QA Investigation Results

Pennsylvania Department of Health
5 STAR HOME CARE
Health Inspection Results
5 STAR HOME CARE
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite home care agency state re-licensure survey conducted on August 8, 2024, Five Star 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 August 8, 2024, 5 Star 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:




611.55(a) LICENSURE
Competency Requirements

Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.

Observations:

Based on a review of personnel files (PF's) and an interview with the Administrator, prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry did not show evidence that the direct care worker had completed one of the following: 1) Obtained a valid nurse ' s license in this Commonwealth; (2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c). (3) Has successfully completed one of the following: (i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c). (ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services). (iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us. (iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers. (v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department 's website for three (3) of five (5) PF's: (PF# 1, 2 and 4).

A review of personnel files was conducted on August 8, 2024 at approximately 11:58 a.m.

PF #1: Date of Hire 7/27/2022 did not contain any documentation of a completed initial competency conducted by the agency.

PF #2: Date of Hire 12/19/2022 did not contain any documentation of a completed initial competency conducted by the agency.

PF #4: Date of Hire 3/28/2023 did not contain any documentation of a completed initial competency conducted by the agency.

An interview with the Administrator, on August 8, 2024 at approximately 12: 27 p.m. confirmed the above findings.











Plan of Correction:

1.Going forward aides upon hire(date of hire) will submit written exam results to agency dated.
2.Going forward aides upon hire(date of hire) will submit written exam results to agency dated.
3.Going forward aides upon hire(date of hire) will submit written exam results to agency dated.
4.Going forward aides upon hire(date of hire) will submit written exam results to agency dated.
5.Going forward aides upon hire(date of hire) will submit written exam results to agency dated.

Hilary Gillman and Howard Dall will be responsible for making sure tests are administered on an annual basis and dated Both will make sure nothing falls through the cracks.


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 personnel files (PF), recommendations from the Centers for Disease Control (CDC), an interview with the administrator the agency did not contain documentation that the individual had completed symptom screen questionnaire and an individual TB risk assessment for five (5) of five (5) PF's, (PF # 1, 2, 3, 4 and 5). Also the agency did not contain documentation that the individual had completed annual TB education for four (4) of five (5) PF's, (PF # 1, 2, 4 and 5).

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.

*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 PF's was conducted on August 8, 2024 starting at approximately 10:46 a.m.

PF # 1 DOH 7/27/2022 did not contain documentation of completion of a tuberculosis (TB) symptom screen questionnaire nor a TB risk assessment upon hire. Also did not contain any documentation of a completed annual TB education for 2023 and 2024.

PF # 2 DOH 12/19/2022 did not contain documentation of completion of a tuberculosis (TB) symptom screen questionnaire nor a TB risk assessment upon hire. Also did not contain any documentation of a completed annual TB education for 2023.

PF # 3 DOH 6/23/2024 did not contain documentation of completion of a tuberculosis (TB) symptom screen questionnaire nor a TB risk assessment upon hire.

PF # 4 DOH 3/28/2023 did not contain documentation of completion of a tuberculosis (TB) symptom screen questionnaire, nor a TB risk assessment upon hire. Also did not contain any documentation of a completed annual TB education for 2024.

PF # 5 DOH 6/10/2023 did not contain documentation of completion of a tuberculosis (TB) symptom screen questionnaire nor a TB risk assessment upon hire. Also did not contain any documentation of a completed annual TB education for 2024.

An interview conducted with the administrator on August 8, 2024 starting at 11:27 a.m. confirmed the above findings.















Plan of Correction:

1. Upon hire we will check for signs and symptoms(cough, chest pain, coughing of blood. This will be accomplished before hire

2.A risk assessment will be performed for aide that have a residence in a foreign country, close contact with a TB infected person, also current or planned immunosuppression.

3A A TB test(either interferon gamma-Release. assay, or IGRA, blood test or 2step tuberculin skin test or chest xray.

4.Annually education about TB risk factors and noting signs and symptoms of TB disease and TB infection control policies and procedures

Hilary Gillman and Howard Dall will be responsible for TB tests for new employee hiring(checking on status of vaccinations)
They will also be responsible for ongoing TB education and monitoring of employees. Both will be responsible so nothing falls through the cracks




Initial Comments:

Based on the findings of an onsite home care agency state re-licensure survey conducted on August 8, 2024, 5 Star Home Care, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).






Plan of Correction: