Every finding on record at Yakima Valley Memorial Hospital Association

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 Part 484 for Home Health Services conducted this health and safety survey. Service Category: Home Health Examination number: X2021-835 Dates Onsite: 09/20-22/21 This survey was conducted by: Surveyor #4 Surveyor #5 DOH staff found the facility in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below. DOH recommends recertification based on an acceptable plan of correction. .

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, document review, and interview, the agency failed to properly prevent COVID-19 through failure to ensure that staff wore eye protection consistent with Washington State regulations for 6 of 7 Home Health staff (Staff #405, #407, #408, #409, #503, and #504). Failure to ensure staff wear eye protection when performing patient care, risks staff and patients' exposure to infectious organisms including COVID-19. References: WAC 246-335-525(15) personnel, contractor, and volunteer policies. The applicant or license must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (15) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include at minimum: (a) Standard precautions such as hand hygiene, respiratory hygiene and cough etiquette, and personal protective equipment; WAC 206-800-160 You must make sure that your employees have, use, and care for the appropriate personal protective equipment (PPE). PPE is an item or items used to protect the eyes, face, head, body, arms, hands, legs, and feet such as goggles, helmets, head covers, gloves, rubber slickers, disposable coveralls, safety shoes, protective shields, and barriers. WAC 296-800-16040 You must require your employees to use necessary PPE on the job. Findings included: 1. Document review of the guidance document issued by the Department of Health (DOH) and Labor & Industries (L&I) titled, "L&I and DOH Respirator and PPE for In-Home Care Agencies: Employer responsibilities for respiratory protection program and provision of personal protective equipment (PPE)," (DOH 420-329) issued March 30, 2021, and updated July 7, 2021, showed that In-home care agencies are required to develop and maintain a Respiratory Protection Program (RPP) under WAC 296-842-12005. The document also showed that agencies are required to provide gowns, gloves, and eye protection to staff who are entering patient's homes. The document further stated that staff must wear eye protection when there is moderate to substantial community transmission of COVID-19. The document defined eye protection as, goggles or a face shield that covers the front and sides of the face. The document stated that personal eyeglasses are not PPE and do not provide adequate eye protection. Document review of the guidance document issued by the Department of Health (DOH) titled, "COVID-19 Guidance for Home Care, Home Health, and Hospice Agencies," (DOH 420-299) updated June 09, 2021 showed when COVID-19 community transmission case rate is greater than 25 per 100,000, in 2 weeks, Health Care Workers (HCW) are to wear a surgical face mask and eye protection for ALL patient care encounters, regardless of patient/client COVID-19 status. According to DOH COVID-19 cases and testing for Yakima County, the 2-week transmission rate at the time of survey was 672 per 100,000. 2. On 09/20/21 at 3:45 PM, Surveyor #4 conducted a home visit with a Social Worker (Staff #402). Observations showed Staff #402 wore googles over the top of their eyeglasses. The googles were too small to fit securely over the glasses leaving gaps around Staff #402's eyes. The goggles did not provide eye protection. a. On 09/21/21 at 1:00 PM, Surveyor #4 conducted a home visit with a Registered Nurse (Staff #404). Observations showed Staff #404 wore googles over the top of their eyeglasses. The googles were not designed to fit over eyeglasses and left gaps around Staff #404's face. The goggles did not provide eye protection. b. On 09/21/21 at 12:30 PM, Surveyor #5 conducted a home visit with a Registered Nurse (Staff #507). Observation showed Staff #507 failed to wear eye protection while woring with Patient #501. 3. On 09/22/21 Surveyor #4 reviewed the agency's COVID-19 Personal Safety Eyewear policy dated 12/09/20. The policy showed that safety glasses must be: snuggly fitted with minimal gaps, well fitted across the brow, and provide good protection at the corners of the eyes. 4. On 09/22/21 at 12:55 PM, Surveyor #4 interviewed the Executive Director (Staff #401) about staff use of eye protection. Staff #401 stated that all staff were required to wear eye protection during home visits and that staff should have worn a face shield if their goggles didn't fit over their glasses properly.