Every finding on record at Sunrise Primary Care Services

A recertification survey entrance conference was conducted on 09/18/2023 at10:00 a.m. with the Administrator. Census: L&C: 88 An exit conference was conducted on 09/2/2023 at 02:05 p.m. with the Administrator. The preliminary findings were discussed. The agency was in substantial compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A recertification survey entrance conference was conducted on 09/18/2023 at 10:00a.m. with the Administrator. Census: L&C: 88 An exit conference was conducted on 09/2/2023 at 02:05 p.m. with the Administrator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Acronyms: POC - Plan of Care SOC - Start of Care RN - Registered Nurse cc - cubic centimeter ml - milliliter

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, interview, and record review the agency failed to ensure one of three staff (RN A) observed during care of one of three patients (#5) followed accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases in that: RN A did not prevent cross-contamination by wiping from a clean body site to a contaminated body site but wiped the opposite direction during indwelling catheter change. This failure could affect all patients in the agency and could result in spread of infection. The findings were: Record review of Patient # 5's POC (for certification period 06/18/2023 to 08/16/2023) revealed a SOC of 11/06/2019, diagnoses included Encounter for fitting and adjustment of urinary device and Retention of urine. Further review revealed orders for skill nursing to change indwelling catheter with 16 French 10 cc (cubic centimeters, same as milliliters) catheter every month. Record review of RN A's Self-Assessment for Nursing Skills Checklist (dated 07/28/2023) revealed RN A was checked for being competent in catheterization of female on 07/28/2023. During a home visit on 09/20/2023 at time 01:15 p.m., RN A was observed changing Patient #5's indwelling catheter. Further observation revealed during the process, RN A used three betadine swabs to wipe Patient # 5's peri area going from back to front. During an interview following the care on 09/20/2023 at 01:55 p.m., RN A revealed he should have wiped from top to bottom (going from front to back of the peri-area) to not introduce anything from the rectum. During an interview on 09/21/2023 at 11:12 a.m., the Administrator revealed the agency's care practices for nurses included skills self-assessment that was checked off by a supervisor and a video during orientation. The Administrator further revealed staff were trained to wipe from front to back. During an interview on 09/21/2023 at 01:08 p.m., the Administrator revealed the agency did not have an exact procedure for catheter change in their nursing care practices binder. During a concurrent observation on 09/21/2023 at 11:43 a.m. of the agency's catheter care video with RN B titled "Inserting a Foley Catheter on a female patient/skill demo" revealed the procedure included to wipe the peri-area with betadine swabs going from front to back. Interview with RN B, Alternate Supervising Nurse, revealed the standard practice for female catheter change was wiping from top to bottom (front to back). Record review of the agency's policy and procedure titled "Infection Control Program (unknown date)", read in part, "...1. Staff are educated on minimizing the risk of spreading infection and communicable diseases include as a minimum: c. Processes to ensure that all healthcare personnel understand and are competent to adhere to infection prevention requirements as they perform their roles and responsibilities..." Record review of the agency's nursing care practices binder titled "Evidence Based Clinical Practices-Protocols and Interventions to Reduce Avoidable Acute Care Hospitalizations and Improve Patient Self Management Skills (revised 2023)" revealed no procedure for catheter care.