QA Investigation Results

Pennsylvania Department of Health
1ST CARE HOME HEALTH SERVICES OF PENNSYLVANIA
Health Inspection Results
1ST CARE HOME HEALTH SERVICES OF PENNSYLVANIA
Health Inspection Results For:


There are  11 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:

Based on the findings of an onsite unannounced Medicare recertification survey conducted on January 28, 2019 through January 30, 2019, 1st Care Home Health Services was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Part 484, Subparts B & C, Conditions of Participation: Home Health Agencies.






Plan of Correction:




484.105(a) STANDARD
Governing body

Name - Component - 00
Standard: Governing body.
A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program.

Observations:

Based on review of agency policies/procedures, documentation, clinical records, personnel files and interview with the administrator and clinical manager, the governing body failed to assume full legal authority and responsibility for the agency's overall management and operation and the provision of all home health services by not overseeing employee files and following policies for employment by not ensuring documentation of contracted staff workers criminal background checks, job description, competency on hire per agency ' s policy and tuberculin (TST) skin test.

Findings:

Cross reference

484.105(b)(1)(iv) Ensure that HHA Employs Qualified Personnel (952)









Plan of Correction:

The Governing Body and Administrator as well as all staff was re-educated by the Governing Body President regarding the requirement that the governing body must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This is to also include overseeing employee files and following polices for employment by ensuring documentation of contracted staff workers criminal background checks, job description, competency on hire per agency's policy and TST skin test. An individual is designated responsible for the overall operation of services of the HHA and that the Administrator organizes and directs the HHA's ongoing functions and maintains ongoing liaison among the governing body/owner and the personnel including accountability by maintaining responsibility for the QAPI program. The Administrator will audit employee records weekly until 100 percent compliance with documentation in QA minutes, then monthly until 100 percent compliance and then quarterly with documentation for one year in QA minutes.

The Administrator and Governing body will meet weekly for one month, then monthly for 3 months then quarterly thereafter until the end of the year to discuss and review evidence that the governing body is responsible for all programs and services related to the HHA including the QAPI program and personnel files with documentation in minutes. Audits will be completed on the personnel files to ensure all required elements are there. 100% threshold is expected within 30 days. All audit results will be presented to the Governing Body President for further review and follow up. Instances of non-compliance by the Governing Body assuming responsibility will result in counsel and possible removal from the Governing body.


484.105(b)(1)(iv) ELEMENT
Ensure that HHA employs qualified personnel

Name - Component - 00
(iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies.

Observations:

Based on a review of personnel files and interview with the administrator, the agency failed to conduct screening for mycobacterium tuberculosis in accordance with Centers for Disease Guidelines for ten (10) of ten (10) personnel files per agency ' s policies. Personnel files # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.

Findings include:

Review of the CDC (Centers for Disease Control) guidelines state that all Health Care Workers (HCW) should receive 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 screening annually. HCWs 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 the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005 ;( RR-17)
.

Review of policy on January 30, 2019 at 1 pm titled " Services Under Contract " dated 2018 revealed " Contracted personnel must be qualified by experience and training to perform the services they provide for the patient. The necessity to conform to all professional standards and applicable agency policies, including personnel qualifications. "
Review of policy on January 30, 2019 at 1:30 pm titled " Screening and Hiring " dated 2018 states " The administrator makes an appointment for the interview, documentation of current license and certifications., proof of employment eligibility, current physical exam and immunizations, copy of driver ' s license, automobile liability insurance, a signed and dated job description. Per CDC guidelines, the Mantoux test shall be required of all field staff. Staff who have a negative PPD test receive either a one-step Mantoux test every year or fill out a questionnaire, based on local TB prevalence rates in accordance within the CCD and local Department of Health services. "

Review of personnel files on January 30, 2019 from at 12 pm to 1 pm revealed:
Personnel file # 1 with date of hire on January 14, 2019. No documentation of annual tuberculin (TST) skin test on hire. TB questionnaire was documented on January 14, 2019 for calendar year 2017
Personnel file # 2 with date of hire on February 2, 2016. No documentation of annual tuberculin (TST) skin test for calendar year 2017 and 2018.
The following personnel files are for the contracted agency who had documented care delivery to this agency ' s patient ' s.
Personnel file # 3 with no date of hire. No documentation of tuberculin (TST) skin test when working for this agency per agency policies
Personnel file # 4 with no date of hire. No documentation of tuberculin (TST) skin test when working for this agency per agency policies
Personnel file # 5 with no date of hire. No documentation of tuberculin (TST) skin test when working for this agency per agency policies
Personnel file # 6 with no date of hire. No documentation of tuberculin (TST) skin test when working for this agency per agency policies
Personnel file # 7 with no date of hire. No documentation of tuberculin (TST) skin test when working for this agency per agency policies
Personnel file # 8 with no date of hire. No documentation of tuberculin (TST) skin test when working for this agency per agency policies
Personnel file # 9 with no date of hire. No documentation of tuberculin (TST) skin test when working for this agency per agency policies
Personnel file # 10 with no date of hire. No documentation of tuberculin (TST) skin test when working for this agency per agency policies
Interview with the administrator on January 30, 2019 at 1300 confirmed the above findings.


Based on review of agency policies/procedures, documentation, clinical records and personnel files and interview with the administrator and clinical manager, the governing body failed to ensure documentation of contracted staff workers criminal background checks, job description, competency on hire per agency ' s policy. Personnel files for occupational therapy, physical therapy contracted staff for eight (8) of ten (10) personnel files. PF# 3,4,5,6,7,8,9 and 10.

Findings include:
Review of policy on January 30, 2019 at 1 pm titled " Services Under Contract " dated 2018 revealed " Contracted personnel must be qualified by experience and training to perform the services they provide for the patient. The necessity to conform to all professional standards and applicable agency policies, including personnel qualifications. "
Review of policy on January 30, 2019 at 1:30 pm titled " Screening and Hiring " dated 2018 states " The administrator makes an appointment for the interview, documentation of current license and certifications., proof of employment eligibility, current physical exam and immunizations, copy of driver ' s license, automobile liability insurance, a signed and dated job description. Per CDC guidelines, the Mantoux test shall be required of all field staff. Staff who have a negative PPD test receive either a one-step Mantoux test every year or fill out a questionnaire, based on local TB prevalence rates in accordance within the CCD and local Department of Health services. "
According to the Act 169 of 1996 as amended by Act 13 of 1997,"If the applicant/employee has been a resident of the Commonwealth of Pennsylvania for 2 or more years prior to application for employment, the applicant will need to obtain a clearance from the Pennsylvania State Police. This clearance is obtained by doing the following: Request for Criminal Record Check Form (SP4-164)." "When the applicant/employee has not been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application for employment or currently lives out of state, in addition to the Pennsylvania State Police Criminal History Check, the applicant/employee will also need to obtain an FBI Criminal History Check. Facilities are defined by the act to include: Domiciliary Care Homes, Home Health Care Agency, Nursing Facility (licensed by the Department of Aging), and Personal Care Home (licensed by the Department of Public Welfare). A Home Health Care Agency is further defined to include those agencies licensed by the Department of Health and any public or private organization which provides care to a care-dependent individual in their place of residence." "If entities run into special circumstances where they need to hire an employee before the results of their record checks are returned, there is a provision in CPSL that allows for a provisional hiring period. The period is to not exceed 30 days for in state residents and 90 for out of state residents."
Review of personnel files on January 30, 2019 from at 12 pm to 1 pm revealed:
The following personnel files are for the contracted agency who had documented care delivery to this agency ' s patient ' s clinical record.
Personnel file # 3 with no date of hire. No documentation of criminal background check, job description, orientation and competencies.
Personnel file # 4 with no date of hire. No documentation criminal background check, job description, orientation and competencies.
Personnel file # 5 with no date of hire. No documentation criminal background check, job description, orientation and competencies.
Personnel file # 6 with no date of hire. No documentation criminal background check, job description, orientation and competencies.
Personnel file # 7 with no date of hire. No documentation criminal background check, job description and orientation.
Personnel file # 8 with no date of hire. No documentation criminal background check, job description, orientation and competencies.
Personnel file # 9 with no date of hire. No documentation criminal background check, job description and orientation.
Personnel file # 10 with no date of hire. No documentation criminal background check, job description and orientation.
Interview with the administrator on January 30, 2019 at 1 pm confirmed the above findings.
























Plan of Correction:

The Administrator and Director of Nursing have been re-educated regarding the requirement that the HHA must ensure they employ qualified personnel, both direct hire and contracted employees including assuring the development of personnel qualifications and policies to include policies and qualifications on TB testing on hire and annually, TB questionnaire being completed annually; hire dates being noted, criminal background checks, signed job descriptions, orientation completed and competencies performed.
The Administrator has scheduled for all employees with personnel files #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 to obtain TB skin testing and for employees #3, 4, 5, 6, 7, 8, 9, and 10 to have criminal background checks performed.
The Director of Nursing will be responsible to ensure that all employees receive initial and annual testing.
The Administrator will audit employee records weekly until 100 percent compliance with documentation in QA minutes, then monthly until 100 percent compliance and then quarterly with documentation for one year in QA minutes. Audits will be completed on the QAPI program data collection and Current Performance Improvement progress.
25% of all HR files will be audited by the Administrator/Designee quarterly (total of 100% of all HR files to be audited annually) for evidence of personnel documentation requirements including TB testing on hire and annually, dates of hire being noted as well as background checks being performed prior to hire. All new employee HR files will be audited within 7 days of hire for evidence of personnel documentation requirements to include date of hire being noted and background checks being performe by the Administrator/designee. The Administrator will report findings to the QAPI Committee quarterly. All findings that fall below 95% compliance threshold will be reported to the Governing Body for further recommendations.



Initial Comments:

Based on the findings of an unannounced Medicare recertification and complaint investigation survey conducted on January 28, 2019 through January 30, 2019, 1st Care Home Health Services was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.







Plan of Correction:




484.102(a)(1)-(2) STANDARD
Plan Based on All Hazards Risk Assessment

Name - Component - 00
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

*[For LTC facilities at 483.73(a)(1):] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.

*[For ICF/IIDs at 483.475(a)(1):] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at 418.113(a)(2):] (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

Observations:

Based on interview with the administrator and clinical manger, the review of agency documentation and the agency's emergency preparedness plan, the agency failed to
base the emergency preparedness plan on and to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.

Findings:
A review of the agency emergency preparedness plan was conducted on January 30, 2019 at 2 pm. There was no documentation that the emergency preparedness plan was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.

Interview with the administrator and clinical manger on January 30, 2019 at 3 pm confirmed the above findings.










Plan of Correction:

The Administrator has prepared an emergency preparedness plan that is based on and outlines the process for meeting patient and personnel needs in a disaster or crisis situation. Part of this process includes conducting a community based risk assessment, using an all-hazards approach and the development of strategies and collaboration with other health organizations in the same geographic area. The Administrator has had a mandatory staff meeting to conduct the emergency preparedness plan that was based on and included a documented, facility based and community based risk assessment, utilizing an all hazards approach which also included strategies for addressing emergency events identified by the risk assessment. All staff education has been performed by Administrator
The Administrator will conduct the Emergency Preparedness Plan (EP) training with all staff twice yearly with documentation being noted in the QA minutes. The Administrator will educate all staff verbally and in writing of the Emergency Plan once monthly for three months with documentation in the QA minutes. Administrator will also audit the Emergency Preparedness Plan and staff education twice yearly and report findings to QAPI committee who will monitor results for quality outcomes and performance improvement.



484.102(a)(4) STANDARD
Local, State, Tribal Collaboration Process

Name - Component - 00
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:]

(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.

* [For ESRD facilities only at 494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the dialysis facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.

Observations:

Based on interview with the administrator, the review of agency documentation and the agency ' s emergency preparedness plan, the agency failed to have included a process for cooperation and collaboration with local, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency.
Findings:
Review of agency change of owner status (855A) application from March 1, 2018 on January 30, 2019 revealed that the agency provides services to patients in Lehigh, Northampton, Bucks, Berks, Carbon and Monroe counties.
Review of emergency preparedness plan on January 30, 2019, revealed no documentation of a process of collaboration with local emergency management officials, regional, State, and Federal emergency preparedness officials.
Interview with the administrator and clinical manger on January 30, 2019 at 3 pm confirmed the above findings.














Plan of Correction:

The agency has developed and implemented an emergency preparedness program that includes a process for cooperation and the collaboration with local, tribal, regional, state and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The plan includes documentation of efforts by the agency to contact such officials and, when applicable, the agency's participation in collaborative and cooperative planning efforts. The Administrator has forwarded the plan to the Governing Body for approval and will educate staff regarding the plan.
The Administrator has audited the emergency preparedness program to ensure compliance with implementation. Each year, the Administrator will ensure that there is a Safety Committee meeting held and that the emergency preparedness plan is reviewed and revised as appropriate then sent to the Governing Body for approval. The Administrator will maintain a calendar for upcoming committee meeting dates.

Contacts would include the following for all counties services:

PEMA - For all Counties is their Eastern Area Offices at 610-562-3003 or 800-372-7362

FEMA - for all counties is Region III and can be reached at 215-931-5500

The Emergency Management contacted for each county are as follows:
Lehigh County - 610-782-4600
Northampton County -610-746-3194
Carbon County - 570-325-3097
Bucks County - 215-340-8700
Berks County which is part of Lehigh County emergency services was contacted at 610-782-4600
Monroe County - 570-992-4113


484.102(c)(1) STANDARD
Names and Contact Information

Name - Component - 00
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually. The communication plan must include all of the following:]

(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.

*[For RNHCIs at 403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.

*[For ASCs at 416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For Hospices at 418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.

*[For HHAs at 484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For OPOs at 486.360(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).

Observations:

Based on a review of facility policies/procedures, documentation, and interview with the administrator and clinical manager, the facility failed to ensure the emergency preparedness plan included the names and contact information for agency staff.

Findings include:

Review of the agency's policies titled " Emergency Preparedness Policy " on January 30, 2019 at 2 pm revealed a page " List of staff and contact information "
No names or contact information for the agency staff on this page. The only documentation was the title of the page.


Interview on January 30, 3019 at 3 pm, the administrator and the clinical manager confirmed the "Emergency Preparedness Plan" did not include the names and contact information of agency staff.









Plan of Correction:

The agency has developed and implemented an emergency preparedness program that includes a process that complies with Federal, State and local law and must be reviewed and updated at least annually and this plan must include names and contact information for the following: staff; entities providing services under arrangement - contracted staff and physicians; a patient list with next of kin or guardian or custodian. The Administrator will review the above monthly to ensure this list is up to date. The Administrator has ensured that the contact information for the agency staff has been placed in the emergency management plan and has forwarded the plan to the Governing Body for approval and will educate staff regarding the plan.
The Administrator has audited the emergency preparedness program to ensure compliance with all required elements. Each year, the Administrator will ensure that there is a Safety Committee meeting held, the emergency preparedness plan is reviewed and revised as appropriate then sent to the Governing Body for approval. The Administrator will maintain a calendar for upcoming committee meeting dates.



Initial Comments:

Based on the findings of an unannounced on-site state licensure survey conducted on January 28, 2019 through January 30, 2019, 1st Care Home Health Services was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, and Subpart G. Chapter 601.





Plan of Correction:




601.21(c) REQUIREMENT
GOVERNING BODY

Name - Component - 00
601.21(c) Governing Body. A governing
body (or designated persons so
functioning) assumes full legal
authority and responsibility for the
operation of the agency. The
governing body appoints: (i) a
qualified administrator, (ii) arranges
for professional service, (iii) adopts
and periodically reviews written
bylaws or an acceptable equivalent,
and (iv) oversees the management and
fiscal affairs of the agency. The
name and address of each officer,
director, and owner are disclosed to
the State agency with changes reported
promptly.



Observations:

Based on review of agency policies/procedures, documentation, clinical records, personnel files, and interview with the administrator and clinical manager, the governing body failed to assume full legal authority and responsibility for the agency's overall management and operation and the provision of all home health services by not overseeing employee files and following policies for employment by not ensuring documentation of contracted staff workers criminal background checks, job description, competency on hire per agency ' s policy and tuberculin (TST) skin test.

Findings:

Cross reference

601.21(f) Personnel Policies (1007)











Plan of Correction:

The Governing Body and Administrator as well as all staff was re-educated by the Governing Body President regarding the requirement that an individual is designated responsible for the overall operation of services of the HHA and this individual is appointed by the Governing Body and that this individual is qualified, arranges for professional services, adopts and periodically reviews written bylaws or an acceptable equivalent and oversees the management and fiscal affairs of the agency. The Administrator and Governing body will meet weekly for one month, then monthly for 3 months then quarterly thereafter until the end of the year to discuss and review evidence that the Governing Body is responsible for all programs and services related to the HHA including ensuring that all employee files are completed and that the agency is following polices for employment by ensuring documentation of contracted staff workers criminal background checks, job description, competency on hire per agency policy and TST skin test. The Administrator will audit employee records weekly until 100 percent compliance with documentation in QA minutes, then monthly until 100 percent compliance and then quarterly with documentation for one year in QA minutes. Audits will be completed on the QAPI program data collection and Current Performance Improvement progress. 100% threshold is expected within 30days. All audit results will be presented to the Governing Body President for further review and follow up. Instances of non-compliance by the Governing Body assuming responsibility will result in counsel and possible removal from the Governing body.


601.21(f) REQUIREMENT
PERSONNEL POLICIES

Name - Component - 00
601.21(f) Personnel Policies.
Personnel practices and patient care
are supported by appropriate, written
personnel policies. Personnel records
include qualifications, licensure,
performance evaluations, health
examinations, documentation of
orientation provided, and job
descriptions, and are kept current.

Observations:

Based on a review of personnel files and interview with the administrator, the agency failed to have tuberculin skin test for ten (10) of ten (10) personnel files per agency ' s policies. Personnel files # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.

Findings include:

Review of the CDC (Centers for Disease Control) guidelines state that all Health Care Workers (HCW) should receive 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 screening annually. HCWs 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 the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005 ;( RR-17)
.

Review of policy on January 30, 2019 at 1 pm titled " Services Under Contract " dated 2018 revealed " Contracted personnel must be qualified by experience and training to perform the services they provide for the patient. The necessity to conform to all professional standards and applicable agency policies, including personnel qualifications. "
Review of policy on January 30, 2019 at 1:30 pm titled " Screening and Hiring " dated 2018 states " The administrator makes an appointment for the interview, documentation of current license and certifications., proof of employment eligibility, criminal background check, current physical exam and immunizations, copy of driver ' s license, automobile liability insurance, a signed and dated job description. Per CDC guidelines, the Mantoux test shall be required of all field staff. Staff who have a negative PPD test receive either a one-step Mantoux test every year or fill out a questionnaire, based on local TB prevalence rates in accordance within the CCD and local Department of Health services. "

Review of personnel files on January 30, 2019 from at 12 pm to 1 pm revealed:
Personnel file # 1 with date of hire on January 14, 2019. No documentation of annual tuberculin (TST) skin test on hire. TB questionnaire was documented on January 14, 2019 for calendar year 2017
Personnel file # 2 with date of hire on February 2, 2016. No documentation of annual tuberculin (TST) skin test for calendar year 2017 and 2018.
The following personnel files are for the contracted agency who had documented care delivery to this agency ' s patient ' s.
Personnel file # 3 with no date of hire. No documentation of tuberculin (TST) skin test when working for this agency per agency policies
Personnel file # 4 with no date of hire. No documentation of tuberculin (TST) skin test when working for this agency per agency policies
Personnel file # 5 with no date of hire. No documentation of tuberculin (TST) skin test when working for this agency per agency policies
Personnel file # 6 with no date of hire. No documentation of tuberculin (TST) skin test when working for this agency per agency policies
Personnel file # 7 with no date of hire. No documentation of tuberculin (TST) skin test when working for this agency per agency policies
Personnel file # 8 with no date of hire. No documentation of tuberculin (TST) skin test when working for this agency per agency policies
Personnel file # 9 with no date of hire. No documentation of tuberculin (TST) skin test when working for this agency per agency policies
Personnel file # 10 with no date of hire. No documentation of tuberculin (TST) skin test when working for this agency per agency policies
Interview with the administrator on January 30, 2019 at 1300 confirmed the above findings.


Based on review of agency policies/procedures, documentation, clinical records and personnel files and interview with the administrator and clinical manager, the governing body failed to ensure documentation of contracted staff workers criminal background checks, job description, competency on hire per agency ' s policy. Personnel files for occupational therapy, physical therapy contracted staff for eight (8) of ten (10) personnel files. PF# 3,4,5,6,7,8,9 and 10.

Findings include:
Review of policy on January 30, 2019 at 1 pm titled " Services Under Contract " dated 2018 revealed " Contracted personnel must be qualified by experience and training to perform the services they provide for the patient. The necessity to conform to all professional standards and applicable agency policies, including personnel qualifications. "
Review of policy on January 30, 2019 at 1:30 pm titled " Screening and Hiring " dated 2018 states " The administrator makes an appointment for the interview, documentation of current license and certifications., proof of employment eligibility, current physical exam and immunizations, copy of driver ' s license, automobile liability insurance, a signed and dated job description. Per CDC guidelines, the Mantoux test shall be required of all field staff. Staff who have a negative PPD test receive either a one-step Mantoux test every year or fill out a questionnaire, based on local TB prevalence rates in accordance within the CCD and local Department of Health services. "
According to the Act 169 of 1996 as amended by Act 13 of 1997,"If the applicant/employee has been a resident of the Commonwealth of Pennsylvania for 2 or more years prior to application for employment, the applicant will need to obtain a clearance from the Pennsylvania State Police. This clearance is obtained by doing the following: Request for Criminal Record Check Form (SP4-164)." "When the applicant/employee has not been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application for employment or currently lives out of state, in addition to the Pennsylvania State Police Criminal History Check, the applicant/employee will also need to obtain an FBI Criminal History Check. Facilities are defined by the act to include: Domiciliary Care Homes, Home Health Care Agency, Nursing Facility (licensed by the Department of Aging), and Personal Care Home (licensed by the Department of Public Welfare). A Home Health Care Agency is further defined to include those agencies licensed by the Department of Health and any public or private organization which provides care to a care-dependent individual in their place of residence." "If entities run into special circumstances where they need to hire an employee before the results of their record checks are returned, there is a provision in CPSL that allows for a provisional hiring period. The period is to not exceed 30 days for in state residents and 90 for out of state residents."
Review of personnel files on January 30, 2019 from at 12 pm to 1 pm revealed:
The following personnel files are for the contracted agency who had documented care delivery to this agency ' s patient ' s clinical record.
Personnel file # 3 with no date of hire. No documentation of criminal background check, job description, orientation and competencies.
Personnel file # 4 with no date of hire. No documentation criminal background check, job description, orientation and competencies.
Personnel file # 5 with no date of hire. No documentation criminal background check, job description, orientation and competencies.
Personnel file # 6 with no date of hire. No documentation criminal background check, job description, orientation and competencies.
Personnel file # 7 with no date of hire. No documentation criminal background check, job description and orientation.
Personnel file # 8 with no date of hire. No documentation criminal background check, job description, orientation and competencies.
Personnel file # 9 with no date of hire. No documentation criminal background check, job description and orientation.
Personnel file # 10 with no date of hire. No documentation criminal background check, job description and orientation.
Interview with the administrator on January 30, 2019 at 1 pm confirmed the above findings.






































Plan of Correction:

The Administrator and Director of Nursing have been re-educated regarding the requirement the CDC guidelines state that all Health Care Workers should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test of a single blood assay for tuberculosis to test for infection with tuberculosis. After baseline testing, TB screenings should be annually.
The Administrator has scheduled for all employees with personnel files #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 to obtain TB skin testing.
The Director of Nursing will be responsible to ensure that all employees receive initial and annual testing.
25% of all HR files will be audited by the Administrator/Designee quarterly (total of 100% of all HR files to be audited annually) for evidence of personnel documentation requirements including TB testing on hire, annually. The Administrator will audit employee records weekly until 100 percent compliance with documentation in QA minutes, then monthly until 100 percent compliance and then quarterly with documentation for one year in QA minutes. All new employee HR files will be audited within 7 days of hire for evidence of personnel documentation requirements by the Administrator/designee. The Administrator will report findings to the QAPI Committee quarterly. All findings that fall below 95% compliance threshold will be reported to the Governing Body for further recommendations.



Initial Comments:

Based on the findings of an unannounced on-site state licensure survey conducted on January 28, 2019 through January 30, 2019, 1st Care Home Health Services was found to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, and Subpart A. Chapter 51.





Plan of Correction:




Initial Comments:

Based on the findings of an unannounced on-site state licensure survey conducted on January 28, 2019 through January 30, 2019, 1st Care Home Health Services was found to be in compliance with the requirements of 35 P.S. 448.809 (b).






Plan of Correction: