Every finding on record at Touch of Love Home Health Care Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 09-26-2023 and 09-27-2023 Current Census: 16 At this Emergency Preparedness survey, Touch of Love Home Health Care Inc, was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR completed by Area 3 on 09-28-2023.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 09-26-2023 and 09-27-2023 Partial Extended Survey Announced 09-27-2023 at 3:20 PM. 12 Month Unduplicated Skilled Admissions: 8 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR completed by Area 3 on 09-28-2023.

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, record review, and interview, the agency failed to ensure infection control practices were upheld according to the agency’s policy in 3 of 3 home visits for hand hygiene and gloving. (Employee: Home Health Aide (HHA)1, HHA 4 and the Alternate Clinical Manager) Findings Include: On 09-27-2023 at 10:06 AM, the Alternate Clinical Supervisor was observed performing wound care at Patient #1’s residence. The Alternate Clinical Supervisor opened their bag and reached in to grab a Silicone faced foam and border pad and two normal saline bullets and placed them on a clean barrier. The Alternate Clinical Supervisor failed to perform hand hygiene prior to entering their bag. They reached into the bag again without sanitizing their hands and retrieved a clear dressing. They reached into their second bag without sanitizing their hands and grabbed gloves. They reached back into the first bag and failed to sanitize their hands prior to entering the bag to grab alcohol pads, 4x4 gauze, and Q-tips. The Alternate Clinical Supervisor failed to use hand sanitizer prior to donning gloves. They removed the old, soiled bandage and reached onto their clean barrier with the same gloves to grab a normal saline bullet and a 4x4 gauze, then proceeded to clean the wound with the normal saline and gauze. They reached back onto the clean barrier to open the clean Q-tip bag with the same gloves and grabbed one Q-tip and placed the Q-tip bag back on the clean barrier. They reached back onto the clean barrier to grab another Q-tip, 4x4 gauze, and a normal saline bullet and cleaned the wound. After the Alternate Clinical Manager placed the Silver Alginate (wound dressing) in the wound using a clean Q-tip and a gloved hand, they grabbed the clean Silicone faced foam and border and Superabsorbent pad on top of the wound with the same gloves used to help place the Silver Alginate in the wound. They then retrieved a clear dressing ion top of the foam dressings with the same gloves. The Alternate Clinical Manager failed to ensure they sanitized hands at the proper times during the home visit. 1. On 09-27-2023 at 4:20 PM, the Administrator provided a policy updated 07-18-2022, titled, “Handwashing/Hand Hygiene”. The policy indicated but was not limited to, “Policy: In effort to reduce the risk of infection in clients and staff … Indications for hand washing and hand antisepsis: … d. Between tasks on the same client. e. before touching a wound. f. After removing gloves. g. After touching objects that are potentially contaminated … l. Before eating, drinking, handling food, or serving food … q. Decontaminate hands after contact with inanimate objects including equipment in the immediate vicinity of the client … ” 2. A home visit observation occurred on 09-27-2023 at 9:30 AM, at the residence of Patient #5. The Home Health Aide (HHA) 1, was observed to don gloves without hand hygiene, provided a dish of applesauce, obtain ice out of the freeze, and prepare lemon water in a glass, for Patient #5 to take their medications. HHA 1 removed their gloves, discarded them in the trash receptacle, donned new gloves without performing hand hygiene, washed the dishes, put away the dishes, and took out the trash. The HHA reminded Patient #5 to check their Dexcom meter (a digital machine that gives digital readings of the blood sugar in the blood) after they ate. Patient #5 indicated they needed grape juice due to their reading was a little lower than it was. The HHA donned gloved gloves, without performing hand hygiene, then prepared a glass of grape juice with ice, and a straw and handed it to Patient #5. During an interview on 09-27-2023 at 10:30 AM, when queried regarding when they were to perform hand hygiene, HHA 1 confirmed they did not wash their hands before donning gloves or after they removed them. 3. A home visit observation occurred on 09-27-2023 at 1:35 PM, at the residence of Patient #4. The HHA 4, was observed donning gloves without hand hygiene and washed a pot in the sink. Afterward, HHA was observed to reach in their pocket with their gloved hand to look at their phone that rang. HHA 4 removed their gloves, discarded their gloves in the trash receptacle, washed their hands at the kitchen sink, used a towel obtained from the drawer, then turned the sink faucet off with their bare hand, and donned gloves they obtained from their pocket. The HHA failed to perform hand hygiene before donning gloves and failed to perform hand hygiene after touching an innate object. During an interview on 09-27-2023 at 3:20 PM, the Clinical Manager indicated hand hygiene is to be completed before donning gloves and after gloves are removed, after getting into their bag, after touching equipment, or when their hands are visibly soiled.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the after-hours-on-call number was operating and available to the public, patients, and employees as noted after 4 of 4 unsuccessful attempts to reach the Nurse on call on the agency after-hours phone number. Findings Include: 1. On 09-27-2023 at 4:20 PM, the Administrator provided an undated Touch of Love Home Health Care Incorporated (Inc.) policy titled “On-Call Procedure Policy”. The policy indicated but was not limited to, “ … Policy: Touch of Love Home Health Care Inc. requires 24/7 on call services for emergencies and urgent situations for our home health care clients … outside of regular business hours … Procedure … On -call personnel shall respond to calls promptly and assess the situation …” 2. On 09-26-2023 at 6:00 PM, an attempt to call the after-hours-on-call phone was made. A voicemail was left on the answering machine requesting a return call. The on-call number was listed in the admission packet. The agency failed to answer the on-call phone. 3. On 09-26-2023 at 6:06 PM, an attempt to call the office phone was made. Pressed 2 after direction from recording to reach the nurse, a voicemail was left on the answering machine requesting a return call. The agency failed to answer the on-call phone. 4. On 09-27-2023 at 6:45 AM, an attempt to call the after-hours-on-call phone was made no answer received voicemail. The agency failed to answer the on-call phone. 5. On 09-27-2023 at 6:47 AM, an attempt to call the office phone was made. Pressed 2 after direction from recording to reach the nurse, no answer received voicemail. The agency failed to answer the on-call phone. 6. During the Entrance Conference on 09-26-2023 at 9:21 AM, the Alternate Administrator indicated the agency’s on-call process was handled via a nurse carrying the on-call phone. The Alternate Administrator further confirmed if someone were to call the office phone, the call would be transfer to the on-call nurse. 7. A review of the employee file of the Alternate Administrator, contained a job description signed and dated 10-18-2019, titled "Position: Administrator/Alternate Administrator." The job description indicated but was not limited to, " … 7. Assures compliance with federal/state regulations governing home health services … " 8. During an interview with the Administrator, Alternate Administrator, and Clinical Manager on 09-27-2023 at 3:20 PM, they confirmed the on-call number was correct, and that the office phone had the option to press 2 for a nurse and the call rolled to the on-call nurse phone. The Administrator called the on-call phone and verified the on-call phone number was working. The on-call phone did not ring, the phone ring volume was off. The Alternate Administrator indicated they were on call had not received any calls on 09-26-2023 and 09-27-2023. Upon further investigation the Alternate Administrator checked the call history and confirmed calls had been made to the on-call phone after hours on 09-26-2023 and 09-27-2023. 410 IAC 17-12-1 (c)(1)