QA Investigation Results

Pennsylvania Department of Health
BETHLEN COMMUNITIES COMPANION CARE PROGRAM
Health Inspection Results
BETHLEN COMMUNITIES COMPANION CARE PROGRAM
Health Inspection Results For:


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Initial Comments:



Based on the findings of an unannounced onsite State Re-licensure conducted on March 13, 2020 Bethlen Communities Companion Care 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 unannounced onsite State Re-licensure conducted on March 13, 2020 Bethlen Communities Companion Care was found not to be in compliance with the requirements of 28 PA Code, Part IV, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.






Plan of Correction:




611.56(b) LICENSURE
Health Screening

Name - Component - 00
(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.

Observations:


Based on review of CDC guidelines, personnel files (PF), and staff (EMP) interviews, it was determined the agency failed to require each direct care worker, and other office staff with direct consumer contact, to complete annual TB screening requirements per CDC guidelines for six (6) of six (6) employees with 12 or more months of employment.(PF4-7, 9, & 10)


Findings included:


Review of CDC Guidelines (updated May 2019) revealed; "...health care personnel should receive TB education annually. TB education should include information on TB risk factors, the signs and symptoms of TB disease, and TB infection control policies and procedures..."

Review of PF's on March 13, 2020 between approximately 12:45 p.m. and 3:30 p.m. revealed:

PF4, date of hire (DOH) 5/7/19, PF contained evidence of TB risk and symptom screening dated 8/24/19. No evidence of required annual TB education.

PF5, DOH 12/27/18, PF contained evidence of TB risk and symptom screening dated 12/26/19. No evidence of required annual TB education.

PF6, DOH 8/20/18, PF contained evidence of TB risk and symptom screening dated 8/11/19. No evidence of required annual TB education.

PF7, DOH 2/19/18, PF contained evidence of TB risk and symptom screening dated 2/13/2020. No evidence of required annual TB education.

PF9, DOH 8/6/18, PF contained evidence of TB risk and symptom screening dated 8/6/19. No evidence of required annual TB education.

PF10, DOH 2/11/19, PF contained evidence of TB risk and symptom screening dated 11/10/19. No evidence of required annual TB education.


Exit interview confirmed findings on March 13, 2020 at approximately 3:00 p.m. with Director and Director Assistant




Plan of Correction:

The following employees PF#4, PF#5, PF#6, PF#7, PF#8, PF#9, PF#10 with the findings of no required annual TB education, were called in and education with quiz was provided. Completed by 03/19/2020

All remaining personnel files were audited for Annual TB Risk and symptom screening and Education, by the Companion Care Director and Director Assistant. Completed by 03/19/2020

Findings of no required annual TB education will be provided and completed by 03/31/2020.

Director implemented a power point education and a 10 question quiz. Completed 03/16/2020.

TB Policy and Procedures were revised to meet State and Federal Regulations and CDC Guidelines.

Director and Director Assistant added the Required TB education and Quiz to the Orientation Process. Director and Director Assistant are tracking personnel files by spreadsheet to ensure that we are compliant with the required Annual TB Risk and symptom screening and TB education.

POC will be completed for the appropriate files by 03/31/2020.









Initial Comments:


Based on the findings of an unannounced onsite State Re-licensure conducted on March 13, 2020 Bethlen Communities Companion Care was found to be in compliance with the requirements of 35 P.S.448.809 b.





Plan of Correction: