QA Investigation Results

Pennsylvania Department of Health
BLESSED HANDS HOME HEALTH CARE
Health Inspection Results
BLESSED HANDS HOME HEALTH CARE
Health Inspection Results For:


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Initial Comments:


Based on the findings of an unannounced onsite state re-licensure survey conducted on May 3, 2024, Blessed Hands Home Health 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 unannounced onsite state re-licensure survey conducted on May 3, 2024, Blessed Hands Home Health 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(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 review of new consumer enrollment package, employee handbook, Center for Disease and Control (CDC) guidelines, review of employee files, agencies policy, and an interview with the agency administrator, the agency failed to ensure each direct care worker with direct consumer contact, prior to consumer contact, was screened for and is free from active mycobacterium tuberculosis (TB) for five (5) out of five (5) EFs reviewed (EFs#1-5).


Findings include:


Review conducted on May 3, 2024, at approximately 8:37 AM, of agency new consumer enrollment package revealed: "Acknowledgement of DCW Hiring & Competency Notice ... 3. Testing for TB."


Review conducted on May 3, 2024, at approximately 9:05 AM, of agency employee handbook revealed: Page 29 "TB Policy BHHC TB testing requirements" has no written requirments of onhire TB risk assessment questionnaire completion as required by CDC Guidelines.


Review conducted on May 3, 2024, at approximately 9:30 AM, of CDC guidelines revealed: "all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs with a baseline positive or newly 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)."


Review conducted on May 3, 2024, at approximately 9:35 AM to 10:45 AM, of employee files (EFs) revealed:

EF#1 date of hire (doh) 2/9/24, no onhire TB risk assessment questionnaire (TB-RAQ).

EF#2 doh 9/23/23, no onhire TB-RAQ.

EF#3 doh 10/27/23, no onhire TB-RAQ.

EF#4 doh 2/12/24, no onhire TB-RAQ.

EF#5 doh 6/7/23, no onhire TB-RAQ.


Interview conducted on May 3, 2024, at approximately 11:AM, with agency adminstrator confirmed above findings.









Plan of Correction:

1. On 5/6/2024 Blessed Hands Directed EF#2, EF#3 to complete the tuberculosis (TB) symptom screening questionnaire. This document is maintained in EF#2's and EF#3 employee file.

2. On 5/7/2024 Blessed Hands Directed EF#4 EF#5 to complete the tuberculosis (TB) symptom screening questionnaire. This document is maintained in EF#4's and EF#5 employee file.


3.Beginning 5/8/24 the agency BHHHC will audit all current employees for required TB two-step skin test or chest x-ray results. If any employee is missing a TST result, the employee will complete the TB screening questionnaire. This document will be maintained in the employee's file.


4.Beginning 5/10/24 the agency BHHHC will implement a new electronic Tracking spreadsheet to ensure required TST Results are documented for each new employee and prior.


5.Beginning 5/13/24 the agency BHHHC in order to ensure compliance will audit all new employees flies, monthly for 2 months (Total of 2 months) documented in electronic tacking spreadsheet.


Completion date: 07/01/2024


Initial Comments:


Based on the findings of an unannounced onsite state re-licensure survey conducted on May 3, 2024, Blessed Hands Home Health Care was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: