QA Investigation Results

Pennsylvania Department of Health
CARING SENIOR SERVICE OF STROUDSBURG
Health Inspection Results
CARING SENIOR SERVICE OF STROUDSBURG
Health Inspection Results For:


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Initial Comments:
Based on the findings of an on-site state licensure survey conducted on August 20 2019,
Caring Senior Service of Stroudsburg was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, and Subpart A




Plan of Correction:




Initial Comments:
Based on the findings of an on-site state licensure survey conducted on August 20 2019,
Caring Senior Service of Stroudsburg was found not to be in compliance with the following requirement of Title 28 Health and Safety Part IV, Health Facilities, Subpart H. Chapter 611 Home Care Agencies and Home Care Registries.



Plan of Correction:




611.56(a) LICENSURE
Health Screening

Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.

Observations:

Based on a review of CDC [Centers for Disease Control] guidelines, direct care worker files and interview with the operations manager, the agency failed to ensure that four (4) of nine (9) direct care workers files had been screened for mycobacterium tuberculosis in accordance with the CDC guidelines prior to direct consumer contact. Personnel files # 2, 3, 6 and 8.

Findings include:

According to the "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005," "...Baseline testing for M. Tuberculosis infection is recommended for all newly hired HCWs [health care workers]...If TST [tuberculin skin testing] is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative...If the first-step TST result is negative, the second-step TST should be administered 1--3 weeks after the first TST result was read...A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST result within the previous 12 months, a single TST can be administered in the new setting...This additional TST represents the second stage of the two-step testing... "

Findings include:
Review of direct care workers files on August 20, 2019 from 1200 to 130PM revealed:
Direct care workers file # 2 with a date of hire on April 1, 2019, no required documentation of two-step TST on hire.
Direct care workers file # 3 with a date of re-hire on July 21, 2019, no required documentation of two-step TST on re-hire.
Direct care workers file # 6 with a date of hire on February 2, 2017, no required documentation of annual TST testing for calendar year 2018 and 2019.
Direct care workers file # 8 with a date of hire on July 15, 2018, no required documentation of annual TST testing for calendar year 2019.
Interview with the administrator on August 20, 2019 at 130PM confirmed that the required documentation for TST testing had not been conducted and was not documented in the above direct care workers file.






Plan of Correction:

For the 4 current files that were deficient, employees will be given 30 days to obtain the necessary information, if the information is not received within the 30 days, the employee will be suspended until the proper information is obtained.

For all new hires, no one will be placed into a field setting without proper documentation of a two step TB test being in hand at the office. Caregiver files will be kept in a holding capacity until the proper documentation is obtained at which point they will then be placed in the active caregiver pool.

Monitoring will take place every 6 months during our QAPI process while auditing caregiver charts. Findings will be kept in the QAPI binder and reported during our 6 month QAPI meetings.

Date of completion for this corrective action will be 09/27/2019.


Initial Comments:

Based on the findings of an on-site state licensure survey was conducted on August 20 2019,
Caring Senior Service of Stroudsburg was found to be in compliance with the requirements of 35 P.S. 448.809(b)




Plan of Correction: