Initial Comments:
Name - Component - --Based on the findings of an onsite unannounced Medicare Recertification and State Licensure Survey conducted May 18, 2026, through May 21, 2026, Interim Healthcare Of Erie 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.
Plan of Correction:
Initial Comments:Based on the findings of an onsite unannounced Medicare Recertification and State Licensure Survey conducted May 18, 2026, through May 21, 2026, Interim Healthcare Of Erie 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.
Plan of Correction:
484.70(a) STANDARD
Infection Prevention
Name - Component - 00
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.
Observations:
Based on review of agency policy and procedure, observations (OBS) during home visits and staff (EMP) interview, the agency failed to ensure staff followed infection control standards of practice and agency policy and procedure for four (4) of seven (7) observations providing direct care to patients (OBS2, OBS5, OBS6, OBS7).
Findings Included:
Review of the agency policy and procedures was conducted 5/18/2025 at approximately 11:00am revealed, "Policy Addendum: Equipment/Medical Supply Bag Process...
Policy
Health care staff prevent contamination of the supply bag and its contents.
Health care staff protect patients, household members, and health care workers from the spread of infection....
PURPOSE: To prevent the spread of pathogens from one patient to another. d) Spread an impervious barrier (e.g., disposable under pad, plastic bag, wax paper, etc.) on the surface before setting the bag down to help prevent the transmission of infections.
10) After the completion of care, decontaminate your hands by washing your hands with soap and water, wipe off reusable equipment with a disinfecting wipe or alcohol swab before replacing into the bag and repack your bag...."
During a home visit observation Consumer Record (CR) #2 OBS2, on 5/19/2026 at approximately 11:00am Employee (EMP)10 provided direct patient care. EMP10 placed bag on surface without a barrier under the bag and then removed a non-disposable barrier from the bag to place supplies on. Barrier was then wiped with disinfectant and returned to the supply bag.
During a home visit observation CR #4 OBS5, on 5/19/2026 at approximately 2:00pm EMP11 provided direct patient care. EMP11 used a non-disposable barrier from the bag to place supplies on.
During a home visit observation CR #5 OBS6, on 5/20/2026 at approximately 8:30am EMP12 provided direct patient care. EMP11 Placed sanitized pulse oximeter and thermometer in pocket instead of returning to supply bag. Stethoscope was not cleaned, remained around EMP11 neck when leaving the residence.
During a home visit observation CR #6 OBS7, on 5/20/2026 at approximately 9:45am EMP13 provided direct patient care. Household pets laid on cleaned barrier and previously cleaned location of stethoscope, blood pressure cuff, pulse oximeter, and thermometer. Items returned to the bag without cleaning after household pets had explored.
An exit interview with the Regional Manager and Clinical Manager on 5/21/2026 at approximately 2:45pm confirmed the above findings.
Plan of Correction:G0682 – 484.70(a) Infection Prevention
The Home Health Administrator will ensure 100% compliance June 20th, 2026, with accepted standards of infection control practice, and agency infection policy including the use of standard precautions to prevent the transmission of infections and communicable diseases.
The Clinical Manager and/or Regional Administrator will in-service all visiting clinical staff on infection control, bag technique, and the agency Infection Control Policy by 6/4/26.
Bag set-up, including the use of appropriate disposable barriers, will be verified for all visiting clinical staff. Bag technique competency will be demonstrated by visiting clinical staff following the in-service on 6/4/26 and signed off by the Regional Administrator, Clinical Manager, or Regional Manager of Clinical Operations. Clinical field staff unable to attend the in-service will receive the PowerPoint presentation and handout and must sign off on the education by 6/19/26.
The Regional Administrator or Clinical Manager will complete and document a supervisory visit with clinical staff cited during the DOH survey to validate infection prevention compliance by 6/12/26.
The Regional Administrator or Clinical Manager will complete and document supervisory visits for an additional 25% of current visiting clinical staff to validate infection prevention compliance by 6/19/26.
To ensure ongoing compliance with infection prevention and control standards, the Regional Administrator and/or Clinical Manager will be responsible for the following:
Completing and documenting a supervisory visit for 100% of newly hired visiting clinical staff within 60 days of their start date. The supervisory visit will include direct observation and demonstration of infection prevention practices in the home, including equipment cleaning and disinfection, appropriate bag set-up, use of disposable barriers, and proper bag technique.
Ensuring all visiting clinical staff demonstrate competency in infection prevention practices, including equipment cleaning and disinfection, appropriate bag set-up, use of disposable barriers, and proper bag technique through direct observation at least annually.
Maintaining a tracking log of infection prevention competency validations and supervisory visits to ensure compliance with agency requirements.
Reporting infection prevention competency compliance rates quarterly through the Quality Assurance Performance Improvement (QAPI) program until 100% compliance is achieved and sustained for four (4) consecutive quarters.
Following achievement of 100% compliance for four (4) consecutive quarters, infection prevention competency compliance will continue to be monitored annually and reported during the fourth quarter QAPI meeting and to the Governing Body/Board of Directors on an ongoing basis.
Initial Comments:Based on the findings of an onsite unannounced Medicare Recertification and State Licensure Survey conducted May 18, 2026, through May 21, 2026, Interim Healthcare Of Erie was found not to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.
Plan of Correction:
601.32(b) REQUIREMENT
DUTIES OF THE REGISTERED NURSE
Name - Component - 00
601.32(b) Duties of the Registered
Nurse. The registered nurse:
(i) makes the initial evaluation
visit,
(ii) regularly reevaluates the
patient's nursing needs,
(iii) initiates the plan of treatment
and necessary revisions,
(iv) provides those services
requiring substantial specialized
nursing skill,
(v) initiates appropriate
preventive and rehabilitative nursing
procedures,
(vi) prepares clinical and progress
notes,
(vii) coordinates services, and
(viii) informs the physician and other
personnel of changes in the patient's
condition and needs, counsels the
patient and family in meeting nursing
and related needs, participates in
inservice programs, and supervises and
teaches other nursing personnel.
Observations:
Based on review of agency policy and procedure, observations (OBS) during home visits and staff (EMP) interview, the agency failed to ensure staff followed infection control standards of practice and agency policy and procedure for four (4) of seven (7) observations providing direct care to patients (OBS2, OBS5, OBS6, OBS7).
Findings Included:
Review of the agency policy and procedures was conducted 5/18/2025 at approximately 11:00am revealed, "Policy Addendum: Equipment/Medical Supply Bag Process...
Policy
Health care staff prevent contamination of the supply bag and its contents.
Health care staff protect patients, household members, and health care workers from the spread of infection....
PURPOSE: To prevent the spread of pathogens from one patient to another. d) Spread an impervious barrier (e.g., disposable under pad, plastic bag, wax paper, etc.) on the surface before setting the bag down to help prevent the transmission of infections.
10) After the completion of care, decontaminate your hands by washing your hands with soap and water, wipe off reusable equipment with a disinfecting wipe or alcohol swab before replacing into the bag and repack your bag...."
During a home visit observation Consumer Record (CR) #2 OBS2, on 5/19/2026 at approximately 11:00am Employee (EMP)10 provided direct patient care. EMP10 placed bag on surface without a barrier under the bag and then removed a non-disposable barrier from the bag to place supplies on. Barrier was then wiped with disinfectant and returned to the supply bag.
During a home visit observation CR #4 OBS5, on 5/19/2026 at approximately 2:00pm EMP11 provided direct patient care. EMP11 used a non-disposable barrier from the bag to place supplies on.
During a home visit observation CR #5 OBS6, on 5/20/2026 at approximately 8:30am EMP12 provided direct patient care. EMP11 Placed sanitized pulse oximeter and thermometer in pocket instead of returning to supply bag. Stethoscope was not cleaned, remained around EMP11 neck when leaving the residence.
During a home visit observation CR #6 OBS7, on 5/20/2026 at approximately 9:45am EMP13 provided direct patient care. Household pets laid on cleaned barrier and previously cleaned location of stethoscope, blood pressure cuff, pulse oximeter, and thermometer. Items returned to the bag without cleaning after household pets had explored.
An exit interview with the Regional Manager and Clinical Manager on 5/21/2026 at approximately 2:45pm confirmed the above findings.
Plan of Correction:M 1023 601.32(b) DUTIES OF THE REGISTERED NURSE
The Home Health Administrator will ensure 100% compliance June 20th, 2026, with accepted standards of infection control practice, and agency infection policy including the use of standard precautions to prevent the transmission of infections and communicable diseases.
The Clinical Manager and/or Regional Administrator will in-service all visiting clinical staff on infection control, bag technique, and the agency Infection Control Policy by 6/4/26.
Bag set-up, including the use of appropriate disposable barriers, will be verified for all visiting clinical staff. Bag technique competency will be demonstrated by visiting clinical staff following the in-service on 6/4/26 and signed off by the Regional Administrator, Clinical Manager, or Regional Manager of Clinical Operations. Clinical field staff unable to attend the in-service will receive the PowerPoint presentation and handout and must sign off on the education by 6/19/26.
The Regional Administrator or Clinical Manager will complete and document a supervisory visit with clinical staff cited during the DOH survey to validate infection prevention compliance by 6/12/26.
The Regional Administrator or Clinical Manager will complete and document supervisory visits for an additional 25% of current visiting clinical staff to validate infection prevention compliance by 6/19/26.
To ensure ongoing compliance with infection prevention and control standards, the Regional Administrator and/or Clinical Manager will be responsible for the following:
Completing and documenting a supervisory visit for 100% of newly hired visiting clinical staff within 60 days of their start date. The supervisory visit will include direct observation and demonstration of infection prevention practices in the home, including equipment cleaning and disinfection, appropriate bag set-up, use of disposable barriers, and proper bag technique.
Ensuring all visiting clinical staff demonstrate competency in infection prevention practices, including equipment cleaning and disinfection, appropriate bag set-up, use of disposable barriers, and proper bag technique through direct observation at least annually.
Maintaining a tracking log of infection prevention competency validations and supervisory visits to ensure compliance with agency requirements.
Reporting infection prevention competency compliance rates quarterly through the Quality Assurance Performance Improvement (QAPI) program until 100% compliance is achieved and sustained for four (4) consecutive quarters.
Following achievement of 100% compliance for four (4) consecutive quarters, infection prevention competency compliance will continue to be monitored annually and reported during the fourth quarter QAPI meeting and to the Governing Body/Board of Directors on an ongoing basis.
Initial Comments:Based on the findings of an onsite unannounced Medicare Recertification and State Licensure Survey conducted May 18, 2026, through May 21, 2026, Interim Healthcare Of Erie was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:Based on the findings of an onsite unannounced Medicare Recertification and State Licensure Survey conducted May 18, 2026, through May 21, 2026, Interim Healthcare Of Erie was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
|