Stonerise Home Health South Charleston

“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, document review, and interview, the facility failed to follow accepted standards of practice to prevent infection in one (1) of one (1) patient, (#9), observed during a peripherally inserted central catheter (PICC) line dressing change. This failure increases the potential for infection for all patients requiring PICC line dressing changes. A review of the website cdc.gov for the Centers of Disease Control (CDC) and Prevention guidelines for the Prevention of Intravascular Catheter-Related Infections (2011); dated: 02/28/24; revealed: “2. Prepare clean skin with a >0.5% [greater than zero point five percent] chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% [seventy percent] alcohol can be used as alternatives.” A policy titled: “Peripherally inserted central catheter (PICC) dressing change;” revised 09/15/25; was reviewed, and stated: “...Equipment: Antiseptic agent (alcoholic chlorhexidine gluconate solution containing at least 2% [two percent] chlorhexidine gluconate preferred; if contraindicated, use an iodophor [such as povidone iodine] or 70% [seventy percent] alcohol…Many facilities stock a commercially prepared or facility-prepared sterile dressing change kit that contains the necessary supplies…Implementation:…Clean the patient’s skin using an antiseptic agent (alcoholic chlorhexidine gluconate solution containing at least 2% [two percent] chlorhexidine gluconate preferred; if contraindicated, use an iodophor [such as povidone iodine] or 70% [seventy percent] alcohol. Apply using a single-use sterile applicator containing antiseptic solution. Allow the solution to fry completely without fanning, wiping, or blowing. Apply alcoholic chlorhexidine gluconate solution with an applicator using a gentle back-and-forth motion for 30 [thirty] seconds. Allow the area to dry completely. Apply povidone-iodine solution using a swab. Begin at the intended insertion site and move outward in concentric circles. Allow the solution to dry completely (typically at least 2 [two] minutes.” A review of the policy titled: “Home Health Bag Technique;” effective date: 09/15/24; was reviewed and stated: “The bag is placed on a clean surface in the car and in the home. If this is not possible, a barrier (i.e. newspaper, paper towel, etc.) is to be placed under the bag or the bag is to be hung from a door knob or chair…” A review of the medical records for patient #9 revealed the following allergies: acetaminophen, hydrocodone, and penicillins. An observation was conducted on 08/18/26 from 10:15 a.m. to 10:35 a.m. at the home of patient #9. Staff #1 prepared an area at the patient’s dining room table for a dressing change to the PICC line in the left antecubital space, and a lab draw from the PICC line. The patient and the nurse donned a face mask for the procedure. Note, all the supplies were placed directly on the surface of the patient’s table and placemats without the use of a secondary barrier. The barrier was used from the sterile dressing kit appropriately. The dressing kit contained an alcohol swab, but no chlorhexidine or iodine. After removing the dressing, the nurse cleaned the debris at the insertion site but did not cleanse the surrounding skin in either a back and forth or circular motion and allow time for drying before placing the dressing. Staff #1 then picked up the syringes and lab tubes off the patient’s table, drew blood from the PICC line according to policy, and placed the blood-filled syringe and tubes back on the surface of the table while picking up the trash for discarding. An interview was conducted on 08/20/26 at 9:45 a.m. with staff #2, who stated: “The company only puts an alcohol cleanser in our PICC line dressing kits. They don’t supply chlorhexidine or iodine swabs any more. The company didn’t think it was necessary to include them because the CDC doesn’t require it anymore for the prevention of infection.” Regarding the PICC line dressing change process observed for patient #9, staff #2 concurred that the insertion site was not cleaned appropriately per protocol. Regarding laying down a barrier for supplies, staff #2 stated: “Our policy does not address laying a barrier down for supplies, just the bag. Our process is to remove one piece of equipment from the bag at a time, clean it after use, and place it back in the bag. In this situation, I would have used a second barrier.” Later, 08/20/26 at 10:25 a.m., staff #2 confirmed that after speaking with corporation, all were in agreement that a second barrier should have been used for patient #9.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review, documentation review, and interview, it was revealed the facility failed to update or maintain their Emergency Management Plan with current required information. The failure to maintain current information has the potential to have a negative impact on all staff and patients in the agency. A review of the record, titled “Emergency Management Plan (EPP) Notebook” revealed that the agency did not have a current updated license, no evidence of any insurance, an evacuation plan for the agency, and no evidence that the plan has been reviewed since 2021. The (EEP) notebook still had the previous address of the facility and the evacuation plan for a different location. The facility failed to update relevant location, emergency fire exit information and required emergency preparedness information. The current address evacuation plan was not added to the notebook to replace the old evacuation plan. There was no evidence of the staff being trained on a new evacuation plan for the current agency. An interview was conducted with Employee #1 on 2/13/24, at 1:00 p.m. Employee #1 states, “We review the EPP quarterly in our Quality Assurance and Performance Improvement [QAIP] meetings. Our last top table exercise was done in 2023, and our EPP for the patients is reviewed weekly by staff. The EPP Notebook has not been reviewed since 2021.” An interview was conducted with Employee #1 on 2/14/24 at 12:25 p.m. Employee #1 states, “There has not been any training to the staff on the evacuation plan in this new building. I did not think of it until asked on 2/12/24 about the evacuation plan on the walls of this building.” A review of the policy, titled “Emergency Management Plan” dated 10/2017. The policy states, “Purpose: To establish a plan which will allow for the continuation of services in the event of a disaster affecting the organization or the community … Policy … Planned evacuation routes will be known or identified and alternated means of transportation for personnel … Procedures … 9. An annual evaluation of the organization’s hazard vulnerability analysis and emergency management plan, including its objectives, scope, functionality, and effectiveness will be conducted. The annual evaluation may be based on the drill evaluation or actual implementation of the emergency management plan. 10. Organization leadership will provide for orientation and education of all personnel regarding participation in the emergency management plan. Education will be provided during orientation and annually.” A review of the policy, titled “Emergency Plan Policy” dated 5/1/2021. The policy states, “Policy: The agency develops and implements and emergency plan based on a risk assessment and using an “all hazard” approach, which provides an integrated system for emergency planning that focuses on capacities and capabilities. Purpose: To describe the Agency’s approach to responding to internal and external emergencies that would suddenly and significantly affect the need for services, plans for patients or the ability to provide such services. An emergency is defined as a natural or man-made disaster that significantly disrupts the Agency’s environment, disrupts care and service or results in sudden, significant change or increase in demand for Agency services. Procedure: 1. The emergency plan includes, but is not limited to, the following elements: The Agency has developed and maintains an emergency plan and policies that are reviewed and updated at least every two years.””