QA Investigation Results

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


There are  4 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:






Based on the findings of an unannounced on-site State re-licensure survey completed on March 1, 2019, Don Services, Inc. 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 unannounced State relicensure survey completed on March 1, 2019, Don Services Inc, was found not to be in compliance with the requirements of 28 PA Code, Part IV, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.



Plan of Correction:




611.52(a) LICENSURE
Criminal Background Checks

Name - Component - 00
The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.

Observations:


Based on review of personnel files (PF) and staff (EMP) interview it was determined the agency failed to obtain criminal history records at time of application or a report obtained within 1 year immediately preceding date of application for two (2) of ten (10) PF reviewed. (PF1-PF12)

Findings Included:

Review of PF completed on March 1, 2019 between approximately 11:00 a.m. and 2:30 p.m. revealed:

PF3, date of hire (DOH) 4/10/2017, PF contained a Pennsylvania (PA) criminal background check requested and completed on 5/26/2017. [not completed at time of hire]

PF8, DOH 2/23/2018, PF contained a PA criminal background check requested by California University of PA on 2/22/2016. [obtained greater than 1 year immediately preceding date of application]

Interview completed on March 1, 2019 at approximately 3:15 p.m. with EMP18 and EMP20 confirmed the findings.







Plan of Correction:

TAG S 0300

POC:

The Executive Vice President of DON Services Quality Management and Contract Compliance (VP Quality) will review the Policy and Procedure manual to ensure HR standards of employed and contracted personnel reflects the following hiring practices:

1) Human Resource Personnel Conduct a Face to Face interview.

(2) Obtain 2 satisfactory reference checks which are a positive, verifiable reference either verbal or in writing 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) Current TB screenings.

(4) Criminal Background Checks, Child line clearance, if applicable, FBI clearance if had not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report.

(5) The actual hire date to be recorded as per policy, procedure and regulation to be designated as evidenced by written documentation after 1-4 (above as listed) are satisfactorily completed and prior to a home visit with a consumer for placement into a home as an attendant.

(6) The Personal Assistant Supervisors / Independent Supervisors will direct Human Resources to record the date of hire after the home placement as listed in (5).

(7) The Executive Vice President of Quality Management will audit compliance of the documented hire date monthly by initialing and dating the reviewed hiring documents.

The Personal Assistant Supervisors/ Independent Supervisors, Human Resources will be educated on the process by the Executive Vice President of DON Services Operations and/or VP Quality as evidenced by documented minutes and signatures by the date of March 15, 2019.

The Board of Directors will meet to review survey findings, Review Policy and Procedure updates as evidenced by meeting minutes and documented signatures by the date of March 2019 (exact date to be determined).

The VP Quality is responsible to monitor the continued implementation of this Plan of Correction.



611.52(d) LICENSURE
Proof of Residency

Name - Component - 00
The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation

Observations:


Based on a review of personnel files (PF) and staff (EMP) interview, it was determined that the agency failed to show proof of residency through submission of any one of the following documents: motor vehicle records, such as a valid driver's license or a state-issued identification; housing records, such as mortgage records or rent receipts; public utility records and receipts, such as electric bills; local tax records; a completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it; employment records, including records of unemployment compensation for two (2) of ten (10) PF files reviewed (PF6, PF7).

Findings included:

Review of PF completed on March 1, 2019 between approximately 11:00 a.m. and 2:30 p.m. revealed:

PF6, date of hire (DOH) 5/3/2018, PF contained evidence of a Pennsylvania (PA) drivers license issued on 2/14/2018. [PF did not contain evidence of 2 years of PA residency]

PF7, DOH 10/26/2016, PF contained evidence of a PA drivers license issued on 3/3/2015. [PF did not contain evidence of 2 years of PA residency]

Interview completed on March 1, 2019 at approximately 3:15 p.m. with EMP18 and EMP20 confirmed the findings.










Plan of Correction:

TAG S 0330

POC:

The Executive Vice President of DON Services Quality Management and Contract Compliance (VP Quality) will review the Policy and Procedure manual to ensure HR standards of employed and contracted personnel reflects the following hiring practices:

Proof of Residency Requirements


(1) Human Resource Personnel Conduct a Face to Face interview.

(2) Obtain 2 satisfactory reference checks which are a positive, verifiable reference either verbal or in writing 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) Current TB screenings.

(4) Criminal Background Checks, Child line clearance, if applicable, FBI clearance if had not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report.

PROOF OF RESIDENCY REQUIREMENTS

DON P&P: Criminal Background Check

A. Each applicant for a direct care worker shall submit a
criminal history report at the time of application or within 1
year immediately preceding the date of application.

B. If the individual obtaining a criminal history report has been
a resident of Pennsylvania for two (2) years preceding the
date of request for the criminal history report, DON shall
obtain a PA State Police criminal history record.

C. If the individual obtaining a criminal history report has not
been a resident of Pennsylvania for two (2) years preceding
the date of request for the criminal history report, DON shall
obtain a Federal criminal history record and a letter of
determination from the Department of Aging or Human
Services.

D. Proof of residency may be obtained by individual
submitting: (1) motor vehicle records (valid driver's license
or a State-issued Id), (2) Housing records (mortgage or rent
records), (3) Public utility records (electric bills), (4) Local
tax records, (5) Completed and signed Federal, State or
local income tax return with applicant's name and address
preprinted on form, (6) Employment records (unemployment
records).


(5) The actual hire date to be recorded as per policy, procedure and regulation to be designated as evidenced by written documentation after 1-4 (above as listed) are satisfactorily completed and prior to a home visit with a consumer for placement into a home as an attendant.

(6) The Personal Assistant Supervisors / Independent Supervisors will direct Human Resources to record the date of hire after the home placement as listed in (5).

(7) The Executive Vice President of Quality Management will audit compliance of the documented hire date monthly by initialing and dating the reviewed hiring documents.

The Personal Assistant Supervisors/ Independent Supervisors, Human Resources will be educated on the process by the Executive Vice President of DON Services Operations and/or VP Quality as evidenced by documented minutes and signatures by the date of March 15, 2019.

The Board of Directors will meet to review survey findings, Review Policy and Procedure updates as evidenced by meeting minutes and documented signatures by the date of March 2019 (exact date to be determined).
The VP Quality is responsible to monitor the continued implementation of this Plan of Correction.



611.54(a)(1) LICENSURE
Provisional Hiring

Name - Component - 00
The applicant shall have applied for a criminal history report and ChildLine verification, as applicable, and provided the home care agency or home care registry with a copy of the completed request forms.

Observations:


Based on review of personnel files (PF), consumer files (CF) and staff (EMP) interview, the agency failed to ensure that a criminal history report was requested prior to the assignment for one (1) of ten (10) PF who provided services to consumers. (PF8)

Findings Included:

Review of PF completed on March 1, 2019 between approximately 11:00 a.m. and 2:30 p.m. revealed:

PF8, date of hire 2/23/2018, PF contained a PA criminal background check requested by California University of PA on 2/22/2016. [obtained greater than 1 year immediately preceding date of application]. PF 8 was assigned to CF1 on 3/28/2018.


Interview completed on March 1, 2019 at approximately 3:15 p.m. with EMP18 and EMP20 confirmed the findings.











Plan of Correction:

TAG S 0501

POC:

The Executive Vice President of DON Services Quality Management and Contract Compliance (VP Quality) will review the Policy and Procedure manual to ensure HR standards of employed and contracted personnel reflects the following hiring practices:

(1) Human Resource Personnel Conduct a Face to Face interview.

(2) Obtain 2 satisfactory reference checks which are a positive, verifiable reference either verbal or in writing 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) Current TB screenings.

(4) Criminal Background Checks, Child line clearance, if applicable, FBI clearance if had not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report.

(5) The actual hire date to be recorded as per policy, procedure and regulation to be designated as evidenced by written documentation after 1-4 (above as listed) are satisfactorily completed and prior to a home visit with a consumer for placement into a home as an attendant.

(6) The Personal Assistant Supervisors / Independent Supervisors will direct Human Resources to record the date of hire after the home placement as listed in (5).

(7) The Executive Vice President of Quality Management will audit compliance of the documented hire date monthly by initialing and dating the reviewed hiring documents.

The Personal Assistant Supervisors/ Independent Supervisors, Human Resources will be educated on the process by the Executive Vice President of DON Services Operations and/or VP Quality as evidenced by documented minutes and signatures by the date of March 15, 2019.

The Board of Directors will meet to review survey findings, Review Policy and Procedure updates as evidenced by meeting minutes and documented signatures by the date of March 2019 (exact date to be determined).

The VP Quality is responsible to monitor the continued implementation of this Plan of Correction.



611.54(a)(5) LICENSURE
Provisional Hiring

Name - Component - 00
The home care agency or home care registry shall monitor the provisionally hired applicant awaiting criminal background check through random, direct observation and consumer feedback. The results of monitoring shall be documented in the individual 's personnel file.

Observations:


Based on review of personnel files (PF) and staff (EMP) interview it was determined the agency failed to ensure the agency monitored and documented the monitoring of the provisionally hired applicant for one (1) of ten (10) PF reviewed. (PF8)

Findings Included:


Review of PF completed on March 1, 2019 between approximately 11:00 a.m. and 2:30 p.m. revealed:

PF8, date of hire 2/23/2018, PF did not contain evidence of documented monitoring of the provisionally hired applicant.


Interview completed on March 1, 2019 at approximately 3:15 p.m. with EMP18 and EMP20 confirmed the findings.








Plan of Correction:

TAG S0505

POC:

The Executive Vice President of DON Services Quality Management and Contract Compliance (VP Quality) will review the Policy and Procedure manual to ensure HR standards of employed and contracted personnel reflects the following hiring practices:

Provisional Hiring:

DON does not hire potential applicants until the criminal
background check has been completed and the status of the
check is known to the company. However, if a participant is in
need of services and a new hire is available with a pending
criminal background check, DON will take the following steps to
ensure monitored visits will be done regularly until the status of
the criminal background check is known:

A. DON will notify the consumer that the employee's
criminal background check is under review and that a
monitored visit will be required until the status of the
pending criminal background check is know.

B. The IL Coordinator will set up a time with the consumer
so they may enter their home to monitor the employee
during scheduled work hours.

C. During the visit, the PAS coordinator will observe the
attendant while they working with the participant in their
home.

D5. Monitored visits will be conducted on a weekly basis until
the pending criminal background checks status has
changed and DON has the final determination of the
check, not to exceed 30 days for staff who has been found to be a resident of PA for a period of 2 years or more and many not exceed 90 days for staff who has not been found to be a resident of PA for a period of 2 years or more.


(1) Human Resource Personnel Conduct a Face to Face interview.

(2) Obtain 2 satisfactory reference checks which are a positive, verifiable reference either verbal or in writing 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) Current TB screenings.

(4) Criminal Background Checks, Child line clearance, if applicable, FBI clearance if had not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report.

(5) The actual hire date to be recorded as per policy, procedure and regulation to be designated as evidenced by written documentation after 1-4 (above as listed) are satisfactorily completed and prior to a home visit with a consumer for placement into a home as an attendant.

(6) The Personal Assistant Supervisors / Independent Supervisors will direct Human Resources to record the date of hire after the home placement as listed in (5).

(7) The Executive Vice President of Quality Management will audit compliance of the documented hire date monthly by initialing and dating the reviewed hiring documents.

The Personal Assistant Supervisors/ Independent Supervisors, Human Resources will be educated on the process by the Executive Vice President of DON Services Operations and/or VP Quality as evidenced by documented minutes and signatures by the date of March 15, 2019.

The Board of Directors will meet to review survey findings, Review Policy and Procedure updates as evidenced by meeting minutes and documented signatures by the date of March 2019 (exact date to be determined).

The VP Quality is responsible to monitor the continued implementation of this Plan of Correction.



611.54(a)(7) LICENSURE
Provisional Hiring

Name - Component - 00
The period of provisional hire of an individual who is and has been, for a period of 2 years or more. A resident of Pennsylvania, may not exceed 30 days. The period of provisional hire of an individual who has not been a resident of Pennsylvania for two years or more may not exceed 90 days.

Observations:


Based on review of personnel files (PF), and staff (EMP) interview, the agency failed to ensure the period of provisional hire for a resident of Pennsylvania did not exceed 30 days for one (1) of ten (10) PF. (PF8)

Findings Included:


Review of PF completed on March 1, 2019 between approximately 11:00 a.m. and 2:30 p.m. revealed:

PF8, date of hire 2/23/2018, PF contained a PA criminal background check requested by California University of PA on 2/22/2016. [obtained greater than 1 year immediately preceding date of application]. PF 8 was assigned to CF1 on 3/28/2018. PF contained a PA drivers license issued on 6/29/2016. [Provisional hire period has lasted 342 days longer than regulations allowed]


Interview completed on March 1, 2019 at approximately 3:15 p.m. with EMP18 and EMP20 confirmed the findings.






Plan of Correction:

TAG S0507

POC:

The Executive Vice President of DON Services Quality Management and Contract Compliance (VP Quality) will review the Policy and Procedure manual to ensure HR standards of employed and contracted personnel reflects the following hiring practices:

PROVISIONAL HIRING:

D5. Monitored visits will be conducted on a weekly basis until the pending criminal background checks status has
changed and DON has the final determination of the check, not to exceed 30 days for staff who has been found to be a resident of PA for a period of 2 years or more and many not exceed 90 days for staff who has not been found to be a resident of PA for a period of 2 years or more.


(1) Human Resource Personnel Conduct a Face to Face interview.

(2) Obtain 2 satisfactory reference checks which are a positive, verifiable reference either verbal or in writing 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) Current TB screenings.

(4) Criminal Background Checks, Child line clearance, if applicable, FBI clearance if had not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report.

(5) The actual hire date to be recorded as per policy, procedure and regulation to be designated as evidenced by written documentation after 1-4 (above as listed) are satisfactorily completed and prior to a home visit with a consumer for placement into a home as an attendant.

(6) The Personal Assistant Supervisors / Independent Supervisors will direct Human Resources to record the date of hire after the home placement as listed in (5).

(7) The Executive Vice President of Quality Management will audit compliance of the documented hire date monthly by initialing and dating the reviewed hiring documents.

The Personal Assistant Supervisors/ Independent Supervisors, Human Resources will be educated on the process by the Executive Vice President of DON Services Operations and/or VP Quality as evidenced by documented minutes and signatures by the date of March 15, 2019.

The Board of Directors will meet to review survey findings, Review Policy and Procedure updates as evidenced by meeting minutes and documented signatures by the date of March 2019 (exact date to be determined).

The VP Quality is responsible to monitor the continued implementation of this Plan of Correction.



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 personnel files (PF), and staff (EMP) interview 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 one (1) of ten (10) PF reviewed. (PF1).

Findings Included:

Review of PF completed on March 1, 2019 between approximately 11:00 a.m. and 2:30 p.m. revealed:

PF1, date of hire 2/15/2019, PF did not contain evidence of completion of competency testing. PF1 was assigned to CF4 on 2/20/2019.

Interview completed on March 1, 2019 at approximately 3:15 p.m. with EMP18 and EMP20 confirmed the findings. EMP18 stated "we have been after her to complete them. she will be suspended as of March 11, 2019 if she does not complete them."








Plan of Correction:

TAG S0600

POC:

The Executive Vice President of DON Services Quality Management and Contract Compliance (VP Quality) will review the Policy and Procedure manual to ensure HR standards of employed and contracted personnel reflects the following hiring practices:

COMPETENCY

Competency:
Prior to assigning or referring a direct care worker to provide
services to a consumer, DON shall ensure that the direct care
worker has done of the following:
1. Obtained a valid nurse's license in Pennsylvania.
2. Demonstrated competency by passing a competency
developed by DON which meets the requirements of (3).
3. Successful completed one of the following:
(A) A training program developed by DON or another
entity which meets the following:
1. Confidentiality.
2. Consumer control and the independent living
philosophy.
3. Instrumental activities of daily living.
4. Recognizing changes in the consumer that need to
be addressed.
5. Basic infection control.
6. Universal precautions.
7. Handling of emergencies.
8. Documentation.
9. Recognizing and reporting abuse or neglect.
10. Dealing with difficult behaviors.
11. Bathing, shaving, grooming and dressing.
12. Hair, skin and mouth care.
13. Assistance with ambulation and transferring.
14. Meal preparation and feeding.
15. Toileting.
16. Assistance with self-administered medications.
(B) A home health aide training program meeting the
requirements of 42 CFR 484.36 (relating to the
conditions of participation; home health aide services.
(C) The nurse aid certification and training program
sponsored by the Department of Education and located
at www.pde.state.pa.us
(D) A training program meeting the training standards
imposed on the agency by virtue of the agency's
participation as a provider in a Medicaid Waiver or
other publicly funded program providing home and
community based services to qualifying consumers.
(E) Another program identified by the Department of
Health by subsequent publication in the Pennsylvania
Bulleting or on the Department's web site.


(1) Human Resource Personnel Conduct a Face to Face interview.

(2) Obtain 2 satisfactory reference checks which are a positive, verifiable reference either verbal or in writing 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) Current TB screenings.

(4) Criminal Background Checks, Child line clearance, if applicable, FBI clearance if had not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report.

(5) The actual hire date to be recorded as per policy, procedure and regulation to be designated as evidenced by written documentation after 1-4 (above as listed) are satisfactorily completed and prior to a home visit with a consumer for placement into a home as an attendant.

(6) The Personal Assistant Supervisors / Independent Supervisors will direct Human Resources to record the date of hire after the home placement as listed in (5).

(7) The Executive Vice President of Quality Management will audit compliance of the documented hire date monthly by initialing and dating the reviewed hiring documents.

The Personal Assistant Supervisors/ Independent Supervisors, Human Resources will be educated on the process by the Executive Vice President of DON Services Operations and/or VP Quality as evidenced by documented minutes and signatures by the date of March 15, 2019.

The Board of Directors will meet to review survey findings, Review Policy and Procedure updates as evidenced by meeting minutes and documented signatures by the date of March 2019 (exact date to be determined).

The VP Quality is responsible to monitor the continued implementation of this Plan of Correction.



611.55(d) LICENSURE
Competency Requirements

Name - Component - 00
(d) The home care agency or home care registry shall include documentation of the direct care worker's satisfactory completion of competency requirements in the direct care worker's file.

Observations:


Based on a review of personnel files (PF), and staff (EMP) interview, the agency failed to ensure direct care workers (DCW) file included documentation of satisfactory completion of competency requirements for one (1) of ten (10) PF reviewed (PF1).

Findings included:

Review of PF completed on March 1, 2019 between approximately 11:00 a.m. and 2:30 p.m. revealed:

PF1, date of hire 2/15/2019, PF did not contain evidence of completion of competency testing. PF1 was assigned to CF4 on 2/20/2019.

Interview completed on March 1, 2019 at approximately 3:15 p.m. with EMP18 and EMP20 confirmed the findings. EMP18 stated "we have been after her to complete them. she will be suspended as of March 11, 2019 if she does not complete them."













Plan of Correction:

TAG S0610

POC:

The Executive Vice President of DON Services Quality Management and Contract Compliance (VP Quality) will review the Policy and Procedure manual to ensure HR standards of employed and contracted personnel reflects the following hiring practices:

COMPETENCY

HR Department will document in eFile the satisfactory completion of competency requirements. This will be include certificate of completion of the 16 mandatory trainings (as listed below).

3. Successful completed:
(A) A training program developed by DON or another
entity which meets the following:
1. Confidentiality.
2. Consumer control and the independent living
philosophy.
3. Instrumental activities of daily living.
4. Recognizing changes in the consumer that need to
be addressed.
5. Basic infection control.
6. Universal precautions.
7. Handling of emergencies.
8. Documentation.
9. Recognizing and reporting abuse or neglect.
10. Dealing with difficult behaviors.
11. Bathing, shaving, grooming and dressing.
12. Hair, skin and mouth care.
13. Assistance with ambulation and transferring.
14. Meal preparation and feeding.
15. Toileting.
16. Assistance with self-administered medications.


(1) Human Resource Personnel Conduct a Face to Face interview.

(2) Obtain 2 satisfactory reference checks which are a positive, verifiable reference either verbal or in writing 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) Current TB screenings.

(4) Criminal Background Checks, Child line clearance, if applicable, FBI clearance if had not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report.

(5) The actual hire date to be recorded as per policy, procedure and regulation to be designated as evidenced by written documentation after 1-4 (above as listed) are satisfactorily completed and prior to a home visit with a consumer for placement into a home as an attendant.

(6) The Personal Assistant Supervisors / Independent Supervisors will direct Human Resources to record the date of hire after the home placement as listed in (5).

(7) The Executive Vice President of Quality Management will audit compliance of the documented hire date monthly by initialing and dating the reviewed hiring documents.

The Personal Assistant Supervisors/ Independent Supervisors, Human Resources will be educated on the process by the Executive Vice President of DON Services Operations and/or VP Quality as evidenced by documented minutes and signatures by the date of March 15, 2019.

The Board of Directors will meet to review survey findings, Review Policy and Procedure updates as evidenced by meeting minutes and documented signatures by the date of March 2019 (exact date to be determined).

The VP Quality is responsible to monitor the continued implementation of this Plan of Correction.



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 Centers for Disease Control (CDC) guidelines, agency personnel files (PF) and staff (EMP) interview, it was determined the agency failed to ensure direct care workers, prior to consumer contact, ensured the individual had been screened for and was free from active mycobacterium tuberculosis (TB) for two (2) of ten (10) PF reviewed. (PF11,PF12)

Findings Included:

According to the "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005," "...Baseline testing for M. Tuberculosis infection is recommended for all newly hired HCWs [health care workers]...If TST [tuberculin skin testing] is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative...If the first-step TST result is negative, the second-step TST should be administered 1--3 weeks after the first TST result was read...A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST result within the previous 12 months, a single TST can be administered in the new setting...This additional TST represents the second stage of the two-step testing..."


Review of PF completed on March 1, 2019 between approximately 11:00 a.m. and 2:30 p.m. revealed:

PF11, date of hire (DOH) 9/21/2018 PF contained a 1st step TB test dated 9/28/2018, and documentation from a physician office that stated "Mantoux administered by [MD name] on 5/3/2018 and "Mantoux read by [MD name] on 5/5/2018" form did not contain results of TB test.

PF12, DOH 9/11/2018, PF contained a 1st step TB test dated 8/31/2018 and a form that read TST #1 administered 9/12/18...date read 9/14/12...results 0 mm..." Person who documented was not available to confirm date.

Interview completed on March 1, 2019 at approximately 3:15 p.m. with EMP18 and EMP20 confirmed the findings.




Plan of Correction:

TAG S0700

POC:

The Executive Vice President of DON Services Quality Management and Contract Compliance (VP Quality) will review the Policy and Procedure manual to ensure HR standards of employed and contracted personnel reflects the following hiring practices:

Health Screening

DON 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.

The screening shall be conducted in accordance with CDC
guidelines for preventing the transmission of mycobacterium
tuberculosis in health care settings. The documentation must
indicate the date of the screening which may not be more than 1
year prior to the individual's start date.

DON shall require each direct care worker, and other office staff
or contractors with direct consumer contact, to update the
documentation at least every 12 months and provide the documentation to DON.
The 12 months must run from the date of the last evaluation. This documentation shall be included in the individual's file.

DON shall have HR Department review documentation from a physician office or lab to assure it contains results of TB test.


(1) Human Resource Personnel Conduct a Face to Face interview.

(2) Obtain 2 satisfactory reference checks which are a positive, verifiable reference either verbal or in writing 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) Current TB screenings.

(4) Criminal Background Checks, Child line clearance, if applicable, FBI clearance if had not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report.

(5) The actual hire date to be recorded as per policy, procedure and regulation to be designated as evidenced by written documentation after 1-4 (above as listed) are satisfactorily completed and prior to a home visit with a consumer for placement into a home as an attendant.

(6) The Personal Assistant Supervisors / Independent Supervisors will direct Human Resources to record the date of hire after the home placement as listed in (5).

(7) The Executive Vice President of Quality Management will audit compliance of the documented hire date monthly by initialing and dating the reviewed hiring documents.

The Personal Assistant Supervisors/ Independent Supervisors, Human Resources will be educated on the process by the Executive Vice President of DON Services Operations and/or VP Quality as evidenced by documented minutes and signatures by the date of March 15, 2019.

The Board of Directors will meet to review survey findings, Review Policy and Procedure updates as evidenced by meeting minutes and documented signatures by the date of March 2019 (exact date to be determined).

The VP Quality is responsible to monitor the continued implementation of this Plan of Correction.



611.56(a) LICENSURE
Health Screening

Name - Component - 00
The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.

Observations:


Based on a review of Centers for Disease Control (CDC) guidelines, agency personnel files (PF), and staff (EMP) interview it was determined the agency failed to ensure direct care workers, in accordance with CDC guidelines, had been screened for and was free from active mycobacterium tuberculosis (TB) for two (2) of ten (10) PF reviewed. (PF11, PF12)

Findings Included:

According to the "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005," "...Baseline testing for M. Tuberculosis infection is recommended for all newly hired HCWs [health care workers]...If TST [tuberculin skin testing] is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative...If the first-step TST result is negative, the second-step TST should be administered 1--3 weeks after the first TST result was read...A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST result within the previous 12 months, a single TST can be administered in the new setting...This additional TST represents the second stage of the two-step testing...".

Review of PF completed on March 1, 2019 between approximately 11:00 a.m. and 2:30 p.m. revealed:

PF11, date of hire (DOH) 9/21/2018 PF contained a 1st step TB test dated 9/28/2018, and documentation from a physician office that stated "Mantoux administered by [MD name] on 5/3/2018 and "Mantoux read by [MD name] on 5/5/2018" form did not contain results of TB test. 2nd step not completed within 1-3 weeks from 1st step in accordance with CDC guidelines.

PF12, DOH 9/11/2018, PF contained a 1st step TB test dated 8/31/2018 and a form that read TST #1 administered 9/12/18...date read 9/14/12...results 0 mm..." Person who documented was not available to confirm date. 2nd step not completed within 1-3 weeks from 1st step in accordance with CDC guidelines.

Interview completed on March 1, 2019 at approximately 3:15 p.m. with EMP18 and EMP20 confirmed the findings.








Plan of Correction:

TAG S0701

The Executive Vice President of DON Services Quality Management and Contract Compliance (VP Quality) will review the Policy and Procedure manual to ensure HR standards of employed and contracted personnel reflects the following hiring practices:

Health Screening

DON 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.

The screening shall be conducted in accordance with CDC
guidelines for preventing the transmission of mycobacterium
tuberculosis in health care settings. The documentation must
indicate the date of the screening which may not be more than 1
year prior to the individual's start date.

DON shall require each direct care worker, and other office staff
or contractors with direct consumer contact, to update the
documentation at least every 12 months and provide the documentation to DON. The 12 months must run from the date of the last evaluation. This documentation shall be included in the individual's file.

DON shall have HR Department review documentation from a physician office or lab to assure it contains results of TB test.

(1) Human Resource Personnel Conduct a Face to Face interview.

(2) Obtain 2 satisfactory reference checks which are a positive, verifiable reference either verbal or in writing 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) Current TB screenings.

(4) Criminal Background Checks, Child line clearance, if applicable, FBI clearance if had not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report.

(5) The actual hire date to be recorded as per policy, procedure and regulation to be designated as evidenced by written documentation after 1-4 (above as listed) are satisfactorily completed and prior to a home visit with a consumer for placement into a home as an attendant.

(6) The Personal Assistant Supervisors / Independent Supervisors will direct Human Resources to record the date of hire after the home placement as listed in (5).

(7) The Executive Vice President of Quality Management will audit compliance of the documented hire date monthly by initialing and dating the reviewed hiring documents.

The Personal Assistant Supervisors/ Independent Supervisors, Human Resources will be educated on the process by the Executive Vice President of DON Services Operations and/or VP Quality as evidenced by documented minutes and signatures by the date of March 15, 2019.

The Board of Directors will meet to review survey findings, Review Policy and Procedure updates as evidenced by meeting minutes and documented signatures by the date of March 2019 (exact date to be determined).
The VP Quality is responsible to monitor the continued implementation of this Plan of Correction.



Initial Comments:




Based on the findings of an on site unannounced State relicensure survey completed on March 1, 2019, Don Services, Inc, was found to be in compliance with the requirements of 35 P.S. 448.809 b.



Plan of Correction: