QA Investigation Results

Pennsylvania Department of Health
CARING LIFE SERVICES, INC.
Health Inspection Results
CARING LIFE SERVICES, INC.
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite unannounced relicensure survey completed February 21, 2019, Caring Life Services Inc., was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.







Plan of Correction:




Initial Comments:


Based on the findings of an onsite unannounced state relicensure survey completed February 21, 2019, Caring Life Services Inc., was found NOT to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.






Plan of Correction:




611.55(e) LICENSURE
Competency Requirements

Name - Component - 00
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 review of personnel files, and interview with the Administrative Assistant, it was determined that the agency failed to administer annual competency reviews for seven (7) of 10 Direct Care Worker personnel files reviewed. (DCW #1, 2, 5, 6, 7, 8, and #9).

Findings include:

1. Review of personnel files on February 21, 2019 at approximately 10:46 a.m. revealed that DCW #1 was hired on January 13, 2016. A competency was conducted on February 8, 2016. There was no evidence of an annual competency for the year 2017, 2018 or 2019.

2. Review of personnel files on February 21, 2019 at approximately 11:00 a.m. revealed that DCW #2 was hired on October 31, 2017. A competency was conducted on October 31, 2017. There was no evidence of an annual competency for the year, 2018.

3. Review of personnel files on February 21, 2019 at approximately 11:45 a.m. revealed that DCW #5 was hired on April 23, 2015. A competency was conducted on October 31, 2017. There was no evidence of an annual competency for the year 2017, or 2018.

4. Review of personnel files on February 21, 2019 at approximately 12:00 p.m. revealed that DCW #6 was hired on May 30, 2015. A competency was conducted on May 30, 2015. There was no evidence of an annual competency for the year 2016, 2017 or 2018.

5. Review of personnel files on February 21, 2019 at approximately 12:15 p.m. revealed that DCW #7 was hired on January 13, 2016. A competency was conducted on October 31, 2017. There was no evidence of an annual competency for the year 2017, 2018 or 2019.

6. Review of personnel files on February 21, 2019 at approximately 12:30 p.m. revealed that DCW #8 was hired on September 23, 2013. An initial competency was not conducted in 2013. There was no evidence of an annual competency for the year 2014, 2015, 2016, 2017, or 2018.

7. Review of personnel files on February 21, 2019 at approximately 12:45 p.m. revealed that DCW #9 was hired on February 3, 2017. A competency was conducted on February 3, 2017. There was no evidence of an annual competency for the year 2018 or 2019.

An interview with the Administrative Assistant on February 21, 2019 at 1:30 p.m., confirmed that the agency had failed to conduct annual competencies.













Plan of Correction:

In order to correct the Annual Competency test Requirements deficiency, CLS will improve upon the implementation of it's policy that requires all employees to complete the CLS Competency Test annually according to guidelines as required under PA Code 611.55 (e) by notifying each employee at least 30 days prior to their annual anniversary that they must take a new CLS Competency test.
CLS Human Resource Manager will notify each employee 30 days prior to their annual employment anniversary that they must take a new CLS Competency Test. CLS will arrange the dates & times for the competency test to be given no less then 25 days prior to the employees anniversary date.
In order to prevent a recurrence from happening the title "Annual Employees Competency Test" will be added to the documents to be included check list form in the front of each employees file.
In order to assure this policy is sustained CLS Account Auditor will audit, date & sign all employee files every 180 days to maintain compliance of the Annual CLS Employee Competency Test.
Upon completion of the Account auditors audit the Care Givers supervisor will review Account auditors results and notify human resource of any missing Annual Competency test.



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 upon review of the Center for Disease Control, (CDC) guidelines, employee files, and Administrative Assistant interview, it was determined the facility failed to ensure Direct Care Workers, (DCW) were screened and free from active mycobacterium tuberculosis (TB), (an infectious bacterial disease characterized by the growth of nodules (tubercles) in the tissues, especially the lungs), prior to assignment to clients. Review of personnel files revealed that this did not occur for seven (7), of 10, DCW's reviewed. (DCW #1, 2, 3, 5, 7, 8, and 10).

Findings include:


CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005; (RR-17), revealed that "all Health Care Workers (HCW) should receive a 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, health care workers should receive TB screen annually. Health care workers with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease.

1. Review of personnel files on February 21, 2019 at approximately 11:00 a.m. revealed that DCW #2 was hired on October 31, 2017. A 2-Step TST was conducted on October 17, 2017 and October 24, 2017. There was no evidence or documentation that an annual TST had occurred in 2018.

2. Review of personnel files on February 21, 2019 at approximately 11:15 a.m. revealed that DCW #3 was hired on March 30, 2018. A Chest-X-ray was conducted on October 18, 2017. There was no evidence or documentation that an annual TB screening questionnaire had occurred in 2018. There was no evidence that a risk assessment

3. Review of personnel files on February 21, 2019 at approximately 11:45 a.m. revealed that DCW #5 was hired on April 23, 2015. A 2-Step TST was conducted on May 6, 2015 and May 20, 2015. There was no evidence or documentation that an annual TST had occurred during year 2016, 2017, and 2018.

4. Review of personnel files on February 21, 2019 at approximately 12:00 p.m. revealed that DCW #7 was hired on January 12, 2018. There was no evidence or documentation that an initial TST was conducted during year 2018.

5. Review of personnel files on February 21, 2019 at approximately 12:15 p.m. revealed that DCW #8 was hired on September 23, 2013. There was no evidence or documentation that an initial 2-Step TST was conducted during year 2013. There was no evidence or documentation that TST's had been conducted for the following year 2014, 2015, 2016, 2017, or 2018.

6. Review of personnel files on February 21, 2019 at approximately 12:30 p.m. revealed that DCW #9 was hired on February 3, 2017. There was no evidence or documentation that an initial 2-Step TST was conducted during year 2017. There was no evidence or documentation that TST's had been conducted for the following year 2017, or 2018.

7. Review of personnel files on February 21, 2019 at approximately 1:00 p.m. revealed that DCW #10 was hired on July 27, 2018, A 2-Step TST was conducted on December 2, 2017 and December 8, 2017. There was no evidence or documentation that an annual TST had occurred during year 2018.

An interview with the Administrative Assistant on February 21, 2019, 1:30 p.m., confirmed that the agency failed to ensure that Direct Care Workers were screened and free from active mycobacterium tuberculosis. The administrative Assitants reviewed the files and reported that, "there was no more TB tests in the files."











Plan of Correction:

In order to correct the Health Screening for TB deficiency, CLS will improve upon the implementation of it's policy that requires all employees to complete two step process in accordance with CDC guidelines prior to client contact and screened annually thereafter to prevent the potential infection and spread of TB.
CLS Human Resource Manager will notify each employee who has not completed the two step TB testing that they must do so in order to continue to provide services to the consumer.
The employee must notify CLS of the appointed dates that the test are to be administered. CLS must document the dates of the test so that CLS can follow up with the employee to assure the test was administered and to obtain the status of the results.
Copy of PPD Test is included on the check list form in the front of each employees file and If the first test result is negative, the health care worker may begin to work immediately, but the second PPD must be administered between one and three weeks after the first PPD.
In order to assure this policy is sustained CLS Account Auditor will audit, date & sign all employee files for evidence of the two step PPD Test every 180 days.
Upon completion of the Account Auditors audit the Care Givers supervisor will review Account Auditors results and notify human resource of any missing PPD test.



Initial Comments:

Based on the findings of an onsite unannounced relicensure survey completed February 21, 2019, Caring Life Services Inc., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).







Plan of Correction: