QA Investigation Results

Pennsylvania Department of Health
ANGEL COMPANIONS
Health Inspection Results
ANGEL COMPANIONS
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on May 29, 2024, Angel Companions, 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 May 29, 2024, Angel Companions, 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 a review of personnel files (PF), it was determined the agency failed to ensure the direct care worker, prior to consumer contact, to be screened for mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for four (4) out of seven (7) personnel files (PF) reviewed (PF#2, PF#3, PF#5, PF#7).

Findings Include:

The CDC guidelines state that 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.)
Personnel files were reviewed on 5/29/24 from approximately 11:30 AM-12:00 PM revealing the following:

PF#2 (Date of hire (DOH) 10/24/2023): No documentation of completed baseline testing. PF included documentation of only one (1) TST.
PF#3 (DOH: 1/18/2024): No documentation of completed baseline testing. PF included documentation of only one (1) TST.
PF#5 (DOH: 9/01/2023): No documentation of completed baseline testing. PF included documentation of only one (1) TST.
PF#7 (DOH: 9/21/2023): No documentation of completed baseline testing. PF included documentation of only one (1) TST.



An interview with the agency administrator on 5/29/24 at approximately 12:00 PM confirmed the above findings.




Plan of Correction:

For the personnel files identified in the observation including PF#2, PF#3, PF#5, and PF#7, our agency will send those Direct Care Staff (DCS) for a QuantiFERON Gold TB test. This is a one-step TB test which will eliminate the need for the 2nd step, and will provide the required TB negative test results for those DCS's.

The DCS's identified will be put on a leave of absence until they are able to get the QuantiFERON Gold TB test.

Our Agency is conducting a full review of DCS files. Should we come across others in need of final TB test results, they will also be put on leave of absence and sent for the QuantiFERON Gold TB Test. This will be complete by 6/28/2024.

Any new DCS's hired after 5/29/24 will be sent for the QuantiFERON Gold test eliminating the need for the 2nd step, and ensuring our DCS's are negative for TB.

Our Agency will be reviewing DCS files again in August 2024 and again in December 2024 to ensure the process has been adopted and adhered to. Our HR Generalist will be tasked with file review and ensuring that the TB Test results are in the DCS file.

Our Agency will conduct an internal DCS file audit every year in January and again in June.



Initial Comments:

Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on May 29, 2024, Angel Companions, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: