Every finding on record at Gentiva Health Services

The following reflects the findings of the California Department of Public Health, Licensing and Certification during a Recertification Survey of a Home Health Agency. Representing the Department: HFEN 40678 HFEN 43019 HFEN 44589 Census: 181 Sample Size: 8 Home Visit: 3

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 facility failed to maintain infection control practices and processes when: Staff donned gloves and performed multiple tasks while using the same pair of gloves and using hand sanitizer on the gloves instead of performing hand hygiene and changing gloves between tasks. Staff used alcohol prep pads to clean equipment used for patient care instead of the recommended cleaning and disinfecting wipes. These facility failures had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact patient's health and safety and cause preventable healthcare associated infections (HAI) for patients in an already compromised condition. Review of the APIC website, https://infectionpreventionandyou.org/infographic/ppe-dos-and-donts/ accessed on 4/14/2023, indicated "Do clean hands and change gloves between each task." During an observation and concurrent interview on 4/5/23, at 2:10 p.m., in Patient 1's house, physical therapist (PT1) used hand sanitizer, donned gloves, provided patient care, used hand sanitizer on gloves, picked up pen, used hand sanitizer on gloves, returned to patient care, used hand sanitizer on gloves, used electronic pad, used hand sanitizer on gloves, used stethoscope and blood pressure cuff, used hand sanitizer on gloves, picked up medication bottles, used hand sanitizer on gloves, returned to patient care, and continued using the same same pair of gloves until the end of visit. PT1 stated I decided to clean the gloves on my own it is just something I do. During an interview and concurrent record review on 4/7/23 at 10:35 a.m., with administrator (ADM), ADM confirmed with PT1 should be removing gloves and performing hand hygiene between tasks and not using hand sanitizer on gloves. 2. During a review of the facility's competency assessment titled, "Bag Technique" dated 8/25/19 indicated in part... "reusable equipment cleaned using all approved disinfectant and/or soap and water as appropriate..." During an on observation and concurrent interview on 4/6/23, at 10:45 a.m., in Patient 2's house, occupational therapist (OT1) used alcohol pads to clean the blood pressure cuff and pulse oximeter. OT1 stated I use alcohol pads to clean all the equipment OT1 was never given the cleaning and disinfecting wipes. During an interview and concurrent record review on 4/7/23 at 9:37 a.m., with the ADM who confirmed OT1 should be using the cleaning and disinfecting wipes that have been approved for use by the facility.

Officer, a director, agent, managing employee CFR(s): 484.100(a)(2) The name and address of each person who is an officer, a director, an agent, or a managing employee of the HHA as defined in §420.20l, §420.202, and §420.206 of this chapter. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to notify the state agency of the change of Administrator. This failure had the potential for 27 of 27 patients to be unaware of who oversaw their care as the administrator. During a concurrent interview and record review on 4/5/23 at 10:30 a.m., with the administrator (ADM), ADM provided the organizational chart that indicated, the name of the administrator. The name of the administrator did not match the name the state agency has on file. ADM stated "I started working here in December 2022 as the ADM". ADM confirmed the facility did not notify the state agency of the change of ADM. During a review of, "Title 22, section 74667 (b)(6) Report of Changes" indicated in part... (b) Changes Requiring Written Notice. The Licensee shall, within 10 days, notify the Department in writing of the following: (6) Changes of the administrator including the name and mailing address of the administrator, the date of the administrator assumed office and a brief description of qualifications and background of the administrator."

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to operate in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients when the facility used a new name prior to the departments' approval for a name change. These failures have the potential for the public to be misled that the facility is licensed under a different name. During a concurrent interview and record review on 4/5/23 at 4:57 pm, with administrator (ADM), review of the admission packet and documents within, organizational chart, work application, screening forms, building and door signages indicate "CenterWell Home Health" as the name of the facility. ADM verbalized the facility changed their name on 9/1/22. ADM acknowledged the facility cannot use a new name until the California Department of Public Health approves the application for a name change. During a review of Title 22, Chapter 6, Article 2 Section 74667 Report of Changes indicated in part..." Changes requiring written notice...notify the Department in writing of the (1) change of name of home health agency."

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to discard expired medications and vaccines. This failure had the potential for ineffective vaccines and medications to be given to patients and employees. During an observation on 4/7/23 at 3:47 pm, in the supply room, there was 1 box of epinephrine (a blood pressure raising hormone) 1mg/ml epinephrinesnap-v with an expiration date of 12/22 and 1 box of influenza (commonly called the "flu" is an infection of the nose, throat, and lungs) vaccine Afluria Quadrivalent vaccine with expiration date of 6/28/22. During an interview on 4/7/23 at 4:00 pm with administrator (ADM), ADM verbalized, "There is a policy that states that expired medications need to be discarded." During a review of the policy and procedure (P&P) titled, "05-11 Medical Supply Management and Bundle Supplies," dated 8/2021, indicated in part, "Supplies are to be inspected on an ongoing basis for package integrity and expiration dates. Expired or damaged items will be removed from inventory..."