Initial Comments:Based on the findings of an onsite unannounced Medicare recertification and State relicense survey completed 11/7/2024, Advantage Home Health Services Llc 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 relicense survey completed 11/7/2024, Advantage Home Health Services Llc was found not to be in compliance with the following requirement 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 (OBV) 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 two (2) of seven (7) observations providing direct care to patients (OBV4 and OBV7).
Findings Included:
Review of the agency policy and procedures was conducted on 11/6/2024 at approximately 3:53 PM which revealed, "Bag Technique Policy, POLICY The Agency staff will demonstrate and maintain proper bag technique when completing home visits...PROCEDURE 1. Bag is professional in appearance and contains equipment necessary for home visit. 2. Bag placed on barrier on clean/dry/flat surface (or hung from a doorknob or back of a chair) 3. Hand hygiene performed before all patient care and before entering bag to remove supplies...4. Clean section to be kept closed at all times when not actively removing/putting things in bag...5. All supplies/equipment removed from bag will be placed on a "clean" barrier 6. All supplies/equipment after use (before being sanitized) will be placed on a separate "dirty" barrier 7. All supplies/equipment to be sanitized with alcohol wipes, Clorox wipes, or Sani-cloth disinfectant wipes prior to placing back in bag 8. Electronic device to record visit is placed on barrier throughout patient care 9. Clinician will dispose of all waste at end of visit prior to leaving home"
Review of the manufacture's direction for use on 11/7/2024 at approximately 3:45 PM revealed, "Sani-Cloth GERMICIDAL DISPOSABLE WIPE BACTERICIDAL, TUBERCULOCIDAL, VIRUCIDAL* IN 2 MINUTES SUITABLE FOR USE ON EQUIPMENT REQUIRING ALCOHOL-BADSED PRODUCTS...Contact time: Use wipe to thoroughly wet surface. Allow surface to remain visible wet for two (2) minutes. Let air dry..."
Review of the manufacture's direction for use on 11/7/2024 at approximately 3:45 PM revealed, "Clorox Disinfecting Wipes...Direction for Use...To disinfect and deodorize hard, nonporous surfaces: For visibly soiled surfaces, clean first. Wipe surface; use enough wipes for treated surface to remain visible wet for 4 minutes..."
Observations (OBV4), during a visit to residence MR2 on 11/6/2024 at 11:37 AM revealed, EMP5 provided direct patient care. The following equipment was observed being used during treatment: stethoscope, pulse oximeter, thermometer and blood pressure cuff. After patient use EMP5 wiped off each piece of equipment with Sain-Cloth and placed the reusable items immediately into the healthcare/equipment bag with no dry time.
Observations (OBV7) during a visit to residence MR4 on 11/6/2024 at 3:02 PM revealed: EMP6 provided direct patient care. EMP6 placed chucks/barriers on the patient's table. Removed an equipment caring bag from the healthcare/equipment bag. EMP6 placed the equipment caring bag on top of a chuck/barrier with both ends of the equipment caring bag being off the chuck/barrier onto the table. After patient use EMP6 wiped off each piece of equipment with Clorox Disinfecting Wipes and placed the reusable items immediately into the equipment caring bag with no dry time. Then placed the equipment caring bag into the healthcare/equipment bag without cleaning.
An exit interview with the vice president of clinical compliance, vice president of quality &; utilization, regional clinical manager and (via conference call) CEO on 11/6/2024 at approximately 3:52 PM confirmed the above findings.
Plan of Correction:All treating Clinicians will watch bag technique video and receive education on bag technique week of 12/1/24 by the Clinical Director or other assigned designee.
All treating clinicians will be observed and signed off on bag technique prior to 12/31/2024 with 100% compliance, by the Clinical Director or other assigned designee.
Ongoing education will be completed yearly and PRN as needed by the Clinical Director or other assigned designee.
Initial Comments:Based on the findings of an onsite unannounced State relicense survey completed 11/7/2024, Advantage Home Health Services Llc was found to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.
Plan of Correction:
Initial Comments:Based on the findings of an onsite unannounced Medicare recertification and State relicense survey completed 11/7/2024, Advantage Home Health Services Llc was found to be in compliance with the following 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 State relicense survey completed 11/7/2024, Advantage Home Health Services Llc was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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