Initial Comments:
Based on the findings of an onsite unannounced state license survey completed January 24, 2023, Viola's Managing Group, Inc. 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 onsite unannounced state license survey completed January 24, 2023, Viola's Managing Group, Inc. was found not to be in compliance with the following requirements of PA Code, 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
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 on a review of CDC (Center for Disease Control and Prevention) guidelines, direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to ensure each direct care worker was screened for mycobacterium tuberculosis (TB) in accordance with CDC guidelines for six (6) of six (6) personnel files (PF1-PF6). The agency referred new employees for a chest radiograph (chest x-ray) for TB screening when a chest x-ray was not indicated.
Finding included:
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 ... 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. ... Chest Radiography [EMPHASIS] HCWs with a baseline positive or newly positive TST or BAMT result should receive one chest radiograph to exclude a diagnosis of TB disease (or an interpretable copy within a reasonable time frame, such as 6 months). After this baseline chest radiograph is performed and the result is documented, repeat radiographs are not needed unless symptoms or signs of TB disease develop or a clinician recommends a repeat chest radiograph (39,116). Instead of participating in serial testing for M. tuberculosis infection, HCWs with a positive test result for M. tuberculosis infection should receive a symptom screen. The frequency of this symptom screen should be determined by the risk classification for the setting. Serial follow-up chest radiographs are not recommended for HCWs with documentation of a previously positive test result for M. tuberculosis infection, treatment for LTBI or TB disease, or for asymptomatic HCWs with negative test results for M. tuberculosis infection. HCWs who have a previously positive test result for M. tuberculosis infection and who change jobs should carry documentation of a baseline chest radiograph Vol. 54 / RR-17 Recommendations and Reports 31 result (and the positive test result for M. tuberculosis infection) to their new employers." Retrieved from http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf
According to CDC guidelines "Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment." Retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6819-H.pdf
Note: the above guidelines do not recommend a chest x-ray for baseline testing for HCWs unless that HCW has a documented past positive TB test result. Agency considers employee hire date the date the employee begins providing services to consumers.
Findings included:
Review of personnel files was conducted on January 24, 2023, at 10 a.m.
PF1 applied on 7/6/2022. PF1 received a chest x-ray on 7/14/2022. The x-ray results showed, "History: Tuberculosis screening." PF1 was hired on 12/4/2022 and began providing services to consumers the same day. PF1 contained no symptom screen and no individual risk assessment.
PF2 applied on 10/10/2022. PF2 received a chest x-ray on 12/8/2022. The x-ray results showed, "History: ENCOUNTER FOR SCREENING FOR RESPIRATORY TUBERCULOSIS." PF2 was hired on 12/22/2022 and began providing services to consumers the same day. PF2 contained no symptom screen and no individual risk assessment.
PF3 applied on 9/16/2022. PF3 received a chest x-ray on 9/22/2022. The x-ray results showed, "Provided History: TUBERCULOSIS SCREENING." PF3 was hired on 10/1/2022 and providing services to consumers the same day. PF3 contained no symptom screen and no individual risk assessment.
PF4 applied on 6/18/2019. PF4 received a chest x-ray on 6/19/2019. The x-ray results showed, "History: TUBERCULOSIS SCREENING." PF4 was hired on 6/21/2019 and providing services to consumers the same day. PF4 contained no symptom screen and no individual risk assessment.
PF5 was hired on 11/14/2022 and providing services to consumers the same day. PF5 contained no symptom screen and no individual risk assessment.
PF6 was hired on 11/6/2022 and providing services to consumers the same day. PF6 contained no symptom screen and no individual risk assessment.
Interview with EMP1 (administrator) on January 24, 2023, at 12 p.m. confirmed above findings and that the employees who received chest x-rays had no previous past positive TB test to indicate the need for a chest x-ray. EMP1 noted it was more convenient to send employees for chest x-rays because it could be done sooner than a TST because it was difficult to track when employees received both TSTs.
Plan of Correction:Action Steps to correct findings:
Pre-employment process will consist of completing step 1 & step 2 TST or IGRA blood test, TB risk assessment,signs/symptoms screening questionnaire and annual TB education training beginning 1/30/2023. The PF1,PF2,PF3,PF5,PF6 will complete the questionnaire and TB education training by 2/17/20233 and PF4 is no longer working with our agency as of 1/19/2023.
Action Steps to prevent reoccurrences:
Administrator will review new hire packets prior to orientation to ensure that the questionnaire is included and will review completed questionnaire with Human Resources to discuss the results / outcome. Also, HR has updated the Tickler System to monitor monthly the completion of risk assessment/screening that may need further follow-up.
Administrator will do a monthly review of the Pa. Department Health Message Board for any changes and/or updates under Home Health drop down.
Agency Responsible Persons with title:
Administrator
Human Resources Manager
Timeframe for Completion:
PF4 no longer works for the agency as of 1/19/2023.
PF1, PF2 PF3, PF5 and PF6 will complete both risk assessment/signs/symptoms questionnaire/ TB education by 2/17/2023.
All remaining employees' files were audited and were found not to have completed TB risk assessment/signs/symptoms screening and/ or TB education training completed.
Action taken:
Administrator / Human Resource Manager began in office training on 2/6/2023 for all remaining employees to complete a TB risk assessment/signs/symptoms screening questionnaire and TB education training that will be completed by 2/28/2023. Also, all employee files will be updated
with TB risk assessment/signs/symptoms screening and TB education by 2/28/2023.
Agency Internal Quality Management:
Administrator created a TB Risk Assessment/Signs/Symptoms Screening questionnaire 1/25/2023, Updated Tuberculosis Testing Policy /Procedure 1/27/2023 and Updated the Staff Training Policy to include TB Education 1/27/2023
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 Centers for Disease Control and Prevention (CDC) guidelines, direct care worker personnel files (PF) and staff (EMP) interview, the agency failed to ensure one (1) of one (1) eligible employee received annual mycobacterium tuberculosis (TB) education (PF4).
Findings included:
Review of personnel files was conducted on January 24, 2023, at 10 a.m.
PF4 was hired on 6/21/2019 and providing services to consumers the same day. PF4 contained no annual TB education for the years 2020, 2021, and 2022.
Interview with EMP1 (administrator) on January 24, 2023, at 12 p.m. confirmed above findings.
Plan of Correction:Action Steps to correct finding:
All remaining employees files were audited and were found not to have a completed annual TB Education training.
Administrator / Human Resources Manager began in office training on 2/6/2023 for all remaining employees to complete a TB education training that will be completed by 2/28/2023.
PF4 no longer for our agency as of 1/19/2023 last day worked.
Action Steps to prevent reoccurrences:
Human Resource Manager has updated the Ticker System that will be monitored monthly for the completion of TB risk assessment/signs/symptom screening and TB education training to ensure we are following compliance guidelines.
Administrator will do a monthly review of Pa. Department Health Message Board for any changes and / or updates under Home Health drop down. This will allow for the proper time to implement any additional training needed to inform our office staff and employees.
Agency Responsible Persons with title:
Administrator
Human Resources Manager
Timeframe for Completion:
PF4 no longer works for agency as of 1/19/2023, so we cannot update her personnel files.
All remaining employees will complete a TB education training and files updated by 2/28/2023.
Going forward our annual TB education training will be in the 3rd & 4th Quarter to accommodate the health and safety of our employees.
Agency Internal Quality Management:
Administrator updated the Staff Training Policy to include TB Education annually 1/27/2023.
Initial Comments:
Based on the findings of an onsite unannounced state license survey completed January 24, 2023, Viola's Managing Group, Inc. was found to be in compliance with the requirement of 35 P.S. 448.809 (b).
Plan of Correction:
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