DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
391589 A. BUILDING __________
B. WING ______________ 		01/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
AMEDISYS HOSPICE OF HARRISBURG EAST 3350 PAXTON STREET, SUITE 5, HARRISBURG, PA, 17111
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0784      
38554 Based upon review of agency policy, personnel files (PF), and interview with director of operations ( EMP #1), agency failed to show evidence of professional registered nurse (RN) license for one (1) of three (3) files reviewed. ( PF # 3); failed to show annual performance evaluations for one(1) of three (3) files reviewed ( PF # 2) . Findings included: Request for agency hiring policy on 2/4/2020 at approximately 9:36 AM and none produced. Review of PF on 1/30/20 between approximately 1:15 PM-3:00 PM revealed: PF # 2, Date of Hire (DOH) 5/27/14; agency unable to show evidence of annual performance evaluations for 2019. PF # 3, DOH 12/9/19; agency unable to show evidence of current professional nursing license; hospice orientation; initial skills competency testing. Interview with EMP # 1 at approximatley 3:15 PM confirmed above findings.
L0795      
38554 Based upon review of agency policy, personnel files (PF), and interview with director of operations ( EMP #1), agency failed to show evidence of obtaining a criminal background check for one (1) of three (3) files reviewed. ( PF # 3). Findings included: Request for agency criminal background check policy on 2/4/2020 at approximately 9:36 AM and none produced. Review of PF on 1/30/2020 between approximately 1:15 PM-3:00 PM revealed: PF # 3, Date of Hire (DOH) 12/9/19; agency unable to produce criminal background check. Interview with EMP # 1 at approximatley 3:15 PM confirmed above findings.
L0798      
38554 Based upon review of CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, 2005, and updated 2019 recommendations, agency policy, personnel files (PF), and interview with director of operations ( EMP #1), agency failed to show evidence of initial two (2) step Tuberculin (TB) screening for one (1) of three (3) files reviewed. ( PF # 3) and annual TB screening for one (1) of three (3) files reviewed ( PF # 2). Findings included: Review of CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in health-Care Settings, 2005, included that all Health Care Workers (HCW) should receive baseline TB screening upon hire, using two-step TST or a single BAMT to test for infection with M. Tuberculosis. The second step TST should be administered 1-3 weeks after the first step was read. Annual TB individual risk assessment shall be completed. Request for agency policy on TB screening on 2/4/2020 at approximately 9:36 M with none produced. Review of PF on 1/30/2020 between approximately 1:15 PM-3:00 PM revealed: PF # 2, Date of Hire (DOH) 5/27/14; annual screening read on 9/26/18 but no evidence of TB screening administered for 2019. PF # 3, DOH 12/9/19; agency unable to produce evidence of initial two (2) step TB screening. Interview with EMP # 1 at approximatley 3:15 PM confirmed above findings.