Every finding on record at Faith Home Health Inc

During the recertification survey conducted on 7/10 - 7/11/2023 at Faith Home Health, a Home Health Agency, Emergency Preparedness was reviewed. Faith Home Health is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A survey for Re-Certification was conducted on 7/10/2023 - 7/11/2023. Faith Home Health Inc. was not in compliance with 42 C.F.R. Part 484 requirements for Home Health Agencies.

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 provide wound care using standard universal precautions for one of one sampled patient (#2). Findings included: Patient #2 was admitted on 07/03/2023. Diagnosis included cellulitis of back and chest wall. Review of the physician wound care orders showed clean wound with an aseptic wound cleanser and pack with iodoform packing strips, cover with ABD (abdominal) pads and secure with tape. During Observation of Patient #2 on 07/10/23 at 1:55 p.m. with Staff A , ARNP (Advanced Registered Nurse Practitioner) had entered the home and had placed her nursing bag on the coffee table without a barrier. She applied gloves and opened the nursing bag and removed the pulse ox machine and placed on the patient’s finger. She removed the blood pressure cuff and placed it on the right lower arm. After using the equipment, she placed them both on the furniture. She removed her gloves and without hand sanitizing replaced her gloves. She placed a barrier down on the couch that she had removed from the patient’s supply box. She placed supplies on the barrier both from the patient’s supplies and her bag. The supplies from her bag included wound cleanser, scissors in a baggie, a bottle of wound packing and the dry sterile dressing. She removed and replaced her gloves without hand sanitizing. She opened gauze onto the barrier and removed the old dressing. She removed and applied gloves without hand sanitizing. She used the wound cleanser from her bag on the barrier and sprayed it on gauze and wiped / cleaned the wound. She used a cotton applicator to remove the old packing from the wound. She then opened the bottle of packing dressing and started packing the wound with another cotton tipped applicator. She cut the packing with the pair of scissors she had removed from the plastic baggie from her bag. She then applied the dry sterile dressing. She used a wide tape that was from her bag and replaced into her bag after cutting three strips. She placed the used scissors back into the baggie and replaced them into her bag. She picked the trash up from the floor and placed into the trash can. She removed her gloves and performed no hand hygiene. She replaced the stethoscope, and blood pressure cuff into her bag without cleaning. She then left the home without hand hygiene. Interview with Staff A, ARNP on 07/10/23 at 2:20 p.m. resulted in her stating she thought the visits were not considered sterile. She stated she did not hand sanitize between glove changes, but she was careful removing them and replacing them. She stated that the resident did not have any supplies and they were providing. She stated she left the packing in the patient’s supplies. She verified she returned the scissors in the baggie, the wound cleanser, the box of tape, the blood pressure cuff and stethoscope to the nursing bag without cleaning. She verified she did not place a barrier under her nursing bag. She also verified she had not used hand hygiene upon entering or leaving the home. Record review of the facility’s policy, “Protocols for wound care:” revised 03/15/2023 showed maintain aseptic technique to prevent cross infection to the wound at patient home. Using sterile materials when touching the wound. Wash hands before and after each dressing to avoid cross infection. Disinfecting all articles thoroughly to ensure they are free from pathogens. Using masks, sterile gloves, and use of disinfectant to minimize wound contamination. Follow protocol: Pandemic Infection Disease and Wound Care Protocol. Record review of the facility’s policy, “Pandemic Infection Disease,” not dated showed 6. Staff should follow the organization’s standard precautions, including: A. Hand hygiene: wash hands before and after patient contact, after contact with any potentially infectious material, and before and after donning protective equipment, including gloves and masks. B. Wear gloves for any contact with potentially infectious material (e.g., secretions, tissues, dirty linen). Record review of the facility’s policy, “Infection Control – Universal Precautions,” not dated showed all company personnel who come into contact with patients / clients shall, at all times, follow the Universal Precautions for infection control. Hand Washing: all company personnel shall use the following procedure for washing hands before and after caring for the patient/ client. The procedure also applies after removing gloves. Use of gloves: all company personnel are instructed to wear disposable gloves when: handling items, surfaces or cleaning equipment soiled by blood or body fluids. A potential for exposure to infectious blood or body fluids exists. Follow these universal guidelines: 1. Wear gloves at all times. 2. Do not handle disinfected equipment with contaminated gloves. Record review of the facility’s policy, “Bag Policy,” showed all personal belongings, including treatment bags should be kept with a protective barrier or at a clean surface at the patient’s house.