Every finding on record at Anova Home Healthcare Services Inc

Based on the findings of an unannounced onsite Medicare recertification survey conducted February 22, 2022 through February 25, 2022, Anova Home Healthcare Services, Inc. was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced onsite Medicare recertification survey conducted February 22, 2022 through February 25, 2022, Anova Home Healthcare Services, Inc. was found not to be in compliance with the following requirement(s) of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies. The survey was conducted at the Pittsburgh parent location with review of records from the Pittsburgh parent location, the Charleroi branch location and the New Castle location. Patient visits included Pittsburgh parent location and New Castle branch location.

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 of patient care during home visit (HV), review of clinical record (CR), agency policy, and staff (EMP) interview, it was determined the agency failed to ensure staff followed accepted standard of practice, including the use of standard precautions during patient care, for one (1) of five (5) staff observed during home visits (EMP8). Findings include: Review on 2/25/22 between approximately 2:00 p.m. to 3:00 p.m. of agency policy revealed: Home Health Policy N-120 “Nursing Bag”: Purpose: To carry adequate supplies for home care clients. To maintain supplies in clean environment…Guidelines: …When in a client’s home, place the bag on a clean and dry surface. Policy: “Equipment, Bag Supplies, Cleaning”: #4 The equipment bag should not be placed on any floor surface, but on a clean surface, utilizing a barrier…or hung on a doorknob. Policy: “Bag Technique”: #1 Upon entering the home, place the bag on a clean surface at waist high or above, not on the floor.” Review of CR17 on 2/23/22 at approximately 12:50 p.m. Start of care 2/5/22, Plan of Care (POC) certification period 2/5/22 to 4/5/22, order “SN (skilled nurse) frequency; 1W1, 3W1, 2W2, 1W6 Starting week of 2/5/22.” During observation of patient home visit on 2/23/22 at approximately 12:50 p.m. EMP8 placed the nursing bag on the floor stating, “I know you’re not supposed to put this on the floor, but I have to wipe off the pad.” Interview with agency President on 2/25/22 at 3:00 p.m. confirmed the above findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based upon review of agency documentation and interview with staff (EMP) agency failed to have QAPI program maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. Findings include: Review of agency documentation, “Infection Control” forms used for tracking infections, on 2/25/22 at approximately 10:30 a.m. failed to indicate if improvement, decline or resolution was obtained and physician notification of the outcome. Review of the agency “Infection Report 2020” included the number of infections for each quarter in the areas of urinary, wound and cellulitis. The agency failed to put into place a program to monitor and trend infections with each occurrence and implement action plans to prevent recurrences. Interview with EMP3 on 2/25/22 at approximately 12:30 p.m. “QAPI shows the number of infections but not noted to have put a plan in place to trend and track."