QA Investigation Results

Pennsylvania Department of Health
BRIGHTSTAR CARE OF ERIE COUNTY
Health Inspection Results
BRIGHTSTAR CARE OF ERIE COUNTY
Health Inspection Results For:


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Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed 5/30/2018, Brightstar Care Of Erie County was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.



Plan of Correction:




Initial Comments:

Based on the findings of an onsite unannounced state relicensure survey completed 5/30/2018, Brightstar Care OF Erie County was found not to be in compliance with the following requirement(s) of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.




Plan of Correction:




611.52(d) LICENSURE
Proof of Residency

Name - Component - 00
The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation

Observations:
Based on review of direct care worker (DCW) personnel files (PF), and staff (EMP) interview, the agency failed to ensure four (4) of fourteen (14) DCW personnel files reviewed contained proof of residency (PF1, PF6, PF11 & PF14).

Findings included:

A review of DCW personnel files was conducted on 5/30/2018, between the hours of 10:00 a.m. and 12:00 p.m.

PF1 was hired on 8/10/2017 and contained a PA Driver's license but the license was issued on 4/08/2017; not 2 years preceeding the date of hire. PF contained no other documentation to show requirement was met.

PF6 was hired on 2/10/2018 and contained a PA Driver's license but the license was issued on 5/12/2017; not 2 years preceeding the date of hire. PF contained no other documentation to show requirement was met.

PF11 was hired on 2/02/2018 and contained a PA Driver's license but the license was issued on 6/18/2016; not 2 years preceeding the date of hire. PF contained no other documentation to show requirement was met.

PF14 was hired on 9/14/2017 and contained a PA Driver's license but the license was issued on 1/08/2016; not 2 years preceeding the date of hire. PF contained no other documentation to show requirement was met.

Interview with EMP1 & EMP2 on 5/30/2018 at approximately 12:00 p.m. confirmed findings.





Plan of Correction:

1. All Direct Care Worker Charts will be reviewed by the Branch Director to determine adherence to BrightStar 2 yr Proof of Residency Policy. PURPOSE: To determine if direct care workers require a FBI clearances prior to providing care. POLICY: BrightStar of Erie requires all direct care workers with less than 2 yrs of residency to obtain a Federal criminal history record prior to providing care. A direct care worker can provide proof of residency through accepted forms of identification i.e.( Motor vehicle records, housing records, local tax records, public utility records, and/or a completed and signed Federal, State or Local invoice tax return with the applicants name and address on it.)
2. If a DCW chart has been flagged (Hired on or after 05/30/2016) as requiring proof of residency, the employee will be required to provide proof of residency and/or Federal Criminal History clearance, if neither can be provided the DCW will be placed on suspended status until acceptable forms of proof of residency are received or a Federal Criminal History report from the dept of Aging has been completed.
3.All DCW charts will be reviewed and in compliance by the Branch Manager before 07/08/2018.
4. Effective 05/30/2018 all new hires will be reviewed at time of interview for proof of two year residency. If proof is not provided by valid ID or any other acceptable forms per the 611.52 Standards then the DCW will have to obtain a Federal Criminal History report per our provisional hiring policy.
5. ALl new DCW charts will be reviewed weekly to ensure new procedure is followed.


611.56(a) LICENSURE
Health Screening

Name - Component - 00
The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.

Observations:


Based on review of the Centers for Disease Control and Prevention guidelines (CDC), direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to ensure screenings for mycobacterium tuberculosis (TB) were conducted in accordance with CDC guidelines for two (2) of fourteen (14) active direct care worker personnel files reviewed (PF6 & PF12).

Findings included:

According to the "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005," "Baseline testing for M. Tuberculosis infection is recommended for all newly hired HCWs [health care workers] ... If TST [tuberculin skin testing] is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative ... If the first-step result is negative, the second-step TST should be administered 1--3 weeks after the first TST result was read ... A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST result within the previous 12 months, a single TST can be administered in the new setting ... This additional TST represents the second stage of the two-step testing."

A review of personnel files was conducted on 5/30/2018, between 10:00 a.m. and 12:00 p.m.

PF6 was hired on 2/10/2018. PF6 contained a negative first-step TB test result dated 2/11/2018. The second step TB test was given 3/13/2018; not 1--3 weeks after the first TST result was read.

PF12 was hired on 8/04/2016. PF12 contained a negative first-step TB test result dated 8/06/2016. The second step TB test was given 9/26/2016; not 1--3 weeks after the first TST result was read.

Interview with EMP1 & EMP2 on 5/30/2018 at approximately 12:00 p.m. confirmed findings.



Plan of Correction:

1. All Direct Care Worker Files will be reviewed by Director of Nursing for compliance of dates on their 2-Step PPD placed per the CDC regulations. POLICY: BrightStar Care Policy states that all employees will have an initial 2-Step PPD within the CDC regulations of 1-3 weeks after the first TST result was read at the beginning of their employment and followed up annually.

2. All DCWs who have been hired from 05/30/2018 onward files will be in compliance with CDC regulations and BrightStar Policy and the second step will be placed between 7-21 days after the first step's reading. DCWs will not be placed in the homes prior to having their first PPD step placed and read.
3. The D.O.N. will review the DCW database weekly to ensure the DCWs PPD tests are being administered and read per the CDC Guidelines.
4. The D.O.N. will review all new hires charts the day after orientation weekly, to ensure timely PPD testing per the CDC Guidelines.
5. All DCW hired on or after 05/30/2018 charts will be up to CDC compliance by 07/08/2018


Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed 5/30/2018, Brightstar Care Of Erie County was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: