| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017050 | (X3) Date Survey Completed 01/06/2023 |
| Name of Provider or Supplier Central North Alabama Health Services, Inc. | Street Address, City, State 1310 Pulaski Pike, Unit A, Huntsville, 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, review of agency policy and procedure, Centers for Disease Control (CDC) guidance for hand hygiene in healthcare settings, and interviews, it was determined the agency failed to ensure staff performed hand hygiene and followed accepted standards of practice to prevent the transmission of infections. This affected Home Visit (HV) # 1, one of two HV's conducted, and had the potential to negatively affect all patients admitted to the agency. Findings include: Agency Policy: Hand Hygiene Policy and Compliance Program Policy Number: None Revision/Review Date: None Purpose: To prevent transfer of germs and transmission of infections to patients and caregivers, and to implement a hand hygiene compliance program. Procedure: 1. Indications for staff performing hand hygiene are: ...After any contact with contaminated materials... CDC Hand Hygiene in Healthcare Settings: January 2020 The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: a. Immediately before touching a patient b. Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices c. Before moving from work on a soiled body site to a clean body site on the same patient d. After touching a patient or the patient’s immediate environment e. After contact with blood, body fluids, or contaminated surfaces f. Immediately after glove removal 1. HV # 1 was admitted to the agency on 11/10/22 with diagnoses including Lymphedema, Not Elsewhere Classified, and Unspecified Open Wound Abdominal Wall, Unspecified Quadrant Without Penetration Peritoneal Cavity Initially. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 11/10/22 to 1/8/23 revealed a Skilled Nurse (SN) visit frequency of one time a week for one week, then two times a week for eight weeks, and orders for wound # 1, a stage 2 (open) pressure ulcer to the left lower quadrant of the abdomen as follows: SN to perform wound care to wound # 1, Lower Abdominal. Cleanse wound with wound cleanser solution, pat dry, cover with abdominal pad and secure with tape, using aseptic technique. SN to teach patient/caregiver to perform wound care when SN is not in the home. Wound care to be performed once a day. A HV was conducted on 1/4/23 at 1:37 PM to observe wound care provided by Employee Identifier (EI) # 1, Registered Nurse (RN). While wearing gloves, EI # 1 removed the old contaminated dressing to the left lower abdomen, then without changing gloves, cleansed the wound with wound cleanser and gauze. EI # 1 then removed the gloves, donned a new pair of gloves without performing hand hygiene, and placed an abdominal pad over the wound. EI # 1 did not perform hand hygiene after contact with the contaminated dressing per policy. An interview with EI # 1 on 1/6/23 at 3:32 PM confirmed hand hygiene was not performed per policy. |