Every finding on record at Bay Area Home Health Operations

An unannounced Federal recertification survey was completed at this agency on 12/1/2021. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held with the Director and the Clinical Manager on 11/16/2021 at 12:30 PM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: CFR - Code of Federal Regulations HHA - Home health agency

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the home health agency failed to advise patients of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. Findings: Review of the agency admission packet given to patients revealed the information did not have evidence that the HHA advised patients of the names, addresses and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and Quality Improvement Organization that serve the area where patients reside. During an interview with Employee #1 and Employee #2 on 11/18/2021, beginning at 8:20 AM the above finding was presented. Both employees were asked if new patients were provided additional documents on admission that contained the necessary information. Both employees stated they were not aware of any additional documents that contained the information; no additional information was provided. Employee #1 acknowledged the finding and stated "Thank you so much, you're helping us."

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the home health agency failed to inform the patient and representative (if any) of the HHA's policies for transfer and discharge. Findings: Review of the agency admission packet given to patients revealed the information did not have evidence that the HHA informed the patient of the HHA's policies for transfer and discharge. During an interview with Employee #1 and Employee #2 on 11/18/2021, beginning at 8:20 AM the above finding was presented. Both employees were asked if new patients were provided additional documents on admission that contained the necessary information. Employee #1 stated they thought this requirement had been addressed. An opportunity was provided to present additional information. During an interview with Employee #1 and Employee #2 on 12/1/2021, beginning at 8:30 AM, Employee #1 acknowledged the finding and stated "I didn't find that we were meeting that piece."

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 document review, it was determined the agency failed to ensure direct patient care staff followed standard precautions related to environmental cleaning and disinfection to prevent the transmission of infections and communicable diseases during 2 of 4 home visit observations (Home Visits #2 and #3). Findings: Home Visit #2: Observation of a home visit on 11/17/2021 beginning at 10:30 AM revealed Employee #4 provided direct patient care to Patient #8 including, but not limited to, assessment of vital signs. Observation revealed Employee #4 placed their plastic tub containing medical supplies directly on the floor. Home Visit #3: Observation of a home visit on 11/17/2021 beginning at 1:00 PM revealed Employee #5 provided direct patient care to Patient #9 including, but not limited to, performing discipline specific tests using reusable equipment. Observation revealed Employee #5 placed their plastic tub containing reusable equipment directly on the floor. Further observation revealed Employee #5 removed the lid from the tub and placed the lid directly on the floor. Upon completion of the testing, reusable equipment was disinfected prior to being placed back in the tub but the lid was not disinfected prior to being placed back on the tub. Upon completion of the visit, the plastic tub was carried from the patient's home in direct contact with the employee's clothing prior to being disinfected at the employee's car. During an interview with Employee #1 and Employee #2 on 11/18/2021, beginning at 8:20 AM, the above findings were presented. Employee #1 stated the agency had switched from using medical bags to using plastic tubs in response to COVID-19 in an effort to provide a container that could be more easily and completely disinfected. Employee #1 stated that the agency policy had not been updated to reflect the change but the current policy regarding placement of medical bags should be followed for placement of the plastic tubs. Employee #1 acknowledged the findings and stated "That is not what we would expect." Review of agency policy "G.0006" titled "Infection Control Guidelines" with a "Revision Approval Date" of "11/18/19" stipulated "3.23 Staff is instructed to place bag in the home on a clean surface and avoid placing bag on the floor." Review of a document presented to patients as part of the admission packet, titled "What A Patient Should know About Home Visits During Pandemic" stipulated "During Visit:...We will only be bringing in essential items. We will place essential items on a surface disinfected or we will use a clean barrier..."