Every finding on record at Johnson Regional Homecare

On 5/20/2024 at 10:16 AM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare recertification survey for compliance with 42 CFR-Part 484 Conditions of Participation for Home Health Agencies. On 5/23/2024 at 11:22 AM, an exit conference was conducted with Agency Representatives. Preliminary findings were discussed.

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 observations during home visits, Agency Personnel Interview, review of Agency's Policy for PICC (Peripherally Inserted Central Catheter used to administer medications and fluids) care, Agency's policy on Infection Control, review of literature from the Centers For Disease Control (CDC), the National Institute of Health (NIH), and UngerGlobal (cleaning innovation specialist), The Skilled Nurse (SN) failed to follow professional standards for infection control in three of three home visits observed. (#1-#3). This failed practice had the potential to place the patients at risk for infection and rehospitalization. The deficient practices identified, if continued, potentially placed all patients with PICC, other venous access devices or wounds requiring saline for cleansing or packing of wounds, at risk of adverse outcomes and rehospitalization. The common professional standards not adhered to also placed the SN's health at risk as well. Patient Home Visit #1 on 05/21/24 at 9:15 AM, revealed the following: A) SN (Skilled Nurse) cleaned, flushed and obtained blood specimen from Hickman catheter by removing the cap and attaching a syringe. (A Hickman line is a central venous catheter most often used for the administration of chemotherapy or other medications, as well as for the withdrawal of blood for analysis.) Surveyor observed SN attach a needle to the syringe and then proceeded to transfer blood specimen from syringe to lab tubes. After this process was completed, the SN grabbed a (needle) cap and while holding in gloved hand, took the other hand and aimed the contaminated needle at the cap, recapping the needle. According to the NIH,https://www.ncbi.nlm.nih.gov/books/NBK593203/ , “Injuries due to needles and other sharps have been associated with transmission of blood-borne pathogens (BBP), including hepatitis B, hepatitis C, and HIV to health care personnel. The prevention of sharps injuries is an essential element of standard precautions and includes measures to handle needles and other sharp devices in a manner that will prevent injury to the user and to others who may encounter the device during or after a procedure. The Bloodborne Pathogens Standard is a regulation that prescribes safeguards to protect workers against health hazards related to blood-borne pathogens.” B) SN sanitized hands and donned gloves, then opened ETOH (alcohol) wipe and began cleaning on and around sides of the old PICC dressing, trying to break the adhesive seal from the skin/dressing barrier. After this was accomplished, the SN removed gloves, sanitized hands, donned another pair of gloves and began holding down the PICC dressing with the sterile chlorhexidine swab stick included in the sterile CVL (Central Venous Line Dressing Kit) while also scrubbing around the edges of the tegaderm (a clear flexible adhesive type of tape dressing), thus contaminating the sterile chlorhexidine solution as well as the sterile gloves SN was wearing. **This was a frank deviation from a document titled “Peripherally inserted central catheter (PICC) dressing change, home care.” Provided to Surveyor by Agency Director on 5/22/24 at 1:42 PM when asked for a copy of the Agency’s procedure. C) During this same time period, a Personal Care Aide staffed from a different agency was sweeping the floor and emptied the sweepings from the dust bin into a trash can placed approximately 10 inches away from the patient and the same distance to the SN, and SN’s sterile field. The dust bin was emptied 3-5 times during the patient care activities including times when there was no dressing over the Hickman catheter, no cap on the end of the Hickman catheter. Neither the SN nor the Agency Director, redirected the Personal Care Aide to stop shaking dust, dirt and cat litter particles close to the open wounds. D) SN removed gloves and used sanitizer to clean hands. Sterile gloves were donned and a sterile drape was placed around the old PICC dressing. The old dressing was then removed and discarded. A new PICC dressing was then placed. The Blue needless access Cap was replaced The SN did not follow the principles of sterile technique or maintain adequate sterility of the dressing used for the Hickman Catheter. E) SN removed gloves, sanitized hands and donned a clean pair of gloves. Attention was then focused on the abdominal wound with wound vac dressing. Vacuum/Suction machine was turned off and tubes were disconnected from the wound dressing. SN moistened a sponge from a container labeled “Normal Saline.” Surveyor did not see a date on the bottle, so asked the SN when the bottler was opened and how long the saline is good for until it must be discarded. Per SN #1, “It (the bottle) is good for a week. It was opened this past Saturday.” SN continued on with wound care- using the saline moistened sponge to clean the outside of the wound dressing and along the edges of the adhesive dressing. Another gauze sponge, also moistened with the bottled saline, was observed being used by the SN to clean both the outside and the inside of the abdominal wound. According to Tyco Healthcare at https://www.lvhn.org/sites/default/files/uploads/research_education/EmergencyMedicineMedStudents/WoundCleansing.pdf, saline solutions begin to show bacteria growth within 24 hours of opening. F) Surveyor observed SN using a soft measuring ruler to measure both the inside & outside of the wound with no clear “clean to dirty” technique. It should also be noted, that during the time of the abdominal wound care, the Personal Care Aide had brought clothing and towels from the dryer and began folding the items while the SN was delivering care. Lint and particles were visible in the air during this time. Neither the SN completing the skilled care, the Agency director providing the transportation, redirected the Personal Care Aide. According to Unger global, A worldwide, multimarket and cleaning innovation specialty corporation, there are an average of 764 bacteria per square inch of floor.https://usa.ungerglobal.com/blog/why-effective-commercial-floor-cleaning-is-critical-to-combating-infectious-disease-spread/#:~:text=Every%20time%20an%20object%20has,764%20bacteria%20per%20square%20inch G) During an interview post visit at 12:55 PM, Surveyor asked both SN and Agency Director about the Personal Care Aides cleaning and use of the trash can so close to the area of patient care and the skilled nurse stated “I didn’t even notice any of that happening. I was so focused on what I was doing, I didn’t even see any of that (the cleaning). Per Agency Director, “ It was bothering me but I didn’t think to say anything to the Personal Care Aide to stop her. According to “Clinical Procedures For Safer Patient Care” at www.https://opentextbc.ca/clinicalskills/chapter/surgical-asepsis/#:~:text=Do%20not%20sneeze%2C%20cough%2C%20laugh,minimum%2C%20and%20keep%20doors%20closed. “It is the responsibility of all health care workers to speak up and protect all patients from infection.” Upon review of an Agency document titled, “Infection Prevention And Control Program” page 9 states “Patients and families shall also receive infection prevention and control education, as applicable and appropriate.” Patient #2 Home Visit on 05/21/24 at 12:05 PM: 1) Surveyor observed SN (Skilled Nurse) moisten clean gauze with a bottle labeled "Normal Saline." No date was on the bottle. Surveyor asked SN #1 when the bottle had been opened for the patient. Per SN #1, "We opened it the other day." Surveyor watched as SN cleaned the escar or scabbed over area of wound as well as the area surrounding with the saline moistened sponge. According to Tyco Healthcare at https://www.lvhn.org/sites/default/files/uploads/research_education/EmergencyMedicineMedStudents/WoundCleansing.pdf, saline solutions begin to show bacteria growth within 24 hours of opening. Patient home visit #3 on 05/22/24 at 11:40 AM: 1) SN cleaned hands with sanitizer and donned clean gloves. SN then moistened some gauze with a bottle of "Normal Saline." There was no date on the bottle. Surveyor asked SN #2 when bottle of saline was opened and SN replied "Last week I think." According to Tyco Healthcare at https://www.lvhn.org/sites/default/files/uploads/research_education/EmergencyMedicineMedStudents/WoundCleansing.pdf, saline solutions begin to show bacteria growth within 24 hours of opening.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by:

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by:

. On 09/29/2021 at 11:10 AM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare Recertification survey for compliance with the Conditions of Participation for Home Health. On 10/01/2021 at 11:15 AM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. .

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: . Based on Clinical Records review, and staff and Patient interviews, the Home Health Agency failed to follow Physician orders for provision of care and treatments for 1 (#3) of 7 ( #1 through #7) Clinical Records reviewed. This failed practice had the potential to affect the quality of care received by all patients currently on census, in that patients may not receive treatments as ordered by the Physician which could result in adverse outcomes. Findings follow: 1. A review of Clinical Record #3 contained documents titled "Aide Regular Visit Note" dated 09/24/2021 and 09/28/2021. Further review of Clinical Record #3 contained a document titled "Aide Assignment Sheet" which included the aide's care plan for providing services for the Patient by the Home Health Aide. There was no evidence found in the Clinical Record of Physician's orders for provision of Aide services. 2. During an interview on 09/30/2021 at 1:40 PM with Patient #3, the Patient Representative stated they were receiving Aide services in the home two (2) times per week. During an interview on 10/01/2021 at 9:30 AM, Agency Personnel #1 confirmed there was no order in the Medical Record for Patient #3 for Home Health Aide Services . .

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: . Based on Clinical Record review, and staff interview the Agency failed to ensure a Discharge/Transfer Summary was completed and sent to the Physician after the Patient was transferred to an inpatient facility in 1 (#1) of 7 (#1 - #7) Clinical Records records reviewed. This failed practice had the potential to place patients currently on census at risk by preventing effective and efficient coordination of care among health care team members and providers. Findings follow: 1. Review of Clinical Record #1 for a certification period of 09/01/2021 to 10/30/2021 showed the Patient was transferred to a an inpatient facility on 09/12/2021. A review of a document dated 09/15/2021 titled "Nursing Post Hospital" showed that on 09/12/2021 the Patient was transferred to the Emergency Room and "later transferred to (hospital name) and DC (discharged) on 9/12/2021." There was no evidence found in the Medical Record of a Transfer Summary being completed. 2. In an interview on 10/01/2021 at 9: 30 A.M., Agency Personnel #1 verified a Transfer summary was not completed or sent to the Physician, by stating there was "not a Transfer summary was not completed. .