All Generations 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, record review, and interview the agency failed to enforce its written policy addressing infection control including the prevention of the spread of infectious and communicable disease for 1 of 3 Patients (Patient #1) who were visited by the surveyor, in that: LVN A failed to follow proper infection control procedures during wound care while surveyor conducted a home visit with Patient #1: 1.) Failed to sanitize hands between glove changes multiple times. 2.) Failed to change gloves during clean wound care procedure multiple times. This deficient practice could place Patients at risk for increased wound infections, and further deterioration of the Patient #1’s wounds. The findings included: Record review of [Agency Name] Administrative Policy Manual titled “IC.10 Infection Control Program” with a revision date of 01/01/25, quoted in part…Purpose: “Policy: The agency and staff will follow accepted standards of practice…including standard precautions( a set of infection control practices used to prevent the spread of diseases transmitted through blood, body fluids, non-intact skin, and mucous membranes), to prevent the transmission of infections and communicable diseases…3. Other policies to be followed by staff to prevent, control, and improve infections include Hand Hygiene… V. Education…A. Employees… 1. Upon hire and annually thereafter, all Agency employees will be educated regarding the policies and procedures related to: … a. Infection control… c. Bloodborne/ Airborne/HIV(human immunodeficiency virus) Pathogen Program… e. Patient/client care procedures for preventing and/or controlling infections… f. Standard precautions…B. Patient/Clients and Caregivers…2. Education regarding precautions to protect immune-compromised patients/clients for employees, patients/clients and others in the home will include, but not limited to: … a. personal protective equipment (PPE)… b. Hand Hygiene…” Record review of [Agency Name] Administrative Policy Manual titled “IC.15 Hand Hygiene” with a revision date of 05/01/24, quoted in part… “Purpose…To ensure patient care staff practice proper hand hygiene techniques… Definitions… I. Alcohol-base hand rub- an alcohol-containing preparation…Such preparations usually contain 60%--95% ethanol or isopropanol… VIII. Hand hygiene… Policy…All Agency Staff providing care will observe proper hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations… D. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Staff may use an alcohol-based hand rub for routine decontaminating hands in the clinical situations described below: 4. After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings and used supplies (PPE) {Personal Protective Equipment} if hands are not visibly soiled … 5. Before moving from a contaminated-body site to a clean body site during patient care…. 6. After touching a patient/client or the patient’s/client’s immediate environment… 7. After contact with blood, body fluids, or contaminated surfaces…8. After removing gloves…” Record review of [Agency Name] Administrative Policy Manual titled “PC.10 Standards of Practice” with a revision date of 06/01/18, quoted in part, “Purpose: To provided patient care within acceptable standards of practice by Agency staff…Procedure… I. The Agency will have the state professional practice acts and all agency policies and procedures available for staff… II. The Agency will provide ongoing educational opportunities and updates for agency staff by means of verbal and/or written communication… III. Patient/client care staff will adhere to the respective state professional practice acts, and to agency policies and procedures during patient/client visits…” Review of Patient #1 “Home Health certification and plan of care” documented a 84-year-old male with primary diagnosis of pressure ulcer(a localized injury to the skin and underlying tissue, usually over a bony prominence, caused by prolonged pressure) of right hip, unstageable(a full-thickness skin and tissue loss where the depth of the wound cannot be determined because it is obscured by slough(non-viable, usually moist, tissue that is dead or dying and needs to be removed to promote healing) or eschar(a hard, dry, dark scab or crust that forms over a wound due to tissue death (necrosis)), other diagnoses of unspecified wound to left upper arm, pressure ulcer to left buttock, Type 2 Diabetes mellitus(a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels). The form POC also documented a start of care as 05/12/25 and a “current episode” or certification period as 07/11/2025-09/08/2025 with skilled nurse visits for once a week for one week, 5 times per week for 8 weeks, and 3 as needed visits for signs and symptoms of hypo and hyper glycemia (low and high sugar content in blood). Safety Measures: Standard precautions/Infection Control. Further review of “Physician Order” Order#63548524 dated 8/5/25 revealed “new wound care orders” quoted in part… “1. Sn (skilled nurse) to discontinue all previous wound care orders…2. Effective 8/5/2025 Using aseptic technique (without germs to cause infection) and sterile supplies Sn to perform and instruct caregiver on wound care to be performed on Monday, Wednesday, and Friday to Wound #2 Right hip Stage III(full-thickness skin loss that extends into the subcutaneous tissue, meaning the fat layer is visible, but bone, tendon, and muscle are not exposed) pressure ulcer as follows: 1) cleanse with Vashe (a brand name for a wound cleanser containing hypochlorous acid (HOCl). It’s used to clean and moisten wounds, promote healing, and help remove debris and microorganisms (germs.), 2) pat dry using gauze, 3) apply urgoclean AG dressing (an antimicrobial wound dressing). (The dressing helps clean the wound by removing debris and slough (removing old tissue), while the silver component helps to combat infection.), 4) cover with gauze, 5) secure with tape… 3. Effective 8/5/2025 using aseptic technique and sterile supplies, Sn to perform and instruct caregiver on daily wound care to wound #4 trauma wound left arm as follows: 1) cleanse with vashe,2) pat dry using gauze, 3) apply Silvadene (Silvadene is the brand name for silver sulfadiazine, a topical antibiotic used to prevent and treat infections), 4) cover with gauze, 5) secure with tape. Sn to perform wound care Monday through Friday; patient with willing/able/knowledgeable caregiver to perform wound care on Saturday and Sunday… 4 Effective 8/5/2025 Using aseptic technique and sterile supplies, Sn to perform and instruct caregiver on daily wound care to wound #5 non-measurable scattered MASD (Moisture Associated Skin Damage) with Fungal infection to sacrum(a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) (tailbone area)as follows:1) cleanse with vashe, 2) pat dry using gauze, 3) apply mixed Silvadene with clotrimazole (an antifungal medication used to treat a variety of fungal and yeast infections, including athlete’s foot, jock itch, and ringworm. It works by disrupting the fungal cell membrane, leading to cell damage and death) , 4) cover with gauze. Sn to perform wound care Monday through Friday; patient with willing/able/knowledgeable caregiver to perform wound care on Saturday and Sunday…5. SN to assess/ instruct patient/caregiver on signs/ symptoms of infection, healing complications, and when to notify physician/ Sn of abnormalities… 6. +3 PRN( “pro re nata” or as needed) visits for wound complications, dressing dislodgement, or when no caregiver available. SN may discontinue dressings upon wound healed and upon physician approval.” Surveyor arrived at Patient #1’s home on 08/06/25 at 1:45 pm, LVN A was observed to not perform hand washing as per policy. Brief introductions were made, and consent for home visit was signed. LVN A and Surveyor proceeded into Patient #1’s living room. Patient #1 was observed to be lying supine (lying face upward) in bed with legs extended forward. LVN A donned (puts on) new gloves; removed soiled dressing to wound #2 in right hip and placed dirty dressing into trash bag. LVN A then sanitized (to reduce or eliminate bacteria) hands with antiseptic hand gel and used the same soiled gloves and with the same soiled gloves LVN A then proceeded to cleansed wound with Vashe solution, pat dry wound with dry gauze, applied AG dressing and covered with gauze as well as secured with tape. LVN A then proceeded to again sanitize same soiled gloves with antiseptic hand rub. Nurse removed soiled gauze from wound # 4 to left upper arm, disposed of dressing in plastic trash bag, again sanitized same soiled gloves used in previous wound care and proceeded to cleanse wound #4 to left upper arm with Vashe, pat dry with dry gauze, applied Silvadene, covered wound with gauze and secured with tape. LVN A removed soiled gloves and put on new gloves, did not sanitize hands between glove change, turned patient on his right side to access wound #5 in sacrum. LVN A cleansed wound with Vashe solution, pat dry with gauze, applied mix of Silvadene and clotrimazole on wound, covered with gauze. LVN A removed soiled gloves, sanitized hands and started gathering some of the soiled materials that were in the set up used to clean the surface with bare hands, placed soiled materials in trash bag, placed the trash bag on the floor and proceeded to start taking patient’s vital signs without sanitizing hands. LVN A then proceeded to sanitize hands, put on new gloves and check patient’s glucose with finger stick, disposed of biohazard blood soiled lancet and glucose strip on biohazard container. In an interview on 08/07/25 at 09:30 a.m., with LVN A, surveyor presented the above findings during home visits for Patient #1 concerning the 1.) Failed to sanitize hands between glove changes multiple times, the use of antiseptic cleaner on soiled gloves and proceeded to perform wound on the next wounds, and that LVN A did not use antiseptic cleaner when LVN A removed soiled gloves and put on clean gloves) change, and 2.) Failed to change gloves during clean wound care procedure multiple times. LVN A agreed to these infection control findings concerning the transmission of diseases. LVN A confirmed employees were to use infection control precautions at every home visit. LVN A further confirmed LVN A was trained upon hire and yearly for standard and infection control precautions by the agency as well as periodical refreshers that the Agency provides for nurses to review. Surveyor asked LVN A why infection control policy was not followed during wound care “Well I think I got a little overwhelmed with everything, he does have 3 different wounds, I did not feel the glove was contaminated. I did not know that putting hand sanitizer in the on gloves causes the glove to be compromised, I believed that it was ok to just put sanitizer on the gloves when needed, because I have the pt in a supine position already I did not consider both wounds as different, I considered them both as a clean surface”. Surveyor asked LVN A what negative outcome could happen to a wound if proper infection control technique is not utilized, LVN A answered, “Well obviously reinfection and a slower healing wound which could lead to the patient being hospitalized again.” Further interview with Adm/DON on 08/07/25 at 10:00 a.m., the surveyor presented the findings of infection control for home visit with Patient #1. Adm/DON confirmed the agency provided trainings to their nurses for standard and infection control precautions upon hire and annually as well as periodically for nurses to review. Adm/DON confirmed the agency’s infection control policy should be used at every home visit and agreed that the findings were an infection control issue concerning transmission of diseases. Surveyor asked considering the client’s age, diagnosis, comorbidities (medical conditions that you have in addition to a primary diagnosis). You may have one or more comorbidities. Morbidity is a medical term that refers to the state of having a specific disease or condition. So, adding “co” in front of this word means two or more conditions occur together) and wounds how can these infection control findings concerning transmission of disease affect the agency clients. Adm/DON stated, “Well reinfection and a slower healing wound which could lead to the patient being hospitalized again.” Article published by Harmony Lab & Safety Supplies with date of January 2, 2024, with link: https://harmonycr.com/resources/can-you-use-hand-sanitizer-on-gloves/, quotes in part: “ The compatibility of hand sanitizers with latex gloves… Latex gloves are commonly used in various industries and healthcare settings due to their excellent barrier properties and flexibility. However, there is a concern that using hand sanitizers on latex gloves may cause damage or compromise their effectiveness… It is important to note that not all hand sanitizers are compatible with latex gloves. Some hand sanitizers like Purell contain alcohol or other chemicals that can degrade the latex material, weakening, tearing, or completely breaking the gloves. This can render the gloves ineffective in providing a barrier against pathogens…” The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information. No additional information was presented to this surveyor upon exit on 08/07/25.”