Every finding on record at Sev Home Care, Inc.

An Entrance Conference was conducted on 06/26/2023 with the Administrator/Alternate Supervising Nurse, Supervising Nurse and the Biller at 1:24 PM. The Agency representative was informed that the purpose of the survey was a Recertification survey. Written information regarding “What to Expect During Your Agency’s Survey” was provided. The Agency census was: L&CHHS – 147 LHHS – 0 PAS - 0 An Exit Conference was conducted on 06/29/2023 with the Administrator/Alternate Supervising Nurse, Supervising Nurse, and the Office Manager at 5:28 PM. The preliminary findings of the survey were discussed. The agency is in substantial compliance with no deficiencies cited.

An Entrance Conference was conducted on 06/26/2023 with the Administrator/Alternate Supervising Nurse, Supervising Nurse and the Biller at 1:24 PM. The Agency representative was informed that the purpose of the survey was a Recertification survey. Written information regarding “What to Expect During Your Agency’s Survey” was provided. The Agency census was: L&CHHS – 147 LHHS – 0 PAS - 0 An Exit Conference was conducted on 06/29/2023 with the Administrator/Alternate Supervising Nurse, Supervising Nurse, and the Office Manager at 5:28 PM. The preliminary findings were discussed. The Agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of receipt of the Statement of Deficiencies. Abbreviations/Acronyms: ADM – Administrator ALT – Alternate Administrator DON – Director of Nursing LVN – Licensed Vocational Nurse LHH – Licensed Home Health L&CHHS – Licensed and Certified Home Health Services PAS – Personal Assistance Services POC – Plan of Care RN – Registered Nurse

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 interview, record review and observation, the Agency failed to enforce its Hand Hygiene policy during 2 of 4 home visits, in that the Licensed Vocational Nurse (LVN A and LVN B) did not utilize proper hand hygiene when providing care and services to Client #2 and Client #3. Failure of the Agency to enforce its policy on Hand Hygiene has the potential to result in the spread of bacteria and may lead to infections amongst clients. Review of the Agency’s policy and procedure manual revealed a policy entitled “Administrative Policy Manual, IC.3 Hand Hygiene,” undated which read in part, “All Agency staff providing patient care will observe proper hand hygiene at a minimum: … 1. Prior to initial entry or re-entry into supply bag; 2. Before patient contact or providing direct patient care; 3. Before and after performing an invasive procedure/aseptic task; 4. After contact with the patient or objects in the immediate vicinity of the patient even when gloves are worn; … 6. Moving from a contaminated body site to a clean body site during patient care.” Review of the clinical record of Client #2 revealed a start of care date of 01/19/2023. Review of the Plan of Care for the certification period of 03/20/2023 to 05/18/2023 revealed a primary diagnosis of Intermittent A-fib (erratic heartbeat) and secondary diagnoses which included other instability, right knee, type 2 diabetes mellitus. The Plan of Care revealed the following orders, “SN to provide skilled assessment...” Review of the clinical record of Client #3 revealed a start of care date of 09/26/2022. Review of the Plan of Care for the certification period of 03/20/2023 to 05/18/2023 revealed a primary diagnosis of type 2 diabetes mellitus with foot wound and secondary diagnoses other bone infection, left ankle and foot. The Plan of Care revealed the following orders, “SN to assess for wound/skin signs and symptoms of infections. SN to instruct patient/caregiver regarding care of the skin including, care of wound, equipment sanitation and storage of supplies...” A home visit was conducted with Client #2 on 06/28/2023 at 10:00 AM. During the home visit, the surveyor observed LVN A placed gloves on to assess Client #2, during assessment sock was removed from foot. Foot area assessed, and pulses palpated. LVN A then proceeded to touch Client #2 medication’s bottles and glucometer. LVN A completed assessment without changing gloves or utilizing antibacterial after assessment of Client and contaminated Client’s personal belongings. A home visit was conducted with Client #3 on 06/28/2023 at 12:00 PM. During the home visit, the surveyor observed LVN B placed gloves on to assess Client #3. LVN B set up area for wound care on Client #3 bed. LVN B changed gloves and started to perform wound care on Client #3. During treatment LVN B clean wound using aseptic technique. LVN B noted to need additional 4x4’s. The 4x4’s was located in a strip pack in a plastic bag. LVN B placed soiled glove in clean 4x4 strip pack and removed 4x4’s and continued wound care. LVN B continued this process two additional times during performing the wound care. Review of the personnel record of LVN A revealed a signed job description for the position of Licensed Vocational Nurse, dated 03/17/2022. Further review of the personnel record of LVN A revealed a document entitled, “Nurse Competency Checklist,” which revealed orientation on Infection Control and Hand Hygiene had been provided to the Licensed Vocational Nurse. The “Nurse Competency Checklist,” was signed by LVN A, dated 03/19/2022. Review of the personnel record of LVN B revealed a signed job description for the position of Licensed Vocational Nurse, dated 11/15/2022. Further review of the personnel record of LVN B revealed a document entitled, “Nurse Competency Checklist,” which revealed orientation on Infection Control and Hand Hygiene had been provided to the Licensed Vocational Nurse. The “Nurse Competency Checklist,” was signed by LVN B, dated 11/28/2022. An interview was conducted with LVN A on 06/28/2023 at approximately 09:52 AM. LVN A was asked when she should change her gloves based on the Agency’s Policy and Procedures for Infection Control. She stated after contact with the Client and when soiled. LVN A was asked if she was aware that she had touched the Client’s foot to assess and then reviewed her medications and checked her glucometer reading with the same gloves. LVN A stated that she did not realize that she had done that. LVN A stated that she is aware that she should have changed her gloves after assessing the Client’s foot area. An interview was conducted with LVN B on 06/28/2023 at approximately 12:48 PM. LVN B was asked when he should change gloves based on the Agency’s Policy and Procedures for Infection Control. LVN B stated before and after wound care. LVN B was asked if he was aware that he contaminated the 4x4 sleeve. LVN B stated he did not realize that he did not change his gloves. LVN B said that he knew he was to have changed his gloves each time he entered the wound items. An interview was conducted with the Administrator/Alternate Supervising Nurse on 06/28/2023 at 2:15 PM. The Administrator stated the Agency orients staff on infection control protocols at the time of hire. The Administrator was informed of the lack of hand hygiene that was observed during the Licensed Vocational Nurses visit with Client #1 and Client #2. The Administrator was asked what harm improper hand hygiene practices including this occurrence could have on Agency clients. The Administrator stated the LVN’s were trained in hand hygiene when working with Clients.