Every finding on record at First Call Home Health Agency, LLC

An unannounced Federal recertification survey was completed at this agency on 12/28/2022. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484.102 Emergency Preparedness. An entrance conference was held with the Director of Education on 12/12/2022 at 10:45 AM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers, and comments. No deficiencies were cited. Definitions and abbreviations: CFR - Code of Federal Regulations

An unannounced Federal recertification survey was completed at this agency on 12/28/2022. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held with the Director of Education on 12/12/2022 at 10:45 AM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers, and comments. Definitions and abbreviations: CFR - Code of Federal Regulations CDC - Centers for Disease Control and Prevention HHA - Home Health Agency RN - Registered Nurse

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 policy review, it was determined the agency failed to ensure direct patient care staff followed accepted standards of practice for the prevention of infection transmission for 2 of 7 home visits. Findings: Home Visit #6: Observation of a home visit on 12/14/2022 at 1:00 PM revealed Employee #11 provided direct patient care to Patient #11 including, but not limited to, assessment of vital signs and physical therapy exercises. Observation revealed Employee #11 failed to sanitize the stethoscope, thermometer, and pulse oximeter used during the procedure before placing them in their pocket. Home Visit #7: Observation of a home visit on 12/14/2022 at 3:15 PM revealed Employee #12 provided direct patient care to Patient #12 including, but not limited to assessment of vital signs and physical therapy exercises. Observation revealed Employee #12 failed to sanitize the stethoscope, thermometer, and pulse oximeter used during the procedure before placing them in their bag. During an interview with Employee #12 right after the home visit on 12/14/2022 at 4:00 PM, Employee #12 stated "I don't clean [equipment] between patients. I try to clean once a week or once every two weeks." Employee #12 further asked "Was I supposed to clean between patients?" During an interview with the Director of Operations and Director of Education on 12/22/2022 beginning at 10:00 AM, the Director of Education stated "That's our policy of infection control. As long as it is not contaminated by bodily fluid or visibly soiled, we do not have to clean or disinfect [equipment between patients]." Review of a document dated November 29, 2022 and titled "CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings" revealed under "Core Practices Table" for "Reprocessing of Reusable Medical Equipment," to "1. Clean and reprocess (disinfect or sterilize) reusable medical equipment (e.g., blood glucose meters and other point-of-care devices, blood pressure cuffs, oximeter probes, surgical instruments, endoscopes) prior to use on another patient or when soiled... 2. Maintain separation between clean and soiled equipment to prevent cross contamination." https://www.cdc.gov/infectioncontrol/guidelines/core-practices/index.html

An entrance conference was held on 04/12/2021 with the Chief Executive Officer (CEO) and Director of Clinical Operations. The purpose of the investigation and the investigation needs were explained. An opportunity was provided for questions, answers, and comments.

Rights of the patient CFR(s): 484.50(c) The patient has the right to- This STANDARD is not met as evidenced by: Resident/Patient/Client Rights-Unsubstantiated POLICIES AND PROCEDURES & OTHER DOCUMENTS REVIEWED: * "(SARS-CoV-2):Field Staff & Office, Disease Prevention & Control Policy" revised 04/06/21; * "(SARS-CoV-2): Disease Response and Management" revised 04/06/21; "Exposure to Coronavirus" (COVID-19): Disease Response and Management" revised 03/21/2020; * "Person Filing Complaint" form; * "Grievance tracking & reporting"; * "Patient Grievance Summary Log" for the past 12 months; * List of direct and contracted employees with title and hire date. Findings: This report reflects the findings of an onsite complaint survey, #OR28438, that was initiated on 04/12/2021 and concluded on 05/03/2021. During the course of the investigation, policies/procedures, and other home health agency documents were reviewed, and staff interviews were conducted. Review of a document titled "SARS-associated CoronaVirus...(SARS-CoV-2): Field Staff & Office, Disease Prevention & Control Policy," revised 04/06/21 stipulated "In addition to the standard precautions found in the [agency] Infection Prevention and Control policy; it is expected that all field staff wear at the minimum cloth masks during patient care when unable to keep > 6 ft apart from the patient or caregiver." During an interview with the Director of Clinical Operations on 04/12/2021 at 3:42 PM, he/she stated "Everyone in the field has to wear masks in the field. If the client is COVID-19 positive, full PPE is required. We are a little laxed in the office but during meetings, everybody has to wear a mask." A review of undated document titled, "Caregiver Complaint" stipulated "January 12, 2021: [Patient #1] and [Patient #2] were discharged from [agency] services January 15, 2021 [Employee #1] tested positive for Covid-19. January 16, 2021 [Employee #1] reported positive Covid-19 test to the office, and also informed the office that [he/she] had already let [his/her] clients at [The Assisted Living] know, including our former clients [Patient #1 and #2]. January 16, 2021 CEO reported [Employee #1's] positive Covid test to Marion County and was told that they would notify [The Assisted Living] and the residents that [Employee #1] had been visiting. January 26, 2021 Received a letter from [The Assisted Living] reporting a list of details on their timeline for when [Employee #1] first called to report [his/her] positive test to [his/her] clients including: [Employee #1's] lack of cooperation with their vetting/screening process for people entering facility, and that both our client and their spouse tested positive as well. February 3, 2021 Received a follow-up letter from [The Assisted Living] informing us that [Patient #1] passed away from symptoms related to Covid-19." During an interview with the Chief Executive Officer (CEO) on 04/28/2021 at 10:00 AM, regarding the above complaint, the CEO stated "As soon as we found out [Employee #1] tested positive for COVID-19, we had suspended his/her service for us. We pulled all [his/her] client's and restaffed. [Patient #1 and Patient #2] were discharged before we found out [Employee #1] was COVID-19 positive." Patient #1 and Patient #2 were discharged from the agency on 12/18/2020 and 01/12/2020, respectively. When asked if the agency noised the Assisted Living Facility regarding Employee #1's positive test results for COVID-19, the CEO stated "No, as soon as we found out [Employee #1] was positive for COVID-19, we communicated with Marion County and we were told they would notify everybody." This allegation filed by the complainant was not substantiated due to insufficient evidence.