Every finding on record at Kah Development 4, LLC

On 02/27/2023 at 1200 PM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Recertification Survey for compliance with the Conditions of Participation for Home Health. On 03/02/2023 at 0900 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 observation during home visits, staff interviews, review of Agency Policy and Procedures, the Skilled Nurse (SN) failed to follow accepted professional standards for infection control in 2 (#1 and #2) of 3 (#1, #2 and #3) home visits conducted. This deficient practice had the potential to place all patients and staff at risk for infection, cross-contamination, and hospitalization. 1. The Center for Disease Control publication Morbidity and Mortality Weekly Report dated October 25, 2002 Vol. 51/ N. RR-16 "Guide for Hand Hygiene in Health-Care Settings" viewed at: https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf on 10/30/2019 defined the indications for hand washing and hand antisepsis including after removing gloves and prior to donning another pair of gloves. 2. Review of Agency Procedure for "Hand Hygiene, Home Care", showed "using an alcohol-based hand rub is appropriate for decontaminating the hands before putting on gloves; before inserting an invasive device. After removing gloves ..…after contact with inanimate objects in the patient’s environment.” 3. During a home visit with patient #1 on 2/28/2023 at 12:10 PM, the SN was observed providing wound care. The SN donned clean gloves and proceeded to remove the soiled dressing. SN removed soiled gloves sanitized hands using gel sanitizer, cleansed patient #1 wound. The SN failed to remove soiled gloves, re-sanitize hands and don clean gloves prior to applying the new dressing to the wound. 4. During a home visit with patient #2 on 2/28/23 at 1:00 P.M., the SN was observed providing wound care. The SN failed to re-sanitize hands after removal of soiled gloves and prior to donning clean gloves. The Surveyor observed the SN applying gel sanitizer to gloves and picking up electronic tablet to record assessments findings for patient #2. 5. On 3/2/2023 at 8:30 AM, Agency Personnel were given an opportunity to present additional information. Agency Personnel #1confirmed the SN failed to adhere to infection control procedures and the Agency's standards of practice during the home visit as required. Agency Personnel #2 stated “this will be fixed immediately.”