Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on June 21, 2021, Comfort Keepers #488, 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 June 21, 2021, Comfort Keepers # 488, 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 agency policy, personnel files (PF) and interview with the agency administrator, it was determined the agency failed to ensure direct care workers had a screening for mycobacterium tuberculosis prior to consumer contact in five (5) of ten (10) files reviewed. (PFs #1, 3, 6, 8, and 9)
Findings include:
The CDC guidelines state that all Health Care Workers (HCW) should received baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screen annually. HCWs with a baseline 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.
Review of agency policy titled "Tuberculosis (TB)", conducted 6/21/21, at 2:00 PM revealed "1. When an employee is hired by Comfort Keepers they will be required to receive a baseline TB screening, using two s-step TST or a single BAMT to test for infection with M. Tuberculosis. a. A health care worker who has never had a PPD test: if the first test result is negative, the health care worker may begin to work immediately, and the second PPD will be adminsitered between one and three weeks after the first PPD. b. A health care worker who has had one previous negative PPD test: if a health care worker brings in a negative test result from a previous test, the test results can count as the first step. A second PPD test can now be applied provided the interval between the first and second test is no more than 1 year. Comfort Keepers will ensure that the health care worker's second step PPD is negative prior to the health care worker's contact with client."
Review of employee files, conducted 6/21/21, between 11:35 AM-1:30 PM revealed the following:
PF #1, date of hire (DOH): 8/23/16, the file did not contain any documentation that a screening for mycobacterium tuberculosis was completed on an annual basis in year 2017, 2018, 2019.
PF #3, (DOH): 10/22/20, the file did not contain documentation that a two-step screening for mycobacterium tuberculosis was completed upon hire.
PF #6, (DOH): 5/25/21, the file did not contain documentation that a two-step screening for mycobacterium tuberculosis was completed upon hire.
PF #8, (DOH): 1/24/19, the file did not contain any documentation that a screening for mycobacterium tuberculosis was completed on an annual basis in year 2021.
PF #9, (DOH): 11/9/20, the file did not contain documentation that a two-step screening for mycobacterium tuberculosis was completed upon hire.
An interview with the agency administrator, conducted 6/25/21 at 3:30 PM, confirmed the above findings.
Plan of Correction:Upon on boarding with Comfort Keepers for the orientation the 2 Step PPD process will have been started at the time of orientation. Within 21 days from the orientation the 2 step PPD must be completed and on file. Comfort Keepers will supply site for 2 step PPD to be completed. Annual the 1 step PPD and/or questionnaire will be completed by the caregiver. The monitoring system will be through ClearCare tasks for each caregiver. The Staffing Coordinator, will be monitoring these caregivers and tasks. Also, the responsible party for monitoring will be the Senior Staffing Coordinator.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on June 21, 2021, Comfort Keepers # 488, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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