QA Investigation Results

Pennsylvania Department of Health
CROSSROADS HOSPICE OF PHILADELPHIA
Health Inspection Results
CROSSROADS HOSPICE OF PHILADELPHIA
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite unannounced state re-licensure survey completed on June 13, 2018 through June 15, 2018, Crossroads Hospice of Philadelphia was found to be in compliance with the requirements of 42 CFR, Part 418.113, Subpart D, Conditions of Participation: Hospice Care-Emergency Preparedness.









Plan of Correction:




Initial Comments:


Based on the findings of an onsite unannounced state-re-licensure survey conducted June 13, 2018 through June 15, 2018, Crossroads Hospice of Philadelphia was found to be in compliance with the following requirements of 42 CFR, Part 418, Subparts A, C, and D, Conditions of Participation: Hospice Care.











Plan of Correction:




418.60 STANDARD
INFECTION CONTROL

Name - Component - 00
The hospice must maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases.


Observations:


Based on review of Center for Disease Control, (CDC) guidelines, employee files, (EF), and administrator interview, it was determined the facility failed to ensure that employees were screened and free from active mycobacterium tuberculosis (TB) prior to assignment to patients for five (5) of nine (9) Employee Files, (EF), reviewed. (EF #3, 4, 5, 7 and 8)

Findings include:

CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005; (RR-17), revealed that "all Health Care Workers (HCW) should receive a 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, health care workers should receive TB screen annually. Health care workers with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease."

1. Review of personnel files on June 13, 2018 at approximately 10:00 a.m. revealed that EF #3 was hired on May 11, 2015. A two-step of a TST was administered by December 18, 2015, and a TST was administered on January 24, 2017, seven months after hire. There was no documented evidence that an annual TST had occurred during the year of 2016, or for Jaunary 2018.

2. Review of personnel files on June 13, 2018 at approximately 10:25 a.m. revealed that EF #4 was hired on October 29, 2012. A two-step of a TST was administered by December 31, 2014, and an annual TST was administered on December 24, 2015 and an annual was administered on January 3, 2017. There was no documented evidence that an annual TST had occurred for January 2018. The two step TST was administered two years after date of hire.

3. Review of personnel files on June 13, 2018 at approximately 10:50 a.m. revealed that EF #5 was hired on July 7, 2010. The Quantiferon Gold test was was administered on July 5, 2016, six years after date of hire. There was no documented evidence that an annual TB screening questionnaire had been administered for the year 2017.

4. Review of personnel files on June 13, 2018 at approximately 11:10 a.m. revealed that EF #7 was hired on July 1, 2017. A Chest X-Ray was administered on July 17, 2015. There was no documented evidence that an annual TB screening questionnaire had been administered for the years, 2016 and 2017.


5. Review of personnel files on June 14, 2018 at approximately 11:50 a.m. revealed that EF #8 was hired on July 24, 2006. A two-step of a TST was administered by January 3, 2017, There was no documented evidence that an annual TST had occurred for January 2018.

An interview with the administrator and the clinical manager on June 13, 2018, at approximately 3:0 p.m., confirmed that the agency failed to assure that all personnel were screened for TB in accordance to the CDC guidelines. "We hired someone new to replace persons responsible for tests".










Plan of Correction:

The hospice will ensure all regulations regarding TB testing. This will be met by following the established agency policy which includes the requirements of 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, health care workers should receive TB screen annually. Health care workers with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. Compliance will be met by performing staff in-service with all personnel responsible for the administration, tracking and documentation of testing. An attendance record will be obtained and retained as evidence of completion. Additionally, the agency will maintain tracking method(s) to ensure all employee health testing,including TB testing, is performed timely. A monthly report, reflecting those individuals due for testing will be printed and distributed to the appropriate personnel. To ensure ongoing compliance, the report will be reviewed by the agency's Executive Director monthly for a period of six (6) months until compliant and then quarterly indefinitely, to ensure that the appropriate personnel are performing the testing and associated tasks timely, correctly and efficiently. The Executive Director will sign the report as evidence of review. These reports will be retained as evidence of audit. Employees who fail to meet the required duties will receive progressive, disciplinary action, up to and including termination. As an additional measure to ensure compliance, random audits of the HR file(s) will be performed by the Home Office personnel as often as possible but at least annually. If ongoing issues are noted during these audits, progressive, disciplinary action will ensue for the appropriate personnel. Evidence of said audits will be retained at the home office.


418.116 STANDARD
FEDERAL, STATE, LOCAL LAWS & REGULATIONS

Name - Component - 00
The hospice and its staff must operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations related to the health and safety of patients. If State or local law provides for licensing of hospices, the hospice must be licensed.


Observations:


Based on review of facility policy, personnel files, and interview with the administrator, it was determined that the agency failed to provide a Pennsylvania State Police Criminal History Check prior to a patient assignment, for one (1) of nine (9) Personnel Files, (PF), reviewed. (Employee #7).

Findings include:

According to the Act 169 of 1996 as amended by Act 13 of 1997,"If the applicant/employee has been a resident of the Commonwealth of Pennsylvania for 2 or more years prior to application for employment, the applicant will need to obtain a clearance from the Pennsylvania State Police. This clearance is obtained by doing the following: Request for Criminal Record Check Form (SP4-164)." "When the applicant/employee has not been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application for employment or currently lives out of state, in addition to the Pennsylvania State Police Criminal History Check, the applicant/employee will also need to obtain an FBI Criminal History Check. Facilities are defined by the act to include: Domiciliary Care Homes, Home Health Care Agency, Nursing Facility (licensed by the Department of Aging), Personal Care Home (licensed by the Department of Public Welfare). A home Health Care Agency is further defined to include those agencies licensed by the Department of Health and any public or private organization which provides care to a care-dependent individual in their place of residence." "If entities run into special circumstances where they need to hire an employee before the results of their record checks are returned, there is a provision in CPSL that allows for a provisional hiring period. The period is to not exceed 30 days for in state residents and 90 for out of state residents."


Review of personnel file number seven (7), on June 13, 2018 at 11:50 a.m. revealed the date of hire on July 24, 2006. EF #7's file revealed a completed from entitled, "Pennsylvania state Police Request for Criminal Record Check", on July 28, 2006. There were no results documented for this request. Futher review revealed no documented evidence that an additional request, or background results were obtained from 2006 through June 2018.

An interview with the administrator on June 14, 2018 at approximately 3:10 p.m.confirmed that the Agency did not administer a state criminal record check prior to assigning PF #7 to a patient.























Plan of Correction:

The agency performs background check(s) and required testing on all employees and volunteers prior to the employee having access to patient records or any contact with patient(s)/family members. The file #7 in question indeed showed a "hire" date of 7/24/16. However, in 2006, "hire" dates (date that the individual was offered employment) and actual start dates may be different. We have subsequently (since 2006) adopted a procedure that reflects this on the HR file. Also, by law, a background check cannot be performed prior to an employment offer and acceptance of employment but must be performed prior to the individual having access to patient/patient records. The background check in question was then ran/requested on 7/28/06 and was returned on 8/16/2006. During the time from hire and actual assignment to the field,employees, such as nursing is a nurse) is required to spend several weeks in orientation, completing reading of policies/procedures, standards of practice, viewing of safety and training videos, required educational training such as TB, infection control, HIPAA etc., review of agency HR policies (time sheets, benefit enrollment, employee health testing, etc.) as well as the philosophy of hospice and the agency as a whole. Additionally, direct care employees receive weeks of orientation prior to any patient assignment. This employee did not provide care, have contact with a patient nor have access to a patient's record prior to the return of the background check on 8/16/2006. However, the agency will continue to aggressively follow the requirements, will perform the required background check(s) and other checks (LEIE, etc) prior to any employee performing any patient related assignments or open access to patient records. This process is met by maintaining an HR tracking system that includes all HR requirements such as TB testing, new hire and annual training, reference reviews, but also all criminal background checks. As currently in place, but to continue, to ensure ongoing compliance, A monthly report, reflecting those individuals due for any HR required element, including new hire background checks will be printed and distributed to the appropriate personnel. To ensure ongoing compliance, the report will be reviewed by the agency's Executive Director monthly for a period of six (6) months until compliant and then quarterly indefinitely, to ensure that the appropriate personnel are performing, monitoring and tracking all required/ associated tasks timely, correctly and efficiently. The Executive Director will sign the report as evidence of review. These reports will be retained as evidence of audit. Employees who fail to meet the required duties will receive progressive, disciplinary action, up to and including termination. As an additional measure to ensure compliance, random audits of the HR file(s) will be performed by the Home Office personnel as often as possible but at least annually. If any ongoing issues are noted during these audits, progressive, disciplinary action will ensue for the appropriate personnel. Evidence of said audits will be retained at the home office. This will ensure that no employee will be hired and allowed any type of patient contact or any provision of care prior to the return of a clear background check and all other State and Federally mandated employee background checks/reviews.


Initial Comments:


Based on the findings of an onsite unannounced state re-licensure survey conducted June 13, 2018 through June 15, 2018, Crossroads Hospice of Philadelphia 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 re-licensure survey conducted on June 13, 2018 through June 15, 2018, Crossroads Hospice of Philadelphia was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: