Every finding on record at Divine Healthcare LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 02-03-2025, 02-04-2025, and 02-05-2025 Active census: 8 At this Emergency Preparedness survey, Divine Healthcare, LLC. was found to be in compliance with Emergency Preparedness Requirements for Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR completed by Area 3 on 2-7-2025.

This visit was for an Initial Federal Certification of a Home Health provider. Facility number: 018196 Survey Dates: 02-03-2025, 02-04-2025, and 02-05-2025 12-month unduplicated skilled census: 11 The agency was found to be out of compliance with 42 CFR 484, in regard to an Initial Federal Certification. QR completed by Area 3 on 2-07-2025.

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 record review, observation, and interview the agency failed to ensure clinicians adhered to infection prevention measures during the provision of care, in 2 of 2 skilled home observations. (Clinical Manager, Registered Nurse (RN) 1) Findings include: 1 . A review of an agency document dated August 2024, titled 'UNIVERSAL AND STANDARD PRECAUTIONS FOR ALL HEALTHCARE WORKERS' stated, "… 7. Universal and Standard Precautions education and training shall include the following: a. Hand Hygiene/Handwashing 1. Employees are to perform hand hygiene in accordance with Canter for Disease Control and Prevention (CDC) and/or World Health Organization (WHO) recommendations as follows: … after contact with patient's immediate environment, including inanimate objects …" 2. On 02-04-2025 at 10:30 AM, during a home observation, the Clinical Manager was observed refilling a weekly pillbox for Patient #4. The Clinical Manager performed hand hygiene, donned gloves proceeded to handle, open up, and rearrange individual removable sections of the pillbox. The Clinical Manager proceeded to handle and open a prescription bottle, using both gloved hands to twist the lid off. Medications were poured into the palm of the left gloved hand and then each pill was picked out of the palm with the right gloved thumb and forefinger, then placed into individual slots of the pillbox. 3. On 02-04-2025 at 12:30 PM, during a home observation, Registered Nurse (RN) 1 was observed refilling a pillbox for Patient #9. RN 1 performed hand hygiene, donned gloves, then proceeded to handle and open a prescription bottle with both gloved hands, then stuck their right gloved forefinger into the bottle, retrieved each pill from the bottle this way, and then placed the pills into individual slots of the pill box. RN 1 handled and opened another prescription bottle, and shook some of the pills out and onto the inner lid of the bottle, intermittently used the same right gloved forefinger to reach in, touching and guiding some of the pills out, helping them land on the lid. The right gloved forefinger and thumb were used to pick some of the pills off of the lid, and into individual slots of the pillbox. When all the medications had been refilled, gloves were doffed and hygiene was performed. 4. On 02-04-2025 at 11:25 AM, after the home visit with Patient #4, when queried as to how the patients pills were handled and contaminated, the Clinical Manager indicated perhaps a better way would be to change her gloves more frequently during the process. 5. On 02-04-2025 at 1:41 PM, after the home visit for Patient #9, RN 1 was queried as to the contamination of the patient's medication. RN 1 indicated changing lots of gloves when setting up meds would have been helpful, or they might think up other strategies to avoid contamination. 6. On 02-04-2025 at 3:08 PM, the Administrator indicated had been made aware of the infection control breaches during the nursing visits and pillbox set-ups and had already begun to strategize as to how to mitigate this concern, had found a tool which could be utilized and easily sanitized which might prevent contamination from occurring during the refilling of pillboxes in the future. 7. On 02-05-2025 at 3:00 PM, the Administrator indicated the agency had no specific policy in place specific to infection precautions in relation to managing/refilling Medi planners.