Every finding on record at Cullman Regional Medical Center, Inc.

Based on a recertification survey conducted on 08/16/22 to 08/18/22, the agency was found to be in substantial compliance with the Emergency Preparedness regulations.

A recertification survey was conducted at Cullman Regional Home Care on 8/16/22 through 8/1822, standard level deficiencies were cited and will require a plan of correction.

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, agency policy and procedure, and interview, it was determined the agency failed to ensure staff followed agency policy for hand hygiene and infection control. This deficient practice affected one of seven home visits (HV) including HV # 2 and had the potential to negatively affect all patients admitted to the agency. Findings include: Agency Policy: HC/HOS-120-503.1 Title: Hand Hygiene Date Revised: 10/2017 Purpose: To provide guidelines for hand hygiene and to prevent infection and/or contamination between patients and the Home Care/Hospice personnel. Policy: Routine hand hygiene is performed at the beginning of each patient contact, ...Alcohol based (60%) waterless hand cleaner may be used... Procedure: ...II. A. Alcohol based waterless hand cleaner may be used in addition to hand washing or in place of hand washing in the following situations: ...2. Before direct patient contact. 3. After removing gloves. ...5. When moving from contaminated patient body site to clean site during patient care. 6. After contact with inanimate objects or medical equipment close to patient. ...III. Use of gloves A. Gloves are not a substitute for hand hygiene. B. Gloves should be: ...2. Changed or removed if moving from a contaminated to a clean patient site... 1. HV # 2 was admitted to the agency 8/15/22 and certified for care 8/15/2022 to 10/13/2022 with a diagnosis of Urinary Tract Infection, Site Not Specified. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 8/15/22 revealed Aide frequency two times a week for four weeks and one time a week for week five. Review of the Aide Care Plan dated 8/15/22 revealed a bed bath was assigned each visit. A HV was conducted on 8/16/22 at 2:55 PM to observe a bed bath and care provided by Employee Identifier (EI) # 2, Home Health Aide (HHA). During the visit, EI # 2 performed hand hygiene and donned gloves to assist patient to rollator and transferred to bedroom/bed. Without performing hand hygiene and wearing the same gloves, EI # 2 began washing the patient's face, hands, arms, chest, feet, legs and perineal area with a "rinseless soap". After perineal care was completed, EI # 2 removed gloves and without performing hand hygiene, donned gloves and washed buttocks. Then, without performing hand hygiene and wearing the same gloves, EI # 2 applied Remedy Essentials Cream to the reddened area on the buttocks and between the legs of HV # 2. EI # 2 doffed gloves and without performing hand hygiene, donned clean gloves and finished the bath, washing the patient's back. EI # 2 then assisted caregiver to pull up diaper/ pull-up and repositioned the patient in the bed. EI # 2 doffed gloves and without performing hand hygiene, tidied the patient's area. An interview conducted on 8/18/22 at 5:24 PM with EI # 1 Director, confirmed hand hygiene was not performed per agency policy.