Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on November 9, 2022 and offsite November 15, 2022, Blue Mountain Home Health Care, Inc, 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 unannounced home care agency state re-licensure survey conducted on November 9, 2022 and offsite November 15, 2022, Blue Mountain Home Health Care, Inc., 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(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 review of agency policy, personnel files (PF) and interview with the Agency Office Manager, it was determined the agency failed to ensure direct care workers had baseline testing for mycobacterium tuberculosis upon hire in four (4) of ten (10) files reviewed. (PFs #1, 2, 4, and 8)
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.
Review of agency policy titled " Employee Initial Tuberculosis (TB) testing", conducted 11/9/22, at 12:30 PM revealed: "Policy: Blue Mountain Home Health Care, Inc. may perform the Tuberculin skin test for employees who are appropriate candidates on an as needed basis, upon employment and annually. Procedure: 1. The Registered Nurse (RN) or Medical Director will administer the Tuberculin purified protein derivative (P.P.D.) by intradermal route. 2. Test will be read within forty eight (48) to seventy two (72) hours. If the test is not read within seventy two (72) hours, the test will need to be repeated."
Review of agency policy titled "Employee Health Screening" conducted on 11/15/22 at 2:00 PM revealed: "Policy: Any employee who has patient contact is tested initially and annually for tuberculosis infection (TB) to achieve compliance with the health evaluation regulation. Procedure: 1. The screening shall be conducted in accordance with the Center for Disease Control (CDC) guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings. 2. Annually each employee will: receive a skin test (PPD) unless known as positive reactor or showing documented proof of a negative PPD within the past year. Known reactors may submit a copy of a previous chest x-ray if available and will complete the tuberculosis questionnaire on an annual basis. Agency shall require each direct care worker to provide updated document at least every twelve (12) months..."
Review of employee files conducted 11/9/22 between 11:10 AM-12:40 PM revealed the following:
PF #1, date of hire (DOH): 3/2/22, the file did not contain documentation that baseline testing was completed upon hire.
PF #2, (DOH): 9/22/22, the file did not contain documentation that baseline testing was completed upon hire.
PF #4, (DOH): 7/14/20, the file did not contain documentation that baseline testing was completed upon hire.
PF #8, (DOH): 4/19/19, the file did not contain documentation that baseline testing was completed upon hire.
An interview with the Agency Office Manager on 11/9/2022 at approximately 1:30 PM confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for those individuals and/or practices identified in the deficiency statements?
Agency will review staff files and check for TB baseline testing and TB annual self risk assessment. Staff with missing 2022 Annual assessment will be completed
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
Agency will review staff files and check for TB baseline testing and TB annual self risk assessment. Staff with missing 2022 Annual assessment will be completed
3. What measures (actions/forms/system changes, etc.) will be put in place to ensure that the deficient practice does not reoccur?
For TB Baseline Testing requirement, the Agency is planning on adopting a new staff TB testing checklist, which will include:
- Name of Staff
- Date of Step 1 Results
- Date of Step 2 Results2 Year Residency confirmation
For Annual TB risk assessment, the agency will enter the Step 1 Result date into the electronic charting system as an annual compliance requirement. Once the compliance requirement is entered and saved into the charting system, an automatic reminder will be sent out before the end of 12 months. Both staff and administration will receive the annual renewal notification.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance programs will be established or followed?
Agency will conduct quarterly review of new staff files and document findings in a quarterly report. The report will be discussed within the office administration in order to ensure compliance
5. Date of when the corrective action will be completed?
The corrective actions will be implemented by 1/10/2023
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 agency policy, personnel files (PF) and interview with the Agency Office Manager, it was determined the agency failed to ensure direct care workers had a screening for mycobacterium tuberculosis on an annual basis in two (2) of ten (10) files reviewed. (PFs #7, and 10)
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.
Review of agency policy titled " Employee Initial Tuberculosis (TB) testing", conducted 11/9/22, at 12:30 PM revealed: "Policy: Blue Mountain Home Health Care, Inc. may perform the Tuberculin skin test for employees who are appropriate candidates on an as needed basis, upon employment and annually. Procedure: 1. The Registered Nurse (RN) or Medical Director will administer the Tuberculin purified protein derivative (P.P.D.) by intradermal route. 2. Test will be read within forty eight (48) to seventy two (72) hours. If the test is not read within seventy two (72) hours, the test will need to be repeated."
Review of agency policy titled "Employee Health Screening" conducted on 11/15/22 at 2:00 PM revealed: "Policy: Any employee who has patient contact is tested initially and annually for tuberculosis infection (TB) to achieve compliance with the health evaluation regulation. Procedure: 1. The screening shall be conducted in accordance with the Center for Disease Control (CDC) guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings. 2. Annually each employee will: receive a skin test (PPD) unless known as positive reactor or showing documented proof of a negative PPD within the past year. Known reactors may submit a copy of a previous chest x-ray if available and will complete the tuberculosis questionnaire on an annual basis. Agency shall require each direct care worker to provide updated document at least every twelve (12) months..."
Review of employee files conducted 11/9/22 between 11:10 AM-12:40 PM revealed the following:
PF #7, date of hire (DOH): 6/22/19, the file did not contain documentation that an annual self risk assessment and symptom screening for mycobacterium tuberculosis was completed in 2022.
PF #10, (DOH): 1/14/19, the file did not contain documentation that an annual self risk assessment and symptom screening for mycobacterium tuberculosis was completed in 2022.
An interview with the Agency Office Manager on 11/9/2022 at approximately 1:40 PM confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for those individuals and/or practices identified in the deficiency statements?
Agency will review staff files and check for TB baseline testing and TB annual self risk assessment. Staff with missing 2022 Annual assessment will be completed
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
Agency will review staff files and check for TB baseline testing and TB annual self risk assessment. Staff with missing 2022 Annual assessment will be completed
3. What measures (actions/forms/system changes, etc.) will be put in place to ensure that the deficient practice does not reoccur?
For TB Baseline Testing requirement, the Agency is planning on adopting a new staff TB testing checklist, which will include:
- Name of Staff
- Date of Step 1 Results
- Date of Step 2 Results2 Year Residency confirmation
For Annual TB risk assessment, the agency will enter the Step 1 Result date into the electronic charting system as an annual compliance requirement. Once the compliance requirement is entered and saved into the charting system, an automatic reminder will be sent out before the end of 12 months. Both staff and administration will receive the annual renewal notification.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance programs will be established or followed?
Agency will conduct quarterly review of new staff files and document findings in a quarterly report. The report will be discussed within the office administration in order to ensure compliance
5. Date of when the corrective action will be completed?
The corrective actions will be implemented by 1/10/2023
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on November 9, 2022 and offsite November 15, 2022, Blue Mountain Home Health Care, Inc., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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