Initial Comments:
Based on the findings of an unannounced onsite State Re-licensure survey conducted on
May 6, 2021, ALSM At Home, 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 survey conducted on
May 6, 2021, ALSM At Home, 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(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 personnel files (PF), and conference with agency staff, the agency failed to ensure all workers with direct consumer contact had an updated screening for tuberculosis completed at least every 12 months for three (3) of ten (10) direct care worker personnel files reviewed (PF3, PF4, PF7).
Findings included:
Personnel file (PF) reviews conducted on 5/6/2021 between approximately 10:45am and 11:30AM revealed:
PF3, Date of hire (DOH) 10/24/2019, PF contained evidence of a negative result TST completed on 11/1/2019. No documented evidence of an annual tuberculosis screening completed in 2020.
PF4, DOH 1/3/2019, PF contained evidence of a negative result TST completed on 1/23/2020. No documented evidence of an annual tuberculosis screening completed in 2021.
PF7, DOH 4/24/2017, PF contained evidence of a negative result TST completed on 5/7/2019. PF contained evidence of a negative result TST completed on 11/2/2020, six months beyond 12 moth time frame for compliance.
An exit conference was conducted on 5/6/2021 at approximately 1:30PM. The above findings were reviewed with the Senior Service Manager, Scheduler, and the Registered Nurse.
Plan of Correction:#0710 TST (TB) screenings of all employees will be reviewed based on their last TB screening and those who have not received an updated Tb screening within the past year will be required to complete the screening assessment and education within 30 days of exit date. (PF3, PF4, PF7)
An audit to be conducted using last dates of TB screening to determine next annual due dates for all employees. Tb and risk assessments to be completed based on upcoming due dates. Audit spreadsheet will be updated as screenings are provided. The RN and manager will be responsible for compliance with the deficient practice.
Initial Comments:
Based on the findings of an unannounced onsite State Re-licensure survey conducted on
May 6, 2021, ALSM At Home, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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