QA Investigation Results

Pennsylvania Department of Health
BAYADA HOME HEALTH CARE, INC.
Health Inspection Results
BAYADA HOME HEALTH CARE, INC.
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced agency state re-licensure survey conducted on May 7, 2019, Bayada Home Health Care, Inc, was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.



Plan of Correction:




Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted on May 7, 2019, Bayada Home Health Care, Inc., was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries.



Plan of Correction:




611.56(b) LICENSURE
Health Screening

Name - Component - 00
(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.

Observations:

Based on a review of personnel files (PF), The Centers for Disease Control Guidelines, and an interview with the administrator, the agency failed to provide documentation of annual tuberculosis screening for two (2) of ten (10) PF's, PF #2 and 7.

Findings:

The CDC guidelines state that all Health Care Workers (HCW) should received 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. After baseline testing for infection with tuberculosis, HCWs should receive TB screen annually. HCWs with a baseline 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.

A review of PF's was conducted on May 7, 2019 from approximately 11:00 am to 12:10 pm.

PF #2 Date of Hire 12/26/17 did not contain any documentation of an annual tuberculosis screening for 2018.

PF #7 Date of Hire 10/16/17 did not contain any documentation of an annual tuberculosis screening for 2018.

An interview with the administrator on May 7, 2019 at approximately 12:30 pm confirmed the above findings.






Plan of Correction:

Based on an analysis of the specific deficiencies cited, the corrective plan and actions taken are to address the lack of demonstrated knowledge resulting in failure to conduct annual TB screenings. The plan of correction will be completed through comprehensive focused education and re- instruction.

At the time of the survey, employee #2 did not have an annual TB screening conducted for the year of 2018. This employee does not have a current annual screening and will not be scheduled to see clients until an annual screening has been completed.

At the time of the survey, employee #7 did not have an annual TB screening conducted for the year of 2018. This employee completed a TB symptom screening on 3/18/2019 and is currently up to date with their annual TB screening and in compliance with state regulation.

By 6/1/2019, all office staff will be re-educated by the Director/designee on policy 0-1999 - TB EXPOSURE PLAN with emphasis on the requirement to complete TB screenings annually for all HCW in accordance with state regulation. The education will include a review of form 0-660 - EMPLOYEE TB SCREENING TOOL and instruction to complete annually for all HCW to satisfy the annual TB screening requirement.

An audit of all active employees will be completed by 6/6/2019 to ensure annual TB screenings have been conducted for the current year according to state regulation.

Effective 6/7/2019, the Director/designee will review weekly for three months and until 100% compliance is achieved, the "TB Screening Due Date" report to facilitate timely administration of annual TB screenings in accordance with state regulation. If during the record review any discrepancies are found, corrections will be made and the employee responsible will be counseled. Subsequently, sustained improvement will be monitored through quarterly clinical record reviews conducted as a required component of the Organizations Quality Assurance and Performance Improvement program.

The Director has overall responsibility for implementation and oversight of the plan.





Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted on May 7, 2019, Bayada Home Health Care, Inc., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: