Every finding on record at Volunteer Homecare of West Tennessee Inc.

E0000 An Emergency Preparedness Survey was conducted on 6/1/2026 through 6/3/2026 with the recertification survey. The agency meets all Federal Health Emergency Preparedness requirements.

A Recertification survey was conducted 6/1/2026 through 6/3/2026. An entrance conference was held with the Clinical Informatics Registered Nurse (RN) and the Clinical Supervisor. An exit conference was held on 6/3/2026 at 12:00 PM with the Administrator, Clinical Informatics RN, and Director of Nursing. They were given the opportunity to ask questions regarding the survey findings.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, medical record review, observation and interview, the agency failed to ensure medications were accurately documented in the medical record for 4 of 7 (Patient #1, #2, #4, and #5 ) sampled patients observed during home visits. The findings included: 1. Review of the agency's "Medication Reconciliation" policy revealed, "...The Agency will reconcile patient's medications at time of admission and on an ongoing basis...Medications ordered while the patient is receiving care will be compared to the medication list/profile. The mediation list/profile will be updated with each new or changed medication and reviewed at least every 60 days..." 2. Medical record review for Patient #1 revealed a Start of Care (SOC) date of 3/9/2026 with diagnoses which included After care following joint replacement surgery and iron deficiency anemia. Observations in Patient #1's home on 6/1/2026 at 2:45 PM revealed the following medications were not included on the Patient's medication profile: a. Ondansetron (medication for nausea) 4 milligrams (mg) 1 tablet under the tongue every 8 hours as needed for nausea. The prescription was filled on 4/28/2026. b. Hydrocodone-Apap (medication for pain) 7.5 -325 mg 1 tablet by mouth every 4 hours as needed for pain. The prescription was filled on 5/5/2026. c. Metformin HCL (medication for diabetes) 500 mg by mouth once a day. The prescription was filled on 5/18/2026. Additional findings revealed Ascorbic acid (Vitamin C) 500 mg tablet by mouth once daily was listed on the medication profile but was not found in the Patient's home. During an interview on 6/1/2026 at 2:47 PM, Patient #1 stated she was currently taking the Ondansetron, Hydrocodone-Apap, and Metformin which were not included on the medication profile. Patient #1 stated she had stopped taking Vitamin C "a long time ago." 3. Medical record review for Patient #2 revealed a SOC date of 1/31/2025 with diagnoses which included orthopedic aftercare and non-pressure chronic ulcer of unspecified part of the left lower leg with muscle involvement without evidence of necrosis. Observations in Patient #2's home on 6/1/2026 at 1:30 PM revealed Nicotine Transdermal Patch (medication to help stop smoking) 21 mg to be applied every 24 hours was in the Patient's home, but the medication profile showed the dosage was 14 mg. During an interview on 6/1/2026 at 1:32 PM, Patient #2 confirmed she was using the 21 mg Nicotine patches. 4. Medical record review for Patient #4 revealed a SOC date of 4/17/2026 with diagnoses which included Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. Observations in Patient #4's home on 6/1/2026 at 1:30 PM revealed Amiodarone (medication used to treat heart rhythm disorders) 200 mg 1 tablet twice a day for Cardiac Arrhythmias was on the medication profile but was not in the Patient's home. During an interview on 6/1/2026 at 1:30 PM, Patient #4 stated she ran out of Amiodarone on 5/26/2026 and was going to wait until her September visit with her Cardiologist to ask for refills. During an interview on 6/1/2026 at 1:35 PM, RN #1 verified that she does not check medications at every visit. During an interview on 6/1/2026 at 1:36 PM, Clinical Manager #1 stated, “Medications should be checked at every visit.” 5. Medical record review for Patient #5 revealed a Start of Care (SOC) date of 5/20/2026 with diagnoses which included Parkinsons Disease and Depression. Observations in Patient #5's home on 6/1/2026 at 3:40 PM revealed the following medications were not included on the Patient's medication profile: a. Synthroid (thyroid hormone replacement) 125 micrograms (mcg) 1 tablet by mouth every morning to treat Hypothyroidism. b. Fluticasone Nasal Spray (a steriod nose spray used to reduce inflammation) 50 micrograms (mcg) 1 spray each nostril every morning to treat Allergies. During an interview on 6/1/2026 at 4:30 PM, Patient #5 stated she was currently taking the Synthroid and Fluticasone Nasal Spray and had been on them for “15 years” which were not included on the medication profile. During an interview on 6/1/2026 at 4:35 PM, Clinical Manager #2 verified that medications should be checked at every visit and with any changes. During an interview on 6/3/2026 at 11:45 AM, the Clinical Informatics the Registered Nurse verified medications should be checked at every visit and anytime there is a change in medication.

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 policy review, observation and interview, the agency failed to ensure measures to prevent the spread of infectious agents were followed by 2 of 7 (Registered Nurse (RN) #1 and RN #2) staff observed providing direct patient care in the home setting. The findings included: 1. Review of the agency's "Wound Management Policy" revealed, "...Clinicians will follow standard precautions and infection prevention practices during all wound care procedures..." Review of the agency's "Hand Hygiene Policy and Compliance Program" policy revealed, "...Hand hygiene will be done by all employees to reduce the transfer of microbes to patients and to prevent the growth of microorganisms on the nails, hands and forearms...Indications for staff performing hand hygiene are...Before re-entering nursing bag or patient's clean supplies...The Agency may follow the Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene when home conditions permit...CDC Hand Hygiene Guidelines...Indications for handwashing and hand antisepsis...After contact with blood, body fluids, mucous membranes, non-intact skin and wound dressings...Moving from contaminated patient body site to clean site during patient care..." Review of the agency's "Exposure Control Plan: OSHA Regulations/Disinfection/Bag Technique" policy revealed, "...Infection Control and Standard Precautions...Blood body fluids and tissues of all patients are presumed infectious...Hand hygiene is the most important procedure in the prevention of infections. Handwashing will be performed by all staff according to established Hand Hygiene Policy...Infectious waste may include soiled dressings...Bags used by nurses, home health aides and other staff which contain equipment, e.g. [such as] a thermometer, stethoscope, blood pressure cuff, etc. [etcetera], and are brought into the home are classified as clean on the inside...Nursing Bag Technique...Upon entering the home, place the bag on a clean surface...Open the bag near the care area...Wash hands thoroughly with bacteriostatic foam/liquid/gel...Remove all items which will be needed for the visit...Place items on one of the paper towels. Close the bag and give the patient care...If additional items are needed after care has started, wash hands before re-entering bag..." 2. Observations in Patient # 4”s home on 6/1/2026 at 12:50 PM revealed RN #1 providing direct patient care. RN #1 performed hand hygiene, donned gloves, removed the Patients right lower leg wound dressing, cleaned the wound without changing gloves and performing hand hygiene. During an interview on 6/1/2026 at 1:35 PM with RN #1, Surveyor asked when she should change gloves and perform hand hygiene during wound care, she stated, “I take off the old dressing, clean the wound, remove gloves, perform hand hygiene and put on new gloves.” During an interview on 6/1/2026 at 1:36 PM with Clinical Manager #1, she verified hand hygiene should be performed after taking off the old dressing and before starting the cleaning process. During an interview on 6/3/3036 at 11:55 AM with the Director of Nursing, she verified after removing the old dressing, you should discard gloves, perform hand hygiene and apply new gloves. 3. Observations in Patient #7"s home on 6/2/2026 at 10:50 AM revealed RN #2 providing direct patient care. RN #2 performed hand hygiene, donned gloves, administered the Patient's Toradol (a medication used to decrease inflammation and provide pain relief) injection into his left arm, and removed her gloves. Without performing hand hygiene, the RN reached into her nursing bag and gathered another pair of gloves, performed hand hygiene, and donned new gloves. RN #2 counted the Patient's narcotic pills and removed her gloves. Without performing hand hygiene, RN #2 reached into her nursing bag, obtained another pair of gloves and performed hand hygiene. RN #2 failed to perform hand hygiene before entering the nursing bag repeatedly. During an interview on 6 /2/2026 at 11:42 AM with RN #2, she stated, “I knew I had already gone in my bag once without hand hygiene, and I should perform hand hygiene more than I do.” During an interview on 6/3/2026 at 11:58 AM with the Administrator, she verified all staff should perform hand hygiene before entering their bag.