Initial Comments:
Based on the findings of an onsite unannounced survey completed 2/5/2024, VNA Family Hospice was found to be in compliance with the requirements of 42 CFR, Part 418.113, Subpart D, Conditions of Participation: Hospice Care - Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey conducted 1/31/2024 through 2/5/2024, VNA Family Hospice was found not to be in compliance with the following requirement of 42 CFR, Part 418, Subparts A, C, and D, Conditions of Participation: Hospice Care.
Plan of Correction:
418.60(a) STANDARD
PREVENTION
Name - Component - 00
The hospice must follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions.
Observations:
Based on review of agency policy and procedure, observation (OBV), and staff (EMP) interviews, the agency failed to ensure two (2) of four (4) employees followed infection control policy and procedure during observations for bag technique conducted during (OBV2 MR2 and OBV3 MR3).
Findings included:
Review of the agency policy and procedures was conducted on 2/9/2024 at approximately 3:30 PM which revealed, " COMPETENCY CHECKLIST-BAG TECHNIQUE ...Principles: The nursing bagis to placed on a clean, dry, and hard surface. The inside of the bag and its contents are considered clean; therefore, following the procedure for hand washing prior to removing equipment and/or supplies must be followed first. Equipment used for patient care need cleansed or disinfected before returning them into the bag. The bag should not be left open in an unprotected area or on the floor ...8. Performed hand hygiene with soap and water or with Agency-approved Hand Sanitizer according to hand washing policy ...COMMENTS ...If retrieving additional items from the bag outside of this step, perform hand hygiene before and after retrieving the items. 9. Opened bag and removed the proper equipment including paper towels and disinfectant wipes needed to perform visit, and then closed bag. 10. After clean, reusable equipment is used, returns them to a paper towel designated for disinfecting... "
Observations (OBV2), during a visit to MR2 residence on 2/5/2024 at 9:40 AM revealed, EMP5 provided direct patient care. EMP5 placed the bag on a clean chuck/barrier on a chair. Then placed reusable items from the nursing bag on the chuck/barrier. A section of the nursing/supply bag was left unzipped and open during direct patient care. The electronic tablet was placed on top of the nursing bag during patient care and at 8:48 AM Clorox wipes were removed from the unzipped section of the nursing bag.
A visit was conducted to (OBV3) MR3 residence on 10/23/2023 at 8:35 AM revealed: EMP6 provided direct patient care. EMP6 removed items from open nursing/supply bag and placed the bag on a clean chuck/barrier on a bedside table. A paper tablet and pen were placed on a chuck/barrier the electronic tablet was placed on top of the paper tablet and pen. No observation of disinfectant or cleaning was observed of the paper table and pen before or after services were provided.
An exit interview was conducted on 2/5/2024 at approximately 2:00 PM with the executive director, quality manager and quality and compliance manager which confirmed the above information.
Plan of Correction:
How will the agency correct the deficiency?
- Re-education to all clinical staff regarding best practices for infection prevention in the home, including appropriate bag technique which includes keeping the strap of the bag out of the patient's environment, keeping the bag zipped, appropriate intervals for hand washing, and cleaning of equipment.
Measures or systems the Agency will alter to ensure the problem does not occur:
- Onboarding and Annual Infection control competency for all clinical staff that addresses appropriate use of barriers, bag technique and infection control practices.
Plans to monitor the Agency's performance to ensure the problem does not occur:
- The Clinical Manager or appropriate designee will complete 3 joint visits per week for 4 weeks with various field clinicians to ensure proper infection control and bag technique are used in the home. Subsequently, 5 visits per quarter will be completed with various field staff to ensure compliance with infection control standards and bag technique. Joint visits to begin the week of 3/25/2024
Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed 2/5/2024, VNA Family Hospice 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 state relicensure survey completed 2/5/2024, VNA Family Hospice was found to be in compliance with the requirements of 35 P.S. 448.809
Plan of Correction:
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