QA Investigation Results

Pennsylvania Department of Health
ASSURANCE HEALTH CARE SERVICES
Health Inspection Results
ASSURANCE HEALTH CARE SERVICES
Health Inspection Results For:


There are  3 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 state re-licensure survey conducted on March 1, 2019, Assurance Health Care Services, 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 1, 2019, Assurance Health Care Services, 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:




611.52(b) LICENSURE
State Police Criminal History Record

Name - Component - 00
If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.

Observations:



Based on review of personnel files, and an interview with the agency's owner, it was determined that the agency failed to ensure PA State Police Criminal background checks at the time of application for employment and/or have the potential employee submit documentation of a state police criminal background check that was obtained within one year preceding the application date for seven (7) of eight (8) direct care worker's personnel files (PF) reviewed (PF #1, 2, 3, 4, 5, 6, & 7).

Findings include:

Interview with Agency's owner occurred on 3/1/2019 at approximately 12:00 P.M. Agency owner stated running "ADP" background checks and not the PA state police criminal background checks on new employees.

A review of the PFs was conducted on 3/1/19 between approximately 10:00 A.M. to 12:00 P.M revealed:


1. PF#1, Date of Hire (DOH): 2/4/19. File revealed no documentation of a State Police Criminal Background check.

2. PF#2, Date of Hire (DOH): 2/9/19. File revealed no documentation of a State Police Criminal Background check.

3. PF#3, Date of Hire (DOH): 11/9/18. File revealed no documentation of a State Police Criminal Background check.

4. PF#4, Date of Hire (DOH): 12/17/18. File revealed no documentation of a State Police Criminal Background check.

5. PF#5, Date of Hire (DOH): 4/6/18. File revealed no documentation of a State Police Criminal Background check.

6. PF#6, Date of Hire (DOH): 4/6/18. File revealed no documentation of a State Police Criminal Background check.

7. PF#7, Date of Hire (DOH): 2/14/19. File revealed no documentation of a State Police Criminal Background check.



An interview with the agency's owner on 3/1/2019 at approximately 2:00 PM confirmed the above findings.












Plan of Correction:

In addition to the existing criminal background records obtained at time of hire, the agency requested the Pennsylvania Police criminal history records for PF#1, PF#2, PF#4, PF#5, PF#6, AND PF#7 on 3/6/2019. The agency requested the Pennsylvania Police criminal history check for PF#3 on March 4, 2019.

The agency will ensure that ADP grants access to run new employees' criminal background checks for the entire state of Pennsylvania, and not only by county.

The agency will add task to the existing checklist for new hires, outlining tasks, deadlines, and actions to ensure proper monitoring so that the deficiency does not recur.

The administrator will be responsible to implement the corrections by conducting quarterly audits to ensure that the deficiency does not recur.



611.55(a) LICENSURE
Compentency Requirements

Name - Component - 00
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 the agency's personnel files (PF), and an interview with the agency's owner, it was determined the agency failed to ensure that the direct care worker has done one of the following prior to assigning the caregiver:
(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 CFR 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aide 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 for three (3) of eight (8) PFs reviewed (PF#2, 3, & 8).

Findings Included:

Review of PFs completed on 3/1/19 between approximately 10:00 A.M. and 12:00 P.M. revealed:

1.) PF#2, Date of Hire (DOH): 2/9/19, did not contain evidence of competency requirements met prior to consumer assignment.

2.) PF#3 DOH: 11/9/18, did not contain evidence of competency requirements met prior to consumer assignment.

3.) PF#8 DOH: 1/17/19, did not contain evidence of competency requirements met prior to consumer assignment.



Interview completed on 3/1/19 at approximately 2:00 P.M. with the agency's owner who confirmed the above findings.










Plan of Correction:

The administrator will obtain competency verifications for PF#2, PF#3, and PF#8.

The agency will closely monitor and insure that all direct care workers have verification of their competencies prior to providing care for clients.

The agency will add task to the existing checklist for new hires, outlining tasks, deadlines, and actions to ensure proper monitoring so that the deficiency does not recur.

The administrator will be responsible to implement the corrections by conducting quarterly audits to ensure that the deficiency does not recur.



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 (PFs) and an interview with the Agency's owner, the agency did not conduct testing for mycobacterium tuberculosis according to the Center for Disease Control (CDC) guidelines four (4) of eight (8) personnel files reviewed (PFs #'s 1, 2, 3 & 6).

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) 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) http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.


A review of PF's conducted on 3/1/19, from approximately 10:00 A.M. through 12:00 P.M. revealed the following:

1.) PF #1. Date of Hire: 2/14/19: There was a Chest X-ray completed on 11/11/16. There was no documentation of a TB screening being completed in 2018.

2.) PF #2. Date of Hire 2/9/19: There was documentation a single TST being completed on 2/8/19. There was no documentation of the second step of the TST being completed.

3.) PF #3. Date of Hire: 11/9/18: There was a Chest X-ray completed on 5/23/17. There was no documentation of a TB screening being completed in 2018.

4.) PF #6. Date of Hire: 4/6/18: There was documentation a single TST being completed on 3/29/18. There was no documentation of the second step of the TST being completed.



Interview with the agency's owner on 3/1/19 at approximately 2:00 PM confirmed the personnel files lacked screening according to the CDC guidelines.
























Plan of Correction:

The agency will insure that TB screenings are completed for PF#1 and PF#3.

The agency will insure that the second steps in TB testing are completed for PF#2, and PF#6.

The administrator will verify that all employees have TB testings/screenings prior to client contact.

The administrator will develop a particular checklist outlining deadlines, expirations, and actions anticipated, to ensure proper monitoring.

The administrator will be responsible to implement the corrections by conducting quarterly audits to ensure that the deficiency does not recur.




Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted on March 1, 2019, Assurance Health Care Services, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: