Every finding on record at Star Valley Healthcare Inc Dba/Symbii Home Health

An Emergency Preparedness survey was conducted by Healthcare Licensing and Surveys on 1/15/25. Based upon the findings of the survey, it was determined that no deficiencies were identified pertaining to the Emergency Preparedness Rule.

A recertification survey was conducted by Healthcare Licensing and Surveys from 1/13/25 to 1/16/25.

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, staff interview and policy and procedure review, the agency failed to ensure infection prevention practices were performed during 1 of 3 patient home visits (#4) while providing cares. The findings were: Review of the plan of care for patient #4, certification period of 1/4/25 to 3/4/25, showed diagnoses which included encounter for change or removal of drains, malignant pleural effusion, malignant neoplasm of unspecified lung, malignant neoplasm of bone, of liver and intrahepatic bile duct, hypo-osmolality and hyponatremia, and lymphedema. Review of the orders showed "indwelling pleural catheter site and drainage wound care is as follows: wipe the circumference of peri wound with sterile alcohol wipe, apply foam dressing and sterile 4 by 4 covered with tegaderm all dressing supplies provided by Huntsman Cancer Institute along with indwelling pleural catheter (IPC) drainage device, Skilled nurse (SN) to perform care 3 times (x) weekly. As needed (PRN) visits for dressing failure of signs symptoms (s/s) of infection. Review of the goals included patient / caregiver will verbalize understanding of infection control / prevention. The following concerns were identified: a. Observation on 1/15/25 at 8:30 AM of LPN #1 providing wound care for patient #4 showed the nurse performed hand hygiene and setup the wound care supplies in a sterile process. She donned gloves, removed the old dressing on the right upper back, donned sterile gloves, connected the drain tubing, and drained 50 cubic centimeters (cc). She disconnected the tubing and cleansed the wound area. She then applied a sterile dressed over the site. The nurse then doffed her gloves. The nurse failed to perform hand hygiene between glove changes during wound care. She then performed the same care to the left upper back wound care. Again, failing to perform hand hygiene between donning and doffing of gloves during the wound care. b. Interview at that time with the LPN revealed she always did wound care that way. She acknowledged she should have done hand hygiene between the glove changes. 2. Interview with the Director of Clinical Services on 1/15/25 at 10:17 AM revealed it was the expectation for staff to do hand hygiene prior to donning gloves, between donning and doffing gloves, and after doffing gloves. 3. Review of policy and procedure “Hand Hygiene” revised 5/2024 showed “…3. Hand decontamination using an alcohol-based hand rub should be performed: B. Before donning sterile gloves when performing sterile procedures… G. After removing gloves…”

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, staff interview, professional standard review, and policy and procedure review, the agency failed to ensure supplies available for patient use were not expired for 1 of 1 supply room. The findings were: 1. Observation of the supply room on 1/15/25 at 2:39 PM with the Office Manager showed the following concerns: a. Ten Heparin lock flush solution 30 USP (using a USP reference standard based on units of heparin activity per milligram) units per 3 milliliters (ml) expired on 11/24. b. Heparin Lock flush 500 USP units per 5 ml, 2 expired on 8/1/24, 1 expired on 8/1/23, and 46 expired on 11/30/24. 2. Interview at that time with the Office Manager revealed the agency checked for expirations monthly. He confirmed the medical supplies were for client use and were expired. 3. Review of the website "fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines"[sec] accessed on 1/24/25 showed "...The expiration date is a critical part of deciding if the product is safe to use and will work as intended... It is important to know and stick to the expiration date on your medicine. Using expired medicines is risky and possibly harmful to your health." 4. Review of the policy "Supply management, ambulatory care" reviewed 11/17/24 showed "...Complications ...stockpiling, supplies expiring before use..."

An Emergency Preparedness survey was conducted by Healthcare Licensing and Surveys from 1/4/22 to 1/6/22. Unless otherwise indicated, the general use of the terms "facility" or "facilities" refers to all providers and suppliers affected by this regulation. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. Based upon the findings of the survey team, it was determined that no deficiencies were identified pertaining to the Emergency Preparedness Rule.

A recertification survey was conducted by Healthcare Licensing and Surveys from 1/4/22 to1/6/22. In addition, a COVID-19 focused infection control survey was conducted by Healthcare Licensing and Surveys from 1/4/22 to 1/6/22. Based on the findings of the survey team, it was determined that no deficiencies were identified pertaining to the infection control survey.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation and staff interview, the agency failed to ensure supplies available for use were not expired for 1 of 1 supply room. The findings were: 1 Observation of the supply room on 1/4/22 at 2:18 PM identified the following concerns: a. Four 12 inch extension set, minibore, male/female luer lock with pinch clamp expired 11/2019. b. Seventy-six BD vacutainer serum blood collection tubes expired 12/31/21. c. Three Promogran Matrix 4.34 inch wound dressings expired 9/30/21. d. Six 20 French (Fr) silicone-elastomer - coated latex foley catheters expired 12/28/21. e. Two 22 Fr silicone-elastomer - coated latex foley catheters expired 11/28/21. 2. Interview with the administrator on 1/4/22 at 2:30 PM confirmed the medical supplies were available for client use, and were past the expiration dates.