Every finding on record at VNA Health System

Based on the findings of an onsite unannounced home health care agency medicare recertification and state re-licensure survey completed on 1/8/26 VNA Health System, 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 onsite unannounced home health agency medicare recertification and state re-licensure survey completed on 1/9/25, VNA Health System, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on a review of policies, clinical records (CR), observation, and staff interview the agency failed to ensure that treatments were provided as ordered by a physician for one (1) of two (2) CR's reviewed requiring wound care (CR#5) Review of policy and procedure for verbal and telephone orders on 1/8/25 at 9:00 AM states, "17. The medical record should reflect a clear picture of the care/services provided...the medical record is composed of...physical assessments/reassessments, observations and responses to care...physicians orders. The progress notes should reflect the problem(s) or symptom(s) being treated, procedures performed, other interventions, patient outcomes in response to treatment...plan for next visit (including follow-up and monitoring), physician communication and content...when changes in plan of care occur, reason for change in plan of care. All documentation should correlate to the patient's care plan." Review of medical records on 1/7/26 PM at approximately 10:00 AM revealed the following: CR5: Start of Care 12/10/25, certification period 12/10/25-2/7/25. Primary diagnosis: Venous Insufficiency (poor blood flow). The physician ordered plan of care dated 12/10/25 required skilled nursing (SN) to be provided one (1) to two (2) times a week for 9 weeks. Skilled nursing was to assess, teach, manage, and perform wound care to (wound 1) the right posterior leg stasis ulcer (Wound 1, a slow-healing leg sore caused by venous insufficiency where blood pools in the legs, increasing pressure, leaking fluid, and damaging skin tissue), cleanse with antibacterial soap and water, apply ammonium acitate peri wound, place calcium alginate with silver onto wound bed, cover with a DSD (dry sterile dressing) secure with gauze wrap, apply tubi grip, and top with two (2) ace wraps daily. CR5’s caregiver to complete the days SN not in. On 12/15/25, CR5’s physician reviewed orders from the 12/12/25 wound visit, ordered that the SN continue the same wound care, and increased the SN visits to one (1) to three (3) times a week until the end of the current certification period as CR5 no longer requires weekly wound clinic appointments. On 12/26/25, M\CR5’s physician discontinued the prior wound care and ordered SN to cleanse the right lower extremity (RLE) wound with antibacterial soap and water, apply ammonium lactate or Vaseline to the entire foot and leg (excluding the wound), apply oil of emulsion gauze to the open wound, cover with a DSD, and secure with gauze wrap three (3) times per week. CR5 was to apply a single layer of tubi grip and ace wrap in the morning to both legs (bilateral lower extremities, BLLE) and remove at night (HS) from the base of the toes to below the knee. Review of CR5’s SN visits and treatment documentation revealed the following: On 12/15/25, 12/17/25, and 12/19/25, SN applied ammonium lactate to CR5’s RLE posterior wound (Wound 1), not ammonium acetate as ordered. On 12/22/25, SN identified that CR5 had the following new BLLE wounds: Wound 2: On the anterior (front) proximal (upper) shin of the RLE, a stasis ulcer measuring 2 centimeters (cm) long (L) by 2 cm wide (W) by 0.1 cm deep (D). Wound 3: On the anterior mid-shin of the RLE, a stasis ulcer measuring 2 cm L by 2 cm W by 0.1 cm D. Wound 4: On the lateral (outside) aspect of the L ankle, a stasis ulcer measuring 2 cm L by 2 cm W by 0.1 D. Wound 5: On the lateral aspect of the L ankle, a stasis ulcer measuring 2 cm L by 22 cm W by 0.1 cm D. On 12/22/25, the SN indicated “new popped blisters noted on the BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wound covered with calcium alginate and DSD, gauze wrap, tubi (grip) and ace x2.” There was no documentation that the SN notified the physician and/or wound clinic of CR5’s newly identified additional BLLE wounds or documentation that the SN received new orders regarding the four (4) new wounds identified on 12/22/25. The SN completed wound treatments on the four (4) newly identified wounds without a physician’s order and utilized ammonium lactate on Wound 1, `not ammonium acetate as ordered. On 12/24/25, the SN identified that CR5 had a new, additional wound (Wound 6) located on the L anterior, proximal shin measuring 2 cm L by 2 cm W x 0.1 D. The SN documented “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and dry skin, wounds covered with calcium alginate and DSD, gauze wrap, tubi (grips) and ace x2.” There was no documentation that the SN notified the physician and/or wound clinic of CR5’s Wound 6 and not documentation that the SN received new orders regarding Wound 6. The SN completed wound treatments on Wounds 2, 3, 4, and, and the newly identified wound (Wound 6) without a physician’s order and utilized ammonium lactate on Wound 1, not ammonium acetate as ordered. On 12/29/25, the SN documented that Wounds 3 and 4 were resolved, however Wounds 1, 2, 5, and 6 continued. The SN indicated “new popped blisters noted on the BL shin, all wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and abd (abdominal pad), gauze wrap, tubi, and ace x2.” The SN completed wound treatments on the LLE (Wounds 5 and 6) without a physician’s order. On 12/31/25, the SN documented that Wounds 1, 2, 5, and 6 continued. The SN indicated “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and ABD, gauze wrap, tubi (grips) and ace x2. The SN completed wound treatments on Wounds 5 and 6 without a physician’s order. On 1/2/26, the SN documented that Wound 2 was resolved, however Wounds 1, 5, and 6 continued. The SN documented that Wound 4 had re-opened, but no measurements were provided. The SN indicated “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and ABD, gauze wrap, tubi (grips) and ace x2. The SN completed wound treatments on Wounds 4, 5 and 6 without a physician’s order. On 1/4/26, the SN documented that Wounds 2, 3, 4, and 5 were resolved, however Wounds 1 and 6 continued. The SN indicated “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and ABD, gauze wrap, tubi (grips) and ace x2. The SN completed wound treatments on Wound 6 without a physician’s order. On 1/7/26, the SN documented that Wounds 1 and 6 continued. The SN indicated “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and ABD, gauze wrap, tubi (grips) and ace x2. The SN completed wound treatments on Wound 6 without a physician’s order. Observation of CR5’s wound care during a home visit on 1/7/26 at approximately 10:15 AM confirmed continuance of both Wounds 1 and 6, with dressings noted on CR5’s BLLE upon entry to the home. Employee 7, Registered Nurse, completed BLLE dressing changes for CR5. Prior to exiting the home at approximately 10:40 AM, Employee 7 reviewed CR5’s physician orders regarding the dressing changes with the surveyor and could not located physician’s orders for CR5’s LLE dressings that were completed during the home visit. Employee 7 confirmed the BLLE wounds observed and that there were no physician orders documented for the LLE dressing(s). Interview with the Agency Director on 1/7/26 at approximately 11:30 AM confirmed the above findings.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on a review of policies, clinical records (CR) and staff interview the agency failed to promptly alert the physician of changes in the patient's condition requiring the plan of care to be altered for one (1) of two (2) CR's reviewed requiring wound care (CR#5) Review of policy and procedure for verbal and telephone orders on 1/8/25 at 9:00 AM states, "17. The medical record should reflect a clear picture of the care/services provided...the medical record is composed of...physical assessments/reassessments, observations and responses to care...physicians orders. The progress notes should reflect the problem(s) or symptom(s) being treated, procedures performed, other interventions, patient outcomes in response to treatment...plan for next visit (including follow-up and monitoring), physician communication and content...when changes in plan of care occur, reason for change in plan of care. All documentation should correlate to the patient's care plan." Review of clinical records on 1/7/26 at 1000 AM revealed the following: CR#5 Start of care 12/10/15 for the certification period 12/10/25-2/7/26. Primary diagnosis: Venous Insufficiency (poor blood flow). The physician ordered plan of care dated 12/10/25 required skilled nursing (SN) skilled nursing to assess, teach, manage, and perform wound care to (wound 1) the right posterior leg stasis ulcer (a slow-healing leg sore caused by venous insufficiency where blood pools in the legs, increasing pressure, leaking fluid, and damaging skin tissue), cleanse with antibacterial soap and water, apply ammonium acitate peri wound, place calcium alginate with silver onto wound bed, cover with a DSD (dry sterile dressing) secure with gauze wrap, apply tubi grip, and top with two (2) ace wraps daily. CR5’s caregiver to complete the days SN not in. On 12/22/25, SN identified that CR5 had the following new BLLE (bilateral lower extremity) wounds: Wound 2: On the anterior (front) proximal (upper) shin of the RLE, a stasis ulcer measuring 2 centimeters (cm) long (L) by 2 cm wide (W) by 0.1 cm deep (D). Wound 3: On the anterior mid-shin of the RLE, a stasis ulcer measuring 2 cm L by 2 cm W by 0.1 cm D. Wound 4: On the lateral (outside) aspect of the L ankle, a stasis ulcer measuring 2 cm L by 2 cm W by 0.1 D. Wound 5: On the lateral aspect of the L ankle, a stasis ulcer measuring 2 cm L by 22 cm W by 0.1 cm D. On 12/22/25, the SN indicated “new popped blisters noted on the BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wound covered with calcium alginate and DSD, gauze wrap, tubi (grip) and ace x2.” There was no documentation that the SN notified the physician and/or wound clinic of CR5’s newly identified additional BLLE wounds or documentation that the SN received new orders regarding the four (4) new wounds identified on 12/22/25. On 12/24/25, the SN identified that CR5 had a new, additional wound (Wound 6) located on the L anterior, proximal shin measuring 2 cm L by 2 cm W x 0.1 D. The SN documented “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and dry skin, wounds covered with calcium alginate and DSD, gauze wrap, tubi (grips) and ace x2.” There was no documentation that the SN notified the physician and/or wound clinic of CR5’s Wound 6 and no documentation that the SN received new orders regarding Wound 6. Interview with the director on 1/9/26 at approximately 11:00 AM confirmed the above findings

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on a review of policies, clinical records (CR) and staff interview the agency failed to provide services ordered by the physician as indicated in the plan of care for one (1) of two (2) CR's reviewed requiring wound care (CR#5) Review of policy and procedure for verbal and telephone orders on 1/8/25 at 9:00 AM states, "17. The medical record should reflect a clear picture of the care/services provided...the medical record is composed of...physical assessments/reassessments, observations and responses to care...physicians orders. The progress notes should reflect the problem(s) or symptom(s) being treated, procedures performed, other interventions, patient outcomes in response to treatment...plan for next visit (including follow-up and monitoring), physician communication and content...when changes in plan of care occur, reason for change in plan of care. All documentation should correlate to the patient's care plan." Review of clinical records on 1/7/26 at 1000 AM revealed the following: CR5: Start of Care 12/10/25, certification period 12/10/25-2/7/25. Primary diagnosis: Venous Insufficiency (poor blood flow). The physician ordered plan of care (POC) dated 12/10/25 required skilled nursing (SN) to be provided one (1) to two (2) times a week for 9 weeks. Skilled nursing was to assess, teach, manage, and perform wound care to (wound 1) the right posterior leg stasis ulcer (Wound 1, a slow-healing leg sore caused by venous insufficiency where blood pools in the legs, increasing pressure, leaking fluid, and damaging skin tissue), cleanse with antibacterial soap and water, apply ammonium acitate peri wound, place calcium alginate with silver onto wound bed, cover with a DSD (dry sterile dressing) secure with gauze wrap, apply tubi grip, and top with two (2) ace wraps daily. CR5’s caregiver to complete the days SN not in. On 12/15/25, CR5’s physician reviewed orders from the 12/12/25 wound visit, ordered that the SN continue the same wound care, and increased the SN visits to one (1) to three (3) times a week until the end of the current certification period as CR5 no longer requires weekly wound clinic appointments. On 12/26/25, CR5’s physician discontinued the prior wound care and ordered SN to cleanse the right lower extremity (RLE) wound with antibacterial soap and water, apply ammonium lactate or Vaseline to the entire foot and leg (excluding the wound), apply oil of emulsion gauze to the open wound, cover with a DSD, and secure with gauze wrap three (3) times per week. CR5 was to apply a single layer of tubi grip and ace wrap in the morning to both legs (bilateral lower extremities, BLLE) and remove at night (HS) from the base of the toes to below the knee. Review of CR5’s SN visits and treatment documentation revealed the following: On 12/15/25, 12/17/25, and 12/19/25, SN applied ammonium lactate to CR5’s RLE posterior wound (Wound 1), not ammonium acetate as ordered/indicated in CR5’s POC. On 12/22/25, SN identified that CR5 had the following new BLLE wounds: Wound 2: On the anterior (front) proximal (upper) shin of the RLE, a stasis ulcer measuring 2 centimeters (cm) long (L) by 2 cm wide (W) by 0.1 cm deep (D). Wound 3: On the anterior mid-shin of the RLE, a stasis ulcer measuring 2 cm L by 2 cm W by 0.1 cm D. Wound 4: On the lateral (outside) aspect of the L ankle, a stasis ulcer measuring 2 cm L by 2 cm W by 0.1 D. Wound 5: On the lateral aspect of the L ankle, a stasis ulcer measuring 2 cm L by 22 cm W by 0.1 cm D. On 12/22/25, the SN indicated “new popped blisters noted on the BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wound covered with calcium alginate and DSD, gauze wrap, tubi (grip) and ace x2.” There was no documentation that the SN notified the physician and/or wound clinic of CR5’s newly identified additional BLLE wounds or documentation that the SN received new orders and/or updated CR5’s POC regarding the four (4) new wounds identified on 12/22/25. The SN completed wound treatments on the four (4) newly identified wounds without a physician’s order or what was identified in CR5’s POC and utilized ammonium lactate on Wound 1, `not ammonium acetate as ordered/indicated in CR5’s POC. On 12/24/25, the SN identified that CR5 had a new, additional wound (Wound 6) located on the L anterior, proximal shin measuring 2 cm L by 2 cm W x 0.1 D. The SN documented “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and dry skin, wounds covered with calcium alginate and DSD, gauze wrap, tubi (grips) and ace x2.” There was no documentation that the SN notified the physician and/or wound clinic of CR5’s Wound 6, update CR5’s POC, and no documentation that the SN received new orders regarding Wound 6. The SN completed wound treatments on Wounds 2, 3, 4, and, and the newly identified wound (Wound 6) without a physician’s order and utilized ammonium lactate on Wound 1, not ammonium acetate as ordered/indicated in CR5’s POC. On 12/29/25, the SN documented that Wounds 3 and 4 were resolved, however Wounds 1, 2, 5, and 6 continued. The SN indicated “new popped blisters noted on the BL shin, all wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and abd (abdominal pad), gauze wrap, tubi, and ace x2.” The SN completed wound treatments on the LLE (Wounds 5 and 6) without a physician’s order or as indicated in CR5’s POC. On 12/31/25, the SN documented that Wounds 1, 2, 5, and 6 continued. The SN indicated “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and ABD, gauze wrap, tubi (grips) and ace x2. The SN completed wound treatments on Wounds 5 and 6 without a physician’s order or as indicated in CR5’s POC. On 1/2/26, the SN documented that Wound 2 was resolved, however Wounds 1, 5, and 6 continued. The SN documented that Wound 4 had re-opened, but no measurements were provided. The SN indicated “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and ABD, gauze wrap, tubi (grips) and ace x2. The SN completed wound treatments on Wounds 4, 5 and 6 without a physician’s order or as indicated in CR5’s POC. On 1/4/26, the SN documented that Wounds 2, 3, 4, and 5 were resolved, however Wounds 1 and 6 continued. The SN indicated “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and ABD, gauze wrap, tubi (grips) and ace x2. The SN completed wound treatments on Wound 6 without a physician’s order or as indicated in CR5’s POC. On 1/7/26, the SN documented that Wounds 1 and 6 continued. The SN indicated “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and ABD, gauze wrap, tubi (grips) and ace x2. The SN completed wound treatments on Wound 6 without a physician’s order or as indicated in CR5’s POC. Observation of CR5’s wound care during a home visit on 1/7/26 at approximately 10:15 AM confirmed continuance of both Wounds 1 and 6, with dressings noted on CR5’s BLLE upon entry to the home. Employee 7, Registered Nurse, completed BLLE dressing changes for CR5. Prior to exiting the home at approximately 10:40 AM, Employee 7 reviewed CR5’s physician orders and POC regarding the dressing changes with the surveyor and could not located physician’s orders for CR5’s LLE dressings that were completed during the home visit. Employee 7 confirmed the BLLE wounds observed and that there were no physician orders documented for the LLE dressing(s). Interview with the director on 1/9/26 at approximately 11:30 AM confirmed the above findings.

Based on the findings of an onsite unannounced home health care agency Medicare recertification and state re-licensure survey conducted January 10, 2023, through January 12, 2023, VNA Health System, 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 onsite unannounced home health agency Medicare recertification and state re-licensure survey conducted January 10, 2023, through January 12, 2023, VNA Health System, was found not to 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 policies, observations (OBS), made during home visits, and interview with agency Administrator (EMP #1) the agency failed to ensure staff maintained standard precautions including but not limited to: doffing and donning gloves prior to and following hand hygiene, performing hand hygiene, and bag technique for three (3) of six (6) observations made. OBS #1, #3 and #5. Findings include: Review of policies completed January 11, 2023, between approximately 12:00 PM and 1:00 PM revealed: POLICY AND PROCEDURE FOR CLEAN AND STERILE TECHNIQUE: Procedure: b) "The clinician begins (and ends) with hand hygiene, with a clean barrier used for supplies to use for the procedure". POLICY AND PROCEDURE FOR BAG TECHNIQUE: Procedure: 2. "Nurses bag must be placed on clean, dry surface in the home... Remember, the floor is considered dirty- never put the bag on the floor". 3. "Remove only those items that are needed for patient care and place on a clean, dry or barrier covered surface". 4. " Items removed from the bag that are not disposable must be disinfected prior to placing the equipment back into the bag". 6. "As the bag is considered clean, hand hygiene must be done before entering and re-entering your bag". Observations completed on January 11, 2023, between approximately 9:00 AM and 11:00 AM and again, on January 12, 2023, between approximately 10:30 AM and 11:30 AM revealed the following: OBS #1, completed on January 11, 2023, at approximately 9:00 AM showed the nurse did not place a barrier under her bag before placing it on a clean, dry surface. Nurse performed wound care on patient's right heel. She did not remove her gloves and perform hand hygiene before performing wound care on the patient's left heel. Following procedure, nurse removed gloves, performed hand hygiene but did not disinfect equipment before placing it back into the bag. OBS #3, completed January 11, 2023, at approximately 10:00 AM revealed the nurse placed the bag on an upholstered chair with no barrier underneath. Changed the dressings of the patient's wound without donning new gloves or performing hand hygiene. After disposing of the dirty dressings, took the patient's vital signs without performing hand hygiene and donning new gloves, then placed the pulse oximeter just used on the patient into her pocket. OBS #5, completed January 12, 2023, at approximately 10:35 AM revealed the physical therapist placing her bag on the floor. Equipment was removed from the bag and placed on the table without a barrier being placed. Interview with the agency Administrator completed January 12, 2023, at approximately 3:00PM confirmed the policies as current and the above findings.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on review of policies/procedures, medical records and interview with the Clinical Supervisor the agency failed to ensure that staff completed weekly would measurements on patients with wounds for two (2) of eighteen (18) records reviewed. #11 and #18. Findings include: Review of policies/procedures completed on January 11, 2023, between approximately 12:00 PM and 1:00 PM revealed: POLICY: INTEGUMENTARY-PRESSURE ULCER AND WOUND ASSESSMENT: PROCEDURE: Assessing the wound (3) length and width: "Length and width are measured as linear distances from wound edge to wound edge. Wound length and width can also be documented by making a tracing of the wound on transparent paper with a permanent marker, tracing on an acetate guide, photographic documentation". 2. Reassessment: a. "Reassess the wound weekly, according to the initial assessment guidelines". POLICY: SKILLED NURSING SERVICE: PROCEDURE: "Skilled nursing service will be provided in the patient's residence ... Skilled nursing service includes... Provision and demonstration of nursing procedures, techniques, or treatments which require professional nursing skills... Initiating appropriate preventive and rehabilitative nursing measures to promote positive health status for the patient ... The registered nurse providing skilled nursing care will: 4. "Regularly reevaluate the patient's nursing needs, alerting the physician to changes in the patient's condition which suggest the need to alter the plan of care". POLICY: PLAN OF CARE DEVELOPMENT, REVIEW, AND REVISION: PROCEDURE, 14. "The patient's plan of care is to be reviewed on a continuous basis and revised as needed. This is to occur at a minimum every 55-60 days... The plan of care will be revised to reflect the change as needed. The physician ordered plan of care should include best practices". Review of medical records (MR) completed January 11, 2023, and January 12, 2023, between approximately 10:00 AM and 2:00 PM revealed: MR #11, start of care (SOC): 3/16/22; certification period: 11/11/22-1/9/23; Physician orders: "skilled nursing 1-3 times per week for 9 weeks for wound care". No documented wound measurements during wound care during visits made weeks 11/15/22-11/29/22 and 12/13/22-12/25/22. MR#18, SOC: 5/13/22; certification period: 11/9/22-1/7/23; Physician orders: "skilled nursing 1-2 times per week for 9 weeks". No documented wound measurements during wound care during visits made weeks 11/16/22-11/28 and 12/14/22-12/27/22. Interview with the agency Administrator completed January 12, 2023, at approximately 3:00PM confirmed the policies as current and the above findings.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on reviews of policies/procedures, personnel files (PF) and interview with the Clinical Supervisor the agency failed to ensure that employees were free from Mycobacterium Tuberculosis (TB) in accordance with policy and CDC guidelines for four (4) of ten (10) files reviewed. PF #1, #3, #6 and #8. Findings include: 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 policy completed January 11, 2023, between approximately 12:00 PM and 1:00 PM revealed the following: Policy: TUBERCULOSIS SURVEILANCE PROGRAM section: TESTING: " All new staff/volunteers who have contact with patients are required to consent to an initial TST with symptom assessment and Proof of Documented Negative PPD in the past twelve months". Review of personnel files (PF) completed January 10, 2023, at approximately 1:00 PM revealed: PF #1, Date of Hire (DOH): 1/11/18, contained a second step PPD skin test placed 6/28/20. No documented reading of the placement. PF#3, DOH:11/8/21, contained no TB screening for 2021. PF#6, DOH:4/19/21, contained no TB screening for 2021. PF #8, DOH: 7/21/21, contained no TB screening for 2021. Interview with the agency Administrator completed January 12, 2023, at approximately 3:00PM confirmed the policies as current and the above findings.