Every finding on record at Lakes Region Visiting Nurse Association

An Emergency Preparedness Survey was conducted on 02/12/26 pursuant to the Emergency Preparedness Regulations as referenced in the Centers for Medicare and Medicaid State Operations Manual, 42 CFR part 484.102 Appendix Z - Rev. 204, Home Health Agencies (HHA) Issued: 04/16/21 with no deficiencies cited.

A health recertification survey was conducted on 2/10/26 to 2/11/26 pursuant to 42 CFR Part 484, Home Health Agencies with deficiencies cited.

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, record review, and interview, the home health agency failed to follow standards of practice for safe handling and disposal of sharps containers. Findings include: Review on 2/11/26 of the OSHA's website titled, 'Protecting Yourself When Handling Contaminated Sharps' revealed, "...Sharps Containers: Containers for contaminated sharps must be puncture-resistant. The sides and the bottom must be leakproof. They must be appropriately labeled or color-coded red to warn everyone that the contents are hazardous. Containers for disposable sharps must be closable (that is, have a lid, flap, door, or other means of closing the container), and they must be kept upright to keep the sharps and any liquids from spilling out of the container. The containers must be replaced routinely and not be overfilled, which can increase the risk of needlesticks or cuts… Handling Containers: Before sharps disposal containers are removed or replaced, they must be closed to prevent spilling the contents. If there is a chance of leakage from the disposal container, the employer must ensure that it is placed in a secondary container that is closable, appropriately labeled or color-coded red, and constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping..." Observation on 2/10/26 at 9:00 a.m. in the dirty supply room revealed a plastic lined biohazard box that was overflowing with small sharp disposal containers. Several of the disposal sharps container were not closed and were overfilled (more than three quarters full). Several needles were not completely inside the containers increasing the risk of needlesticks. Interview on 2/10/26 at 12:00 p.m. with Staff A (Care Manager) confirmed the above observation and revealed that all staff members have access to the dirty supply room. Review on 2/10/26 of the facility policy titled, Standard Precautions, Policy No. 6-004-1 revised on May 2024, revealed under the section titled “3. Syringe/Sharps Disposal: A. ...When 3/4 full, the disposal container will be sealed and transported to the dirty supply area located in the office.”