Every finding on record at Visiting Nurse Association of Cleveland

Emergency Preparedness Survey At the time of the emergency preparedness survey completed on 08/19/21, Visiting Nurse Association of Cleveland is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Partial Extended Recertification Survey COVID 19 FOCUSED INFECTION CONTROL SURVEY The following deficiency is based on the partial extended recertification survey and the COVID 19 Focused Infection Control Survey completed on 08/19/21. Visiting Nurse Association of Cleveland, 367022, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C, Home Health Agency. An entrance conference was conducted on 08/16/21 at 12:40 PM with administrative staff, an exit conference was conducted on 08/19/21 at 2:30 PM with administrative staff.

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, policy review, and staff interview, the facility failed to ensure a proper infection control was maintained during staple removal. This affected one(#11) of one patient observed to have staples removed. The census was 712. Findings included: Observation on 08/17/21 at 11:00 AM during a home visit to Patient #11 revealed the Registered Nurse (RN) present to remove staples. The RN was observed to set up clean field on table across the room with supplies. The RN then opened 4 by 4 gauze and placed the wrapper on a second table next to Patient #11, who was in a recliner chair. The RN placed scissors and the staple removal on this 4 x 4 paper without placing a clean barrier underneath first. The handles of the scissors and staple removal both touched the bare table. With the same pair of gloves, the RN then placed their left hand on the RN's left thigh when reaching over the patient's leg to remove a staple with the staple remover in the right hand. The RN then picked up the steri-strips with the left hand and placed them on the patient's leg while cutting them with the scissors held in the right hand. Using the same pair of gloves this process repeated for all 22 staples removed. Review of facility policy titled "Surgical Staple/Suture Removal" with no effective date, revealed prepare clean field, open supplies, maintaining asepsis, then apply clean gloves. Per interview on 08/19/21 at 9:38 AM the Director of Infection Control confirmed a clean barrier should have been placed under all supplies, gloves should have been changed after the supplies were set up and the RN, should not have touched their own leg and used same gloves to apply Steri-Strips. Based on observation, policy review, and staff interview, the facility failed to ensure a proper infection control was maintained during staple removal. This affected one(#11) of one patient observed to have staples removed. The census was 712. Findings included: Observation on 08/17/21 at 11:00 AM during a home visit to Patient #11 revealed the Registered Nurse (RN) present to remove staples. The RN was observed to set up clean field on table across the room with supplies. The RN then opened 4 by 4 gauze and placed the wrapper on a second table next to Patient #11, who was in a recliner chair. The RN placed scissors and the staple removal on this 4 x 4 paper without placing a clean barrier underneath first. The handles of the scissors and staple removal both touched the bare table. With the same pair of gloves, the RN then placed their left hand on the RN's left thigh when reaching over the patient's leg to remove a staple with the staple remover in the right hand. The RN then picked up the steri-strips with the left hand and placed them on the patient's leg while cutting them with the scissors held in the right hand. Using the same pair of gloves this process repeated for all 22 staples removed. Review of facility policy titled "Surgical Staple/Suture Removal" with no effective date, revealed prepare clean field, open supplies, maintaining asepsis, then apply clean gloves. Per interview on 08/19/21 at 9:38 AM the Director of Infection Control confirmed a clean barrier should have been placed under all supplies, gloves should have been changed after the supplies were set up and the RN, should not have touched their own leg and used same gloves to apply Steri-Strips.