Every finding on record at Evangelical Lutheran Good Samaritan Society

An unannounced, on-site recertification survey was conducted on 03/25/25 through 03/28/25 at Good Samaritan Society Home Care in St. Croix Falls, WI. Good Samaritan Society Home Care is in compliance with Medicare Conditions of Emergency Preparedness for Home Health Agencies, 42 CFR 484.102.

An unannounced, on-site recertification survey was conducted on 03/25/25 through 03/28/25 at Good Samaritan Society Home Care in St. Croix Falls, WI. Good Samaritan Society Home Care is in compliance with the Medicare Conditions of Participation for Home Health Agencies, 42 CFR 484. For an unduplicated admission number of 627 in the last 12 months a total of 13 medical records (9 current and 4 discharged), 8 employee files were reviewed and 5 home visits were completed. Citations are issued at a standard level or below.

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, record review, and interview agency staff failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases in 1 of 5 home observation visits completed (Patient #8). Findings include: Review of policy “Bag Technique” last revised 6/14/2024 revealed in part, “5. Perform hand hygiene prior to removing equipment/supplies from the bag. 6. Remove all necessary equipment at the start of the visit. Enter the bag as few times as possible. 7. Perform hand hygiene prior to direct contact with patient. 8. Do not reenter the bag while wearing gloves. Remove gloves, perform hand hygiene, then reenter the bag, if necessary. 11. Computers are to be treated as dirty. Hand hygiene must be performed before and after using the computer.” Review of policy “Infection Prevention: Hand Hygiene” last revised 3/29/2022, revealed in part, " 2. Hand hygiene should be performed after glove removal.” Further review revealed, “Procedure: If gloves are used to perform a clean/aseptic procedure, hand hygiene must be completed before donning gloves. After removing gloves regardless of task completed. When moving from contaminated body site to a clean body site during patient care.” On 3/26/2025 at 10:00 AM a visit to the home of Patient #8 was conducted to observe wound care performed by Registered Nurse C. During the visit, there were 5 instances of Registered Nurse C entering the nursing bag without performing hand hygiene prior to entering and/or entering the nursing bag with dirty gloves. There were 5 instances of gloves being donned without hand hygiene prior and/or gloves being removed without hand hygiene after removal. There were 2 instances of moving from a contaminated body site to clean body site without performing hand hygiene/changing gloves. There were 2 instances of entering information on the computer without hand hygiene performed afterward. During an interview conducted on 3/26/2025 at 11:30 AM with Administrator A and Nursing Supervisor B, Administrator A was asked if hand hygiene was expected to be performed in the above instances. Administrator A stated yes.