Initial Comments:
Based on the findings of an unannounced onsite state licensure complaint survey completed October 25, 2023, Home Instead Northampton was found not to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.
Plan of Correction:
51.3 (h) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification
(h) A health care facility shall
send the written notification required
under subsections (a)-(f) to the
director of the division in the
Department responsible for the
licensure of the health care
facility.
Observations:
Based on a review of the Department of Health Event Reporting System (ERS) and an interview with the agency Administrator, the agency failed to follow Department of Health procedure for event reporting for one (1) out of one (1) ERS events reviewed (Event #1).
Findings Include:
'28 PA Code - 51.3 Notification Confidential Information': "........... 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. After facility submission of an event, Department of Health professional staff will review each submitted event and either accept or reject the submission. When a submitted event is rejected, the facilities have three (3) calendar days to either correct and resubmit the event information or to withdraw the original submission. It is expected that only a small number of events will have to be withdrawn. An example of when a facility would withdraw an event would be if they made a duplicate submission of the same event in error. "
A review of the ERS conducted on October 25, 2023 at approximately 8:30 a.m. revealed the following:
Event #1: Event (#873938) was entered by the agency Owner/Administrator on 11/16/22 at 1:50 p.m. The event entry was rejected by the Department on 11/16/22. The agency did not correct and resubmit the event information within the required three (3) calendar days. As of October 24, 2023, the event was still in rejection status.
An interview conducted with the agency Administrator on October 24, 2023 at approximately 12:30 p.m. and email correspondence with the Administrator on October 25, 2023 at approximately 1:45 p.m. confirmed the above findings.
Plan of Correction:1. What plan of correction:
The ERS event 873938 was rejected by the reviewer, the initial report due to not enough information.
On 11/13/2023 a new event was created to re-open and address the original event.
New event number is: 962364.
2. The report has been re-created with past details to explain original concerns for the client, added contact information, and included that creating a new event is part of the POC process.
3. Education improvement in agency staff and leadership. Caregivers were not a factor in the missed follow up to complete the ERS system or specific event. Timely reports are 'day of' and written within 48 hours. Agency administrator has met with state inspector, learned and been informed of the dual reporting system. Administrator has printed and built a ERS proper process binder on his desk with contents of ACT-13, PA 28, chapt 51 containing guidance on reportable events. Time limits to complete or respond to Rejected events is now understood and can be easily referenced for future concerns. A clear list of examples has been printed and provided in binder to include all past reports from this Agency going back 10 years with all determinations.
PA guidelines for reporting are no longer only kept digitally but printed and added to ERS Binder for quick reference and to enhance fast and accurate responses to ERS requirements.
4.Quaterly in-house inspection of agency now includes review of PA ERS system for open items.
Initial Comments:
Based on the findings of an unannounced onsite state licensure complaint survey completed October 25, 2023, Home Instead Northampton 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.
Plan of Correction:
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 employee files and an interview with the agency Administrator, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, was screened for and is free from active mycobacterium tuberculosis (TB), in accordance with CDC (Center for Disease and Control) guidelines, for two (2) out of two (2) employee files (EF) initial TB screening reviewed (EF#2, EF#3).
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.)
*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).
A review of EFs was conducted on October 24, 2023 at approximately 9:30 a.m. Employee date of hire (DOH) is listed below.
EF#2 DOH 08/04/2023: No documentation provided of a symptom screen questionnaire upon hire.
EF#3 DOH 10/04/2023: No documentation provided of a symptom screen questionnaire upon hire.
An interview conducted with the agency Administrator on October 24, 2023 at approximately 12:30 p.m. and email correspondence with the Administrator on October 25, 2023 at approximately 1:45 p.m. confirmed the above findings.
Repeat deficiency.
Plan of Correction:Element# 1.
EF#2 DOH 08/04/2023: Initials: S.D.: Was contacted to complete the required TB Screening Questionnaire. Which was completed on date:10/25/2023_. The TB Screening form is placed into the 'initial hire' folder of the employee.
EF#3 DOH 10/04/2023: Initials: JW. This employee has been terminated. Her last day of providing services to a client was on 10/26/2024. Her last day of employment was the 2nd day after the inspection and notification of the error in her file.
Element #2.
How to identify other employees who might be affected. Home Instead Northampton's office was inspected during the last week of January 2023. During the inspection and its subsequent inspection debriefing, the training office and manager understood that the TB Screening questionnaire was to be removed from the onboarding process and moved to the annual/reoccurring folder of requirements. Home Instead misunderstood the process change. The TB Screening questionnaire is a requirement as mentioned in the report and specifically during the initial hiring process. This is why all prior to January 2023 employees have the appropriate documentation in their onboarding 'Initial' hire folders. Therefore, our office will conduct a review of all Caregivers hired after 1 February 2023 and identify and ensure that they all comply with the TB regulations (with emphasis on the Onboarding requirements). It is expected that employees hired after 1 February 2023 until present will require proper TB Screening questionnaire. A staff wide review of new hires since 1 February 2023 will be conducted for those who are still employed as of 11/6/2023. All identified employees and their records will comply with requirements.
As of 11/9/2023 about 50% of all employees have completed and corrected during a full company review for the TB Symptom Screening Questionnaire.
Element #3.
The agency trainer has added the 3rd and appropriate TB screener questionnaire to the agency's onboarding requirements list. The folders for 'Onboarding' requirements have an updated label which specifies the TB requirements. No longer is a general 'TB' bullet point utilized on the cover of our training and onboarding labels of each content document which should be contained within.
Element #4.
Plan to monitor performance and make sure that solutions are sustained.
Agency will monitor via self-inspections which occur less than every 6 months.
The Agency's Inspection Binder for has been reviewed and updated. It ensures that during the initial hiring process the TB screening questionnaire is included with the other 2 elements. The TB questionnaire will be a specific item of interest during future inspections and audits of each direct care worker's records.
Each inspection checklist specifies 3 requirements for proper onboarding TB documents. A separate column identifies annual and ongoing TB requirement.
The Agency's most recent inspection of 8 care workers or the 55 occurred on 9/22/2023.
A Full review of 100% of all care workers resolved and ensured that each individual employee has accomplished the TB screening questionnaire to be finalized by 11/10/2023.
Element#5.
45 days past 10/25/2023 = 12/9/2023 for completion. Corrective action will be completed by date.
Initial Comments:
Based on the findings of an unannounced onsite state licensure complaint survey completed October 25, 2023, Home Instead Northampton was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
|