An on-site follow up survey conducted on November 1, 2017, Epic Health Services
(East), 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. Based upon an unannounced on-site home care agency state relicensure survey conducted on September 7, 2017-September 8, 2017 and a complaint investigation survey conducted on September 15, 2017.
Plan of Correction:
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.
Based upon review of agency policy, CDC Guidelines, personnel files, agency failed to obtain a two step TB test, required for one (1) of five personnel file reviews . (PF #5).
Review of TB policy "Health Clearance" on November 1, 2017 at 10:00 AM states: " prior to first assignment the following requirements must be met " two-step tuberculin skin test with negative results; or one documented negative tuberculin skin test within the last 12 months and one additional negative tuberculin test: If an employee presents a documented previously positive skin test and a negative chest x-ray following the positive tuberculin skin test, and initial TB Screening questionnaire must be completed and reviewed by a Registered Nurse to ensure employee is not exhibiting signs and symptoms of TB. "
Review of CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in health-Care Settings, 2005, included that all Health Care Workers (HCW) should receive baseline TB screening upon hire, using two-step TST or a single BAMT to test for infection with M. Tuberculosis. The second step TST should be administered 1-3 weeks after the first step was read.
Review of personnel files on November 1, 2017 between 9:30 AM-10:30 AM revealed:
PF # 5 Date of Hire (DOH) 6/24/17 had been file selected on prior survey and this follow up survey was to determine compliance. The PPD had been administered 10/18/17 and read on 10/20/17. The second step PPD was not obtained.
Interview with EMP # 1 at 10:30 AM reported " This second step PPD was missed" "
Plan of Correction:
The EPIC Location submits this plan of correction under procedures established by the Department of Health in order to comply with the Departments directive to change conditions which the department alleges are deficient under state and federal regulations relating to home health care, This plan of correction should not be construed as either a waiver of the facilities right to appeal and to challenge the accuracy of the alleged deficiencies or an admission of past or ongoing violations of state and federal regulatory requirements
1.) ND re-educated staff on PPD policy. Completion Date: November 13,2017
2.) Nursing director and Executive director to audit 100% of active employee files for 2 step PPD. Completion Date: November 13,2017
3.) Any active employee missing evidence of a 2 step PPD will have 3 weeks to achieve compliance. ED/ND to send completed PPD Audit to Area Vice President/Area Clinical Director . Completion date: December 08,2017
4.) Going forward, hiring checklist will be included on front of all new hire files to be sure all documents are present per policy. Completion date: November 13, 2017