Initial Comments:
Based on the findings of an onsite Complaint Investigation Survey completed 10/27/2023, Moravia Health 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 Complaint Investigation Survey completed 10/27/2023, Moravia Health was found not to be in compliance with the 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(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 personnel files (PF), and staff (EMP) interview, the agency failed to ensure one (1) of three (3) direct care worker personnel files reviewed contained proof of residency ( PF3).
Findings included:
A review of direct care worker personnel files was conducted on 10/27/2023 between 12:30 p.m. and 2:00 p.m.
PF3 revealed a hire date of 9/20/2023. PF did not contain any documentation as proof of 2 years PA Residency.
Interview with Agency Director of Outreach and Agency Scheduling Manager on 10/27/2023 at approximately 2:00 p.m. confirmed the above findings.
Plan of Correction:Action Steps to Correct Each Finding(s) and Date(s) for Completion:
Documentation of 2 proofs of residency or receipt of criminal backgrounds will not be obtainable for PF3 due to DCW termination of employment status. PF3's direct care worker file has been inactive since 10/19/23
Provider will retain all records for at least 7 years
Action Steps to Prevent Future System Reoccurrences:
Moravia Health will ensure all required new hires will obtain a criminal history record or 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
Agency Responsible Persons with Title:
Tish Jackson, Senior Compliance Audit Analyst
Agency Internal Quality Management:
An internal audit will be conducted weekly, to ensure that all active new hire files contain two proofs of residency and/or criminal history record as required. Documentation is being retained in the employee fie.
This documented
information will be reviewed by the HR department weekly for 3 months and
revisions to practice made if needed to
ensure compliance
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 review of direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to ensure a direct care worker, prior to consumer contact, was screened for and free from mycobacterium tuberculosis (TB) for one (1) of three (3) direct care worker personnel files reviewed (PF3).
Findings included:
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) or 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.)
*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. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
Review of direct care worker personnel files was conducted on 10/27/2023 between 12:30 p.m. and 2:00 p.m.
PF3 was hired on 9/20/2023 and began providing services to consumers on 10/17/2023. PF did not contain any documentation to prove that PF was screened for and free from TB prior to consumer contact.
Interview with Agency Director of Outreach and Agency Scheduling Manager on 10/27/2023 at approximately 2:00 p.m. confirmed the above findings.
Plan of Correction:Action Steps to Correct Each Finding(s) and Date(s) for Completion:
A review of the EVV system documentation confirms PF3's Quantiferon Gold test was ordered on 9/28/23 and results were not received prior to start date of 10/17/23. PF3's direct care worker file has been inactive since 10/19/23.
Current active employees will be re-evaluated to ensure completion and continued receipt of required TB screening, testing, and education as needed.
Documentation of the TB test results and/or Chest X-Ray will be uploaded to the employee record. New hires will be eligible to start employment when compliant results are received.
Action Steps to Prevent Future System Reoccurrences:
Moravia Health will continue to complete the required TB Screening and Testing Upon
Hire of all employees that will be in direct contact of consumers. TB Tracking TB tests and Chest
X-Rays will be tracked in Renewable Requirements based on applicable requirements
Agency Responsible Persons with Title:
Tish Jackson, Senior Compliance Audit Analyst
Agency Internal Quality Management:
A weekly audit shall occur to ensure that all new hires that will be in direct contact with consumers have received the
required TB Screening, PPD and/or Chest Xray testing as required. This documented
information will be reviewed the HR department weekly for 3 months and
revisions to practice made if needed to
ensure compliance.
Initial Comments:
Based on the findings of an onsite Complaint Investigation Survey completed 10/27/2023 Moravia Health was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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