Every finding on record at Signal Tree Home Health

EMERGENCY PREPAREDNESS SURVEY At the time of the emergency preparedness survey completed on 01/27/22, Signal Tree Home Health is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Recertification Survey An entrance conference was conducted on 01/25/22 at 10:28 AM with administrative staff. An exit conference was conducted on 01/27/22 at 3:51 AM with administrative staff. The following deficiency is based on the recertification survey completed 01/27/22. Signal Tree Home Health 369181, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

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 record review, observation and staff interview, the agency failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections for two of three patients with home visits (Patient #1 and 3). The total sample was seven. The census was 25. Findings include: Per interview on 01/27/22 at 11:43 AM Staff I stated this agency used the Robin Rice Home Health Procedures for sterile dressing changes. Review of "Robin Rice Home Health Procedures" for sterile dressing changes revealed the staff were to put on gloves then remove and discard the old dressing. Remove and discard dirty gloves, reapply clean or sterile gloves then continue. Review of agency policy titled, "Hand Hygiene Policy and Compliance Program," revised 10/2020, revealed indications for staff performing hand hygiene included after any contact with contaminated material (old dressing) and before re-entering nursing bag or patient's clean supplies (getting alcohol pads out of box on patient's table). Review of agency policy titled, "Exposure Control Plan: OSHA Regulations," revised 10/2020, revealed use aseptic technique for invasive procedures and care of intravenous devices (peripherally inserted central catheter (PICC) line). Bags used by nurses and other staff which contain equipment and are brought into the home are classified as clean on the inside and dirty on the outside therefore a barrier should be used under the bag. 1. On 01/26/22 at 11:00 AM a home visit was made to Patient #3 with Staff L, contracted occupational therapy assistant and Staff D, physical therapist, present. Staff L was observed to place his/her bag on the patient's floor without a clean barrier. Without wearing gloves, Staff L handed an exercise ball to patient's wife who handed the ball to the patient. The patient then handed the ball back to his wife who then handed it to Staff L. Staff L then placed the ball back in his/her bag without sanitizing it first. Interview with Staff D on 01/26/22 at 11:25 AM revealed he/she had also observed the interaction with Staff L, the patient and the patient's wife. 2. On 01/26/22 at 10:00 AM a home visit was made to Patient #1 with Staff J present. Staff J was observed to put on gloves and take the old PICC line dressing off and discard it. While using the same gloves, Staff J cleansed the site, applied a clean dressing, reached for alcohol pads from a box on the patient 's table, opened supplies, changed the PICC line cap and flushed both ports. Interview with Staff I on 01/27/22 at 1:56 PM confirmed the gloves should have been changed after the old dressing was removed and discarded. A PICC line dressing change should be as sterile as possible and reaching to obtain supplies from a box on the patient's table would contaminate the gloves.