Every finding on record at Western Pennsylvania Home Health Association

Based on the findings of an unannounced onsite State relicensure and Medicare recertification survey completed May 10, 2024, Western Pennsylvania Home Health Association was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced onsite Medicare recertification survey completed May 10, 2024, Western Pennsylvania Home Health Association, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 agency tour and observation of the supply cupboard, observations (OBS) during patient home visits (HV), review of agency policy and procedure and interview with the agency staff (EMP), the agency failed to ensure that acceptable standards of practice for infection control/prevention were maintained for one (1) of one (1) observation of agency supplies and two (2) of three (3) HV OBS (HV#2, HV#3). Findings include: Tour of the agency occurred on 5/7/24 at approximately 10:00 a.m. Observation of the supply cabinet at approximately 10:15 a.m. found the following expired supplies: (1) Zetuvit plus dressing with expiration date 8/1/23. (6) WHIN infusion sets with expiration date 4/30/22. (4) Small Bore Extension sets with expiration date 1/1/24. (2) with expiration date 2/1/24. (1) Claved Connection set with expiration date 5/2018. (2) with expiration date 8/2019. (1) with expiration date 11/2019. (1) with expiration date 11/2023. (3) Centurion VersaDerm 2/1/2 X 3 with expiration date 9/2021. Multiple 1/2 ml syringes with expiration date 7/31/22. Multiple Safety Lock 5 ml syringes with expiration date 2/28/22. Multiple AG packets with expiration date 9/2021. (3) Enluxtra wound dressing 4 x 4 with expiration date 10/2020. (1) Que 2450 culture kit with expiration 9/21/22. Interview with the agency Office Manager on 5/7/24 at approximately 10:25 a.m. confirmed the above findings. Review of the home health agency's (HHA) Policy and Procedure on 5/9/24 at approximately 10:00 a.m.: “Clean Bag Technique Policy ... 2. Objective: Minimizing the risk of cross -contamination and ensuring a clean and safe environment for patients…5. Procedure: Bag cannot be placed on a surface without a barrier. Setting up: Staff should ensure that bag is placed on barrier or hung…” On 5/8/24 at approximately 1:00 p.m.- HV#2. Surveyor observed employee (EMP3) placing equipment bag directly on the floor of the patient’s bedroom. No barrier was used between bag and the floor. On 5/8/24 at approximately 3:15 p.m.- HV#3. Surveyor observed (EMP4) wash patient’s wound with a cloth with a back-and-forth motion. Take the same cloth and dip the tip into a container to re-wet the cloth, return to the wound and wash patient’s wound with the up and down back and forth movement. After removing gloves, reach to the hand sanitizer bottle that was attached to her ID badge (string) that was hanging from her neck and use the hand sanitizer that was located under her ID badge. RN retrieved scissors from the supplies that were on a cart, cut the dressing and return the scissors back to the cart without cleaning them. Findings were reviewed on 5/9/24 at approximately 10:30 a.m. with the Administrator and the Office Manager.