Initial Comments:
Based on the findings of an onsite unannounced state license survey and complaint investigation completed March 1, 2024, The Wright Agency, Llc was found not to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
51.3 (f) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification
(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.
Observations:
Based on review of the Department's event reporting system (ERS), ERS manual, a consumer file (CR), and staff (EMP) interview, the agency failed to notify the Department concerning the occurrence of an event at the agency which could compromise quality assurance or patient safety. The agency failed to notify the department of an instance of Misappropriation of Patient/Resident (Consumer) Property for one (1) of one (1) consumer file reviewed with an incident report (CR4).
Findings included:
Per the Department's ERS Manual, "PA Department of Health (PA-DOH) Event Notification Internet Site Overview - Facilities ... Purpose: To provide a system to enter events per 28 PA Code - 51.3 that is readily available to all appropriate PA-DOH facilities, a simple process to insure consistent data entry and submission, and a source for quick and meaningful feedback on event notification submissions. All facilities are required to submit notification of events as defined in 28 Pa Code Chapter 51 to the Department of Health within 24 hours of occurrence or discovery. The Electronic Event Reporting System is the mechanism the Department will use to meet this regulatory requirement. ... The following is a list of all Categories that should be submitted: ... Misappropriation of Patient/Resident Property."
Review of CR4 on February 29, 2024, at 9:30 a.m. showed that services started on 5/27/2022. Per "Critical Incident Report" from 8/18/2022, "[CR4] called the office to report a theft of her belongings. [CR4]'s daughter [...] who was her Direct Care Worker by request, stole [CR4]'s EBT card, [CR4]'s SSI check, and [CR4]'s rent rebate check."
A review of ERS submissions from 8/1/2022 to 2/29/2024 was conducted on February 29, 2023, at 11 a.m. and did not show agency had reported the above event.
Interviews with EMP1 on February 29, 2024, at 11:30 a.m. confirmed above event was not submitted to ERS.
Plan of Correction:A. Corrective action for those individuals identified in the deficiency.
As per the survey conducted on 03/01/2024, The Wright Agency, LLC will meet the requirement of provision 51.3(f) Licensure Notification by alerting the PA Department of Health in writing any time a situation or an occurrence of any event that would seriously compromise quality assurance or participant safety via the ERS system, which includes full and sufficient detail and information to alert the Department as to the reason for its occurrence and the steps which the health care facility shall take to rectify the situation.
B. How we will identify other individuals having the same deficiency.
The Human Resources department will reaudit active clients and close any open investigations. We will notify the Department of Health via the ERS system of any incidents.
C. Measures will be put in place to prevent deficiency going forward.
After the ERS reports have been submitted, agency management of either the Administrator or the Human Resources Manager will then log in daily to check the status of any outstanding ERS reports until they have either been marked as accepted or rejected by the PA Department of Health. In the event of a rejected report, agency management will make the necessary changes within three (3) business days to ensure that the initial report made via the ERS system is therefore accepted by the PA Department of Health and thusly that the agency has met its obligation under the requirement.
D. Plan to monitor that the deficient practice will not recur.
Any time an ERS report needs to be entered, the Human Resources Manager will notify the Administrator via email for the Administrator to submit the necessary information via the ERS site. After completion, the Human Resource Manager will check daily until the report is either accepted or rejected and send an email to the Administrator stating the status. After acceptance (including the necessary corrections to be made to get to accepted status), the need to check daily and send follow-up emails will no longer apply.
E. Date of when the corrective action will be completed.
The corrective action will be completed April 30, 2024.
Initial Comments:
Based on the findings of an onsite unannounced state license survey and complaint investigation completed February 29, 2024, The Wright Agency, Llc was found not to be in compliance with the following requirements 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(a) LICENSURE
Criminal Background Checks
Name - Component - 00
The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.
Observations:
Based on review of direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to obtain a State Police criminal history record at time of application for four (4) of six (6) personnel files reviewed (PF2-PF4, & PF6).
Findings included:
Review of personnel files was conducted on March 23, 2023, at 11 a.m.
PF2 was hired on 8/29/2023 but the criminal history report was initiated after hire on 2/27/2024 (not at time of application).
PF3 was hired on 7/23/2023 but the criminal history report was not obtained until after hire on 8/1/2023.
PF4 was hired on 3/29/2023 but the criminal history report was not obtained until after hire on 4/2/2023.
PF6 was hired on 8/4/2023 but the criminal history report was not obtained until after hire on 8/24/2023.
Interview with EMP1 on February 29, 2024, at 12:30 p.m. confirmed above findings.
.
Plan of Correction:A. Corrective action for those individuals identified in the deficiency.
As per the survey conducted on 03/01/2024, The Wright Agency, LLC will meet the requirement of the provision of 611.52 (a). We will focus on implementing preventative actions to ensure appropriate criminal background checks are performed at the time of hire on a go-forward basis. We will obtain records from the PA State Police Department.
B. How we will identify other individuals having the same deficiency.
The Administrator will review the records of all current employees to identify any employees who do not have a criminal background check documented. This review was completed by March 15, 2024. We will obtain appropriate criminal background checks for any employees who are missing this documentation.
C. Measures will be put in place to prevent deficiency going forward.
The Administrator will monitor to ensure that this item on the onboarding checklist is completed with new Direct Care Workers at the time of hire.
D. Plan to monitor that the deficient practice will not recur.
Confirming documentation on appropriate criminal background checks will be included in quarterly auditing conducted by the Compliance Officer.
E. Date of when the corrective action will be completed.
The corrective action will be completed on April 30, 2024.
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 a review of CDC (Center for Disease Control and Prevention) guidelines, direct care worker personnel files, and staff (EMP) interview, the agency failed to ensure each direct care worker was screened for mycobacterium tuberculosis (TB) in accordance with CDC (Center for Disease and Control) guidelines prior to consumer contact for six (6) of six (6) active personnel files (PF1-PF6).
Findings included:
According to CDC guidelines "Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment." Retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6819-H.pdf
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 ... 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." Retrieved from http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf
Review of personnel files was conducted on February 29, 2024, at 9:20 a.m.
PF1 was hired on 5/26/2023. PF1 contained a negative TB skin test from 2/4/2023 with no other testing performed (an incomplete two-step test).
PF2 was hired on 8/29/2023. PF2 contained a negative TB skin test from 9/28/2022 with no other testing performed.
PF3 was hired on 7/23/2023. PF3 contained a negative TB skin test from 6/19/2023 with no other testing performed.
PF4 was hired on 3/29/2023. PF4 contained no TB symptom screen, and no individual risk assessment completed.
PF5 was hired on 1/1/2024. PF5 contained a negative TB skin test from 9/18/2023 with no other testing performed.
PF6 was hired on 8/4/2023. PF6 contained a negative TB skin test from 8/2/2023 with no other testing performed. There was also no TB symptom screen, and no individual risk assessment completed.
Interview with EMP1 on February 29, 2024, at 12:30 p.m. confirmed above findings.
Plan of Correction:A. Corrective action for those individuals identified in the deficiency.
In order to comply with regulation 611.56(a): The Wright Agency employees within one year with both steps having been administered within 1-3 weeks of each other. If a DCW new hire or rehire does not have evidence of a 2 step that is at most 12 months preceding the date of hire. The Wright Agency will not accept valid one-step or questionnaires. A new 2-step TB will be required before sending a DCW into the field to work with Participants. The Wright Agency will implement recommendations from the Centers for Disease Control which is to ensure that each direct care worker with direct consumer contact has documentation that the individuals have been screened for and is free from active Mycobacterium tuberculosis using an annual questionnaire. The Human Resource Manager will conduct an audit of all health screens (TB test) within the next 60 days ensuring the Plan of Corrections is being implemented. The Wright Agency will implement a new hiring policy or Final check to be completed by the Human Resource Manager and Administer this policy will require each new employee to have their file reviewed for elements listed in this corrective action plan prior to being placed on assignment with a consumer. Each month an audit of all new employees will be conducted and verified by the Administrator and Human Resources Manager to make sure that the new hire is intact. This monthly audit will be conducted during the last week of the month but before the 30th and 31st. It will be done each month and documented in a binder where the chapter of our regulations is maintained. So that each regulation can be read and the Human Resource Manager and Administer will be assured that all regulations are being followed. Staff training will include a review of the entire 611.51-56A so that the regulation is understood clearly, review of our policy to follow the regulation and our procedure.
B. How we will identify other individuals having the same deficiency.
The Human Resource Manager will review the employee files of all active and inactive employees to identify any individual where we are missing documentation of the TB symptom screening questionnaire and an individual TB risk assessment. For all active employees for whom we do not have this documentation, the Human Resources Manager will follow up with those employees to obtain documentation of the TB symptom screening questionnaire and an individual TB risk assessment. All employee files have been audited and an Audit checklist has been included in each file to verify the date that it was completed. This will also be signed off on by the Human Resource Manager and Administer. For any files that are found to be out of compliance, the employee will be brought in and retrained, and documentation will be completed to bring the file into compliance.
C. Measures will be put in place to prevent deficiency going forward.
Documentation of an individual TB symptom screening questionnaire and an individual TB risk assessment will be included in a revised onboarding checklist. The Human Resources Manager will monitor to ensure that this item on the onboarding checklist is completed with new employees prior to the start of the service.
D. Plan to monitor that the deficient practice will not recur.
Confirming documentation of the TB symptom screening questionnaire and the individual TB risk assessment will be included in quarterly auditing conducted by the Administrator.
E. Date of when the corrective action will be completed.
The corrective actions will be implemented by April 30, 2024
Initial Comments:
Based on the findings of an onsite unannounced state license survey and complaint investigation completed February 29, 2024, The Wright Agency, Llc was found to be in compliance with the requirement of 35 P.S. 448.809 (b).
Plan of Correction:
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