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 06/18/2025
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 medical records (MR), observations, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure agency policies and procedures for infection prevention were followed.

This deficient practice affected two of five home visits (HV) reviewed including HV # 1 and HV # 2, and had the potential to negatively affect all patients admitted to this agency.

Findings include:

Agency Policy: Cleaning of Re-Useable Equipment

Policy Number: 8.006

Revised: 6/1/25

Purpose: To ensure equipment required for patient care is clean and sanitized to prevent the spread of infections.

Definition: Semi-Critical Items: Equipment that comes in contact with mucous membranes or non-intact skin...All other semi-critical items will undergo intermediate level disinfection.

Definition: Intermediate-Level Disinfection: destroys vegetative bacteria, mycobacterium tuberculosis and most fungi. it neutralizes most viruses but does not kill bacterial spores.

Agency Policy: Hand Hygiene

Policy Number: 8.004

Revised: 5/1/19

Purpose: To help prevent the spread of microorganisms 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 performs hand hygiene by handwashing with soap and water or using an alcohol based hand sanitizer: 

...f. before and after removal of personal protective equipment (PPE).

...4. When using an alcohol based hand sanitizer, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are day...

Agency Policy: Dressing Change Procedure for Central Venous, Midline, and Peripherally Inserted Central Catheters (PICC)

Policy Number: 10.027

Revised: 10/01/16

Purpose: To keep insertion sites clean, stabilize catheters, and minimize the risk of infection. 

Policy: ...Sterility will be maintained throughout this procedure. 

...Procedure: 

...10. Allow solution to air dry completely...

 


2.HV # 2 was admitted to the agency on 5/21/25 with diagnoses including Type 2 Diabetes Mellitus with Other Specified Complication, Acute Hematogenous Osteomyelitis, Right Ankle and Foot, and Non-pressure Chronic Ulcer of Other Part of Right Foot with Necrosis of Bone.

A HV was conducted on 6/16/25 at 2:00 PM with EI # 5, Registered Nurse, to observe site care to the Peripherally Inserted Central Catheter (PICC) line. EI # 2, Patient Care Manager, was present during the HV. 

During the HV, EI # 5 failed to perform hand hygiene after removing gloves and donning clean gloves five times, failed to allow hands to dry following performing hand hygiene twice prior to donning clean gloves, and failed to cover all surfaces of the hands and fingers when using hand sanitizer once. 

While cleaning the PICC site with chlorprep, EI # 5 held the PICC line (outside of the sterile dressing site) with the left sterile gloved hand then obtained the stabilizing device and used both hands to place the device on the patient's skin. EI # 5 then obtained the antimicrobial disc, placed the disc around the PICC insertion site then held the disc in place with the left hand. EI # 5 failed to maintain sterility by using the contaminated left handed glove to place and/or hold the stabilizing device and antimicrobial disc. 

An interview was conducted on 6/18/25 at 9:29 AM with EI # 2 who confirmed the staff failed to ensure agency policies and procedures for infection prevention were followed.

 

1.HV # 1 was admitted on 6/13/25 with diagnosis of Type 2 Diabetes Mellitus with Foot Ulcer.

Review of the Home Health Certification and Plan of Care dated 6/13/25 revealed physician's orders for Skilled Nurse (SN) three visits per week for one week, two visits per week for eight weeks, and one visit per week for one week to perform procedure of wound care to wound # 1, left plantar foot ulcer.

A HV was conducted on 6/16/25 with Employee Identifier (EI) # 3, Licensed Practical Nurse (LPN) to observe wound care.

EI # 3 performed hand hygiene, donned gloves, removed soiled bandage from patient's left foot wound with bandage scissors, and placed scissors on dirty side of barrier.

EI # 3 removed gloves, performed hand hygiene, donned gloves, picked up bandage scissors from barrier, cut clean wound dressing, and applied to wound bed on left foot.

EI # 3 failed to cleanse the bandage scissors after removing soiled bandage, and prior to cutting wound dressing.

An interview was conducted on 6/18/25 at 10:25 AM with EI # 1, Executive Director (ED) who confirmed staff failed to follow the agency policy for cleaning of re-useable equipment.