Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on January 31, 2024, Aura Home Care, 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 home care agency state re-licensure survey conducted on January 31, 2024, Aura Home Care, 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 contain documentation that the individual has completed annual TB education for three (3) of three (3) PF's reviewed, (PF #1, 2 and 3).
Findings include:
CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings: "....https://www.cdc.gov/tb/topic/testing/healthcareworkers.htm for updated guidances. 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. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19)."
A review of PFs was conducted on January 31, 2024 at approximately 10:45am.
PF #1, Date of Hire: 7/26/2016, did not contain any documentation of a completed annual TB education for 2022 and 2023.
PF #2, Date of Hire: 5/24/2016, did not contain any documentation of a completed annual TB education for 2022 and 2023.
PF #3, Date of Hire: 5/5/2016, did not contain any documentation of a completed annual TB education for 2022 and 2023.
An interview with the administrator on January 31, 2024 at approximately 11:00 am confirmed the above findings.
Plan of Correction:1.
A) The administrator will audit Personnel File #1 file to determine the missing documentation.
The administrator will develop a form that includes information about TB risk factors, the signs and symptoms of TB disease and TB infection control policies and procedures. The administrator will document that Personnel File #1 has completed their annual TB education, and the documentation will be placed in their file.
B) The administrator will audit Personnel File #2 file to determine the missing documentation.
The administrator will develop a form that includes information about TB risk factors, the signs and symptoms of TB disease and TB infection control policies and procedures. The administrator will document that Personnel File #2 has completed their annual TB education, and the documentation will be placed in their file.
C) The administrator will audit Personnel File #3 file to determine the missing documentation.
The administrator will develop a form that includes information about TB risk factors, the signs and symptoms of TB disease and TB infection control policies and procedures. The administrator will document that Personnel File #3 has completed their annual TB education, and the documentation will be placed in their file.
2. The administrator will audit all remaining Personnel Files to determine the missing documentation.
The administrator will develop a form that includes information about TB risk factors, the signs and symptoms of TB disease and TB infection control policies and procedures. The administrator will document that all personnel have completed their annual TB education, and the documentation will be places in the personnel files.
3. For all future employees, the administrator will develop a form that includes information about TB risk factors, the signs and symptoms of TB disease and TB infection control policies and procedures. The administrator will document that all future employees have completed their annual TB education, and the documentation will be placed in their files.
4. The administrator will monitor on a quarterly basis -
A) Aura Home Care maintains copies of the TB education forms to administer to all personnel.
B) All personnel are receiving the TB education forms annually.
C) Documentation that personnel received the TB education forms are placed in their files.
Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on January 31, 2024, Aura Home Care, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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