Every finding on record at Avera at Home

A recertification survey for compliance with 42 CFR Part 484, Subpart G, Subsection 484.102 Emergency Preparedness Requirements for Home Health Agencies, was conducted from 12/2/25 through 12/3/25. Avera @ Home was found in compliance.

A recertification health survey for compliance with 42 CFR Part 484, Subparts B-C, requirements for Home Health Agencies, was conducted from 12/2/25 through 12/3/25. Avera @ Home was found not in compliance with the following requirement: G682

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 policy review, the provider failed to follow standard infection prevention practices regarding the cleaning of reusable equipment by one of one physical therapist assistant (PTA) D for one of three sampled home health patients (1) during a home visit. Findings include: Observation on 12/02/25 at 11:53 p.m., in patient 1’s house, revealed that upon arrival, he was sitting in his chair. Patient 1 had a gait belt (a waist strap used for safe mobility and transfers) around his waist, and throughout the therapy session, patient 1 walked around his home with his walker, while contracted PTA D held onto the gait belt for his safety. After the therapy session, contracted PTA D removed the gait belt from patient 1's waist, tore open a sanitizer wipe package, removed it from that package, wiped down the metal and cloth parts of the gait belt, then rolled it up and put the belt back in her backpack. Phone interview on 12/3/25 at 12:14 p.m. with contracted PTA D revealed that she had used her personal gait belt when she worked with patient 1. She confirmed that the contracted staff did not leave gait belts in the patients' homes. Contracted PTA D stated she used a sanitizer wipe to clean the metal piece of the gait belt used during the above observed visit, but agreed that the gait belt's cloth was not a cleanable surface it could create an infection control risk. Phone interview on 12/3/25 at 12:17 p.m. with the contracted PTA/ manager C revealed that he confirmed the contracted staff did not leave gait belts in the patient's home. He agreed that the cloth of the gait belts was not a cleanable surface and was an infection control risk. He stated that the contracted staff had completed an annual infection control training. Interview on 12/3/25 at 2:50 p.m. with registered nurse (RN)/agency supervisor A and senior director B regarding the use of the staff's gait belts for provident patient care revealed that they were unaware that the contracted therapy staff were using their personal gait belts. Senior director B stated their standard infection control prevention practice was to leave gait belts in the patients' homes for individual patients use. Review of the provider’s 12/3/25 Infection Control and Prevention Plan policy revealed: Home Health Care Infection Control and Prevention Plan: “The HHA {Home Health Agency] maintains and documents an infection control program which has as its goal the prevention and control of infections and communicable diseases. The HHA follows accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.” “1. The following 6 elements apply for episodes of patient care including; Hand Hygiene; Environmental Cleaning and Disinfection; Injection and Medication Safety; Appropriate Use of Personal Protective Equipment; Minimizing Potential Exposures; and reprocessing of reusable medical equipment between each patient and when soiled.” Review of the provider’s 8/13/25 Bag and Equipment Disinfection policy revealed: Disinfection of Reusable Equipment “2. All reusable equipment will be disinfected using alcohol, soap and water, or other appropriate solution per manufacturer's instructions.” Review of the manufacturer’s instructions revealed that the steps to clean a gait belt included to machine wash with mild detergent in warm water, then either tumble dry on low or air dry completely.