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 017035 (X3) Date Survey Completed 03/27/2025
Name of Provider or Supplier Infirmary Home Health Agency, Inc. Street Address, City, State 851 E I-65 Service Rd S, Suite 1000, Mobile, 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 observation, medical record (MR) review, agency policy and procedure and interviews with staff, it was determined the agency failed to ensure:

a. Staff performed hand hygiene (HH) per agency policy.

b. Staff cleaned re-usable equipment per agency policy.

This deficient practice did affect three of seven home visits (HV) patients including HV # 3, HV # 2, HV # 4, and had the potential to affect all patients served by the agency. 

Findings include: 

Agency Policy: Cleaning of Re-Useable Equipment

Policy Number: 8.006

Revised: 6/1/22

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

Policy: Equipment used for more than one patient is cleaned between each patient use.

Definitions: 

Low-Level Disinfection - destroys most bacteria...Examples include at least 70 % isopropyl alcohol/ehtyl alcohol...3. Non-Critical Items - Equipment that is only meant to come in contact with intact patient skin...(...stethoscopes, blood pressure cuffs, pulse oximeters...)

Procedure: 

Non-critical items which will come in contact with intact patient skin will undergo a low-level disinfection between each patient use... Agency Policy: Hand Hygiene

 Policy Number: 8.004

 Revised Date: 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 (HH) prior to, at specified time points during, and following patient contact…

 Procedure:

 1. Staff performs HH …

    a. Before direct contact with the patient.

    b. Before performing an aseptic task (ergo, insertion of invasive devices, wound care).

    c. After contact with wound dressing, contaminated surfaces.

    d. If moving from a contaminated body site to a clean body site.

    e. After contact with inanimate objects.

 

5. a. …Gloves will be worn during any patient care activities or interaction with any potentially contaminated surfaces or items…

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

 


2. HV # 2 was admitted on 2/27/25 with diagnoses including Abscess of Liver and Malignant Neoplasm of Pancreas, unspecified.

Review of the Home HHC and POC 2/27/25 revealed physician's orders for Skilled Nurse (SN) two visits for one week and then one visit for eight weeks.

Further review of the HHC and POC revealed SN to obtain IV (intravenous) access via aseptic technique using Huber Needle. SN to change Huber needle 1x (time) a week and PRN (as needed) contamination/malfunction. Flush IV access with 10 ml (milliliter) of Normal Saline (NS) before infusion and 10 ml NS and Heparin 100 Units / (per) ml after infusion. Cleanse site with Chlorhexidine. Air dry. Apply transparent dressing weekly.

A HV was conducted on 3/25/25 at 3:00 PM to observe IV care provided by EI # 7, Registered Nurse (RN).

EI # 7 performed HH, donned gloves and began opening supplies to change the Huber Needle and begin infusion of HV # 2's antibiotic. While opening wrapped 3 ml syringes of NS, a wrapper fell to the floor. EI # 7 picked up the wrapper off of the floor and put it in the trash. EI # 7 continued opening supplies, wearing the same pair of gloves. 

EI # 7 opened a pair of sterile gloves which were donned over the contaminated gloves and began to clean the site with the Chlorhexidine prep stick. The sterile gloves were removed and a second pair of sterile gloves were donned over the previously contaminated gloves. The Huber Needle was inserted into the port site, and the dressing change was completed. The sterile gloves were removed while the contaminated non sterile gloves remained on EI # 7's hands. More adhesive was applied to the site and the non sterile gloves were removed. The trash was disposed of into HV # 2's garbage and HH was then performed.

EI # 7 failed to follow the agency policy for HH and glove use.

An interview was conducted on 3/27/25 at 11:53 PM with EI # 1, Area Administrator of Operations, who confirmed the agency failed to ensure staff followed the agency HH policy.

3. HV # 4 was admitted on 3/15/25 with diagnoses including Type Two Diabetes Mellitus with Diabetic Polyneuropathy and Hypertensive Chronic Kidney Disease with Stage 1-4 Unspecified Chronic Kidney Disease.

Review of the HHC and POC revealed Physical Therapy two times a week for seven weeks effective 3/16/25.

A HV was conducted on 3/25/25 at 4:25 PM to observe care provided by EI # 8, Physical Therapy Assistant .

EI # 8 placed a barrier on a television stand with his/her bag in the middle of the barrier. HH was performed, gloves were donned and equipment was removed from the bag and placed on the right side of the bag, on the barrier. Vital signs were obtained and used equipment was placed back on the right side of the bag, onto the barrier, contaminating the right side of the bag. 

Gloves were removed and without performing HH, an ankle circumference was obtained.

Without performing HH or donning gloves, a Sani Cloth was used to clean the used equipment that was then placed back on the contaminated right side of the barrier. The equipment was allowed to dry and without performing HH, placed back in the bag.

EI # 8 failed to follow the agency policy for HH.

An interview was conducted on 3/27/25 at 12:03 PM with EI # 1, who confirmed the agency failed to ensure the staff followed the agency HH policy.

 

 

1. HV # 3 was admitted on 2/6/25 with diagnoses including Urinary Infection, Unspecified Atrial Fibrillation, and COVID-19. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 2/6/25 revealed physician's orders for SN one visit per week for nine weeks. 

Review of the Physician Order dated 2/19/25 revealed orders for wound care to left dorsal foot, cleanse with saline moistened gauze, apply enzymatic debriding agent Santyl Ointment to the wound bed, pack wound with Isosorbide 1/4 inch packing, cover with two inch cling, and cover with cling every day. 

A home visit was conducted on 3/25/25 at 12:15 PM to observe wound care provided by Employee Identifier (EI) # 4, Licensed Practical Nurse. 

EI # 4 placed a barrier on a chair for bag and clean items. Blood pressure cuff and stethoscope removed from the bag, vital signs taken, and dirty items placed back on the same barrier. 

EI # 4 then wiped the reusable items with sanitizing wipes then placed the items back onto the same location of the barrier the contaminated items were removed from. 

EI # 4 then placed a barrier under HV # 3's left foot onto the floor. EI # 4 then placed HV # 3's wound supply bag onto the barrier and removed the wound supplies.

EI # 4 then removed the dressing from the left foot and disposed of the soiled dressing in a plastic bag. After providing wound care, EI # 4 removed HV # 3's wound care supplies from the side of the barrier and placed them back into the box with the patient's clean supplies. 

An interview was conducted on 3/27/25 at 12:25 PM with EI # 9, Registered Nurse, who confirmed the agency failed to ensure the staff followed agency infection prevention policy.