QA Investigation Results

Pennsylvania Department of Health
ABLE MIND & BODY HOME CARE, LLC
Health Inspection Results
ABLE MIND & BODY HOME CARE, LLC
Health Inspection Results For:


There are  2 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 28, 2019, Able Mind and Body Home Care, LLC, 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 28, 2019, Able Mind and Body Home Care, LLC, 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

Name - Component - 00
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 a review of personnel files (PF) and an interview withe the director, the agency failed to conduct a face to face interview for eight (8) of ten (10) PF's, PF # 2, 3, 4, 5, 6, 7, 8, and 9. and failed to obtain at least two satisfactory and verifiable references for ten (10) of ten (10) PF's, PF # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.

Findings include:

A review of PF's was conducted on March 28, 2019 from approximately 12:40 pm to 1:00 pm.

PF #1 Date of Hire 8/13/18 did not contain documentation of any references contacted.

PF #2 Date of Hire 2/23/18 did not contain any documentation of a face to face interview or documentation of any references contacted.

PF #3 Date of Hire 12/5/16 did not contain any documentation of a face to face interview or documentation of any references contacted.

PF #4 Date of Hire 11/29/18 did not contain any documentation of a face to face interview or documentation of any references contacted.

PF #5 Date of Hire 12/21/18 did not contain any documentation of a face to face interview or documentation of any references contacted.

PF #6 Date of Hire 12/21/18 did not contain any documentation of a face to face interview or documentation of any references contacted.

PF #7 Date of Hire 4/18/18 did not contain any documentation of a face to face interview or documentation of any references contacted.

PF #8 Date of Hire 7/27/18 did not contain any documentation of a face to face interview or documentation of any references contacted.

PF #9 Date of Hire 11/7/18 did not contain any documentation of a face to face interview or documentation of any references contacted.

PF #10 Date of Hire 8/25/15 did not contain documentation of any references contacted.

An interview with the director on March 29, 2019 at approximately 1:00 pm confirmed the above findings.










Plan of Correction:

The Office Manager of Operations has contacted each staff member to update their references. Its been corrected. A new form has been created to confirm interviews and dates. The office manager is responsible for monitoring progress. To ensure that this does not recur all necessary documentation must be in employee files before orientation.


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 a review of personnel files (PF) and an interview withe the director, the agency failed to provide documentation of a Pennsylvania State Police Criminal Background Check at the time of application or within 1 year immediately preceding the date of application
for three (3) of ten (10) PF's, PF # 1, 3, and 8.

Findings include:

A review of PF's was conducted on March 28, 2019 from approximately 12:40 pm to 1:00 pm.

PF #1 Date of Hire 8/13/18 contained a Pennsylvania State Police Criminal Background Check dated 3/14/19.

PF #3 Date of Hire 12/5/16 did not contain any documentation of a Pennsylvania State Police Criminal Background Check.

PF #8 Date of Hire 7/27/18 contained a Pennsylvania State Police Criminal Background Check dated 2/11/16.



An interview with the director on March 29, 2019 at approximately 1:00 pm confirmed the above findings.








Plan of Correction:

Employees have been contacted and awaiting certificates to be mailed to them.

Before the hiring process, caregivers must submit Criminal background checks. If they do not obtain a background check, the Records & Compliance manager will be responsible to get this documentation before caregiver starts working with clients. All Employees who's files were missing this document has been contacted by office manager in operations and are waiting for certificates to be mailed to them. Every year records and compliance will follow up with new criminal background checks to ensure the problem does not recur.


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 an interview with the director, the agency failed to provide documentation of the direct care worker's satisfactory completion of initial competency requirements in the direct care worker's file for seven (7) of ten (10) PF's, PF # 3, 4, 5, 6, 7, 8, and 9. And did not contain documentation of annual competency requirements in the direct care worker's file for two (2) of ten (10) PF's, PF # 3 and 10.

Findings include:

A review of PF's was conducted on March 28, 2019 from approximately 12:40 pm to 1:00 pm.

PF #3 Date of Hire 12/5/16 did not contain any documentation of the direct care worker's satisfactory completion of initial competency requirements and did not contain any documentation of an annual competency for 2018.


PF #4 Date of Hire 11/29/18 did not contain any documentation of the direct care worker's satisfactory completion of initial competency requirements.

PF #5 Date of Hire 12/21/18 did not contain any documentation of the direct care worker's satisfactory completion of initial competency requirements.

PF #6 Date of Hire 12/21/18 contained an incomplete record of documentation of initial competency requirements.

PF #7 Date of Hire 4/18/18 did not contain any documentation of the direct care worker's satisfactory completion of initial competency requirements.

PF #8 Date of Hire 7/27/18 did not contain any documentation of the direct care worker's satisfactory completion of initial competency requirements.

PF #9 Date of Hire 11/7/18 did not contain any documentation contained an incomplete record of documentation of initial competency requirements.

PF #10 Date of Hire 8/29/15 did not contain any documentation of an annual competency for 2018.

An interview with the director on March 29, 2019 at approximately 1:00 pm confirmed the above findings.










Plan of Correction:

The office manager in operations started providing a competency test which will be given prior to being hired. Competency tests will also be given yearly to assure caregivers are properly trained. Caregivers must have satisfactory results prior to hire and continuation of services.


611.55(d) LICENSURE
Competency Requirements

Name - Component - 00
If the direct care worker has a nurse's license or other licensure or certification as a health professional, the individual's file shall include a copy of the current license or certification.

Observations:

Based on a review of personnel files (PF) and an interview withe the director, the agency failed to provide a copy of the direct care worker's current CNA certification for one (1) of ten (10) PF's, PF #10.

Findings include:

PF #10 Date of Hire 8/29/15 did not contain a copy of the direct care worker's current CNA certification.


An interview with the director on March 29, 2019 at approximately 1:00 pm confirmed the above findings.











Plan of Correction:

The office manager in operations has contacted he PF in question and are in process of submitting current CNA certification. New certifications must be turned in before continuing aide to clients.



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 (PF), CDC (Centers for Disease Control) Guidelines for mycobacterium tuberculosis (TB) screening, and an interview withe the director, the agency failed to 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 (TB) for six (6) of ten (10) PF's, PF # 1, 2, 5, 6, 8, and 10.

Findings include:

The CDC guidelines state that all Health Care Workers (HCW) should received 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 screen annually. HCWs with a baseline 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 was conducted on March 28, 2019 from approximately 12:40 pm to 1:00 pm.

PF #1 Date of Hire 8/13/18 contained documentation of only a one-step TB test at hire.

PF #2 Date of Hire 2/23/18 did not contain any documentation of TB screening evaluation at hire.

PF #5 Date of Hire 12/21/18 contained documentation of only a one-step TB test at hire.

PF #6 Date of Hire 12/21/18 contained documentation of only a one-step TB test at hire.

PF #8 Date of Hire 7/27/18 contained documentation of only a one-step TB test at hire.

PF #10 Date of Hire 8/25/15 contained documentation of only a one-step TB test at hire and no annual TB screening evaluation for 2016, 2017, and 2018.


An interview with the director on March 29, 2019 at approximately 1:00 pm confirmed the above findings.









Plan of Correction:

The agency has contacted all of the PF's in question and are in the process of submitting their TB forms. Both steps should be completed and documented. Failure for these workers to produce these documents will result in their suspension until all of the forms have been submitted.
The agency's official caregiver supervisor is responsible for making sure the caregiver staff are up to date and have completed forms.
In the future this staff member will accept these forms at the time of caregiver interviews.
It is a part of the interview process. This way if the caregiver is hired these documents will already be on file. If they are not hired, documents will be destroyed.
This procedure has already been implemented.


611.57(a) LICENSURE
Consumer Rights

Name - Component - 00
(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

Observations:

Based on a review of consumer files (CF) and an interview with the director, the agency failed to provide documentation that the consumer received information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services for ten (10) of ten (10) CF's, CF # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.

Findings include:

A review of CF's was conducted on March 28, 2019 from approximately 11:50 am to 12:45 pm.

CF #1 Date of Service 4/1/16 did not contain any documentation that the agency provided information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services .

CF #2 Date of Service 1/2/16 did not contain any documentation that the agency provided information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services .

CF #3 Date of Service 1/4/15 did not contain any documentation that the agency provided information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services .

CF #4 Date of Service 12/11/17 did not contain any documentation that the agency provided information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services .

CF #5 Date of Service 3/21/19 did not contain any documentation that the agency provided information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services .

CF #6 Date of Service 4/4/17 did not contain any documentation that the agency provided information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services .

CF #7 Date of Service 2/5/18 did not contain any documentation that the agency provided information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services .

CF #8 Date of Service 2/10/16 did not contain any documentation that the agency provided information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services .

CF #9 Date of Service 2/6/18 did not contain any documentation that the agency provided information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services .

CF #10 Date of Service 4/27/18 did not contain any documentation that the agency provided information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services .

An interview with the director on March 28, 2019 at approximately 1:00 pm confirmed the above findings.









Plan of Correction:

In a formal letter, consumers will be provided with documentation stating that the agency will provide at least 10 calendar days advance written notice of agencies intent to terminate. The intake administrator is responsible for this task.


611.57(b) LICENSURE
Prohibitions

Name - Component - 00
(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

Observations:


Based on a review of consumer files (CF) and an interview with the director, the agency failed to provide documentation that the consumer received information stating the agency may not assume power of attorney or guardianship over a consumer utilizing the services of that agency and the agency may not require a consumer to endorse checks over to the agency for ten (10) of ten (10) CF's, CF # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.

Findings include:

A review of CF's was conducted on March 28, 2019 from approximately 11:50 am to 12:45 pm.

CF #1 Date of Service 4/1/16 did not contain any documentation that the agency provided information stating the agency may not assume power of attorney or guardianship of the consumer and the agency may not require the consumer to endorse checks over to the agency.

CF #2 Date of Service 1/2/16 did not contain any documentation that the agency provided information stating the agency may not assume power of attorney or guardianship of the consumer and the agency may not require the consumer to endorse checks over to the agency.

CF #3 Date of Service 1/4/15 did not contain any documentation that the agency provided information stating the agency may not assume power of attorney or guardianship of the consumer and the agency may not require the consumer to endorse checks over to the agency.

CF #4 Date of Service 12/11/17 did not contain any documentation that the agency provided information stating the agency may not assume power of attorney or guardianship of the consumer and the agency may not require the consumer to endorse checks over to the agency.

CF #5 Date of Service 3/21/19 did not contain any documentation that the agency provided information stating the agency may not assume power of attorney or guardianship of the consumer and the agency may not require the consumer to endorse checks over to the agency.

CF #6 Date of Service 4/4/17 did not contain any documentation that the agency provided information stating the agency may not assume power of attorney or guardianship of the consumer and the agency may not require the consumer to endorse checks over to the agency.

CF #7 Date of Service 2/5/18 did not contain any documentation that the agency provided information stating the agency may not assume power of attorney or guardianship of the consumer and the agency may not require the consumer to endorse checks over to the agency.

CF #8 Date of Service 2/10/16 did not contain any documentation that the agency provided information stating the agency may not assume power of attorney or guardianship of the consumer and the agency may not require the consumer to endorse checks over to the agency.

CF #9 Date of Service 2/6/18 did not contain any documentation that the agency provided information stating the agency may not assume power of attorney or guardianship of the consumer and the agency may not require the consumer to endorse checks over to the agency.

CF #10 Date of Service 4/27/18 did not contain any documentation that the agency provided information stating the agency may not assume power of attorney or guardianship of the consumer and the agency may not require the consumer to endorse checks over to the agency.


An interview with the director on March 28, 2019 at approximately 1:00 pm confirmed the above findings.








Plan of Correction:

In the formal letter which provides the consumer information on consumer rights, included will be information indicating that agency employees can not assume power of attorney, guardianship over all consumers utilizing services and the agency may not require a consumer to endorse checks over to the agency. This will be sent before or by 5/25/19

The office manager in operations will send a formal letter which will provide consumer information on consumer rights. Included will be information indicating that agency employees cannot assume power of attorney guardianship. Over all consumers utilizing services and the agency may not require a consumer to endorse checks over to the agency. This will be sent before of by 5/25/19 by the office manager in operations. To ensure this does not recur documentation will be given to consumers before starting services with us.


611.57(c) LICENSURE
Information to be Provided

Name - Component - 00
(c) Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.

Observations:

Based on a review of consumer files (CF) and an interview with the director, the agency failed to provide documentation that the consumer received information stating who to contact at the Department for information about licensure requirements for the agency, the Department's complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). And the agency failed to provide documentation of a disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry for ten (10) of ten (10) CF's, CF # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.

Findings include:

A review of CF's was conducted on March 28, 2019 from approximately 11:50 am to 12:45 pm.

CF #1 Date of Service 4/1/16 did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency, the Department's complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) and did not contain any documentation of a direct care worker disclosure.

CF #2 Date of Service 1/2/16 did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency, the Department's complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) and did not contain any documentation of a direct care worker disclosure.

CF #3 Date of Service 1/4/15 did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency, the Department's complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) and did not contain any documentation of a direct care worker disclosure.

CF #4 Date of Service 12/11/17 did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency, the Department's complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) and did not contain any documentation of a direct care worker disclosure.

CF #5 Date of Service 3/21/19 did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency, the Department's complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) and did not contain any documentation of a direct care worker disclosure.

CF #6 Date of Service 4/4/17 did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency, the Department's complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) and did not contain any documentation of a direct care worker disclosure.

CF #7 Date of Service 2/5/18 did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency, the Department's complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) and did not contain any documentation of a direct care worker disclosure.

CF #8 Date of Service 2/10/16 did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency, the Department's complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) and did not contain any documentation of a direct care worker disclosure.

CF #9 Date of Service 2/6/18 did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency, the Department's complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) and did not contain any documentation of a direct care worker disclosure.

CF #10 Date of Service 4/27/18 did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency, the Department's complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) and did not contain any documentation of a direct care worker disclosure.


An interview with the director on March 28, 2019 at approximately 1:00 pm confirmed the above findings.









Plan of Correction:

The information packet will be revised and updated. It will include the telephone number of the Ombudsman Program located with the local area Area Agency on Aging (AAA), and the departments complaint hotline.
Also along with a formal letter delivered to the clients, their individual SOC information will be provided to them for their records.
Moving forward the agency's intake supervisor will have a detailed consultation where she will go over the employee status of the direct care worker providing services to consumers.
Also along side of that information all obligations and responsibilities of the consumer and agency


Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted on March 28, 2019, Able Mind and Body Home Care, LLC, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: