after she disposed of used glucometer testing strip and lancet in trash bag instead of approved biohazard receptacle. LVN C failed maintain aseptic technique by not performing hand hygiene at appropriate intervals during wound care including after cleansing the wound and initiating the application of the prescribed treatment. Record review of Patient #11’s EMR included a POC signed and dated 05/21/25 that documented a SOC date of 04/25/25 and a certification period of 04/25/25 through 06/23/25. Furthermore, the POC documented a principal diagnosis of other acute osteomyelitis, right ankle and foot (inflammatory condition of bone secondary to infection of the bone in right ankle and foot) The POC documented the following orders for disciplines and treatment: · SN frequency: 1 time a day for 60 days (1d60) and 3 prn visits for wound complications, new/changed medications, skin breakdown, health concern, falls/injuries, labs. · SN using aseptic technique and sterile supplies to perform wound care qd (every day) to rt (right) 2nd toe arterial wound as follows: Cleanse with NS (normal saline) and gauze, pat dry with gauze, apply betadine cast, cover with gauze, wrap with kerlix and secure with tape. SN Using aseptic technique and sterile supplies, to perform wound care qd to skin tears to right forearm/left forearm, left upper arm as follows: Cleanse with NS and gauze, pat dry with gauze, apply skin prep, leave open to air. Record review of Patient #11’s EMR included a physician wound care order received by Agency on 06/02/25 via fax that documented the following order for treatment: · Topical management: Wound #1 (Diabetic ulcer to Right 2nd toe, grade 3 (an ulcer classified into one of 6 different stages based on severity and risk that is used to determine the appropriate treatment course)) Cleanse with wound cleanser, pat dry, apply Santyl (ointment that promotes wound healing by removing dead tissue from a wound) mixed with gentamycin (topical antibiotic used to treat bacterial skin infections), to wound bed, cover with dry gauze and secure with tape daily. During a home visit to Patient #11 on 06/11/25 at 09:50 p.m., an observation was made of LVN D performing a blood glucometer test and wound care. Upon arrival to the home visit, the surveyor arrived at a hotel where LVN D was waiting. LVN D escorted the surveyor to a single bed hotel room where she knocked and asked permission to enter. LVN D and the surveyor entered the room with an adjacent washroom and shower/restroom. LVN D washed her hands in the washroom’s sink for 5 seconds timed. LVN D placed a pad on the bed and placed her nursing bag on top of it. LVN D sanitized her hands and retrieved a plastic bag to be used for trash from her nursing bag. LVN D donned gloves and assessed Patient #11’s vital signs and all body systems. LVN D doffed her gloves, sanitized her hands, and donned a new pair of clean gloves. LVN D prepared a glucometer taken from her nursing bag. LVN D placed a new blood glucose test strip in the glucometer, wiped Patient #11’s right thumb using an alcohol wipe and pricked the finger using a new single use lancet taken from the glucometer bag. LVN D then collected the blood sample with the glucose test strip. After a few seconds of analyzing the blood, the glucometer produced a glucose reading and LVN D removed the glucose test strip from the glucometer. LVN D then disposed of the lancet and the glucose test strip in a small red sharps container located in a side pocket on the outside of her nursing bag. LVN D doffed her gloves, sanitized her hands, and donned clean gloves, all while Patient #11 was positioning herself in a lying position on the bed. LVN D gathered wound care supplies and placed them on the bed next to Patient #11’s foot (no barrier was placed under Patient #11 or wound care supplies). LVN D removed the soiled dressing from Patient #11’s right second toe and assessed the wound. (LVN D did not change gloves or sanitize her hands before proceeding to cleanse wound or placing new dressing on wound). LVN D opened sterile 4x4 gauze, she placed a drop of gentamycin and a drop of Santyl on the inside of the wrapper and mixed them using a cotton-tipped applicator. LVN D placed the cotton tip of the cotton-tipped applicator down on the inside of the wrapper with the remaining handle hanging over the edge of the wrapper. LVN D proceeded to cleanse Patient #11’s right 2nd toe with wound cleanser and a dry 4x4 gauze, discarding the gauze in the trash bag once she was done. LVN D then picked up the cotton-tipped applicator by the handle, applied the mixture of gentamycin and Santyl on the wound and discarded the cotton-tipped applicator in the trash. LVN D continued by covering the wound with a sterile dry 4x4 gauze and secured it with tape. LVN D placed unused supplies including tape, wound cleanser, gentamycin and Santyl back into Patient #11’s clean supplies. LVN D discarded used supplies in plastic trash bag. LVN D doffed gloves, sanitized her hands and donned clean gloves. Using a sanitizing wipe, LVN D sanitized her supplies including the glucometer and stethoscope and placed them back in her nursing bag. LVN D doffed her gloves, disposed them, sanitized her hands, picked up her nursing bag, disposed of the pad under the nursing back in the plastic bag and concluded her visit with Patient #11. LVN D discarded the plastic bag containing trash in an outside waste can. In an observation and interview on 06/11/25 at 09:10 a.m., Patient #11 was observed using a walker to walk around her living quarters. Patient #11 was observed unable to see due to blindness and touching her way around the room to get around. Patient #11 stated she had been referred to the Agency for wound care. Patient #11 stated she relied on her sister for assistance in all aspects of her daily living including medical choices. Patient #11 stated she received dialysis (a treatment for advanced kidney failure that involves a machine filtering wastes, salts and excess fluids from the blood when the kidney can no longer perform this function adequately) Tuesday, Thursday, and Saturdays. Patient #11 stated she was happy with the services received by the nurses and had no concerns. LVN D failed to wash hands for at least 20 seconds prior to and after performing wound care to Patient #11. LVN D failed to place a barrier under Patient #11 or wound care supplies to prevent soilage and cross contamination. LVN D failed maintain aseptic technique by not performing hand hygiene at appropriate intervals during wound care including after cleansing the wound and initiating the application of the prescribed treatment. In an interview on 06/11/25 at 09:30 a.m., LVN D stated she provided wound care to Patient #11 daily Monday through Fridays. LVN D stated wound care orders included cleansing the wound with wound cleanser, pat dry, apply Santyl mixed with gentamycin to the wound, and covering with a dry gauze daily. LVN D stated she did not wash her hands for 20 seconds and was putting the Patient #11 at risk of infection. LVN D stated “I always wash my hands before”. LVN D stated she did not know why she washed her hands “so fast”. LVN D stated she had been told by “state workers” it was ok to not create a clean field by placing a pad under clean supplies or a wound to prevent contaminating and/or soiling. LVN D stated it would be safer to prevent infection if she placed supplies on a pad because not doing risks introducing bacteria from the outside into the wound. LVN D stated there was a risk for infection to Patient #11 in not performing proper aseptic technique. In a telephone interview on 06/11/25 at 03:35 p.m., LVN C stated she provided wound care to Patient #9 daily. LVN C stated wound care orders included cleansing the wound with normal saline, patting dry, covering with dry 4x4 gauze, and securing with tape. LVN C stated she usually counts the “happy birthday song” when she washes her hands and thinks it lasted approximately 1-2 minutes. LVN C stated she could not remember how long she washed her hands for, “I am not going to lie”. LVN C stated that the world health organization says 20 seconds is the recommended time to wash hands. LVN C stated she did not wash her hands for the recommended time. LVN C stated she was nervous during the home visits. LVN C stated she was not rushing. LVN C stated she did not consider her hands clean because she did not wash her hands for the correct time. LVN C stated she did not consider the wound cleansed properly because she did not change her gloves and because she picked up the tape from the floor. LVN C stated, “I should have gotten a new tape”. LVN C stated she put the tape in an empty box and in with the clean supplies. LVN C stated she knew she had dropped the tape, “it had rolled off”. LVN C stated, “I should have thrown it away”. LVN C stated she took new supplies to Patient #9 the following day. LVN C stated her actions could negatively affect Patient #9 because it could cause infections to the wound and cross contamination. LVN C stated it was her responsibility to prevent infections. LVN C stated the DON provides infection control training in the Agency and that it had not been provided recently. LVN C stated she last received an in-service on infection control upon hire. In an ongoing telephone interview on 06/11/25 at 03:35 p.m., LVN C stated she provided wound care to Patient #12 daily. LVN C stated wound care orders included cleaning the wound with normal saline, patting dry with dry 4x4 gauze, applying a betadine cast, securing the dressing with kerlix and tape. LVN C stated she was not in a hurry, and she could not remember how long it took her to wash her hands. LVN C stated she did not wash her hands for the required time. LVN C stated she placed the lancet and glucometer testing strip in the plastic trash bag. LVN C she had a biohazard box on the “outside” but did not place the lancet or the glucometer testing strip in the biohazard sharps container. LVN C stated should have disposed of the lancet and glucometer testing strip in the biohazard sharps container. LVN C stated she should have “double checked”. LVN C stated there was a risk of needle stick to herself or others. LVN C stated she did not consider her hands clean while providing wound care. LVN C stated she should have sanitized her hands in between glove changes. LVN C stated there was a risk for infection to Patient #12 because she did not do proper hand hygiene. LVN C stated she was nervous and that she should have “put a timer”. In a simultaneous record review and interview on 06/12/25 at 08:45 a.m., the DON stated the Agency followed CDC guidelines for washing hands and per the Agency’s policies the nurse should have washed her hands for at least 20 seconds. The DON stated the nurse should have washed her hands for the appropriate time or hand sanitized during wound care in each of their visits. The DON stated the LVN C and LVN D did not wash their hands for the recommended length of time during wound care. The DON confirmed Patient #9’s SOC as 03/07/25 and a certification period of 03/07/25 through 05/05/25. The DON stated LVN C should not have picked up the tape from the floor to secure Patient #9’s clean dressing or placed it back with the clean supplies. The DON stated tape should have been discarded. The DON stated LVN C should have changed her gloves and sanitized her hands during wound care after removing soiled dressing and prior to starting the clean process. The DON confirmed Patient #12’s SOC as 05/29/25 and a certification period of 05/29/25 through 07/27/25. The DON stated LVN C did not dispose of the lancet and used glucometer strip in an OSHA approved sharps container. The DON stated the nurse should have disposed of the used supplies in an appropriate receptacle. The DON stated LVN C did not perform aseptic technique while providing wound care in that she did not sanitize her hands between glove changes. The DON confirmed Patient #11’s SOC as 04/25/25 and a certification period of 04/25/25 through 06/23/25. The DON stated washing hands for 5 seconds was too fast. The DON stated the Agency will have to go over that again. The DON acknowledged LVN D did not place a barrier under Patient #11. The DON stated LVN D should have placed a barrier under Patient #11 while providing wound care because if anything fell out of her sterile field, it would not be considered clean or sterile anymore. The DON stated LVN D should have changed gloves and sanitized her hands during wound care. The DON stated it was her responsibility for ensuring infection control was being followed and that Agency policy for infection control was not followed by LVN C and LVN D. The DON stated not following agency policy for infection control had negative impact on all patients because it could lead to cross contamination. In a follow up telephone interview on 06/12/25 at 09:30 a.m., LVN C stated she did have a biohazard sharps container with her but did not put the lancet or the used glucometer strip into it after she had used them. LVN C stated she placed them in the blue pad and in the plastic trash bag. LVN C stated she was aware she was not supposed to discard the lancet and used glucometer strip into the plastic trash bag. LVN C stated, “it was my mistake”. LVN C there was a risk for infection and of needlestick injury for herself and others. LVN C stated she should have disposed of it “right away” in the biohazard box. LVN C stated throwing the lancet in the trash puts people at risk of “accidentally stepping on it and so many ways of being contaminated with someone’s body fluid”. LVN C stated handwashing for less than 20 seconds was not “sufficient time” and she should have put hand sanitizer in between glove changes during wound care. In an interview on 06/12/25 at 10:30 a.m., the Alt Adm, stated LVN C and LVN D did not follow Agency policy for infection control in hand hygiene or needle safety. The Alt Adm stated there was an increased risk of “picking up an infection” for patients when staff did not follow Agency policies for infection control. The Alt Adm stated the nurse did not follow agency policy in hand hygiene or needle safety because, “honestly, she was nervous”. The Alt Adm stated the ADON, and the DON were responsible for ensuring the Agency’s infection control policies were followed. Record review of LVN C personnel file included an “Application for Employment” and an “Orientation Checklist” both signed and dated 10/30/23. Further record review of LVN C personnel file included a “Job Description/Performance Evaluation” signed and dated 10/30/24 that documented LVN C “Meets and occasionally exceeds job requirements” for the following “Essential Functions…Provides care using infection control measures that protect both staff and patient…” Record review of LVN C personnel file included a “Skilled Nursing Competency Checklist” signed and dated 10/30/24 that documented LVN C demonstrated “Satisfactory Competence” in the following skills “Infection control…Hand hygiene, Safe needle technique, Use of personal protective equipment, exposure plan…Sterile dressing change…Use, care, and teaching of glucose monitoring system”. Record review of LVN D personnel file included an “Application for Employment” and an “Orientation Checklist both signed and dated 08/09/24. Further record review of LVN D personnel file included a “Job Description/Performance Evaluation” signed and dated 08/09/24 that documented the following “Essential Functions…Provides care using infection control measures that protect both staff and patient…” for the position of licensed vocational/practical nurse. Record review of LVN D personnel file included a “Skilled Nursing Competency Checklist” signed and dated 08/09/24 that documented LVN C demonstrated “Satisfactory Competence” in the following skills “Infection control…Hand hygiene, Safe needle technique, Use of personal protective equipment, exposure plan…Sterile dressing change…Use, care, and teaching of glucose monitoring system”. Record review of Agency policies titled, “Hazardous Materials/Waste EC.35” with a revise date 09/01/24, quoted in part, “(I) The Agency will comply with federal/state/local laws and regulations regarding the identification, handling, transportation, and disposal of hazardous materials/waste…(IV) Hazardous materials/waste include but are not limited to: (E) All materials and wastes that require special handling (i.e., sharps)…(1)(D) Agency will implement appropriate work practice controls, engineering controls, and PPE (personal protective equipment) in provision of patient care. This includes labeling all transportation containers with the “BIOHAZARDOUS” label…” Record review of Agency policies titled, “Exposure Control Plan IC.5” with a revised date 05/01/25, quoted in part, “The Agency is committed to providing a safe and health work environment for the entire staff. In accordance with federal, state and regulations, the Agency will design, implement, and evaluate annually an Exposure Control plan which will include…(II)(B) Standard precautions…” Record review of Agency policies titled, “Exposure Control Plan IC.5” with a revised date 05/01/25, quoted in part, “The Agency is committed to providing a safe and health work environment for the entire staff. In accordance with federal, state and regulations, the Agency will design, implement, and evaluate annually an Exposure Control plan which will include…(II)(D) Work practice controls…” Record review of Agency policies titled, “Exposure Control Plan IC.5” with a revised date 05/01/25, quoted in part, “The Agency is committed to providing a safe and health work environment for the entire staff. In accordance with federal, state and regulations, the Agency will design, implement, and evaluate annually an Exposure Control plan which will include…(II)(G) Sharps Protection Program…” Record review of Agency policies titled, “Infection Control Program IC.10” with a revised date 01/01/25, quoted in part, “(I) The Agency’s Infection Control Program will be based on the following criteria…(D) CDC guidelines updated annually…(F) The Occupational Safety and Health Administration (OSHA), 29 CFR Part 1910.1030 and Appendix A relating to Bloodborne pathogens…(G) Current federal, state and local laws and regulations… Record review of Agency policies titled, “Hand Hygiene IC.15” with a revised date 05/01/24, quoted in part, “All Agency staff providing patient/client care will perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations… (I) Hand hygiene with soap and water…(C) Staff will apply the amount of product recommended by the manufacturers to hands and rub hands together vigorously for at least 15 seconds (with the recommendations of 20 seconds, but either time is acceptable), covering all surfaces of the hands and fingers…(II) Hand Hygiene with an alcohol-based hand rub (B) staff will rub hands together covering all surfaces of hands and fingers, until hands are dry. This should take around 20 seconds… Record review of OSHA 29 CFR 1910.1030, titled “Bloodborne pathogen”, accessed on 06/16/25, quoted in part, “Bloodborne pathogens means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) (a serious viral liver infection that damages the liver) and human immunodeficiency virus (HIV) (a virus that attacks the body’s immune system)…Contaminated sharps means any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, capillary tubes, and exposed ends of dental wires…Occupational exposure means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties…Parenteral means piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions…Regulated waste…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; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials…(d)(1) General. 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 (d)(2)(v) Employers shall ensure that employees wash their hands immediately or as soon as feasible after removal of gloves or other personal protective equipment…(d)(2)(vi) Employers shall ensure that employees wash hand and any other skin with soap and water, or flush mucous membranes with water immediately or as soon as feasible following contact of such body areas with blood or other potentially infectious materials…. (d)(2)(viii) Immediately or as soon as possible, after use, contaminated reusable sharps shall be placed in appropriate containers until properly processed. These containers shall be: (A) Puncture resistant; (B) Labeled or color-coded in accordance with this standard; (C) Leakproof on the sides and bottom; and (D) In accordance with the requirements set forth in paragraph (d)(4)(ii)(E) for reusable sharps…(d)(3)(ix) Gloves. Gloves shall be work when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and non-intact skin; when performing vascular access procedures except as specified in paragraph (d)(3)(ix)(D); and when handling or touching contaminated items or surfaces…(d)(4)(ii)(E) Reusable sharps that are contaminated with blood or other potentially infectious materials shall not be stored or processed in a manner that requires employers to reach by hand into the containers where these sharps have been placed…(d)(4)(iii) (A)(1) Regulated waste. Contaminated Sharps Discarding and Containment. (1) Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are: (i) Closable (ii) Puncture resistant; (iii) Leakproof on sides and bottom; and (iv) labeled or color-coded in accordance with paragraph (g)(1)(i) of this standard) …” Record review of Lippincott Advisor and Lippincott Procedures titled, “Sharps Disposal”, with a revised date 08/18/24, quoted in part, “Sharps are medical devices that have points or edges capable of puncturing or cutting the skin, such as needles, syringes, lancets, scalpels, broken glass, dental wires, and other devices…Injuries involving contaminated sharps are linked to transmission of various pathogens, including hepatitis B, hepatitis C, and human immunodeficiency virus. Proper handling and disposal of sharps can help prevent injury and transmission of pathogens to everyone in the health care environment…Perform hand hygiene…Put on gloves, and as needed, other PPE to comply with standard precautions… Place all sharps into a sharps container in the area where you used them immediately after use. Make sure that the sharps container is large enough to accommodate the entire device. Keep your hands behind the sharp tip during disposal to prevent injury…” Record review of Lippincott Advisor and Lippincott Procedures titled, “Standard Precautions, home care”, with a revised date 08/18/24, quoted in part, “The Centers for Disease Control and Prevention (CDC) developed standard precautions to protect against the transmission of infection. Standard precautions are a group of infection prevention practices based on the idea that all blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes may be infectious. CDC officials recommend that health care workers assume that all patients, regardless of their diagnosis, are potentially infected or colonized (carrying an organism but not showing signs or symptoms of infection) with an organism that the patient may transmit to others. Standard precautions include hand hygiene, appropriate use of personal protective equipment (PPE), and proper handling of potentially contaminated items, including patient equipment, items in the environment, sharps, and specimens… Perform hand hygiene before and after patient care; before putting on and after removing gloves; before handling an invasive device; when moving from a contaminated body site to a clean body site; after contact with body fluids, excretions, mucous membranes, nonintact skin, or wound dressings (even if you wore gloves); and after contact with inanimate objects in the patient’s environment. If your hands aren’t visibly soiled, use an alcohol-based hand rub for routine hand hygiene. If they’re visibly soiled, wash them with soap and water and dry them with a paper towel… Wear gloves if you may or will come into contact with blood, specimens, tissue, body fluids, secretions, excretions, mucous membranes, broken skin, or contaminated surfaces or objects… Change your gloves and perform hand hygiene if your gloves become damaged or heavily soiled and when moving from a contaminated to a clean site during patient care to avoid cross-contamination.. Discard the sharps immediately after use into a puncture-resistant sharps disposal container. Never force a sharp into a container or put your fingers into the container. Never place used sharps in regular household trash, recycling bins, or plastic biohazard bags…” Record review of Lippincott Advisor and Lippincott Procedures titled, “Wound dressing application, home care”, with a revised date 02/23/25, quoted in part, “Organize the equipment and supplies on a clean surface. Place a fluid-impermeable pad between the environment and the equipment and supplies if necessary. Arrange the equipment and supplies according to the order of use to avoid cross-contamination while performing wound care… Place a fluid-impermeable pad under the wound to prevent soiling…Remove the old dressing…Inspect the soiled dressing…discard the soiled dressing…remove and discard your soiled gloves…perform hand hygiene…put on new gloves…assess the wound…clean the wound…discard the soiled gauze…remove and discard your soiled gloves…perform hand hygiene…put on new gloves…pat the surrounding skin dry with a gauze pad to prevent maceration…if necessary, and ordered, apply a protective skin barrier to the skin surrounding the wound that will come in contact with drainage, adhesive tape, dressings or devices following the manufacturer’s instructions…apply topical wound treatments to the wound bed using a cotton-tipped applicator or tongue blade, as prescribed, following safe medication administration practices…apply the prescribed primary dressing to the wound following the manufacturer’s instructions…secure the primary dressing, as necessary, and cover it with a secondary dressing as appropriate. Use tape specifically formulated for fragile skin…seal the waterproof trash bag and discard used supplies in appropriate receptacles…remove and discard your gloves and, if worn, other PPE…perform hand hygiene…” The Agency did not dispute the survey findings and did not provide the surveyor with any additional information upon exit.”