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 onsite unannounced complaint investigation conducted on May 24, 2021, and completed on June 2, 2021, 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 onsite unannounced complaint investigation conducted on May 24, 2021, and completed on June 2, 2021, Bayada Home Health Care, Inc. 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:




611.52(a) LICENSURE
Criminal Background Checks

Name - Component - 00
The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.

Observations:


Based on review of agency policy, direct care worker personnel files (PF) and an interview with the Administrator, it was determined that the agency failed to ensure criminal background checks were obtained at the time of application for employment or within one year immediately preceding the date of application for two (2) of eight (8) PF reviewed. (PF# 7 and 8)

Findings include:

Review of agency policy #0-17105 "Criminal Background Checks, Clearances, and Required Screenings" on June 2, 2021, at approximately 1:30 P.M., stated, "Our Policy: Criminal history background checks are required for all Pennsylvania prospects, employees and owners in accordance with law and regulation upon hire and periodically as required by law... Our Procedure: 3.0 Covered Employees and Background Check Requirements. 3.1 A State Police Check is required for all field employees and contracted personnel, and any Director or other office staff... who may have direct contact with a client and who are hired after July 1, 1998. 3.1.1. Home Care Licensure (non-medical): Also required for all office, field, contracted staff and owner whether or not they may have contact with a client..."

Review of PF conducted on May 24, 2021, from approximately 12:15 P.M. to 2:00 P.M. revealed the following:

PF #7, date of hire April 16, 2021, contained a Pennsylvania State Police background check dated May 28, 2021, which was six (6) weeks after the date of hire.

PF #8, date of hire January 6, 2021, contained no documentation of a Pennsylvania state police criminal background check being completed prior to employment.

An interview with the Administrator on May 24, 2021, at approximately 2:45 P.M. 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 criminal background checks were obtained within the required timeframe. The plan of correction will be completed through comprehensive focused education.

On 5/28/2021, a state criminal background check was conducted for employee #7.

On 5/28/2021, a state criminal background check was conducted for employee #8.

By 6/25/2021 the Director will educate all office staff on policy Criminal Background Checks, Clearances, and Required Screenings PA Offices, 0-17105 with emphasis on the requirement for state police checks to be conducted on all field Employees, Clinical Managers and other office employees who have direct contact with clients at hire as well as the timeframe allowed and requirements for provisional employment.

By 6/25/2021 the Director/designee will complete an audit of all active employee files to ensure a current state police check, or FBI as appropriate, is completed with evidence present in their employee file. Any employees identified who do not have the appropriate criminal background checks will have one completed.

Effective 6/28/2021 for three months, the Director/designee will review weekly the records of all new hires and provisionally hired employees to ensure their background checks are completed in accordance with Agency policy and state regulation. The expected compliance threshold will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members by the Director/designee.

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



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 upon review of the Centers for Disease Control (CDC) guidelines, agency policy, direct care worker personnel files (PF), and interview with Administrator and Human Resources representative, agency failed to show evidence of obtaining an initial Tuberculin (TB) screening in accordance with CDC guidelines for one (1) of eight (8) PF reviewed. ( PF # 8).

Findings included:

The CDC guidelines state that all Health Care Workers (HCW) should received 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 screen annually. HCWs with a baseline 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.

Review of agency policy #0-1999 titled "TB Exposure Plan" on June 2, 2021, stated "Our Procedure: 1.0 TB Screening Requirements. 1.1 Employee's Required to be Screened. TB screening is required for the following employees in all practices: a. All field employees (i.e. home health aides, habilitation technicians, therapists, nurses, social workers, nutritionists, hospice practice volunteers)... 1.2 Initial TB Screening Requirements (upon hire). TB screening is required and performed at the time of hire, before an employee enters a client home..."

Review of PF on May 24, 2021, from approximately 12:30 P.M. to 2:00 P.M. revealed:

PF # 8, date of hire January 6, 2021, contained no documentation of an initial TB testing upon hire.

Interview with the Human Resources representative on May 24, 2021, at approximately 2:45 P.M. revealed that PF #8 did not have initial TB testing because he/she is a family member caregiver.

Interview with the Administrator on May 24, 2021, at approximately 3:15 P.M. confirmed the above findings.





Plan of Correction:

0701
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 initial Tuberculin (TB) screening was obtained in accordance with CDC guidance. The plan of correction will be completed through comprehensive focused education.

Employee #8 did not have a 2 step Mantoux skin test conducted for initial TB screening at hire as a waiver was implemented by the State and this Agency for skin testing / initial TB screening to be temporarily suspended during the Governor's COVID-19 Disaster Declaration so long as an individual risk assessment and symptom evaluation was completed by the employee. On 1/6/2021, at the time of hire, employee #8 completed an individual risk assessment and symptom evaluation. Employee #8 will be scheduled to receive the tuberculin skin test as the Governor's COVID-19 Disaster Declaration is soon ending.

By 6/25/2021, the Director/designee will educate all office staff on policy TB Exposure Control Plan, 0-1999 with emphasis on the requirement for initial TB screenings to be conducted on all field employees including immediate family members and those related to the client.

By 6/25/2021, the Director/designee will review all staff hired as of 5/20/2020, when the State and Agency initial TB screening waiver went into effect, to ensure all hires who did not provide evidence of a Mantoux skin test within the previous 12 months from date of hire are scheduled to receive the tuberculin skin test as soon as possible following termination of the Governor's COVID-19 Disaster Declaration.

Effective 6/28/2021 for three months, the Director/designee will review weekly the records of all new hires who are family members of a client to ensure an initial TB screening was conducted at hire. The expected compliance threshold will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members by the Director/designee.

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




Initial Comments:

Based on the findings of an onsite unannounced complaint investigation conducted on May 24, 2021, and completed on June 2, 2021, Bayada Home Health Care, Inc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: