QA Investigation Results

Pennsylvania Department of Health
BAYADA HOME HEALTH CARE, INC.
Health Inspection Results
BAYADA HOME HEALTH CARE, INC.
Health Inspection Results For:


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Initial Comments:Based on the findings of an unannounced onsite home health agency Medicare recertification survey completed on April 11, 2024, Bayada Home Health Care, Inc., was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.


Plan of Correction:




Initial Comments:Based on the findings of an unannounced onsite home health agency Medicare recertification survey completed on April 11, 2024, Bayada Home Health Care, Inc., was found to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.


Plan of Correction:




Initial Comments:Based on the findings of an unannounced onsite home health agency state re-licensure survey completed on April 11, 2024, Bayada Home Health Care, Inc., was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health facilities, Subpart G. Chapter 601.


Plan of Correction:




601.3 REQUIREMENT
COMPLIANCE W/ FED, ST, & LOCAL LAWS

Name - Component - 00
601.3 COMPLIANCE WITH FEDERAL,
STATE AND LOCAL LAWS.
The home health agency and its staff
are in compliance with all applicable
Federal, State and Local Laws and
regulations.

Observations: Based upon review of the Pennsylvania Child Protective Services Act, Review of the Pennsylvania adult protective Services Act, personnel file (PF) review, and interview with the agency administrator, it was determined the agency failed to ensure personnel who have regular contact with patients under the age of eighteen, to have required clearances, for five (5) out of seven (7) personnel files reviewed (PF#1, PF#2, PF#3, PF#6, and PF#7). Review of https://www.dhs.pa.gov/KeepKidsSafe/Clearances/Pages/default.aspx on 4/10/2024 at approximately 12:00 PM states: "Clearances are required for an employee or unpaid volunteer at a minimum of every 60 months from the date of the oldest clearance. Clearances may be required more frequently based on licensure or employer requirements. Agencies and organizations must ensure that clearances are obtained in accordance with the CPSL. The required clearances may include: Pennsylvania Child Abuse History Clearance Pennsylvania State Police Criminal History Clearance Federal Bureau of Investigations (FBI) Criminal History Clearance (required for all employees and some volunteers)" Personnel files reviewed on 4/10/24 from approximately 12:30 PM-1:30 PM revealed the following: PF#1 (Date of hire: 10/24/2023): No documentation of a Federal Bureau of Investigations (FBI) Criminal History Clearance. PF#2 (Date of hire: 9/26/2023): No documentation of a Pennsylvania Child Abuse History Clearance. PF#3 (Date of hire: 1/03/2018): Federal Bureau of Investigations (FBI) Criminal History Clearance and Pennsylvania Child Abuse History Clearance were dated December 2017, older than 60 months. PF#6 (Date of hire: 5/04/2023): No documentation of a Pennsylvania Child Abuse History Clearance. PF#7 (Date of hire: 5/25/2018): Federal Bureau of Investigations (FBI) Criminal History Clearance, Pennsylvania State Police Criminal History Clearance, and Pennsylvania Child Abuse History Clearance were dated May 2023, older than 60 months. An interview conducted with the agency administrator conducted on 4/11/2024 at approximately 12:30 PM confirmed the above findings.

Plan of Correction:

Based on an analysis of the specific deficiencies cited, the corrective plan and actions taken are to address the lack of demonstrated knowledge resulting in failure to ensure personnel who have regular contact with clients under the age of eighteen had required clearances completed. The plan of correction will be completed through comprehensive focused education.

On 4/9/2024, the employee #2 had a Child Abuse History Clearance completed.

On 4/9/2024, the employee #3 had their Child Abuse History Clearance and FBI Criminal History Clearance resubmitted to meet the 60-month requirement.

On 4/9/2024, the employee #6 had a Child Abuse History Clearance completed.

On 4/9/2024, the employee #7 had their Child Abuse History Clearance, FBI Criminal History Clearance, and Pennsylvania State Police Criminal History Clearance resubmitted to meet the 60-month requirement.

By 5/3/2024, the Director/designee will educate all office staff on policy Criminal Background Checks, Clearances, and Required Screenings PA Offices, 0-17105 with emphasis on the requirement for employees who have contact with clients under the age of 18 to have their State Police Check, Child Abuse History Clearance, and Fingerprint based Federal Criminal History completed every 60 months.

By 6/10/2024 an audit will be conducted of all active field staff to ensure they have a current background screening completed and present in their employee file.

Effective 5/6/2024 for three months, the Director/designee will review weekly the "due date report" to ensure all staff have their background screenings resubmitted to meet the 60-month requirement. The goal for compliance will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members responsible.

The Director has overall responsibility for implementation and oversight of the plan.



601.21(f) REQUIREMENT
PERSONNEL POLICIES

Name - Component - 00
601.21(f) Personnel Policies.
Personnel practices and patient care
are supported by appropriate, written
personnel policies. Personnel records
include qualifications, licensure,
performance evaluations, health
examinations, documentation of
orientation provided, and job
descriptions, and are kept current.

Observations: Based on a review of personnel files (PF), and interview with the agency's administrator, it was determined the agency failed to ensure the direct care worker, prior to consumer contact, to be screened for mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for three (3) out of seven (7) personnel files (PF) reviewed (PF#1, PF#2, PF#5). Findings Include: 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.) Personnel files were reviewed on 4/10/2024 from approximately 12:30 PM-1:30 PM revealing the following: PF#1(Date of hire (DOH) 10/24/2023): No documentation of completed baseline testing. PF#2 (DOH: 9/26/2023): No documentation of completed baseline testing. PF#5 (DOH: 8/24/2023): No documentation of completed baseline testing. An interview with the agency administrator on 4/11/24 at approximately 12:30 PM confirmed the above findings.

Plan of Correction:

Based on an analysis of the specific deficiencies cited, the corrective plan and actions taken are to address the lack of demonstrated knowledge resulting in failure to ensure employees, prior to consumer contact, be screened for mycobacterium tuberculosis, in accordance with CDC guidelines. The plan of correction will be completed through comprehensive focused education.

Evidence of employee #1 and employee #2 TB screenings were obtained and placed in their employee file.

By 6/10/2024 an audit will be conducted of all active field staff to ensure they have an initial TB screening present in their employee file.

On 4/25/2024, the Director of Infection Prevention reviewed initial TB screening requirements with the office Director.
By 5/3/2024, the Director/designee will educate all office staff on agency policy TB Risk Assessment and Exposure Plan, 0-1999 with emphasis on initial TB screenings and the requirement to have a baseline screening completed, and results obtained and filed, prior to entering a client's home.

Effective 5/6/2024 for three months, the Director/designee will review weekly the records of all new hires to ensure initial TB screening is conducted, and results received and placed in their employee file prior to entering a client's home. The goal for compliance will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members responsible.

The Director has overall responsibility for implementation and oversight of the plan.



Initial Comments:Based on the findings of an unannounced onsite home health agency state re-licensure survey completed on April 11, 2024, Bayada Home Health Care, Inc., was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.


Plan of Correction:




Initial Comments:Based on the findings of an unannounced onsite home health agency state re-licensure survey completed April 11, 2024, Bayada Home Health Care, Inc., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).


Plan of Correction: