QA Investigation Results

Pennsylvania Department of Health
BETTER IS BETTER, LLC
Health Inspection Results
BETTER IS BETTER, LLC
Health Inspection Results For:


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Initial Comments:


Based on the findings of an unannounced onsite complaint investigation survey conducted on April 3, 2024, Better is Better 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(c) LICENSURE
Federal Criminal History Record

Name - Component - 00
If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code 15.144(b) (relating to procedure).

Observations:


Based on review of Personnel Files (PF), agency policy, and employee (EMP) interview, the agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for two (2) of four (4) PF that did not include proof of residency in the state of Pennsylvania for within 2 years prior to date of hire. (PF 5, & 9.)

Findings included:
Agency Policy reviewed 4/3/24 at approximately 1:15pm revealed:
...Criminal background checks...(c) Federal criminal history record. If the individual required to submit or obtain a criminal history report has not been a resident of this commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a Federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with Pa. Code 15.144(b)... transmission of mycobacterium tuberculosis in health care settings.
Review of PFs on April 3, 2024, at approximately 9:30am revealed:

PF5, date of hire (DOH) 2/12/24, start of service (SOS) 2/12/24, PF, void of proof of residency, failed to include a letter of determination from the Department of Aging.

PF9, DOH 2/20/24, SOS 2/29/24, PF, void of proof of residency, failed to include a letter of determination from the Department of Aging.

Exit interview on April 3, 2024, at approximately 1:30pm with Owner, Office Manager, and both Office Supervisors confirmed findings.

Repeat deficiency, previously cited: 9/20/23.












Plan of Correction:

the owner and/or director will educate the office manager and case manager on chapter 611.52 criminal background check policy.

the owner and/or director will train office manager and case manager on chapter 611.52 criminal background check.

the owner and/or director will monitor background check, letter of determination from department of aging, 2 years residency, and (doh)(sos)

the owner and/or director will perform audit weekly on background check,letter of determination, and 2 years residency

the owner and/or director will have office manager and case manager sign a understanding procedure agreement form to ensure they understand the policy and how to enforce the policy


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 employee (EMP) interview, the agency failed to ensure that each direct care worker with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis (TB) for three (3) of four (4) PF reviewed (PF 4, 5, & 7).

Findings included:

Review of PFs on April 3, 2024, at approximately 9:30am revealed:

PF4, date of hire (DOH) 9/27/24, Start of Service (SOS) 3/4/24, PF failed to include evidence of TB screening.

PF5, DOH 2/12/24, SOS 2/12/24, PF failed to include evidence of TB screening.

PF7, DOH 9/21/23, SOS 3/12/24, PF failed to include evidence of TB screening.

Exit interview on April 3, 2024, at approximately 1:30pm with Owner, Office Manager, and both Office Supervisors confirmed findings.







Plan of Correction:

owner and/or director will educate office manager and case manager on chapter 611.56

owner and/or director will monitor office manager and case manager weekly to ensure eac direct care work start and finish the TB screening process

owner and/or director will conduct audit on direct care worker file to ensure DCW are obtaining a complete and negative result TB before (sos)

owner and/or director will have the case manager and office manager sign a understanding procedure agreement form




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 review of Personnel Files (PF), Centers for Disease Control (CDC) Guidelines, and employee (EMP) interview, the agency failed to ensure that baseline tuberculosis (TB)screening was conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings(TB) for three (3) of four (4) PF reviewed (PF 4, 5, & 7).

Findings included:

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...HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease....A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST within the previous 12 months, a single TST can be administered in the new setting. 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 of PFs on April 3, 2024, at approximately 9:30am revealed:

PF4, date of hire (DOH) 9/27/24, Start of Service (SOS) 3/4/24, PF failed to include documentation of a baseline tuberculosis screening upon hire completed in accordance with CDC guidelines

PF5, DOH 2/12/24, SOS 2/12/24, PF failed to include documentation of a baseline tuberculosis screening upon hire completed in accordance with CDC guidelines.


PF7, DOH 9/21/23, SOS 3/12/24, PF failed to include documentation of a baseline tuberculosis screening upon hire completed in accordance with CDC guidelines.


Exit interview on April 3, 2024, at approximately 1:30pm with Owner, Office Manager, and both Office Supervisors confirmed findings.






Plan of Correction:

owner and/or director will educate office manager and case manager on CDC guidelines that each DCW must receive baseline TB screening upon hiring.

owner and/or director will have office managers and case manager sign a understanding policy and procedure agreement form

owner and/or director will conduct a weekly audit on TB screening Guidelines

the audit will be conducted on matter of new and old consumers dcw obtaining a new or current TB. the office manager, director, and/or owner will review the dcw file to ensure all proper documents is accurate and update before (sos).30 days prior from when dcw TB is about to expire we will enforce them on obtaining new TB to stay in compliance with the cdc guidelines