Every finding on record at Medical Center Home Health LLC

A Health Emergency Preparedness Survey was completed during the Recertification Survey 5/18/20206 through 5/20/2026. This agency was found to be in compliance with all Federal Emergency Preparedness Regulations.

An unannounced Recertification Survey was completed 5/18/2026 through 5/20/2026. Agency reported incident with intake # 2580698 was also investigated during the survey. An entrance conference was conducted on 5/18/2026 at 8:55 AM with the Executive Director. An exit conference was conducted on 5/20/2026 at 11:45 AM with the Executive Director, the Milan Branch Clinical Director, and Patient Care Managers #1 and #2. The Home Health Senior Survey and Performance Improvement Coordinator, the Regional Vice President of Operations, the Regional Home Health Quality and Patient Experience Coordinator, the Home Health Survey and Performance Improvement Manager, the Bolivar Branch Clinical Director, and the Home Health High Impact Survey and Performance Improvement Coordinator joined the conference via video conference. The agency was provided the opportunity to ask questions regarding the survey findings.

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 policy review, document review, observation and interview, the agency failed to ensure measures to prevent the spread of infectious agents were followed by 2 of 7 (Registered Nurse (RN) #1 and RN #2) staff observed providing direct patient care in the home setting. The Findings included: 1. Review of the agency's "Hand Hygiene" policy revised on 5/1/2019 revealed, "...Staff performs hand hygiene by handwashing with soap and water or using an alcohol-based hand sanitizer...after contact with...wound dressings, or contaminated surfaces...before and after removal of personal protective equipment (PPE) [PPE includes gloves, gown, face mask or any protective item used to reduce the risk of exposure to blood/body fluids]..." Review of the agency's "Heparinization of Central Venous Access Device" policy revised 12/1/2021 revealed, "...Procedure...Perform procedure according to [Named Corporate Owner] clinical skills guidelines..." 2. Review of the agency's "Quick Sheet" printed from the agency's Clinical Skills Guidelines document revealed, "...This Quick Sheet is a synopsis of the procedure...It is intended to be a review of how to perform a procedure...Catheter Flushing and Locking 1. Clean hands and put on appropriate PPE based on the risk of exposure to body fluids or infection precautions. 2. Clean the needleless connector...b. Clean the connection surface and sides of the needleless connector using vigorous mechanical scrubbing for 5 to 15 seconds using 70 % [percent] alcohol or alcohol-based chlorhexidine. Allow the solution to dry. Clean the needleless connector before the first entry of the device. Make sure that the clean needless connector does not touch any nonsterile item. Clean the connector again if contamination is suspected..." 3.Observations in Patient #4’s home on 5/18/2026 at 2:30 PM revealed RN #1 completing access patency procedures, access site care, and access dressing change of the Patient's Peripherally Inserted Central Catheter (PICC) line. RN #1 performed hand hygiene and donned gloves. RN #1 attached sterile syringes of normal saline to the venous and arterial ports and flushed the lines. RN #1 failed to clean/scrub the needleless connectors with alcohol or chlorhexidine before attaching the sterile syringes of saline. RN #1 continued the procedure and removed the old dressing from the Patient's PICC insertion site, discarded the dressing and her gloves. Without performing hand hygiene, RN #1 donned new gloves and completed PICC access site care and applied a new sterile dressing to the access site. RN #1 failed to perform hand hygiene after removing her gloves and prior to donning new gloves. During an interview on 5/18/2026 at 3:25 PM, RN #1 verified PICC line ports should be cleaned prior to attaching syringes to the device and hand hygiene should be performed after every glove change. During an interview on 5/18/2026 at 4:00 PM, the Executive Director verified PICC line ports should be cleaned prior to attaching syringes to the device and all staff were expected to perform hand hygiene between glove changes. 4. Observations in Patient #7's home on 5/19/2026 at 9:40 AM revealed RN #2 performing wound care. RN #2 performed hand hygiene, donned gloves and removed the soiled dressing from Patient #7's left heel wound. RN #2 removed her gloves, donned new gloves without performing hand hygiene, then cleaned the Patient's wound per orders and patted dry. RN #2 removed her gloves, donned new gloves without performing hand hygiene, then gathered supplies for the dressing change, placed them on a barrier and removed her gloves. Without performing hand hygiene, RN #2 donned new gloves and placed a new dressing on the wound. RN #2 failed to perform hand hygiene after removing her gloves and prior to donning new gloves repeatedly. During an interview on 5/19/2026 at 10:32 AM, the Clinical Director verified RN #2 failed to perform hand hygiene between glove use repeatedly.