Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 017016 (X3) Date Survey Completed 06/16/2022
Name of Provider or Supplier Southeast Alabama Homecare, Llc Street Address, City, State 804 Glover Avenue, Enterprise, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
G0682 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 review of agency policy and procedure, observation and interview, it was determined the agency failed to ensure staff followed infection control standards and discarded contaminated gloves, performed hand hygiene and donned clean gloves prior to continuing with clean procedures.




This deficient practice affected 1 of 5 home visits (HV) including HV # 5 and had the potential to affect all patients admitted to this agency.




Findings include:




Agency Policy: Hand Hygiene




Policy Number 8.004




Revised: 5/1/19




Purpose:




To help prevent the spread of micro-organisms and infection by cross-contamination and to provide practice guidelines.




Policy:




Staff are required to perform hand hygiene prior to, at specified time points during and following patient contact. Hand hygiene will be performed using soap and water or an alcohol based hand sanitizer.




Procedure:




1. Staff are required to perform hand hygiene by handwashing with soap and water or using an alcohol based hand sanitizer:




a. before direct contact with patients....




d. if moving from a contaminated body site to a clean body site during patient care...




8. c. Change gloves during patient care if moving from a contaminated body site to a clean body site.


1. HV # 5 was admitted on 5/17/22 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 through 4 Unspecified Chronic Kidney disease; and Heart Failure, Unspecified.






Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/17/22 revealed an order for Home Health Aide (HHA) to visit once a week for 4 weeks for assistance with personal care and activities of daily living secondary to functional limitations which prevent self-care.






A HV was conducted on 6/15/22 at 9:15 AM to observe a shower and care provided by Employee Identifier (EI # 6) HHA. EI # 1, Executive Director was also present.




EI # 6 performed hand hygiene, donned gloves and apron to assist HV # 5 with a shower. EI # 6 washed buttocks and continued wearing contaminated gloves throughout the rest of the shower. EI # 6 helped the patient towel dry, get dressed, brush teeth, assisted with walker, and handed hearing aids to the patient in a dish wearing the contaminated gloves.




An interview was conducted with EI # 1 on 6/15/22 at 10:10 AM, who confirmed EI # 6 did not change gloves and perform hand hygiene per agency policy and procedure.