Every finding on record at Mcmanus Home Healthcare Agency Inc

Based on the findings of an onsite unannounced Medicare Recertification and State Licensure Survey conducted 03/17/2026 through 03/18/2026, Golden Home Healthcare Erie was found not 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 onsite unannounced Medicare Recertification and State Licensure Survey conducted 03/17/2026 and 03/18/2026, Golden Home Healthcare Erie was found to not be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 review of policy and procedures, personnel files (PF) and interview with Home Health Administrator/Director of Nursing the agency failed to provide documentation of testing for Mycobacterium Tuberculosis (TB) at time of hire prior to patient contact or within one year prior to hire for two (2) of seven (7) files reviewed. PF#3, and PF#5. Findings include: Agency policies reviewed on 03/17/2026 from approximately 11:15am -1:00pm revealed the following: Review of Policy: "PAHH6.4 – Tuberculosis (TB) Screening Policy: The Agency requires that applicants and persons who are employed be tested for Mycobacterium Tuberculosis (M. tuberculosis) and be free from active M. tuberculosis prior to consumer contact, and that documentation be completed initially and annually. The Agency will follow the Centers for Disease Control Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Settings. . ." ". . .Procedure: Applicants: All applicants are required to provide documentation that a tuberculin skin test or IGRA blood test has been performed by a health care professional. . . . . . . 3. The date of the test must be not more than one year prior to the anticipated or actual start date to be considered in step 1 (in the two-step screening process). 4. If there is no prior testing documentation (within one year of the date of hire), the applicant will require a two-step TB screening. . . ." "The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. HCWs with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. (CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.) *Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19) . . . ." Review of personnel files (PF) completed 03/17/2026 between approximately 1:56pm and 2:45pm. PF #3: Date of hire (DOH), 11/03/2025. QuantiFERON Gold TB test dated 08/29/2023, more than one year prior to the date of hire. PF #5: Date of hire (DOH), 12/14/2025. QuantiFERON Gold TB test dated 08/13/2024, more than one year prior to the date of hire. Interview with the home health administrator/Director of Nursing on 03/17/2026 at approximately 5:05pm confirmed the above findings.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on review of policy and procedures, personnel files (PF), CDC (Centers for Disease Control) guidelines and interview with Home Health Administrator/Director of Nursing the administrator failed to ensure documentation of testing for Mycobacterium Tuberculosis (TB) at time of hire prior to patient contact or within one year prior to hire for two (2) of seven (7) files reviewed. PF#3, and PF#5. Findings include: Agency policies reviewed on 03/17/2026 from approximately 11:15am -1:00pm revealed the following: Review of Policy: "PAHH6.4 – Tuberculosis (TB) Screening Policy: The Agency requires that applicants and persons who are employed be tested for Mycobacterium Tuberculosis (M. tuberculosis) and be free from active M. tuberculosis prior to consumer contact, and that documentation be completed initially and annually. The Agency will follow the Centers for Disease Control Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Settings. . . ." ". . .Procedure: Applicants: All applicants are required to provide documentation that a tuberculin skin test or IGRA blood test has been performed by a health care professional. . .. . . 3. The date of the test must be not more than one year prior to the anticipated or actual start date to be considered in step 1 (in the two-step screening process). 4. If there is no prior testing documentation (within one year of the date of hire), the applicant will require a two-step TB screening. . . ." "The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. HCWs with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. (CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.) *Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19). . . ." Review of personnel files (PF) completed 03/17/2026 between approximately 1:56pm and 2:45pm. PF #3: Date of hire (DOH), 11/03/2025. QuantiFERON Gold TB test dated 08/29/2023, more than one year prior to the date of hire. PF #5: Date of hire (DOH), 12/14/2025. QuantiFERON Gold TB test dated 08/13/2024, more than one year prior to the date of hire. Interview with the home health administrator/Director of Nursing on 03/17/2026 at approximately 5:05pm confirmed the above findings.