Every finding on record at Princeton Community Homecare, LLC

An emergency preparedness survey was conducted at Princeton Community Health on May 20, 2024 through May 22, 2024 as part of a recertification survey conducted during the same survey period. The agency was not in compliance with the Emergency Preparedness Conditions of Participation for Home Health Agencies, with deficiencies cited at E0009.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review, documentation review, and interview it was revealed the facility failed to participation in a coordinated disaster preparedness response mock tabletop exercise with emergency management resources and the local health department. The failure to participate in a mock tabletop drill to plan and address community needs in case of a disaster has a negative impact on the agency staff and patients. Findings are as follows: A policy titled, “Emergency Preparedness/Operation Plan” dated revised 08/01/22; was reviewed and stated, in part, “Purpose: To provide protocol and process for prompt action to be taken to assist the agency’s patients before, during and following man-made and natural emergencies and/or disasters. Policy: The Executive Director, Alternate Execute Director, Clinical Director, or their designed will activate and coordinate the procedures in the plan below according to the needs resulting from the emergency or disaster … B. Preparation for emergencies and Disasters: (Preparation) General … 9. The agency shall test their emergency operations plan annually. The agency must do one of the following … c. Mock disaster drill or tabletop exercise, but this method is only allowed every other year …” A record review of the Emergency Management Plan (EEP) Notebook revealed no evidence that the agency participated in a mock tabletop exercise with emergency management resources or with the local health department to assist in planning and addressing broader community needs in case of a disaster. An interview was conducted with Employee #7 on 05/21/24 at 9:00 p.m. Employee #7 states, “The Princeton and Beckley offices has not participated in any emergency preparedness tabletop exercise since I have been here. I have been here for two (2) years now.”

A recertification survey was conducted at Princeton Community Health on May 20, 2024 through May 22, 2024, 2024. It was determined the agency was not in compliance with the requirement of 42 CFR, Part 484.- The Medicare Condition of Participation for Home Health Agencies, with the deficiencies cited at G0682.

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, document review, and staff interview, the facility failed to ensure that iPad sanitation, hand hygiene, and glove usage were not according to the agency’s policies. This failure has the potential to negatively impact all Patients receiving treatments from the agency. Findings are as follow: A policy, titled “Cleaning of Re-Useable Equipment” revised on 06/01/2022 was reviewed. The policy stated in part, “... Procedure …. 6 … a. The hand-held computer device (i.e. tablet or smartphone) should be wiped down with a low-level disinfectant at the beginning and end of each visit. …” A policy, titled “Hand Hygiene” revised on 05/01/2019 was reviewed. The policy stated in part, “... Policy: Staff are required to perform hand hygiene will be performed using soap and water or an alcohol-based hand sanitizer. Procedure: 1. Staff performs hand hygiene by handwashing with soap and water or using an alcohol-based hand sanitizer: a. Before direct contact with Patients …” A policy, titled “Standard Precautions” revised on 12/01/2021 was reviewed. The policy stated in part, “... Procedure: 1. Tasks are classified in two categories of potential exposure to determine necessary precautions: a. Tasks I: involving potential exposure to bodily fluids; require appropriate protective measure; b. Tasks II: involving no potential exposure to body fluids … 3. All Patients are considered as potentially infected with pathogens … 4. Standard Precautions include: … b. Gloves iii. Change gloves between tasks and procedures on the same Patient and after contact with material that may contain a high concentration of microorganisms. Iv. Remove gloves promptly after use, before touching non contaminated items and environmental surfaces …” A document, titled “Home Care Bag Protocol Job Aid” not dated was reviewed. The document stated in part, “... 10. Perform hand hygiene prior to removing any equipment or supplies from the bag …” An observation was conducted on 05/21/24 at 11:03 a.m. on Patient #1’s home. Employee #1 wiped down the iPad and placed the iPad on the supply bag. An observation was conducted on 05/21/24 at 11:03 a.m. on Patient #1’s home. Employee #1 took out the equipment such as, stethoscope, blood pressure cup, pulse ox, and thermometer but was not observed to perform hand hygiene. An observation was conducted on 05/22/24 at 08:56 a.m. on Patient #2’s home. Employee #2 start using the iPad without disinfecting it. An observation was conducted on 05/22/24 at 09:51 a.m. on Patient #3’s home. Employee #3 performed hand hygiene and wore gloves prior to making direct contact with the Patient’s ankle. After examining the Patient, Employee #4 checked Patient’s medication bottles without changing gloves. An interview was conducted with Employee #1 on 05/21/24 at 11:05 a.m. When asked if the agency allowed the iPad to be laid on the supply bag after it has been disinfected, Employee #1 stated, “I done it this way (placing the iPad on the supply bag) and no one said anything.” Employee #1 further stated that [she/he] was not aware if there was a specific policy regarding where the iPad has to be placed after being disinfected and Employee #1 cleaned the interior and exterior of the supply bag daily. To the question if Employee #1 performed hand hygiene, Employee #1 answered, “I sanitized my hands in my car. But not since I entered the Patient’s home.” An interview was conducted with Employee #2 on 05/22/24 at about 09:00 a.m. To the question of the iPad requiring sanitation, Employee #2 stated, “I don’t think there is any specific policy about sanitizing the iPad.” Employee #2 further stated that just like the equipment was already sanitized and it (equipment) didn’t need to be sanitized, the iPad was considered clean. An interview was conducted with Employee #3 on 05/22/24 at a about 10:00 a.m. Employee #3 explained the glove policy as, “The gloves only need to be changed if there is bodily fluid, blood, visibly soiled, puncture, or ripped. But if the gloves are clean, you don’t have to change the gloves.” An interview was conducted with Employee #4 and Employee #5 on 05/22/24 at 11:13 a.m. Regarding the sanitized iPad being placed on a staff’s supply bag, Employee #5 stated that [she/he] was not aware of any specific policy. Employee #6 responded, “If the iPad was sanitized and placed on the supply bag, I’m going to say that’s not okay. The outside of the supply bag is not considered clean.” Employee #4 and Emp. #5 agreed that iPad had to be sanitized before and after the visit to the Patient's home. Regarding hand hygiene, both Employee #4 and Employee #5 agreed that hand hygiene should have been performed upon entering the Patient’s home. Employee #5 responded, “From the car to the Patient’s home, the hand become contaminated by touching other objects. The hand hygiene should have been performed upon entering the Patient’s home even if it (hand hygiene) was done in the car.” An interview was conducted with Employee #6 on 05/22/24 at about 12:00 p.m. To the question regarding the policy of wearing/changing gloves, Employee #6 stated, “If you were touching a Patient and moved on to touching something else, I would say that it’s a different task and the gloves had to be changed.”