Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on September 6, 2024 and concluded off-site September 11, 2024, 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 state re-licensure survey conducted on September 6, 2024 and concluded off-site September 11, 2024, 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
(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 personnel files (PF) and interview with the agency administrator, it was determined the agency failed to ensure direct care workers were screened for and were free from active mycobacterium tuberculosis (TB) prior to assignment with consumers in two (2) of ten (10) files reviewed. (PFs # 1 and # 8)
Findings include:
The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire... HCWs should receive TB screen annually. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The updated recommendations include for health care personnel to be screened for TB upon hire and involves three (3) steps as follows: TB risk assessment, a TB symptom screen and a TB test using either a two-step tuberculin skin test (TST) or a single blood assay for TB. The 2019 recommendations included that healthcare workers should receive TB screen and TB education annually.
Reviews of personnel files conducted on 9/6/24 between 11:20 AM and 1:10 PM revealed the following:
PF# 1, date of hire (DOH): 10/26/23, The file contained a one-step TB test dated 10/27/23 with no documentation of Tuberculosis risk assessment or screening upon hire.
PF# 8, DOH: 9/11/23: The file contained a one-step TB test dated 9/22/23 with no documentation of Tuberculosis risk assessment or screening upon hire.
An interview conducted with the Agency Administrator on September 11, 2024 at approximately 10:30 AM confirmed the above findings.
Plan of Correction:0700. Two Step PPD:
1. What corrective action will be accomplished for those individuals and/or practices identified in the deficiency statements?
Agency will review staff files of individuals identified during survey and will complete 2-Step PPD for them
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
Agency will review staff files of all current staff and ensure that a 2-Step PPD is present in the files.
3. What measures (actions/forms/system changes, etc.) will be put in place to ensure that the deficient practice does not reoccur?
The agency will ensure that a current 2 Step PPD is available for all new staff members. The agency will also review all active staff file in order to ensure compliance with 2 Step PPD requirement and annual health screening questionnaire.
The agency will also roll out annual educational paper for TB. This paper will be part of the annual health screening questionnaire.
Emp#1 and admin staff will be responsible for implementing this and it will be completed for all new staff files created on or after 10 / 21 / 2024.
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 10/21/2024
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on September 6, 2024 and concluded off-site September 11, 2024, 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:
|