Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on March 18, 2025, Avon Home Care Agency, 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 March 18, 2025, Avon Home Care Agency, 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:
611.56(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 administrator, the agency did not provide documentation that a direct care worker completed screening for mycobacterium tuberculosis according to guidelines for six (6) of seven (7) PFs. ( PF# 1, 2, 3, 4, 6 & 7).
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 3/18/25 at approximately 10:30 AM. and revealed the following:
PF#1 Date of Hire: 5/2/23 file contained TST completed 6/13/23 but there was no documentation of a second step TST completed.
PF#2 Date of Hire: 5/12/23 file did not contain documentation of a baseline tuberculosis (TB) symptom screen questionnaire and an individual TB risk assessment upon hire.
PF#3 Date of Hire: 10/26/23 file did not contain documentation of a baseline tuberculosis (TB) symptom screen questionnaire and an individual TB risk assessment upon hire. In addition, file contained TST completed 1/25/23 but there was no documentation of a second step TST completed.
PF#4 Date of Hire: 12/28/23 file did not contain documentation of a baseline tuberculosis (TB) symptom screen questionnaire and an individual TB risk assessment upon hire.
PF#6 Date of Hire: 9/5/24 file did not contain documentation of a baseline tuberculosis (TB) symptom screen questionnaire and an individual TB risk assessment upon hire.
PF#7 Date of Hire: 1/25/25 file did not contain documentation of a baseline tuberculosis (TB) symptom screen questionnaire and an individual TB risk assessment upon hire. In addition, file contained TST completed 1/22/25 but there was no documentation of a second step TST completed.
An interview conducted with the administrator on 3/18/25 at approximatley 12:30 PM confirmed the above findings.
Plan of Correction:Avon Home Care Agency worked diligently to follow PA state requirements needed in 611.56(a) after the site visit conducted by DOH on 03/18/2025.
Avon Homecare Agency was performing screening tests for each new forthcoming employees, however the agency was not getting TB Risk assessment and Symptom questionnaire upon hire instead was performing for all the employees' assessment annually.
As a corrective action, Avon Homecare Agency will perform TB symptom screen and Risk assessment questionnaire in addition to TB screening (2 Test TST or IGRA or Chest X-ray) upon hire.
Avon homecare agency has updated policies for new hires and added the TB symptom screening and TB risk assessment questionnaire in the welcome package so there is no recurrence of such in future. The company CEO and/or Director will monitor this change.
Going forward, Avon Home care Agency will document the baseline Tuberculosis symptom screening questionnaire along with TB Risk assessment in addition to CDC approved guidelines for TB testing.
As a corrective action for incomplete 2 step TST:
PF#1 provided a most recent chest x-ray dated 3/21/2025.
PF#3 Provided most recent chest x-ray dated 3/21/2025.
PF#7 had 2ndstep TST done on 01/25/2025 but Avon Homecare Agency failed to ask for 2nd step TST result upon hire. PF#7 provided copy of 2nd step TST upon asked on 3/22/2025.
Avon Homecare Agency has self-audited all personnel employee files and we are making sure that each employee is in compliance with CDC requirement of having either Two step TST or Single blood test (IGRA) or Chest X-ray as baseline Tuberculosis screening. We have contacted each employee with the missing 2nd step TST to provide us with the most recent complete two steps TST or IGRA or Chest X-ray as baseline TB screening test and we are anticipating the completion date by 04/30/2025.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on March 18, 2025, Avon Home Care Agency, LLC., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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