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 state re-licensure survey conducted on May 9, 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 9, 2019, Bayada Home Health, 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(a) LICENSURE
Health Screening

Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.

Observations:



Based on a review of personnel files (PF), agency policy, and an interview with the Administrator, the agency did not conduct testing for mycobacterium tuberculosis according to the Center for Disease Control (CDC) guidelines for six (6) of ten (10) personnel files reviewed (PFs #'s 1, 2, 3, 4, 6, 7, & 9).

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) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. 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.

A review of agency policy conducted on May 9, 2019 at approximately 11:30 A.M entitled "0-1999 TB Exposure Plan" stated "Pennsylvania...When an annual TB risk assessment is used to waive annual testing, in addition to completing the annual risk assessment all healthcare workers must complete...Employee TB Screening Tool #0-660 annually to attest he/she is free from signs and symptoms which may indicate active TB disease. The symptom screening must be complete even if annual risk assessment determines low risk."

A review of PF's conducted on May 9, 2019, from approximately 10:30 A.M. through 11:30 A.M. revealed the following:

1.) PF #1. Date of Hire (DOH): 3/20/17: There was no documentation of an annual TB screening completed in 2018.

2.) PF #2. DOH: 9/25/13: There was no documentation of an annual TB screening completed in 2018.

3.) PF #3. DOH: 7/22/15: There was no documentation of an annual TB screening completed in 2017 and 2018.

4.) PF #4. DOH: 5/13/15: (Direct Care worker is a rehire from 6/9/09, the last TST completed in file was from 5/16/11). There was a one step TST completed on 5/13/15 but there no was documentation of the second step of the initial TST being completed. In addition, there was no documentation of an annual TB screening completed in 2018.

5.) PF #6. DOH: 8/15/16: There was no TB screening completed in 2016, 2017, and 2018. There was a note in the file stating history of positive TB testing/TB treatment but there was no documentation of Chest X-rays results/screenings completed.

6.) PF #7. DOH: 10/30/06: There was no documentation of an annual TB screening completed in 2018.



Interview with the Administrator on May 9, 2019 at approximately 1:00 PM confirmed the personnel files lacked screening according to the CDC guidelines.






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 TB screening in accordance with CDC guidelines. The plan of correction will be completed through comprehensive focused education and re- instruction.

At the time of the survey, employee #1 did not have an annual TB screening conducted for the year of 2018. This employee completed a TB symptom screening on 3/7/2019 and is currently up to date with their annual TB screening and in compliance with state regulation.

At the time of the survey, employee #2 did not have an annual TB screening conducted for the year of 2018. This employee completed a TB symptom screening on 5/20/2019 and is currently up to date with their annual TB screening and in compliance with state regulation.

At the time of the survey, employee #3 did not have an annual TB screening present in their file for the years of 2017 or 2018. This employee completed a TB symptom screening on 11/8/2018 and it is currently in their file and they are up to date with their annual TB screening and in compliance with state regulation.

At the time of the survey it was discovered that employee #4 did not have an initial TB screening at hire in accordance with Agency policy or CDC guidelines and also did not have an annual TB symptom screening for the year of 2018. This employee will complete an initial TB screening prior to being scheduled to see clients and will complete an annual TB symptom screening within 12 months of the initial.

At the time of the survey it was discovered that employee #6 did not have an initial TB screening at hire in accordance with Agency policy or CDC guidelines and did not have an annual TB symptom screening for the years 2016, 2017 or 2018. Documentation was provided by the employee and placed in their file detailing a history of a positive TST and chest x-ray results. This employee completed a TB symptom screening on 5/21/2019 bringing them in compliance with TB screening requirements and state regulation.

At the time of the survey, employee #7 did not have an annual TB screening present in their file for the year of 2018. This employee completed a TB symptom screening on 11/8/2018 and it is currently in their file and they are 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 initial screening requirements as well as 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's to satisfy the annual TB screening requirement.

An audit of all active employees will be completed by 6/7/2019 to ensure initial screenings were completed in accordance with Agency policy. If any employees are identified as being out of compliance with initial screening requirements, the employee will complete an initial screening per Agency policy prior to being scheduled to see clients. The audit will also consist of a review of annual TB screenings to ensure they 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 employee files of all new hires for the completion of initial TB screening in accordance with Agency policy. Additionally, the "TB Screening Due Date" report will be reviewed weekly 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. Sustained improvement and compliance will be monitored through quarterly new employee record reviews conducted through 4Q2019.

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 9, 2019, Bayada Home Health, Inc., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: