Every finding on record at Madigan Home Health Care, Inc.

Federal Recertification Survey Survey Dates: 07/18/2022 and 07/19/2022 Madigan Home Health Care, Inc., a Home Health Agency, is in substantial compliance with 42 Code of Federal Regulations, Part 484.22, Condition of Participation: Emergency Preparedness. However, the following standard level requirements were not met:

Integrated EP Program CFR(s): 484.102(e) §416.54(e), §418.113(e), §441.184(e), §460.84(e), §482.15(f), §483.73(f), §483.475(e), §484.102(e), §485.68(e), §485.625(f), §485.727(e), §485.920(e), §486.360(f), §491.12(e), §494.62(e). (e) [or (f)]Integrated healthcare systems. If a [facility] is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the [facility] may choose to participate in the healthcare system's coordinated emergency preparedness program. If elected, the unified and integrated emergency preparedness program must- [do all of the following:] (1) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program. (2) Be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered. (3) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance [with the program]. (4) Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated emergency plan must also be based on and include the following: (i) A documented community-based risk assessment, utilizing an all-hazards approach. (ii) A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach. (5) Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan, and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively. This STANDARD is not met as evidenced by: Based on document reviews and interviews, the agency failed to demonstrate that it has met the testing requirement for the separately certified home health agency as part of the unified emergency preparedness program for the integrated healthcare system. Findings: Review of the integrated healthcare system’s emergency management plan showed no evidence of testing in the last two (2) years focused on the unique patient population and services of the home health agency. This was confirmed in interviews with the administrator. On 7/12/2022 at 2:30 PM, an interview was conducted with the Administrator to review the documentation of a 10/23/2021 “Dangerous Person” incident. When asked, the Administrator confirmed that there is no evidence of home health participation in the after-event report/improvement plan for this incident. On 7/13/2022 at 8:45 AM, an interview was conducted with the Administrator to review the documentation of a 5/20/2022 “Workplace Violence” incident. When asked, the Administrator confirmed that there is no evidence of home health participation in the after-event report/improvement plan for this incident. When asked if that there were any testing exercises focused on the home health agency’s unique patient population and services in the past two years, the Administrator confirmed there were none.

Federal Recertification Survey and Review of Coronavirus 2019 ("COVID-19") Vaccination of Facility Staff Requirements Survey Dates: 07/11/2022 and 07/13/2022 Madigan Home Health Care, Inc., a Home Health Agency (HHA), is in substantial compliance with 42 Code of Federal Regulation, Part 484, Requirements for HHAs and the Coronavirus 2019 ("COVID-19") Vaccination of Facility Staff Requirements. However, the following standard level requirements were not met:

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, document reviews and interviews, the agency failed to ensure accepted standards of practice were followed to prevent the transmission of infection during three (3) of four (4) home visits (Patients #1, #3, #4). Findings: Madigan Home Health Care policy for infection prevention and control program updated and reviewed, on 6/22/2022 includes the following: 1. “Hand Hygiene - …should be performed after contact with the client or objects in the immediate vicinity of the client…before entering the nursing bag…if gloves are worn, wash the hands after removing the gloves… 2. Medical Bag Technique - …the inside of the bag is maintained as a clean area…wash your hands prior to entering the bag…clean all items as needed before returning them to the bag.” 1. On 7/11/2022, a home visit was conducted with Patient #1. Registered Nurse (“RN”) #1, was observed: - conducting an assessment without disinfecting her hands prior to working with Patient #1; and -using medical equipment, including a stethoscope and blood pressure cuff, with Patient #1, and placing back into her medical bag without cleaning the equipment; and -exiting the home of Patient #1 without disinfecting her hands. 2. On 7/12/2022 a home visit was conducted with Patient #3. RN #2 was observed: -removing gloves after wound care and not disinfecting her hands; and -using medical equipment including a blood pressure cuff, stethoscope, thermometer, and a pulse oximeter, and placing back into her medical bag without cleaning the equipment; and -exiting the home of Patient #3 without disinfecting her hands. On 7/12/2022 at 4:00PM, the Home Health Aide Supervisor/RN was interviewed. She confirmed that all infection policies are to be followed, including the infection control procedures for handwashing and medical bag care. On 7/13/2022 at 10:00AM, the Infection Preventionist was interviewed. She stated the following: - the medical bag protocol and hand hygiene are expected to be followed; and - it is not acceptable to leave a home without sanitizing your hands because you are touching everything before you leave; and - it is not appropriate to put dirty equipment in the bag, it should be cleaned prior to placing in the bag and that if that can’t happen then it is to be placed in a zip lock bag so it does not contaminate other items. 3. On 7/12/2022, a home visit was conducted with Physical Therapist (“PT”) #1 . PT #1 was observed: - conducting an assessment without disinfecting her hands prior to working with Patient #4; and - placing reusable medical equipment including a blood pressure cuff and a pulse oximeter back into her medical bag without cleaning the equipment; and - exiting the home of Patient #4 without disinfecting her hands.