Every finding on record at Vital Link Home Care, Inc.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to identify infections and complete agency surveillance infection reports for 4 of 10 sampled patients (Patient #1, Patient #6, Patient #7, and Patient #9) reviewed for infection control. Findings: Review of the agency’s Infection Prevention and Control Plan revealed monitoring and evaluation of key performance aspects of infection prevention and control surveillance, prevention and management. Further review revealed activities included, in part, continuously collecting and/or screening data to identify isolated incidents or potential infectious outbreaks; analyzing data for problems or undesirable trends; and determining if infections are organization acquired or community acquired. Patient #1 Review of Patient #1’s RN (Registered Nurse) Wound Care Note dated 06/23/2021 revealed a medication change was identified during a visit with education provided to Patient #1 on Ampicillin (antibiotic used to treat infection) and Minocycline (antibiotic used to treat infection). Review of Patient #1’s Patient Medication Record revealed Patient #1 was prescribed Ampicillin 500mg (milligrams) one capsule by mouth four times daily for 10 doses and Minocycline HCL (hydrochloride) 100mg one capsule by mouth twice daily for 10 days with a start date of 06/23/2021. Patient #6 Review of Patient #6’s Hospital Discharge paperwork dated 09/18/2021 revealed Patient #6 was to start Bactrim (antibiotic used to treat infection) DS (double strength) 800-160mg one tablet by mouth every Monday, Wednesday, and Friday. Review of Patient #6’s Patient Medication Record revealed Patient #6 was prescribed Bactrim DS 800-160mg by mouth every Monday, Wednesday, and Friday with start date of 09/24/2021. Patient #7 Review of Patient #7’s RN Labs Note dated 09/24/2021 revealed medication change identified at visit for Augmentin (antibiotic used to treat infection) for 7 days. Further review revealed Patient #7 was being treated for a urinary tract infection. Review of Patient #7’s Patient Medication Record revealed the following medications were prescribed: Augmentin 875-125mg one tablet by mouth daily for 7 days prescribed on 09/22/2021; Cefdinir (antibiotic used to treat infection) 300mg one capsule by mouth daily for 14 days prescribed on 10/07/2021; and Cefdinir (antibiotic used to treat infection) 300mg one capsule by mouth daily prescribed on 11/04/2021. Patient #9 Review of Patient #9’s Hospital Discharge paperwork dated 03/23/2021 revealed Patient #9 was to start taking Levofloxacin (antibiotic used to treat infection) 750mg one tablet daily for 7 days. Review of Patient #9’s Patient Medication Record revealed Patient #9 was prescribed Levofloxacin (antibiotic used to treat infection) 750mg one tablet daily for 7 days with a start date of 03/23/2021. Review of the agency’s Infection Control Logs for 2021 and 2022 revealed no documented evidence and the agency presented no documented evidence of the above named patients and infections having been identified by the agency and reviewed for trends in agency infection rates. In an interview on 05/20/2022 at 11:39am, S1DON (Director of Nursing) stated the process once an infection was identified or an antibiotic is started the staff will log into the software system and select the antibiotic, the date started, and type of infection. S1DON stated 6 days later she would get a notification of the infection and speak to the nurse and ensure the follow-up was completed and recorded in the system. S1DON stated she compiles the infections for that quarter, investigates any trends and types of infections and as well as the staff providing the care. S1DON stated the only system to ensure infection reports were completed was when they reviewed random notes. In an interview on 05/20/2022 at 12:31pm, S1DON stated the agency had not completed infection control reports; therefore had not looked for trends regarding these infections for the patients listed above. S1DON confirmed the infections for the above patients were not tracked or trended, and the infection control reports were not completed.