QA Investigation Results

Pennsylvania Department of Health
ALWAYS BEST CARE OF GREATER BETHLEHEM
Health Inspection Results
ALWAYS BEST CARE OF GREATER BETHLEHEM
Health Inspection Results For:


There are  7 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:

Based on the findings of an on-site state licensure survey conducted on February 25, Always Best of Greater Bethlehem 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 February 25, Always Best of Greater Bethlehem 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 administrator, the agency failed to ensure that eight (8) of nine (9) direct care workers files had not been screened for mycobacterium tuberculosis in accordance with the CDC guidelines prior to direct consumer contact on hire and annually. Personnel files # 1, 3, 4, 5, 6, 7, 8 and 9.

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... After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually."
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.
CDC and the National TB Controllers Association released for TB screening, testing, and treatment of health care personnel on May 17, 2019. Baseline Individual TB Risk Assessment is recommended."


Findings include:
Review of direct care workers file on February 25, 2020 from 3 PM to 4:00 PM revealed:

Review of direct care workers file # 1 with a date of hire of February 20, 2020, no required documentation that two-step TST testing had been conducted on hire. One TST was documented on February 23, 2020. There was documentation dated February 20, 2020 of TB risk assessment and TB symptom evaluation, but no documentation of a second TST.

Review of direct care workers file # 3 with a date of hire of August 11, 2016, no required documentation that two-step TST testing had been conducted on hire. One TST documented on August 26, 2016.

Review of direct care workers file # 4 with a date of hire of January 10, 2019, no required documentation that two-step TST testing had been conducted on hire. One TST documented on January 14, 2019.

Review of direct care workers file # 5 with a date of hire of January 29, 2020, no required documentation that two-step TST testing had been conducted on hire. No documentation of TST.

Review of direct care workers file # 6 with a date of hire of February 13, 2015, no required documentation that TB screening had been completed annually for 2015, 2017, 2018 and 2019.

Review of direct care workers file #74 with a date of hire of January 29, 2020, no required documentation that two-step TST testing had been conducted on hire. One TST documented on December 12, 2019.

Review of direct care workers file # 8 with a date of hire of January 16, 2020, no required documentation that two-step TST testing had been conducted on hire.

Review of direct care workers file # 9 with a date of hire of February 23, 2017 August 11, 2016, no required documentation that two-step TST testing had been conducted on hire. One TST documented on January 21, 2017.

Interview with the administrator on January 25, 2020 at 4:00 PM confirmed that the required documentation that TST testing had not been conducted and was not documented in the above direct care worker files.

















Plan of Correction:

Always Best Care misinterpreted the guidance from May 19, 2019 and, based on the surveyor's clarifications, revised the agency's TB Screening policy and procedures to correctly align with the CDC's May 19, 2019 communication regarding CDC's 2005 guidance. The agency's policies and procedures will incorporate initial as well as annual compliance.

Always Best Care will train all appropriate office staff on the new TB Screening policy and procedures.

Always Best Care will conduct a personnel file audit of all active direct-care workers to determine where TB screening is deficient and remediate according to the new TB screening policy and procedures.

To ensure compliance with the new TB screening policy and procedures, the Director or a designee (other than the person responsible for hiring and onboarding direct-care workers) will audit 100% of new hire records each month, until such time that compliance is 90% or higher.

To ensure ongoing TB screening compliance, Always Best Care's Director will audit at least 20% of active direct-care workers' records each quarter, as part of the QMP program.



Initial Comments:

Based on the findings of an on-site state licensure survey conducted on February 25, Always Best of Greater Bethlehem was found not to be in compliance with the requirements of 35 P.S. 448.809(b)






Plan of Correction:




35 P. S. 448.809b LICENSURE
Photo Id Reg

Name - Component - 00
(1) The photo identification tag shall include a recent photograph of the employee, the employee's FIRST name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.



Observations:

Based on the review of identification tags for the agency staff, the agency failed to have the title of the employee in block type and occupying a one-half inch tall strip as close as practicable to the bottom edge of the badge.

Findings:

When identification tags were reviewed on February 25, 2020 at 3 PM, it was determined that the identification tags did not contain the title of the employee (Direct Care Worker) in block type occupying a one-half inch tall strip as close as practicable to the bottom edge of the badge.

Interview with the administrator on February 25, 2020 at 3:30 PM confirmed the above findings.







Plan of Correction:

Update Licensing and Regulation Compliance Policy to reference 35P.S. 448.09b, related to photo ID badge requirements, as well as to the handout provided by the Surveyor during the audit process.

Redesign photo ID badges per 35P.S. 448.09b licensure requirements and with the employee title requirement as listed on the handout provided by the Surveyor.

All new direct care workers hired receive the new, compliant photo ID's.

All existing direct-care workers receive the new, compliant photo ID's. Those with photos over 4 years old will include a more recent photo.