Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed March 28, 2024, Providence Home Care Agency was found not to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.
Plan of Correction:
51.3 (f) LICENSURE
NOTIFICATION
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51.3 Notification
(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.
Observations:
Based on an interview with the agency Director of Compliance, the agency failed to ensure event reporting to the Pennsylvania (Pa.) Department of Health of alleged consumer abuse
for one (1) of one (1) incident log reviews (Incident #1).
Findings Include:
Agency policy reviewed on March 28, 2024 at approximately 2:00 p.m. 'Incident Management' 'EIM Reporting' "Any incident that requires notification of the Department also requires an Incident Report be filed within the HCSIS (Home and Community Services Information System) Electronic Incident Management System ......."
(Note: This policy does not include the required notification to the Department of Health.)
Incident #1: On March 28, 2024 at approximately 1:30 p.m. the agency complaint/incident log was requested for review. A 'Report of Incident' dated February 4, 2024 included consumer (CF#6) abuse allegations by an agency employee (EF#8). "Description of Incident' includes: "Client reported that the assigned caregiver (EF#8) did not leave the premises after completing and clocking out of her shift from 9am-3pm. .... (CF#6) repeatedly told her to leave but she refused to leave. ..... (CF#6) stated (EF#8) was dealing in substance abuse, specifically crack. (CF#6) said between 12 am and 2 am (CF#6) believed (EF#8) was doing drugs and started to behave rowdy, destroying his place. ...... (CF#6) stated (EF#8) took a swing at him, they got into a fight, and (EF#8) punched (CF#6) in the left eye. (CF#6) said (EF#8) stole $47 before leaving the premises."
No documentation provided of the agency reporting the event through the Pa. Department of Health Event reporting System. Per the agency Compliance manager, this was not done. The agency only reported the event through HCSIS.
An interview conducted with the agency Director of Compliance on March 28, 2024 at approximately 3:30 p.m. confirmed the above findings.
Plan of Correction:1. For event regarding CF#6/EF#8, Agency will report event (incident) the Pa. department of Health event reporting system.
2. Agency will conduct an audit of entire consumer files to determine if any other events were not entered in the Pa. department of Health event reporting system.
3. Agency will create an incident tracking spreadsheet, update the incident Reporting policy to include the mandatory reporting of all events to the Pa. department of Health event reporting system, in-service training will be conducted regarding policy changes and the procedure for entering incidents into the Pa. department of Health event reporting system.
4. The agency administrator or designee will audit 100% of the incident tracking spreadsheet monthly.
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed March 28, 2024, Providence Home Care Agency 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:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
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Prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. (3) Require the individual to submit a criminal history report, in accordance with the requirements of § 611.52 (relating to criminal background checks), and a ChildLine verification, if applicable, in accordance with the requirements of § 611.53 (relating to child abuse clearance).
Observations:
Based on review of employee files and an interview with the agency Director of Compliance, the agency failed to obtain not less than two satisfactory references, prior to hire, for seven (7) out of seven (7) employee files (EF) reviewed (EF#1-EF#7).
Findings include:
A review of EFs was conducted on March 28, 2024 at approximately 11:30 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 11/28/23: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable).
EF#2 DOH 04/19/23: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable).
EF#3 DOH 07/10/23: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable).
EF#4 DOH 08/01/23: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable).
EF#5 DOH 09/26/23: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable).
EF#6 DOH 04/27/22: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable).
EF#7 DOH 07/18/22: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable).
An interview conducted with the agency Director of Compliance on March 28, 2024 at approximately 3:30 p.m. confirmed the above findings.
Plan of Correction:1. For EF#1-EF#7, Agency will obtain not less than two satisfactory references.
2. Agency will conduct an audit of entire employee files to determine if any others do not meet the requirement of having not less than two satisfactory references prior to hire.
3. Agency will update the tracking spreadsheet to include a section for reference.
4. The agency administrator or designee will audit 10% of the employee files every quarter.
611.52(c) LICENSURE
Federal Criminal History Record
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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 a review of employee files and an interview with the agency Director of Compliance, agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for two (2) out of seven (7) employee files (EF) reviewed (EF#2, EF#6).
Findings include:
A review of EFs was conducted on March 28, 2024 at approximately 11:30 a.m. Employee date of hire (DOH) is listed below.
EF#2 DOH 04/19/23: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Drivers License issued 05/09/22 with an expiration date of 05/09/26. 'Application for Employment' record was reviewed. 'Work Experience' lists employer with an incomplete address with dates 'From:' "11/13/22" 'To:' "1/12/23." Employer listed with incomplete address with 'From:' and 'To:' sections blank with no entries. No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 04/19/21-05/09/22.
EF#6 DOH 04/27/22: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Identification Card issued 10/21/20 with an expiration date of 10/31/24. 'Application for Employment' record was reviewed. 'Work Experience' section blank with no entries. No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 04/27/20-10/21/20.
An interview conducted with the agency Director of Compliance on March 28, 2024 at approximately 3:30 p.m. confirmed the above findings.
Plan of Correction:1. To provide proof of residency for EF#2, EF#6, Agency will obtain federal criminal history and a letter of determination from the Department of Aging.
2. Agency will conduct an audit of entire employee files to make sure others meet the requirement of proof of Pa. residency for 2 years immediately preceding application for employment in order to determine the need to obtain federal criminal history and a letter of determination from the dept of aging.
3. Agency will update pre employment checklist to better capture dates to track 2 year proof of residency preceding date of employment application.
4. The agency administrator or designee will audit 10% of the employee files every quarter.
611.55(a) LICENSURE
Competency Requirements
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Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.
Observations:
Based on a review of employee files and an interview with the agency Director of Compliance, the agency failed to ensure documentation showing direct care workers, prior to providing services to consumers, completed/demonstrated an initial competency training covering all required sixteen (16) subject areas for three (3) of seven (7) employee files (EF) reviewed (EF#1, EF#3, EF#4).
Findings include:
A review of EFs was conducted on March 28, 2024 at approximately 11:30 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 11/28/23: Documentation provided of a completed written test dated 11/15/23. No documentation provided of initial competency training containing all sixteen (16) required elements.
EF#3 DOH 07/10/23: No documentation provided of initial competency training containing all sixteen (16) required elements.
EF#4 DOH 08/01/23: Documentation provided of completed certificates completed late and dated 09/16/23, 09/18/23, and 09/23/23. No documentation provided of initial competency training containing all sixteen (16) required elements.
An interview conducted with the agency Director of Compliance on March 28, 2024 at approximately 3:30 p.m. confirmed the above findings.
Plan of Correction:1.For EF#1, EF#3, EF#4, Agency will develop and administer competency training for Direct Care Workers covering all 16 subject areas.
2.Agency will conduct an audit of entire employee files to ensure any other employee not having initial competency training covering all required sixteen (16) subject areas are detected and will be trained as well.
3.Agency will update the tracking spreadsheet to include a section for the competency training.
4.The agency administrator or designee will audit 10% of the employee files every quarter.
611.55(e) LICENSURE
Competency Requirements
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The competency review must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction.
Observations:
Based on a review of employee files and an interview with the agency Director of Compliance, agency failed to provide documentation showing annual competency review covering all required sixteen (16) subject areas for two (2) of two (2) employee files (EF) annual documentation reviewed (EF#6, EF#7).
Findings include:
A review of EFs was conducted on March 28, 2024 at approximately 11:30 a.m. Employee date of hire (DOH) is listed below.
EF#6 DOH 04/27/22: Documentation provided of three (3) certificates of training dated 04/20/23 and forty-eight (48) certificates of training completed late, dated 09/24/23.
EF#7 DOH 07/18/22: Documentation provided of three (3) certificates of training dated 03/05/23, 04/18/23, 04/19/23. No documentation provided of a 2023 annual competency review containing all sixteen (16) required elements.
An interview conducted with the agency Director of Compliance on March 28, 2024 at approximately 3:30 p.m. confirmed the above findings.
Plan of Correction:1.For EH#6, EF#7, Agency will develop and administer annual competency review for Direct Care Workers covering all 16 subject areas.
2.Agency will conduct an audit of entire employee files to ensure any other employee not having initial competency training covering all required sixteen (16) subject areas are detected and will be trained as well.
3.Agency will update the tracking spreadsheet to include a section for the annual competency review.
4.The agency administrator or designee will audit 10% of the employee files every quarter.
611.56(a) LICENSURE
Health Screening
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(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 employee files and an interview with the agency Director of Compliance the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, was screened for and is free from active mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for seven (7) out of seven (7) employee files (EF) reviewed (EF#1-EF#7).
Findings Include:
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. 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').(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 EFs was conducted on March 28, 2024 at approximately 11:30 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 11/28/23: No documentation provided of an individual TB risk assessment nor a TB symptom screen upon hire.
EF#2 DOH 04/19/23: No documentation provided of a TB test, an individual TB risk assessment, nor a TB symptom screen upon hire.
EF#3 DOH 07/10/23: No documentation provided of a TB test, an individual TB risk assessment, nor a TB symptom screen upon hire.
EF#4 DOH 08/01/23: No documentation provided of a TB test, an individual TB risk assessment, nor a TB symptom screen upon hire.
EF#5 DOH 09/26/23: Documentation provided of a one step TB skin test conducted on 10/12/23 and read ten (10) days later. No documentation provided of a complete TB test, an individual TB risk assessment, nor a TB symptom screen upon hire.
EF#6 DOH 04/27/22: No documentation provided of a TB test nor an individual TB risk assessment upon hire.
EF#7 DOH 07/18/22: No documentation provided of an individual TB risk assessment nor a TB symptom screen upon hire.
An interview conducted with the agency Director of Compliance on March 28, 2024 at approximately 3:30 p.m. confirmed the above findings.
Plan of Correction:1. For EF#1-EF#7, Agency will obtain missing mycobacterium tuberculosis (TB) screening according to CDC guidelines
2. Agency will conduct an audit of entire employee files to determine if any other individuals did not receive proper TB screening according to CDC guidelines.
3. Agency will update the application package to include TB risk assessment and TB symptom screen, update the tracking spreadsheet to include a section for TB risk assessment and TB symptom screen, update the health screening policy to include TB screening according to CDC guidelines, in-service training will be conducted regarding policy changes and the procedure for TB screening according to CDC guidelines.
4. The agency administrator or designee will audit 10% of the employee files every quarter.
611.56(b) LICENSURE
Health Screening
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(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.
Observations:
Based on a review of employee files and an interview with the agency Director of Compliance, agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, were provided with annual mycobacterium tuberculosis education, for two (2) of two (2) employee files (EF) annual documentation reviewed (EF#6, EF#7).
Findings Include:
The CDC (Center for Disease and Control) 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 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').(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 EFs was conducted on March 28, 2024 at approximately 11:30 a.m. Employee date of hire (DOH) is listed below.
EF#6 DOH 04/27/22: No documentation provided of 2023 annual TB education.
EF#7 DOH 07/18/22: No documentation provided of 2023 annual TB education.
An interview conducted with the agency Director of Compliance on March 28, 2024 at approximately 3:30 p.m. confirmed the above findings.
Plan of Correction:1. For EF#6, EF#7, Agency will obtain missing mycobacterium tuberculosis (TB) and provide education according to CDC guidelines.
2. Agency will conduct an audit of entire employee files to determine if any other individuals did not receive annual TB education according to CDC guidelines.
3. Agency will update the tracking spreadsheet to include a section for TB annual education, update the health screening policy to include TB annual education, in-service training will be conducted regarding policy changes and the procedure for annual TB education according to CDC guidelines.
4. The agency administrator or designee will audit 10% of the employee files every quarter.
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed March 28, 2024, Providence Home Care Agency was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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