Every finding on record at Elite Home Health, LLC

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Elite Home Health, Home Health Agency (HHA) on 08/11/2021 found that your facility was in substantial compliance with the participation requirements under 42 CFR 484.102.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Elite Home Health, Home Health Agency (HHA) on 08/11/2021 resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited:

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 record review, the agency failed to ensure (Staff) S3 (Licensed Practical Nurse /LPN), S4 (Registered Nurse/RN) and S5 (Physical Therapist/PT), followed accepted infection control practices (Bag/Box Technique) during a home visit with 3 (Patient 5, P6, and P7) out of 3 (P5, P6, and P7) patients reviewed. This failed practice exposed Patient P5, P6 and P7 to potential infections from cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect.) The findings are: P7 Findings: A. On 8/10/2021 at 1:05 pm, during home visit observation of care provided to P7 by S3 LPN revealed: 1. S3 placed their treatment bag directly on P7's floor, failing to use any barrier between treatment bag and floor. 2. S3 used pulse oximeter (device used to measure heart rate, and oxygen in the blood) placing device on P7's finger, then putting device back into their treatment bag, without disinfecting device. 3. S3 used oral thermometer (device used to measure body temperature) while using a thermometer probe barrier on P7, S3 did not disinfect thermometer prior to placing device in their treatment bag. 4. S3 used blood pressure cuff on P7's right arm, placing device back into their treatment bag without disinfecting device. B. On 8/10/2021 at 4:03 pm, during interview with S3 LPN, confirmed by stating, "I have not been trained on clean bag technique ( a technique to keep supplies and equipment clean) while I have been here, I will ask for supplies to make sure I am doing that." P6 Findings: C. On 8/10/2021 at 3:03 pm, during home visit observation of care provided to P6 by S4 RN revealed: 1. S4 placed their treatment bag directly on P6's floor, failing to use barrier between treatment bag and floor. 2. S4 used pulse oximeter placing device on P6's finger, then putting device back into their treatment bag, without disinfecting device. 3. S4 used blood pressure cuff on P6's right wrist, placing device back into their treatment bag without disinfecting it. D. On 8/10/2021 at 3:29 pm, interview with S4 RN confirmed by stating, "I wasn't aware of the clean bag technique, it makes sense, and I will start doing that." P5 Findings: E. On 8/10/2021 at 4:00 pm, during home visit observation of care provided to P5 by S5 PT revealed, S5 placed their treatment bag directly on P5's floor, failing to use barrier between treatment bag and floor. F. On 8/10/2021 at 4:16 pm interview with S5 confirmed by stating, "I have not been taught about clean bag technique, I will make sure to do that." G. Record Review of facility's "Bag/Box Technique" policy, no date, revealed: 1. "If carrying the bag/box into the home would compromise (to cause the impairment of) the bag/box, i.e. roach infestation, then personnel may carry on the those articles needed for that visit into the home. In this situation, cleanse articles carefully according to policy before returning them to the bag/box." 2. "Identify a clean area in the home to place the bag/box. If no clean area is available, place the home health bag/box on clean paper, newspaper or disposable apron." 3. "The bag/box is considered clean. Personnel should always try to choose a location to place the bag/box other than the floor, if possible." 4. "The bag/box will contain articles for hand washing: soap and paper towels and appropriate wipes or hand cleaner." 5. "Items that will be used on multiple patients, i.e. stethoscope (a medical instrument for listening to the action of someone's heart or breathing, typically having a small disk-shaped resonator that is placed against the chest, and two tubes connected to earpieces,) thermometer (device used to measure body temperature,) are to be cleaned according to Agency policy." 6. "Contaminated items or items such as lab specimens (a sample of medical testing) should not be placed in the bag/box." 7. "The bag/box should be carried in a clean area in the vehicle."

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the facility failed to maintain documentation of Governing Body (group that makes and applies decisions on behalf of its members and the organization) review of quality assessment and performance improvement programs. This failed practice is likely to result in the Governing Body not being aware of potential negative quality outcomes. The findings are: A. A review of the governing body annual meeting minutes dated March 16, 2020, showed no discussion or evaluation of quality assessment and performance improvement programs by the governing body. B. On 08/11/2021, at 9:30 am, during interview with Administrator, staff #1, (S1) confirmed the absence of documentation in Governing Body minutes to assess the quality improvement program for the year 2020.