Every finding on record at Peacehealth

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 CFR 484, conducted this health and safety survey. Examination number: X2023 - 825 Onsite dates: 02/05/24 – 02/08/24 The survey was conducted by: Surveyor #1 Surveyor #6 DOH staff found the agency in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below. DOH recommends recertification based on an acceptable plan of correction.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on record reviews and interview, the agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) data for M0104 and M0102 for 9 of 19 patients (Patient #104, #108, #109, #603, #610, #612, #616, #618 and #619). Failure to accurately complete the OASIS data places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Surveyors reviewed the records of Patient #104, #108, #109, #603, #610, #612, #616, #618 and #619. a. Surveyor #1 reviewed the records of Patient #104, #108, and #109. The record review showed: i. Patient #104 was admitted for the primary diagnosis of Gastrointestinal Bleed—not a complete list. The OASIS M0104 data showed a date of 01/27/24 rather than the accurate referral date of 01/26/24. Documentation showed the referral was completed on 01/26/24 for Physical Therapy (PT) Services. ii. Patient #108 was admitted for the primary diagnosis of Acute Respiratory Failure—not a complete list. The OASIS M0102 data showed a date of 12/30/23 rather than the accurate physician’s order date of 12/23/23. Documentation showed the agency received a doctor’s order for the start of care on 12/23/23 for SN Services. iii. Patient #109 was admitted for the primary diagnosis of Diabetic Ulcers—not a complete list. The OASIS M0104 data showed a date of 07/13/23 rather than the accurate referral date of 07/12/23. Documentation showed the referral was completed on 07/12/23 for SN Services. b. Surveyor #6 reviewed the records of Patient #603 #610, #612, #616, #618 and #619. The record review showed: i. Patient #603 was admitted for the primary diagnosis of Contusion of Right Lower Leg—not a complete list. The OASIS M0104 data showed a date of 01/14/24 rather than the accurate referral date of 01/09/24. Documentation showed the referral was completed on 01/09/24 for Skilled Nursing (SN) Services. ii. Patient #610 was admitted for the primary diagnosis of Rheumatoid Arthritis—not a complete list. The OASIS M0104 data showed a date of 12/02/23 rather than the accurate OASIS M0102 data date of 12/06/23. Documentation showed the agency received a physician’s order for the start of care on 12/23/23 for SN Services ii. Patient #612 was admitted for the primary diagnosis of Pressure Ulcer of the Sacral Region—not a complete list. The OASIS M0104 data showed a date of 10/23/23 rather than the accurate referral date of 10/20/23. Documentation showed the referral was completed on 10/20/23 for SN services. iv. Patient #616 was admitted for the primary diagnosis of Acute Respiratory Failure—not a complete list. The OASIS M0104 data showed a date of 10/28/23 rather than the accurate referral date of 10/25/23. Documentation showed the referral was completed on 10/25/23 for PT services. v. Patient #618 was admitted for the primary diagnosis of Aftercare following Joint Replacement Surgery—not a complete list. The OASIS M0104 data showed a date of 03/01/23 rather than the accurate referral date of 02/28/23. Documentation showed the referral was completed on 02/28/23 for PT services. vi. Patient #619 was admitted for the primary diagnosis of Encounter For Other Orthopedic Aftercare—not a complete list. The OASIS M0104 data showed a date of 05/12/23 rather than the accurate referral date of 05/11/23. Documentation showed the referral was completed on 05/11/23 for SN services. 2. On 02/06/24 at 3:30 PM, Surveyor #1 interviewed the agency’s Pod Leader (Staff #103) about the inaccurate data entered for OASIS M0104 and M0102 for Patient #104. Staff #103 acknowledged the inaccurate documentation of the OASIS data and was unable to provide the documentation for Patient #104. On 02/07/24 at 4:00 PM, Surveyor #1 interviewed the agency’s Pod Leader (Staff #103) about the inaccurate data entered for OASIS M0104 and M0102 for Patient #108 and #109. Staff #103 acknowledged the inaccurate documentation of the OASIS data and was unable to provide the documentation for Patient #108 and #109. On 02/05/24 at 2:00 PM, Surveyor #6 interviewed the agency’s System Home Health Director (Staff #601) about the inaccurate data entered for OASIS M0104 and M0102 for Patient #603, #610, and #612. Staff #103 acknowledged the inaccurate documentation of the OASIS data and was unable to provide the documentation for Patient #603, #610, and #612. On 02/06/24 at 12:00 PM, Surveyor #6 interviewed the agency’s System Home Health Director (Staff #601) about the inaccurate data entered for OASIS M0104 and M0102 for Patient #616, #618, and #619. Staff #103 acknowledged the inaccurate documentation of the OASIS data and stated that they were unable to provide the documentation for Patient #616, #618, and #619. .

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on document review, record reviews, and interview, the agency failed to conduct the initial assessment visit within the 48 hours of completing the referral and failed to notify the patients’ physician of the delayed services for 6 of 19 patients (Patient #102, #104, #603, #612, #614, and #616) Failure to meet this requirement places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Document review of agency's policy titled, "Home Health Intake Process," (PolicyStat ID: 14555624, Effective: 10/31/23) showed the initial assessment will be conducted within 48 hours of the valid referral. 2. Surveyors reviewed the records of Patient #102, #104, #603, #612, #614, and #616. a. Surveyor #1 reviewed the records of Patient #102 and #104. The record review showed: i. Patient #102’s Start of Care (SOC) date was 01/21/24. The patient was admitted for primary diagnoses of Congestive Heart Failure and Influenza. The agency completed the referral on 01/14/24 for a Skilled Nursing (SN) initial assessment, and the SOC for SN services did not occur until 01/21/24. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed SN admission. ii. Patient #104’s SOC date was 01/31/24. The patient was admitted for a primary diagnosis of Gastrointestinal Bleed. The agency completed the referral on 01/26/24 for a Physical Therapy (PT) initial assessment, and the SOC for PT services did not occur until 01/31/24. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed PT admission. b. Surveyor #6 reviewed the records of Patient #603, #612, #614, and #616. The record review showed: i. Patient #603’s SOC date was 01/14/24. The patient was admitted for a primary diagnosis of Contusion of the Right Lower Leg. The agency completed the referral on 01/09/24 for a SN initial assessment, and the SOC for SN services did not occur until 01/14/24. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed SN admission. ii. Patient #612’s SOC date was 10/23/23. The patient was admitted for a primary diagnosis of Pressure Ulcer of the Sacral Region. The agency completed the referral on 10/20/23 for a SN initial assessment, and the SOC for SN services did not occur until 10/23/23. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed SN admission. iii. Patient #614’s SOC date was 04/27/23. The patient was admitted for a primary diagnosis of Encounter for Orthopedic Aftercare Following Amputation. The agency completed the referral on 04/05/23 for a SN initial assessment, and the SOC for SN services did not occur until 04/27/23. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed SN admission. iv. Patient #616’s SOC date was 01/04/24. The patient was admitted for a primary diagnosis of Acute Respiratory Failure. The agency completed the referral on 12/24/23 for a SN initial assessment, and the SOC for SN services did not occur until 01/04/23. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed SN admission. 3. On 02/06/24 at 3:30 PM, Surveyor #1 interviewed the agency’s Pod Leader (Staff #103) regarding the lack of documentation that the patient’s physician was notified of the delayed SOC services for Patient #102 and #104. Staff #103 acknowledged the findings and stated that they were not able to provide the documentation for Patient #102 and #104. On 02/05/24 at 3:00 PM, Surveyor #6 interviewed the agency’s System Home Health Director (Staff #601) regarding the lack of documentation that the patient’s physician was notified of the delayed SOC services for Patient #603 and #612. Staff #601 acknowledged the findings and was not able to provide the documentation for Patient #603 and #612. On 02/06/24 at 12:00 PM, Surveyor #6 interviewed the agency’s System Home Health Director (Staff #601) regarding the lack of documentation that the patient’s physician was notified of the delayed SOC services for Patient #614 and #616. Staff #601 acknowledged the findings and stated that they were not able to provide the documentation for Patient #614 and #616 . THIS IS A REPEAT OF THE CITATION PREVIOUSLY CITED ON 05/20/21.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to update its policies and procedures and conduct personnel Tuberculosis (TB) testing to comply with agency-wide and state licensing requirements for TB infection control program for 12 of 12 personnel files reviewed (Staff #608, #609, #610, #611, #612, #613, #614, #615, #616, #617, #618, and #619). Failure of the agency to comply with the agency and state requirements for TB screening may place the patients and staff at risk of TB exposure. Findings included: Reference: Washington Administrative Code (WAC) 246-335-525 (15) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include, at minimum: (c) Tuberculosis (TB) infection control program. Key elements include, but are not limited to: (ii) Conducting an annual assessment of new TB risk factors for all employees. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine the agency's responsibility to conduct TB testing of employees. Retesting should only be done for persons who previously tested negative and have new risk factors since the last assessment. 1. Document review of the agency policy titled, “Standard Health Requirements Policy,” (Policy No: 14839070, Revised Date 12/06/2023), showed the policy incorrectly referenced WAC 246-335-625 (for hospice agencies) and did not specify to use of the department-approved TB risk assessment form. 2. On 02/07/24, Surveyor #6 reviewed personnel files for 12 staff members (Staff #608, #609, #610, #611, #612, #613, #614, #615, #616, #617, #618, and #619) The review showed: a. Staff #608 was hired on 12/14/20. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. b. Staff #609 was hired on 06/29/14. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. c. Staff #610 was hired on 09/12/22. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. d. Staff #611 was hired on 09/27/21. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. e. Staff #612 was hired on 06/29/14. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. f. Staff #613 was hired on 07/06/21. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. g. Staff #614 was hired on 08/25/14. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. h. Staff #615 was hired on 10/25/21. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. i. Staff #616 was hired on 03/29/21. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. j. Staff #617 was hired on 02/27/23. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. k. Staff #618 was hired on 04/25/22. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. l. Staff #619 was hired on 08/02/21. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. 3. On 02/07/24 at 1:00 PM, Surveyor #6 interviewed the agency’s Director of Employee Health (Staff #604) about the missing TB risk assessments using the department-approved form in the personnel records. Staff #604 acknowledged the findings and stated that the agency used a different form in 2023. The agency is updating its procedures and will be using the department-approved TB risk assessment form again. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 05/20/21.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to provide evidence that Aide Supervisory visits occurred no less frequently than every 14 days for 1 of 2 patients receiving Home Health Aide (HHA) services (Patient #101). Failure to supervise the HHA at least every 14 days places the patients at risk of receiving services that are not reviewed for continued effectiveness and are not reflective of the patient’s changing needs. Findings included: 1. Document review of the agency’s policy and procedure titled, “HCS: Responsibilities and Supervision of Clinical Services,” (PolicyStat ID 13432145, Effective: 05/09/2023) showed aide supervisory visits will be conducted on-site at least every fourteen days by appropriate skilled personnel. 2. Record review of Patient #101 showed the Start of Care (SOC) was on 01/22/23 and that the patient was admitted with diagnoses of Chronic Venous Ulcers and Hypertension–not a complete list. The Physician ordered HHA services weekly for eight weeks starting on 07/09/23. There was no documentation to show that appropriate skilled staff completed supervisory visits at a minimum of 14-day intervals between 07/09/23 and 08/19/23. 3. On 02/06/24 at 3:00 PM, Surveyor #1 interviewed the agency’s Pod Leader (Staff #103) regarding the lack of documentation of aide supervisory visits. Staff #103 acknowledged the findings and stated that they were unable to provide the documentation on aide supervisory visits.

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to update and operationalize its policies and procedures consistent with state licensing requirements through failure to conduct reference checks for 2 of 12 clinicians (Staff #610 and #617) (Item #1); failure to update its policies and procedures on Mandatory Reporting based on the Washington Administrative Codes regulations (Item #2). Failure to maintain and implement policies and procedures consistent with state home health regulations puts patients at risk of physical and/or psychological harm from inadequate or substandard care. Findings included: Item #1: Reference checks Reference: Washington Administrative Code (WAC) 246-335-530 Personnel, contractor, and volunteer records. The licensee must maintain records on all personnel and volunteers and have access to records on all contractors, to include: (2) Documentation of references. 1. Document review of the agency policy titled, “Hiring Practices Policy,” (Policy No: 14836367, Effective Date 12/15/2023), showed that the Human Resources department will conduct reference checks including contacting previous employers in determining the applicant’s performance and verify the accuracy of the employment application. 2. On 02/07/24, Surveyor #6 reviewed personnel files for 12 staff members (Staff #608, #609, #610, #611, #612, #613, #614, #615, #616, #617, #618, and #619) The review showed: a. Staff #610 was hired on 09/12/22. The record contained no evidence that the agency conducted reference checks before employment. b. Staff #617 was hired on 02/27/23. The record contained no evidence that the agency conducted reference checks before employment. 3. On 02/07/24 at 2:00 PM, Surveyor #6 interviewed the agency’s Human Resource Partner (Staff #605) about the missing reference checks in the personnel files. Staff #605 acknowledged the findings, and stated that the agency was unable to provide the missing documentation of reference checks for the staff mentioned above. Item #2: Mandatory Reporting Reference: Washington Administrative Code (WAC) 246-335-535 Personnel, contractor, and volunteer policies. The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (8) Mandatory reporting: (a) Mandatory reporters shall report failure to comply with the requirements of chapters 246-335 WAC and 70.127 RCW to the department. The report must be submitted on department forms. Reports must be submitted within fourteen calendar days after the reporting person has knowledge of noncompliance that must be reported; (b) Mandatory reporters shall report suspected abandonment, abuse, financial exploitation, or neglect of a person in violation of RCW 74.34.020 or 26.44.030 to the Department of Social and Health Services and the proper law enforcement agency. Reports must be submitted immediately when the reporting person has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred. 1. Document review of the agency policy titled, “Identifying and Reporting Patient Abuse, Neglect, Exploitation or Misappropriation of Property Policy,” (Policy No: 14835899, Effective Date 12/15/2023), showed that the policy lacked the Washington State requirements for mandatory reporting for caregivers. 2. On 02/07/24 at 3:00 PM, Surveyor #6 asked the agency’s Regulatory and Accreditation Consultant (Staff #602) about the missing state requirements for mandatory reporting in the policy and procedure (P&P). Staff #602 acknowledged the findings and stated that the agency would be updating the P&P.

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 CFR 484 - HOME HEALTH regulations, conducted this health and safety survey. Examination number: X2021-439 Onsite date(s): 05/17/21 - 05/20/21 This survey was conducted by: Surveyor #3 Surveyor #6 DOH staff found the facility in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below. DOH recommends recertification based on an acceptable plan of correction. .

Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient's legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This ELEMENT is not met as evidenced by: . Based on record review and interview, the agency failed to ensure patients received a copy of their Patient Rights prior to receiving services for 2 of 17 patient records (Patient #612, and #615). Failure to provide/inform patients/caregivers of their rights could result in physical, psychological, or other forms of harm if patients are unaware of their rights or the agency's responsibility to promote said rights. Findings included: 1. Surveyor #6 reviewed the record of Patient #612. The record showed: Patient #612 had a start of care (SOC) date of 04/24/21. Patient #612 signed their Consent and Service agreement and dated it for 04/24/92. The consent form included an unchecked box that the patient had received the Patient Rights and Responsibilities in a language of their understanding. Surveyor #6 reviewed the record of Patient #615. The record showed: Patient #615 had a SOC date of 04/30/21. Patient #615's Guardian signed their Consent and Service agreement on 04/23/21. The consent form included an unchecked box that the patient had received the Patient Rights and Responsibilities in a language of their understanding. 2. Surveyor #6 interviewed the Home Health Manager, (Staff #612) on 05/20/21 at 9:49 AM. Staff #612 was unable to locate documentation that Patient #612 received or had their patient rights reviewed prior to receiving services. Staff #612 was unable to find documentation that the consent dated 04/24/92 was an error. Staff #612 acknowledged the missing information for Patient #612. Surveyor #6 also interviewed Staff #612 on 05/20/21 at 10:39 AM. Staff #612 was unable to locate documentation that Patient #615 or their guardian received or had their patient rights reviewed prior to receiving services. Staff #612 acknowledged the missing information for Patient #615. .

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: . Based on record review and interview, the agency failed to ensure patients received an initial assessment within 48 hours from the referral date for 4 of 17 patient records (Patient #301, #314, #611, and #615). Failure to meet this requirement places patients at risk for physical harm due to not receiving needed services in a timely manner. Findings included: 1. Surveyor #6 reviewed the agency's policy titled, "Initial Assessment/Comprehensive Assessments," (revised 06/28/19). The policy showed that the agency completes an initial and comprehensive assessment on every patient admitted to services as defined in the Medicare Conditions of Participation and the Washington Department of Health regulations. Surveyor #3 reviewed the record of Patient #301. The record showed: The home health services referral date for Patient #301 was 04/04/21. The agency completed the initial assessment on 04/12/21, 8 days after the referral date. Documentation as to the reason for the delay and physician notification was absent from the record. Surveyor #3 reviewed the record of Patient #314. The record showed: The home health services referral date for Patient #314 was 04/01/21. The agency completed the initial assessment on 04/09/21, 8 days after the referral date. Documentation as to the reason for the delay and physician notification was absent from the record. Surveyor #6 reviewed the record of Patient #611. The record showed: The home health services referral date for Patient #611 was 05/06/21. The agency completed the initial assessment on 05/11/21, 5 days after the referral date. Documentation as to the reason for the delay and physician notification was absent from the record. Surveyor #6 reviewed the record of Patient #615. The record showed: The home health services referral date for Patient #615 was 04/21/21. The agency completed the initial assessment on 04/30/21, 9 days after the referral date. Documentation as to the reason for the delay and physician notification was absent from the record. 2. Surveyor #3 interviewed the Home Health Manager, (Staff #312) on 05/18/21 at 2:00 PM. Staff #312 was unable to locate documentation that justified the delay in the initial assessments and acknowledged the missing information for Patient #301. Staff #312 stated, "Delay due to our capacity issues. We were 7 days out." Surveyor #3 interviewed the Director of Home Services, (Staff #310) on 05/19/21 at 2:00 PM. Staff #310 was unable to locate documentation that justified the delay in the initial assessments and acknowledged the missing information for Patient #314. Surveyor #6 interviewed the Home Health Manager, (Staff #612) on 05/19/21 at 4:55 PM. Staff #612 was unable to locate documentation that justified the delay in the initial assessments and acknowledged the missing information for Patient #611. Staff #612 stated that they were 5 days out for admissions during the time of Patient #611's referral. Surveyor #6 also interviewed Staff #612 on 05/20/21 at 10:50 AM. Staff #612 was unable to locate documentation that justified the delay in the initial assessments and acknowledged the missing information for Patient #615. Staff #612 stated that they were 5 days out for admissions during the time of Patient #615's referral. THIS IS A REPEAT CITATION FROM 11/17/17 .

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: . Based on record review and interview, the agency failed to develop and operationalize infection control policies and procedures that included an annual Tuberculosis (TB) risk assessment screening of Home Health staff consistent with State regulations for 4 of 7 Staff ( Staff #301, #302, #303 and #304). Failure to develop a method to perform annual screening of staff may result in the risk of patients' exposure to tuberculosis. Reference: WAC 246-335-525 PERSONNEL, CONTRACTOR, AND VOLUNTEER POLICIES - The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (15)(c)(ii) Conducting an annual assessment of new TB risk factors for all employees. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine agency's responsibility to conduct TB testing of employees. Retesting should only be done for persons who previously tested negative and have new risk factors since the last assessment. Findings included: 1. Document review of the agency's policy, "Standard Health requirement policy (last revised 02/17/21)" shows that staff will be evaluated for tuberculosis upon employment, following exposure and annually if indicated. The policy also showed staff with a past positive TST and a normal chest x-ray will complete an annual TB symptom questionnaire. 2. Surveyor #3 reviewed the employee file for the agency Home Care Aid (HCA)(Staff #301). The record showed the hire date for Staff #301, was 01/14/14. The review also showed that the agency conducted a blood test for Tuberculosis (T-SPOT) on 02/03/15. The record showed no further testing or screening for TB. Surveyor #3 reviewed the employee file for the agency Registered Nurse (RN)(Staff #302).The record showed the hire date for Staff #302,was 11/25/19. The review also showed that the agency conducted a blood test for Tuberculosis (T-SPOT) on 11/08/19. The record showed no further testing or screening for TB. Surveyor #3 reviewed the employee file for the agency Occupational Therapist (OT) (Staff #303). The record showed that the hire date for Staff #303, was 09/16/19. The review also showed that the agency conducted a blood test for Tuberculosis (T-SPOT) on 09/11/19. The record showed no further testing or screening for TB. Surveyor #3 reviewed the employee file for the agency RN (Staff #304). The record showed that the hire date for Staff #304, was 01/23/17. The review also showed that the agency conducted a blood test for Tuberculosis (T-SPOT) on 04/14/17. The record showed no further testing or screening for TB. 3. Surveyor #3 interviewed the agency Employee Health Manager (Staff # 308), regarding the state requirement to perform an annual TB risk assessment on staff, on 05/20/21 at 9:30 AM. The manager stated, "If completely negative, we don't screen yearly".