Every finding on record at Salud Health Care Services Inc

To conduct a re-licensure/recertification survey. On 03/05/25 at 01:27 p.m., the surveyor conducted an unannounced visit and an entrance conference with the Adm. Census: L&CHHS – 80 LHHS – 0 PAS – 0 The Agency was in compliance with 42 CFR Part 484.102, Emergency Preparedness requirements for Home Health Agencies. Abbreviations: Adm – Administrator Alt Adm – Alternate Administrator HHSC – Health and Human Services Commission HHA – Home Health Agency RN – Registered Nurse LVN -Licensed Vocational Nurse OSHA- Occupational Safety and Health Administration CFR – Code of Federal Regulations CDC – Centers for Disease Control and Prevention

Purpose of Survey – To conduct a recertification Re-licensure survey. On 03/05/25 at 01:27 p.m., the surveyor conducted an unannounced visit and an entrance conference. Census: L&CHHS – 80 LHHS – 0 Abbreviations: Adm – Administrator Alt Adm – Alternate Administrator HHSC – Health and Human Services Commission HHSC – Health and Human Services Commission RN – Registered Nurse LVN -Licensed Vocational Nurse OSHA- Occupational Safety and Health Administration CFR – Code of Federal Regulations CDC – Centers for Disease Control and Prevention

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to enforce its written policies to provide Bloodborne pathogen training as required by the Occupational Safety and Health Administration (OSHA), 29 CFR1910.1030 and Appendix A relating to Bloodborne pathogens for 10 of 13 personnel record review (RN A, LVN B, LVN C, LVN D, LVN F, RN G, LVN H, LVN I, LVN J, LVN K ) whose personnel records were reviewed for 2022, 2023 and 2024. This failure could place staff and agency's current clients at risk for exposure to communicable and/or infectious diseases. The findings include: Review of the OSHA 29 CFR 1910.1030 revealed in part, " ... The employer shall train each employee with occupational exposure in accordance with the requirements of this section... Training shall be provided as follows: At the time of initial assignment to tasks where occupational exposure may take place; at least annually thereafter...Annual training for all employees shall be provided within one year of their previous training..." Record review of agency's policy "Infection Control Program", dated 05/31/16, quoted in part, "Policy, Agency's infection control program will be based on the following criteria ...4. CDC guidelines ...5. communicable disease prevention and control act, Health and safety code, chapter 81 ...6. current federal/state/local laws and regulations ...H. Education of Employee 1. Upon hire and annually thereafter, all agency employees will be educated regarding the policies and procedures related to: Infection control program, exposure control program, Bloodborne/Airborne/HIV Pathogen Program." 1. Review of the RN A personnel record revealed an employment application was completed, signed, and dated 07/19/17. Agency roster listed RN A’s date of hire as 07/019/17. Review of the RN A personnel record included an agency form titled "Annual Employee Training " that revealed last performed Bloodborne pathogen training for RN A dated as 08/03/21. Further review of the RN A's personnel record failed to reveal it contained evidence on annual Bloodborne Pathogen trainings were conducted for the year 2022, 2023, and 2024. 2. Review of the LVN B personnel record revealed an employment application was completed, signed, and dated 05/15/14. Agency roster listed LVN B's date of hire as 012/3/2014. Review of the LVN B personnel record included an agency form titled "Annual Employee Training " that revealed last performed Bloodborne pathogen training for LVN B dated as 08/13/21. Further review of the LVN B's personnel record failed to reveal it contained evidence on annual Bloodborne Pathogen trainings were conducted for the years 2022, 2023, and 2024. 3. Review of the LVN C personnel record revealed an employment application was completed, signed, and dated 10/10/13. Agency roster listed LVN C's date of hire as 08/01/2014. Review of the LVN C personnel record included an agency form titled "Annual Employee Training " that revealed last performed Bloodborne pathogen training for LVN C dated as 08/13/21. Further review of the LVN C's personnel record failed to reveal it contained evidence on annual Bloodborne Pathogen trainings were conducted for the years 2022, 2023, and 2024. 4. Review of the LVN D personnel record revealed an employment application was completed, signed, and dated 09/12/23. Agency roster listed LVN D's date of hire as 09/20/2023. Review of the LVN D personnel record included an agency form titled "Orientation Guidelines With all questions answered " that revealed Initial Bloodborne pathogen training for LVN D dated as 09/21/23. Further review of the LVN D's personnel record failed to reveal it contained evidence on annual Bloodborne Pathogen trainings were conducted for the year 2024. 5. Review of the LVN F personnel record revealed an employment application was completed, signed, and dated 03//04/22. Agency roster listed LVN F's date of hire as 03/07/2022. Review of the LVN F personnel record included an agency form titled " Orientation Guidelines With all questions answered " that revealed Initial Bloodborne pathogen training for LVN F dated as 03/04/22. Further review of the LVN F's personnel record failed to reveal it contained evidence on annual Bloodborne Pathogen trainings were conducted for the year, 2023, and 2024. 6. Review of the RN G personnel record revealed an employment application was completed, signed, and dated 04/21/14. Agency roster listed RN G’s date of hire as 12/03/14. Review of the RN G personnel record included an agency form titled "Annual Employee Training " that revealed last performed Bloodborne pathogen training for RN G dated as 08/03/21. Further review of the RN G's personnel record failed to reveal it contained evidence on annual Bloodborne Pathogen trainings were conducted for the year 2022, 2023, and 2024. 7. Review of the LVN H personnel record revealed an employment application was completed, signed, and dated 09/15/21. Agency roster listed LVN H’s date of hire as 09/15/21. Review of the LVN H personnel record included an agency form titled " Orientation Guidelines With all questions answered " that revealed Initial Bloodborne pathogen training for LVN H dated as 09/15/21. Further review of the LVN H's personnel record failed to reveal it contained evidence on annual Bloodborne Pathogen trainings were conducted for the year 2022, 2023, and 2024. 8. Review of the LVN I personnel record revealed an employment application was completed, signed, and dated 09/29/21. Agency roster listed LVN I’s date of hire as 09/29/21. Review of the LVN I personnel record included an agency form titled " Orientation Guidelines With all questions answered " that revealed Initial Bloodborne pathogen training for LVN I dated as 09/29/21. Further review of the LVN I's personnel record failed to reveal it contained evidence on annual Bloodborne Pathogen trainings were conducted for the year 2022, 2023, and 2024. 9. Review of the LVN J personnel record revealed an employment application was completed, signed, and dated 10/13/23. Agency roster listed LVN J’s date of hire as 10/13/23. Review of the LVN J personnel record included an agency form titled " Orientation Guidelines With all questions answered " that revealed Initial Bloodborne pathogen training for LVN J dated as 10/13/23. Further review of the LVN J's personnel record failed to reveal it contained evidence on annual Bloodborne Pathogen trainings were conducted for the year 2024. 10. Review of the LVN K personnel record revealed an employment application was completed, signed, and dated 12/18/23. Agency roster listed LVN K’s date of hire as 12/18/23. Review of the LVN K personnel record included an agency form titled " Orientation Guidelines With all questions answered " that revealed Initial Bloodborne pathogen training for LVN K dated as 12/18/23. Further review of the LVN K's personnel record failed to reveal it contained evidence on annual Bloodborne Pathogen trainings were conducted for the year 2024. Interview with Alternate Administrator/ Director on Nurses, Alternate Director of Nurses and the Human resources Representative on 03/11/25 at 4:30, the surveyor presented the above findings and surveyor asked what the agency's policy on Bloodborne Pathogen trainings was. Alternate Administrator stated "Bloodborne pathogen training are done upon hire and annually for all staff". Alternate Administrator confirmed that there are no Bloodborne pathogens trainings for several employees for the year 2022, 2023 and 2024. Surveyor asked why no bloodborne pathogen trainings were conducted for the years of 2022, 2023 and2024 for the Employees. Alternate Administrator stated that “Our Previous Human resource representative left from one day to the next, we thought she had been doing the trainings and thought that the former HR representative had put them somewhere else, but we can’t find anything ".Alternate Administrator confirmed the Human resource department was responsible for bloodborne pathogen trainings and by not doing annual bloodborne pathogen trainings, can lead to the spread of infections to themselves and patients. Nurse Surveyor asked Director of Nurses if the annual blood borne Pathogen trainings kept in the personnel file or in another Binder, She Replied, “the initial one is in the employee file and after that there are kept in another binder.” Human Resource Representative was asked by surveyor when was her employment start date, she stated that she started 12/06/2024 and the Previous Human Resource Representative left in March of last year, Surveyor asked the current Human resource Representative if she was aware of the failure to conduct the Bloodborne pathogen training She stated” I did conduct an audit and notified the administrator. Per the information from the Alternate Administrator there was no action taken to rectify the situation Administrator unavailable for Interview due to Out on medical leave for Medical Procedure The agency did not dispute the surveyor's findings. The agency was afforded the opportunity to provided additional policy information upon exit on 03/11/25 at 5:19 pm. No additional documents provided by agency.