QA Investigation Results

Pennsylvania Department of Health
AVAIL PERSONAL IN-HOME CARE SERVICES, LLC
Health Inspection Results
AVAIL PERSONAL IN-HOME CARE SERVICES, LLC
Health Inspection Results For:


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Initial Comments:


Based upon an unannounced on-site home care agency state re-licensure survey conducted on 1/28/20, 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 upon an unannounced on-site home care agency state re-licensure survey conducted on 1/28/20, 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:




611.51(a) LICENSURE
Hiring or Rostering Prerequisites

Name - Component - 00
Prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. (3) Require the individual to submit a criminal history report, in accordance with the requirements of 611.52 (relating to criminal background checks), and a ChildLine verification, if applicable, in accordance with the requirements of 611.53 (relating to child abuse clearance).

Observations:


Based upon review of agency policy, personnel files (PF), and interview with owner, ( EMP # 1), agency failed to show evidence of dated references for eight (8) of ten (10) files reviewed. ( PF # 2-8; PF # 10).

Findings included:

Review of agency policy on 1/28/20 between approximately 2:00 PM-2:30 PM titled " 4.1 Employment" stated " (2.e.7.) Reference Check: ...Reference checks ( minimum of 2) shall be made by the agency.."

Review of PF on 1/28/20 between approximately 10:30 AM-11:45 AM revealed:

PF # 2, Date of Hire (DOH) 11/25/18; Two (2) references present, neither were dated when obtained.

PF # 3, DOH 9/8/19; one (1) reference present, no date when obtained.

PF # 4, DOH 8/26/19; Two (2) references present, neither were dated when obtained.

PF # 5, DOH 4/16/19; Two (2) references present, neither were dated when obtained.

PF # 6, DOH 9/5/19; one (1) reference present, no date when obtained.

PF # 7, DOH 8/27/18; Two (2) references present, neither were dated when obtained.

PF # 8, DOH 3/7/19; Two (2) references present, neither were dated when obtained.

PF # 10, DOH 1/4/19; Two (2) references present, neither were dated when obtained.

Interview with EMP # 1 on 1/28/20 at approximately 2:15 PM confirmed above findings.




Plan of Correction:

Reference form used at time of hire will be revised with the date added at the bottom beside staff signature who performs check. This will insure to remind the staff member completing check to fill in the completed date. All current staff who completes references and any new hired staff who may run references will be trained and sign off that they were and a form will be placed in there employee chart. Staff will be trained on the reference policy of needing a minimum of 2 positive and putting the date completed. Owner will add the references number completed and date checked to her bi-monthly check list to be sure they are being completed.


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 upon review of CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis ( TB) in Health-Care Settings, 2005, and updated 2019 recommendations,
agency policy, personnel files (PF), and interview with owner, ( EMP # 1), agency failed to show evidence two step Tuberculin screening was conducted for two (2) of ten (10) files reviewed. ( PF # 3; PF #8)

Findings included:

Review of CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in health-Care Settings, 2005, included that all Health Care Workers (HCW) should receive baseline TB screening upon hire, using two-step TST or a single BAMT to test for infection with M. Tuberculosis. The second step TST should be administered 1-3 weeks after the first step was read. Annual TB individual risk assessment shall be completed.


Review of agency policy on 1/28/20 between approximately 2:00 PM-2:30 PM titled " 4.8 TB Testing" stated " (2) On any employee or contract personnel providing direct consumer care,.... via the 2 step Mantoux or single BAMT method on hire."

Review of PF on 1/28/20 between approximately 10:30 AM-11:45 AM revealed:

PF # 3, Date of Hire (DOH) 9/8/19; initial PPD was read on 9/2/19 but no evidence the second step TB was obtained.

PF # 8, DOH 3/7/19; no evidence either two (2) step TB screening was conducted.


Interview with EMP # 1 on 1/28/20 at approximately 2:15 PM confirmed above findings.




Plan of Correction:

A new Tb policy has been created reflecting a tb form all new hires will need to have completed and submitted prior to client contact. The form has included on it the date given and the date read and also the results of tb test. All other forms will no longer be accepted unless owner approves the forms and can verify all necessary sections are present on these forms such as date given, site, date read, results and signature of healthcare personnel. Once verified owner will initial back of form with the date verified. Owner will add tb tests to her bi-monthly binder to verify that correct forms are being brought in and filled out correctly. All current and new hired office staff will be trained on the new tb policy and will sign off that they understand.


Initial Comments:


Based upon an unannounced on-site home care agency state re-licensure survey conducted on 1/28/20, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).







Plan of Correction: