QA Investigation Results

Pennsylvania Department of Health
ANN'S CHOICE, INC.
Health Inspection Results
ANN'S CHOICE, INC.
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite state re-licensure survey conducted on May 19, 2021, Ann's Choice, 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 state re-licensure survey conducted on May 19, 2021, Ann's Choice, 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:




611.56(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 a review of personnel files (PF), recommendations from the Centers for Disease Control (CDC), the agency did not conduct an annual screening for mycobacterium tuberculosis for ten (10) of ten (10) PFs. PF# 1-10.

Findings include:


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) of 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.

A review of PFs was conducted on May 19, 2021 at 10:50 AM. The Date of Hire (DOH) is indicated below.

PF#1 DOH 12/31/07 did not contain documentation of an annual TB screen for 2018, 2019, and 2020.

PF#2 DOH 4/22/19 did not contain documentation of an annual TB screen for 2020.

PF#3 DOH 4/27/11 did not contain documentation of an annual TB screen for 2019 and 2020.

PF#4 DOH 7/9/18 did not contain documentation of an annual TB screen for 2019 and 2020.

PF#5 DOH 1/29/16 did not contain documentation of an annual TB screen for 2018, 2019, 2020, and 2021.

PF#6 DOH 3/25/19 did not contain documentation of an annual TB screen for 2020 and 2021.

PF#7 DOH 5/11/17 did not contain documentation of an annual TB screen for 2019, 2020, and 2021.

PF#8 DOH 3/27/13 did not contain documentation of an annual TB screen for 2018, 2019, and 2020.

PF#9 DOH 7/9/18 did not contain documentation of an annual TB screen for 2019 and 2020.

PF#10 DOH 5/13/11 did not contain documentation of an annual TB screen for 2018, 2019, and 2020.

An interview with the administrator and assistant administrator on May 19, 2021 at 1:00 PM confirmed the above findings.






Plan of Correction:

All active home care employees will have an annual TB screening form completed for 2021 by 6/30/2021.
Employees that do not complete a screening form by this date will be removed from the schedule.

Upon hire, employee health and wellness department nurse or medical assistant will conduct initial TB testing/screening for the new employee and place employee on the tracking log.

The employee health and wellness department nurse practitioner will run a report quarterly that details which employees are due for their annual TB screening. Quarterly reports will be sent to the home care administrator and home care assistant administrator for follow-up, starting 5/20/21.

Home care administrator and assistant administrator will obtain annual TB risk assessment forms from employees that are due. Employees will be removed from the schedule if their screening is overdue, and will not be scheduled to work with residents until a risk assessment form has been completed and received by employee health and wellness.



Initial Comments:


Based on the findings of an onsite state re-licensure survey conducted on May 19, 2021, Ann's Choice, Inc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: