Every finding on record at Bello Nurses LLC

Based on the findings of an unannounced onsite home health agency Medicare recertification and state re-licensure survey conducted 11/15/2021, 11/16/2021 & 11/18/2021, Bello Nurses, was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced onsite home health agency Medicare recertification and state re-licensure survey conducted 11/15/2021, 11/16/2021 & 11/18/2021, Bello Nurses, was found to be not in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based upon review of agency policy, medical records (MR), home visits, and interview with owner, EMP # 1, agency failed to include required contents in the Plan of Care (POC) including but not limited to therapy interventions, PICC line site care orders, lab draws, foley catheter, length of PICC line catheter, disposal of biohazard, for seven (7) of ten (10) medical records reviewed. (MR # 1-7). Review of agency policy on 11/18/2021 between approximately 1:30 PM-3:00 PM titled “ Patient Plan of Care; Policy:CN.010” stated “ Patient plan of care (4) The plan of care should include: (n) treatment, (s) any safety measures to protect against injury (u) interventions directed toward the achievement of patient goals (v) measures that are provided in accordance with acceptable standards of practice (6) orders for therapy services include: (a) The specific procedures and modalities to be used (b) comprehensiveness of services” Review of infusion company, Chartwell, policies on 11/18/2021 between approximately 1:30 PM- 3:00 PM stated “ PICC/Midline securement devices” “ The external length of the PICC/Midline must be measured and documented with each dressing change.” “ Labs Orders: document frequency, labs to be drawn, flushing with 10-20 ml saline before and after each lab draw and as needed” Reviewed policy on 11/18/2021 between approximately 1:30 PM-3:00 PM titled “Patient Welcome Handbook” stated “ Disposal of medication and supplies- Discard all used needles of any type and syringes with needles in the provided red sharps container.” Reviewed policy on 11/18/2021 between approximately 1:30 PM-3:00 PM titled “Sharps and Medical Waste Management” stated “ (2) Dressings not saturated in blood…may be placed in a plastic bag and tied. Place this bag in a second plastic bag. (3) Dressings or other supplies saturated with blood or infectious drainage should be double bagged in a plain plastic bag inside the plastic biohazard bags provided by the agency..(7) place needles, syringes, lancets and other sharps into the sharps container” Review of MR on 11/18/2021 between approximately 8:45 AM-10:45 AM and 12:30 PM-1:30 PM revealed: MR # 1, Start of Care (SOC) 11/2/2021; certification period 11/2/2021-12/31/2021; diagnosis: unspecified open wound of right shoulder; essential hypertension {high blood pressure}; sepsis {when harmful microorganisms in the blood or other tissues are present and the body responds leading to malfunction of various organs, shock, and potential death}; type 2 diabetes with orthopedic neurological complications”. Physician orders: “SN {skilled nursing} 2x/week for 8 weeks and 3 prn, PT {physical therapy} 2x/week.” Physical therapy orders: titled PT interventions listed “patient education; transfer training” SN and PT interventions did not include orders for vital signs including pulse ox, or reason for PRN skilled nursing visits. In addition, plan of care did not include specific therapy interventions to be completed. MR # 2, SOC 10/16/2021; certification period 10/16/2021-12/14/2021; diagnosis: unspecified open wound right knee; arthritis due to other bacteria, right knee; essential hypertension {high blood pressure}; infection/inflammation reaction due to internal right knee prosthesis.” Physician orders: “ SN: 1x/wk 1st week then 3x/week for 8 weeks and 3 PRN” “ SN to change central line dressing every week using sterile technique” No specific orders written for PICC line site care or to measure PICC line external length of catheter each visit. No orders documented for blood draws. MR # 3, SOC 11/1/2021; certification period 11/1/2021-12/30/2021; diagnosis: unspecified open wound, left lower leg; Type 2 diabetes mellitus { elevated sugar in blood} without complication; essential hypertension { high blood pressure}; obesity; other idiopathic peripheral autonomic neuropathy {lack of feeling in lower legs}” Physician orders: SN: 3x/week and 3 prn.” No orders documented for wound care or blood draw orders. No oxygen orders documented. MR # 4, SOC 11/9/2021; certification period 11/9/2021-1/7/2022; diagnosis: unspecified open wound, left foot; sepsis; unspecified abnormalities of gait and mobility. “ Physician orders: SN 2x first week then 3x/week and 3 prn. No order for foley- no size or how often to be replaced. No foley site care orders. No specific orders written for PICC line site care or to measure PICC line external length of catheter each visit. No orders documented for blood draws. Patient with history of MS {Multiple Sclerosis}{nervous system disease with wasting of muscle} not listed on diagnoses. No wound care orders for hip wounds or lower sacral wounds. No documentation of who was monitoring these wounds. MR # 5, SOC 11/3/2021; certification period 11/3/2021-1/1/2022; diagnosis: sepsis; other acute osteomyelitis {infection in the bone}. Physician orders: SN: 2x first week for 8 weeks and 3 prn. {no nursing frequency for week 2-9 and no reason for PRN visits listed}. No physician orders for vital signs; PICC line measurement; order for PICC line site cleaning. MR # 6, SOC 10/2/2021; certification period 10/2/2021-11/30/2021;diagnosis: Sepsis { when harmful microorganisms in the blood or other tissues are present and the body responds leading to malfunction of various organs, shock, and potential death}; infection/inflammation reaction due to other internal prosthesis device. Physician orders: SN: 1x/week then 2x/week for 8 weeks and 3 PRN. SN to change central line dressing every week using sterile technique. No physician orders for PICC line measurement; order for PICC line site cleaning or reason for PRN nursing visits. MR # 7, SOC 10/7/2021; certification period 10/7/2021-12/5/2021;diagnosis: Renal and perinephric abscess {pus filled sac near kidney}. Physician orders: “ SN: 1x/wk 1st week then 2x/week for 6 week and 3 PRN. SN to change central line dressing every week using sterile technique”. No physician orders for PICC line measurement; order for PICC line site cleaning or reason for PRN nursing visits. Home visits (HV) conducted on 11/16/2021 between approximately 8:30 AM-4:00 PM revealed: HV # 1, with MR # 1, conducted between 9:00 AM-10:00 AM with PT present. During home visit, therapist took temperature, pulse, respirations, blood pressure, and pulse oximeter readings. During the visit therapist stated “patient is not allowed to actively move her right shoulder. She is doing passive exercises only. Part of the treatment interventions completed during visit included: right arm bends to 90 degrees only x 20 times; right wrist flex to 90 degrees x 20 times; right hand squeeze x 20 times; pendular swing of body keeping arm still x 20; elephant trunk side to side x 20 times; knee lifts x 20 times. HV # 2, with MR # 2, conducted between 10:00 AM-10:30 AM with SN present. During home visit, nurse took temperature, pulse, respirations, blood pressure, and pulse oximeter readings. During the visit, nurse applied a face mask to herself covering only her mouth and not her nose when removing old PICC line dressing and preparing site for new dressing. Old dressing removed and discarded into tall kitchen waste can, PICC area cleaned with chlorohexidine and while allowing to air dry, patient reached for his phone, crossing over the cleaned area and contaminating site. Nurse used an alcohol pad to reclean, and applied sterile dressing. During visit, patient’s wife mentioned blood was to be drawn last Friday, 11/12/2021 and attempt to draw blood by agency nurse was not successful. No further attempts made to draw blood as of 11/16/2021. HV # 3, with MR # 3, conducted between 12:00 PM-1:00 PM with SN present. During home visit, nurse took temperature, pulse, respirations, blood pressure, and pulse oximeter reading. During the visit, nurse removed old gauze dressing using normal saline solution to loosen gauze and discarded into small trach can.. Left lower leg: Drainage visible, serous colored drainage, approximately 2 inch saturated areas on gauze. Nurse cleaned areas with normal saline, applied iodine, and aquacel dressing to seeping areas. Covered with ABD’s, secured with gauze wrappings and tape. Right lower leg: scabbed wound area quarter size. Patient on continuous 4.5 Liters oxygen nasal cannula. Trash not double bagged. HV # 4, with MR # 4, conducted between 2:00 PM-3:00 PM with SN present. During home visit, nurse took temperature, pulse, respirations, blood pressure, and pulse oximeter reading. During the visit, nurse assessed foley draining for color and any evidence of sediment. Patient reported frequent urinary tract infections. Blood was drawn in syringe for discard and placed on table or discard with other dressing supplies. Nurse wrapped up trash and placed all in bathroom trash can with blood filled syringe included. Trash not double bagged. Patient also mentioned history of long term dealing with MS and currently with wounds on both sides of her hips as well as her lower tailbone. Nurse was not aware of wounds. HV # 5, with MR # 5, conducted between 3:00 Pm-4:00 PM with SN present. During home visit, nurse took temperature, pulse, respirations, blood pressure, and pulse oximeter reading. During the visit, nurse removed old PICC line dressing and discarded into waste can. Not double bagged. No measurement of PICC line length. No face mask on patient during dressing change. Interview with EMP # 1 on 11/18/2021 at approximately 3:15 PM confirmed above findings.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based upon review of agency policy, governing body committee minutes, and interview with owner, EMP # 1, agency failed to include and use required data in the QAPI {quality assurance and performance improvement} program for one (1) of one (1) observation (OBS). (OBS # 1). Reviewed policy on 11/18/2021 between approximately 1:30 PM-3:00 PM titled “Quality Assessment and Performance Improvement” stated “ (4) The QI committee will address areas for improvement that are cost effective and perform periodic assessments of care and service. QI monitoring will include.. infection control, adverse drug reactions, wound care, patient satisfactory survey, patient complaints, medication errors.. Reports of all QI data collection will be analyzed to determine trends and patterns” Another policy reviewed on 11/18/2021 between approximately 1:30 PM-3:00 PM titled “ Infection control management and assessment” stated “ (4) incident reports related to infection are analyzed and handled according to the quality improvement policy. (5) all employees are responsible for adhering to established infection control policies and procedures.. (b) proper handling of infectious waste (d) proper handling of sharps (5)(e) performance of aseptic procedures per physician’s orders (g) transporting blood, body fluid specimens in labeled, non-penetrable containers..” “ The QAPI department will log and monitor all reported infections and assess for trends and patterns.” “ An infection control report will be forwarded to the QA?PI committee on a quarterly basis .. with recommendations and follow up as appropriate.” Form attached to this policy titled “ Infection Control Assessment.” Governing body minutes were reviewed on 11/15/2021 between approximately 10:15 AM-11:00 AM. 8/20/2019 meeting minutes under OBQI- Outcome based quality improvement-“ This project team consists of representatives from each discipline. The team addressed and developed clinical expectations in the areas of OASIS, telehealth, outcomes, and the Oasis C requirements.” On 11/15/2021 at approximately 11:00 AM survey requested raw data, which was collected including infections, none was produced. No specific data was produced. No infection control logs or completed infection control assessments, no recommendations or follow up data included in the governing body minutes. 11/20/2020 meeting minutes under OBQI- Outcome based quality improvement- “This project team consists of representatives from each discipline. The team addressed and developed clinical expectations in the areas of OASIS, telehealth, outcomes, and the Oasis C requirements.” On 11/15/2021 at approximately 11:00 AM survey requested raw data, which was collected including infections, none was produced. No specific data was produced. No infection control logs or completed infection control assessments, no recommendations or follow up data included in the governing body minutes. Interview with EMP # 1 on 11/18/2021 at approximately 3:15 PM confirmed above findings

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 upon review of agency policy, medical records (MR), home visits, and interview with owner, EMP # 1, agency failed to show evidence of following acceptable standards of practice to prevent transmission of infections for four (4) of ten (10) medical records reviewed. (MR # 2-5). Reviewed policy on 11/18/2021 between approximately 1:30 PM-3:00 PM titled “Patient Welcome Handbook” stated “ Disposal of medication and supplies- Discard all used needles of any type and syringes with needles in the provided red sharps container.” Reviewed policy on 11/18/2021 between approximately 1:30 PM-3:00 PM titld “ Sharps and Medical Waste Management” stated “ (2) Dressings not saturated in blood…may be placed in a plastic bag and tied. Place this bag in a second plastic bag. (3) Dressings or other supplies saturated with blood or infectious drainage should be double bagged in a plain plastic bag inside the plastic biohazard bags provided by the agency..(7) place needles, syringes, lancets and other sharps into the sharps container” MR # 2, SOC 10/16/2021; certification period 10/16/2021-12/14/2021; diagnosis: unspecified open wound right knee; arthritis due to other bacteria, right knee; essential hypertension {high blood pressure}; infection/inflammation reaction due to internal right knee prosthesis.” Physician orders: “ SN to change central line dressing every week using sterile technique” HV # 2, with MR # 2, conducted on 11/16/2021 between 10:00 AM-10:30 AM with SN present. During the visit, nurse applied a face mask to herself covering only her mouth and not her nose when removing old PICC line dressing and preparing site for new dressing. Old dressing removed and discarded into tall kitchen waste can, PICC area cleaned with chlorohexidine and while allowing to air dry, patient reached for his phone, crossing over the cleaned area and contaminating site. Nurse used an alcohol pad to reclean, and applied sterile dressing. MR # 3, SOC 11/1/2021; certification period 11/1/2021-12/30/2021; diagnosis: unspecified open wound, left lower leg; Type 2 diabetes mellitus { elevated sugar in blood} without complication; essential hypertension { high blood pressure}; obesity; other idiopathic peripheral autonomic neuropathy {lack of feeling in lower legs}” Physician orders: SN: 3x/week and 3 prn.” No orders documented for wound care or blood draw orders. HV # 3, with MR # 3, conducted on 11/16/2021 between 12:00 PM-1:00 PM with SN present. During the visit, nurse removed old gauze dressing using normal saline solution to loosen gauze and discarded into small trach can.. Left lower leg: Drainage visible, serous colored drainage, approximately 2 inch saturated areas on gauze. Nurse cleaned areas with normal saline, applied iodine, and aquacel dressing to seeping areas. Covered with ABD’s, secured with gauze wrappings and tape. Right lower leg: scabbed wound area quarter size. Trash not double bagged. MR # 4, SOC 11/9/2021; certification period 11/9/2021-1/7/2022; diagnosis: unspecified open wound, left foot; sepsis; unspecified abnormalities of gait and mobility. “ Physician orders: SN 2x first week then 3x/week and 3 prn. Patient with history of MS {Multiple Sclerosis}{nervous system disease with wasting of muscle}. HV # 4, with MR # 4, conducted on 11/16/2021 between 2:00 PM-3:00 PM with SN present. During home visit, nurse drew Blood in syringe for discard and placed on table with other dressing supplies. Nurse wrapped up trash and placed all in bathroom trash can with blood filled syringe included. Trash not double bagged. MR # 5, SOC 11/3/2021; certification period 11/3/2021-1/1/2022; diagnosis: sepsis; other acute osteomyelitis {infection in the bone}. Physician orders: SN: 2x first week for 8 weeks and 3 prn. HV # 5, with MR # 5, conducted on 11/16/2021 between 3:00 Pm-4:00 PM with SN present. During home visit, nurse removed old PICC line dressing and discarded into waste can. Not double bagged. Interview with EMP # 1 on 11/18/2021 at approximately 3:15 PM confirmed above findings.

Based upon the findings of an unannounced on site complaint investigation survey, conducted on 8/312021, Bello Nurses, was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based upon the findings of an unannounced on site complaint investigation survey, conducted on 8/312021, Bello Nurses, was found to be not in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based upon review of agency policies, medical records (MR), nursing notes, calendars, and interview with office manager ( EMP # 1), agency failed to include all required elements in the Plan of Care (POC) for three (3) of three (3) files reviewed. ( MR # 1-3). Findings included: Review of agency policy on 8/31/2021 at approximately 2:00 PM titled " Physician Plan of Care Orders" stated " (11) ... the plan of care shall include but not be limited to: (e) patient-specific procedures for all treatments performed by each discipline including the amount, frequency, and duration of the modalities and..." Review of MR on 8/31/2021 between approximately 9:30 AM-12:00 PM revealed: MR # 1, Start of Care (SOC) 2/1/2021; (complaintant's son's file) Diagnosis: Lennox-Gastant Syndrome {severe type of childhood epilepsy}; physician orders: 7/31/2021-9/28/2021. " SN: 60 hours a week" no duration documented. Nutrition: " Regular, enteral nutrition ( formula amount cc/day via pump PEG." No name of formula , rate of infusion, total amount to infuse or over what time period, or if residual check to be completed prior to and after feedings. " safety measures: no documentation of seizure precautions or oxygen precautions." Nursing notes: 7/3/2021 " temperature (97.8), pulse (76), respirations (21), pulse ox (96%), documented. In addition, nurse documented oxygen at 0.5-1 LPM via NC prn. Oral suctioning. ( CPT) {chest physiotherapy). No physician order produced for any of the treatments which were documented. 7/4/2021 " temperature (97.6), pulse (78), respirations (20), pulse ox (96%), documented. In addition, nurse documented oxygen at 0.5-1 LPM via NC prn. Oral suctioning PRN. ( CPT) {chest physiotherapy). No physician order produced for any of the treatments which were documented. 7/7/2021 " temperature (97.8), pulse (76), respirations (20), pulse ox (97%), documented. In addition, nurse documented oxygen at 0.5-1 LPM via NC prn. Oral suctioning PRN. ( CPT) {chest physiotherapy). PEG/GT {percutaneous gastrostomy tube}{ tube into stomach for feedings} "site care cleaned {cleansed cream drsg {dressing}" No physician order produced for any of the treatments which were documented. 7/8/2021 " temperature (97.6), pulse (72), respirations (20), pulse ox (96%), documented. In addition, nurse documented oxygen at 0.5-1 LPM via NC prn. Oral suctioning PRN. ( CPT) {chest physiotherapy). PEG/GT {percutaneous gastrostomy tube}{ tube into stomach for feedings} "site care cleaned {cleansed cream drsg {dressing}" No physician order produced for any of the treatments which were documented. Calendar: week of 8/1/2021-8/7/2021 nursing documented 40 hours. A missed shift note present and documented " Father had {alternate agency} cover 20 hours" No mention physician was informed of this agency not meeting ordered frequency. MR # 2, SOC 11/1/2020; Diagnosis: Quadriplegia unspecified{ full body paralysis}; physician orders: 7/19/2021-9/16/2021. " Skilled Nurse to change central line dressing every week using sterile technique" " Home health aide as ordered for assistance with ADL's/IADL's {activities of daily living}" no frequency or duration for either discipline documented. No mention of what central line dressing type or cleaning of site ordered. " orders: patient/caregiver will demonstrate understanding of flushing central line" no orders documented with what would be taught, amount or type of flush. No flush medications listed in physician orders. Nursing notes: none produced. Calendar: 8/1/2021-8/7/2021- 24 hours/day for 7 days/week coverage documented. 8/8/2021-8/14/2021- 24 hours/ day for 7 days/ week coverage documented. 8/15/2021-8/21/2021- 24 hours/ day for 7 days/ week coverage documented. 8/22/2021-8/28/2021- 24 hours/ day for 7 days/ week coverage documented. 8/29/2021-8/31/2021- 24 hours/ day for 3 days documented. MR # 3, SOC 7/26/2021; Diagnosis: Primary: Essential Hypertension; Secondary: Chronic Kidney Disease; displaced fx { fracture} of body of scapula, left shoulder. Physician orders: 7/26/2021-9/23/2021. "Skilled nursing {SN}: 2x/week for 6 weeks and 3 PRN". "PT{physical therapy} 2x/week". No mention of reason for SN PRN visits and no duration for PT services. No documentation of PT orders for interventions to be completed. Faxed information from referral source in addition to ordering SN and PT also ordered OT{occupational therapy}evaluation. No documentation of OT being refused by patient or services being provided. Nursing notes: 7/28/2021- temperature (97.7), pulse (85), respirations (20) and Blood pressure (120/63). pulse oximeter (96%). No physician order for vital signs or pulse oximeter. 7/30/2021- temperature (97.4), pulse (75), respirations (20) and Blood pressure (132/66). pulse oximeter (96%). No physician order for vital signs or pulse oximeter. 8/2/2021- temperature (97.7), pulse (85), respirations (20) and Blood pressure (120/63). pulse oximeter (96%). No physician order for vital signs or pulse oximeter. 8/4/2021- temperature (97.9), pulse (78), respirations (20) and Blood pressure (145/80). pulse oximeter (97%). No physician order for vital signs or pulse oximeter. Interview with EMP # 1 on 8/31/2021 at approximately 2:00 PM confirmed above findings.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based upon review of updated Center Disease Control ( CDC) Guidelines for Tuberculin ( TB) screening for 2019, personnel files (PF), and interview with office manager ( EMP # 1), agency failed to complete Tuberculin (TB) screening requirements for two (2) of three (3) files reviewed. ( PF # 1-2). Findings included: Review of updated CDC TB guidelines for 2019 on 8/31/2021 at approximately 2:30 PM-3:00 PM with updated guidelines to include individual risk assessment and symptom evaluation at baseline (preplacement) and annual TB education of all healthcare personnel. Review of PF on 8/31/2021 between approximately 12:00 PM-1:00 PM revealed: PF # 1, Date of Hire (DOH) 11/5/2019; no risk assessment tool documented. Tool from CDC is titled " Health Care Personnel (HCP) baseline Individual TB Risk Assessment: which asks (1) Temporary or Permanent residence of >or equal 1 month in a country with a high TB rate (2) or current or planned immunosuppression (3) or close contact with someone who has had infectious TB disease since the last TB test" PF # 2, DOH 8/12/2019; no risk assessment tool documented. Tool from CDC is titled " Health Care Personnel (HCP) baseline Individual TB Risk Assessment: which asks (1) Temporary or Permanent residence of >or equal 1 month in a country with a high TB rate (2) or current or planned immunosuppression (3) or close contact with someone who has had infectious TB disease since the last TB test" Interview with EMP # 1 on 8/31/2021 at approximately 2:00 PM confirmed above findings.