QA Investigation Results

Pennsylvania Department of Health
ALMA CARE, LLC
Health Inspection Results
ALMA CARE, LLC
Health Inspection Results For:

This is the only survey for this facility

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Initial Comments:


Based on the findings of an onsite unannounced state re-licensure survey conducted on May 15, 2024, Alma Care, LLC., 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 May 15, 2024, Alma Care, LLC., 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:




611.52(b) LICENSURE
State Police Criminal History Record

Name - Component - 00
If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.

Observations:



Based on a review of personnel files (PF) and an interview with the administrator, the agency failed to provide documentation of a Pennsylvania State Police Criminal Background Check at the time of application or within 1 year immediately preceding the date of application for two (2) of three (3) PF's reviewed, (PF # 2 & 3 ).

Findings include:

A review of PF's was conducted on 5/15/24 at approximately 11:00 am and revealed the following:


PF #2 Date of Hire: 5/10/19, contained no documentation of a Pennsylvania State Police Criminal Background Check.

PF #3 Date of Hire: 7/7/23, contained no documentation of a Pennsylvania State Police Criminal Background Check.


An interview with the office manager on 5/15/24 at approximately 12:30 PM confirmed the above findings.













Plan of Correction:


Alma Care LLC will obtain the Pennsylvania State Police Criminal Background Check at the time of application for new hires.

To prevent this from happening again, the office manager will be responsible to run the Pennsylvania State Police Criminal Background Check for all selected candidates to be hired.

The office manager will audit the Personnel files at the orientation to make sure the Pennsylvania State Police Criminal Background Check is present for each new hire.

The office manager will use the checklist form to audit the files.

The HR policy was updated to state that: " No direct care worker will start rendering services prior to obtaining the State Police Criminal Background Check .

The corrective actions will be completed by 07/14/2024.



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 a review of personnel files (PF), the Centers for Disease Control (CDC) guidelines, and an interview with the office manager, the agency did not provide documentation that a direct care worker completed screening for mycobacterium tuberculosis according to guidelines for three (3) of three (3) PFs. ( PF# 1, 2, & 3).

Findings include:

In May 2019, the Centers for Disease Control (CDC) updated its recommendation for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should receive 1) 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; 2) Completion of a tuberculosis symptom questionnaire, and 3) Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's 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 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).

A review of PF's was conducted on 5/15/24 at approximately 11:00 AM and revealed the following:

PF#1 Date of Hire (DOH) 8/10/17 did not contain evidence that a baseline tuberculosis (TB) symptom screen questionnaire or an individual TB risk assessment was completed upon hire. In addition, file also did not contain any initial TB testing (IGRA or two-step TST).

PF#2 DOH 5/10/19 did not contain evidence that a baseline tuberculosis (TB) symptom screen questionnaire or an individual TB risk assessment was completed upon hire. In addition, file also did not contain any initial TB testing (IGRA or two-step TST).

PF#3 DOH 7/7/23 did not contain evidence that a baseline tuberculosis (TB) symptom screen questionnaire or an individual TB risk assessment was completed upon hire. In addition, file also did not contain any initial TB testing (IGRA or two-step TST).



An interview conducted with the office manager on 5/15/24 at approximatley 12:30 PM confirmed the above findings.











Plan of Correction:

The direct care workers were notified to obtain TB testing for mycobacterium tuberculosis according to CDC guidelines

To prevent this from recurring again, the candidates will be provided with the Physical Form to be completed by the physician, at the interview.

The form must be returned to the office prior to staff rendering services in the field.

To ensure that the Initial TB testing is completed , Alma Care LLC will collect the documentation( 2 step tuberculin test or a single blood assay for tuberculosis) at the orientation.

The office manager will audit the files using the checklist to ensure the required documents are in place.

The staff that will not submit the physical form / documentation showing the results of the initial testing, will not render services in the field until the office obtains such documentation.

To monitor ongoing compliance the agency will audit the files annually and document the results on the audit form.

The corrective action will be completed by 07/14/2024.







Initial Comments:


Based on the findings of an onsite unannounced state re-licensure survey conducted on May 15, 2024, Alma Care, LLC., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: