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:

This is the only survey for this facility

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 unannounced on-site state home care agency re-licensure survey conducted on March 15, 2016, Able Mind & Body Home Care LLC was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.












Plan of Correction:




51.6 (a)(1) LICENSURE
IDENTIFICATION OF PERSONNEL

Name - Component - 00
51.6. Identification of personnel

(a) When working in a health care
facility and when clinically feasible,
the following individuals shall wear
an identification tag which displays
that person's name and professional
designation:
(1) Health care practitioners
licensed or certified by Commonwealth
agencies.

Observations:

Based on direct observation and an interview with the agency administrator, the agency failed to provide the staff with direct consumer care with identification badges that stated the professional status of the individual.

Findings Include:

On March 15, 2016 at approximately 1300, the surveyor asked if the staff of Able Mind & Body, LLC with direct consumer care wears identification badges. The agency administrator has not issued any identification badges that list the professional status of the direct care worker. The agency administrator stated that they were aware of this requirement and have ordered identification badges.

An interview with the agency administrator on March 15, 2016, at approximately 1430 P.M. confirmed the above findings.













Plan of Correction:

Identification badges were prepared and said to be delivered to the care workers immediately after completion. This is expected to happen by 4/10/16


Initial Comments:

Based on the findings of an onsite unannounced initial state re-licensure survey conducted on March 15, 2016, Able Mind & Body, LLC, was found to not 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 review of personnel files (PF), and an interview with agency staff, it was determined that the agency failed to acquire (2) references prior to employment for four(4) of six (6) files reviewed, (PF #2, #3, #5, #6).

Findings include:

A review of PFs was conducted March 15, 2016 between approximately 1100 and 1230.

1) PF #2, date of hire 11/17/2015. There was no evidence in the file of two (2) satisfactory references prior to employment.

2) PF #3, date of hire 12/14/2015. There was no evidence in the file of two (2) satisfactory references prior to employment.

4) PF #5, date of hire 01/26/2016. There was no evidence in the file of two (2) satisfactory references prior to employment.

5) PF #6, date of hire 11/12/2015. There was no evidence in the file of two (2) satisfactory references prior to employment.

An interview with the agency administrator was conducted on March 15, 2016 at approximately 1430 confirmed the above findings.












Plan of Correction:

Each staff member has been contacted to update their references. It's been corrected.


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 the Personnel (PF), and an interview with the agency administrator, the agency failed to ensure that all employees had criminal background checks. One (1) of the five (5) PFs reviewed did not have criminal background checks in their files (PF #2).

According to the Act 169 of 1996 as amended by Act 13 of 1997,"If the applicant/employee has been a resident of the Commonwealth of Pennsylvania for 2 or more years prior to application for employment, the applicant will need to obtain a clearance from the Pennsylvania State Police. This clearance is obtained by doing the following: Request for Criminal Record Check Form (SP4-164)." "When the applicant/employee has not been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application for employment or currently lives out of state, in addition to the Pennsylvania State Police Criminal History Check, the applicant/employee will also need to obtain an FBI Criminal History Check. Facilities are defined by the act to include: Domiciliary Care Homes, Home Health Care Agency, Nursing Facility (licensed by the Department of Aging), and Personal Care Home (licensed by the Department of Public Welfare). A home Health Care Agency is further defined to include those agencies licensed by the Department of Health and any public or private organization which provides care to a care-dependent individual in their place of residence." "If entities run into special circumstances where they need to hire an employee before the results of their record checks are returned, there is a provision in CPSL that allows for a provisional hiring period. The period is to not exceed 30 days for in state residents and 90 for out of state residents."


Findings Include:

A review of the PFs was conducted on March 16, 2016 at approximately 1100. The date of hire (DOH) was noted for the employee.

PF#2 DOH 11/17/2015: No evidence of the Pennsylvania Access to Criminal History (PATCH) criminal background check.


An interview with the agency administrator on March 15, 2016 at approximately 1430 confirmed the above findings.











Plan of Correction:

This employee has been contacted about the missing document. She has ordered it and is waiting on the certificate to be mailed to her.


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 review of personnel files (PF), and an interview with agency staff, it was determined that the agency failed to acquire proof of residency and/or two (2) references prior to employment for four (4) of six (6) files reviewed, (PF #2, #3, #4, & #6).

Findings include:
A review of PFs was conducted March 15, 2016 between approximately 1100 and 1230.

1) PF #2, date of hire 11/17/15. There was no evidence in the file to show proof of residency.

2) PF #3, date of hire 12/14/15. There was no evidence in the file to show proof of residency.

3) PF #4, date of hire 02/11/16. There was no evidence in the file to show proof of residency.

4) PF #6, date of hire 11/12/15. There was no evidence in the file to show proof of residency.

An interview with the agency administrator was conducted on March 15, 2016 at approximatly 1430 confirmed the above findings.








Plan of Correction:

All identified PF have been contacted about submitted their proof of residency. We accepted a valid drivers license or state ID check to verify this information. We are waiting on only 2 more PF's to submit their remaining material. Their deadline is May 1, 2016

The agency's official Caregiver Supervisor is responsible for maintaining this policy and have completed the process.

In the future this staff member will accept these forms at the time of caregiver interviews. This way IF the caregiver is hired, these documents will already be on file. We have already started this process.




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 the Personnel Files (PFs) and an interview with the agency staff, the agency failed to ensure that the direct care workers received tuberculosis screening prior to providing service to the consumers. Five (5) of the six (6) PFs for direct care workers did not meet this requirement (PF #1, PF #2, PF #3, PF #4, PF #5).

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.


Findings Include:

A review of the PFs was conducted on March 15, 2016 between approximately 1100 and 1230 the date of hire (DOH) was noted for each employee.

PF #1 DOH 11/17/2015: No evidence of TB screening prior to providing services to a consumer.
PF #2 DOH 11/17/2015: No evidence of TB screening prior to providing services to a consumer.
PF #3 DOH 12/14/2015: No evidence of TB screening prior to providing services to a consumer.
PF #4 DOH 02/11/2016: No evidence of TB screening prior to providing services to a consumer.
PF #5 DOH 01/26/2016: No evidence of TB screening prior to providing services to a consumer.

An interview with the agency administrator on March 15, 2016 at approximately 1430 confirmed the above findings








Plan of Correction:

The agency has contacted all of the PFs in question and are in the process of submitting their TB forms. We received 2 of the 5 missing. Failure for these workers to produce these documents will result in their suspension until all of the forms have been submitted. Expected date of completion is on or before or by 5/16/16

The agency's official Caregiver Supervisor is responsible for making sure caregiver staff are up to date and have completed the 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. We have already implemented this procedure.


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 (CFs) and an interview with the agency administrator, the agency failed to ensure that the consumers received all the required information prior to the initiation of services. Seven (7) of seven (7) CFs reviewed did not have all the required information (CF #1, CF #2, CF #3, CF #4, CF #5, CF #6, and CF#7).
Findings include:
A review of the CFs was conducted March 16, 2016 between approximately 1230 and 1430. The start of service (SOS) was noted for each consumer.
CF #1 SOS 02/10/2016. No evidence in the file the consumer of home care services had been involved in the service planning process. No evidence in the file the consumer had been advised on the right 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.
CF #2 SOS 10/26/2015. No evidence in the file the consumer of home care services had been involved in the service planning process. No evidence in the file the consumer had been advised on the right 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.
CF #3 SOS 01/26/2016. No evidence in the file the consumer of home care services had been involved in the service planning process. No evidence in the file the consumer had been advised on the right 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.
CF #4 SOS 02/20/2016. No evidence in the file the consumer of home care services had been involved in the service planning process. No evidence in the file the consumer had been advised on the right 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.
CF #5 SOS 11/19/2015. No evidence in the file the consumer of home care services had been involved in the service planning process. No evidence in the file the consumer had been advised on the right 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.
CF #6 SOS 01/04/2016. No evidence in the file the consumer of home care services had been involved in the service planning process. No evidence in the file the consumer had been advised on the right 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.
CF #7 SOS 02/25/2016. No evidence in the file the consumer of home care services had been involved in the service planning process. No evidence in the file the consumer had been advised on the right 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.
An interview with the executive director on March 15, 2016 approximately 1500 confirmed the above findings.











Plan of Correction:

Consumers are involved in the care planning process, directly with our agency and their service coordinators to create a plan that they are happy with. To correct the initial problem, formal letters providing the consumer information on consumer rights will be released and sent directly to the consumer's home by or before 5/16/2016.
All new clients will be assessed giving consultations so they will have the opportunity to be involved with the care planning. A welcome packet outlining the procedures as well as mandated contact phone numbers will be supplied to all future clients prior to start of service.

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 (CFs) and an interview with agency staff, the agency failed to inform the consumers of the prohibition. Seven (7) of Seven (7) CFs reviewed did not meet the requirement (CF #1, CF #2, CF #3, CF #4, CF #5, CF #6, CF #7).
Findings include:
A review of the CFs was conducted March 15, 2016 between approximately 1230 and 1430. The start of service (SOS) was noted for each consumer.

CF #1 SOS 02/10/2016. No evidence that the consumer was aware that employees of the agency cannot assume power of attorney or guardianship over the consumer nor require the consumer to endorse checks.

CF #2 SOS 10/26/2015. No evidence that the consumer was aware that employees of the agency cannot assume power of attorney or guardianship over the consumer nor require the consumer to endorse checks.

CF #3 SOS 01/26/2016. No evidence that the consumer was aware that employees of the agency cannot assume power of attorney or guardianship over the consumer nor require the consumer to endorse checks.

CF #4 02/20/2016. No evidence that the consumer was aware that employees of the agency cannot assume power of attorney or guardianship over the consumer nor require the consumer to endorse checks.

CF #5 SOS 11/19/2015. No evidence that the consumer was aware that employees of the agency cannot assume power of attorney or guardianship over the consumer nor require the consumer to endorse checks.

CF #6 SOS 01/14/2016. No evidence that the consumer was aware that employees of the agency cannot assume power of attorney or guardianship over the consumer nor require the consumer to endorse checks.

CF #7 SOS 02/25/2016. No evidence that the consumer was aware that employees of the agency cannot assume power of attorney or guardianship over the consumer nor require the consumer to endorse checks.

An interview was conducted with the executive director on March 15, 2016 at approximately 1500 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 or guardianship over all consumers utilizing serves. This package will be sent before or by 5/16/2006
Moving forward The agency's Intake Supervisor will have a detailed consultation where she will go over the agreement and paperwork, indicating that the consumer is aware of these guidelines. Only when the consumer have been fully verbally briefed will the Intake Supervisor receive a signature indicating that he/she understands these laws and guidelines.


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 review of consumer records, review of admission packet, and interview with the agency administrator, it was determined the agency failed to ensure that the consumers received all the required information prior to the initiation of services for Seven (7) of Seven (7) consumer records (Consumer record #'s 1, 2, 3, 4, 5, 6, and 7) reviewed.

Findings include:


Review of consumer records on March 15, 2016 at approximately 1230 through 1430 revealed the following:


1. Review of consumer record #1, start of care (SOC) 02/10/2016, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ), the consumer had not been advised of the Department's complaint Hot Line (1-800-254-5164), and had not received contact information to 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.

2. Review of consumer record #2, SOC 10/26/2015, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ), the consumer had not been advised of the Department's complaint Hot Line (1-800-254-5164), and had not received contact information to 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.

3. Review of consumer record #3, SOC 01/26/2016, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ), the consumer had not been advised of the Department's complaint Hot Line (1-800-254-5164), and had not received contact information to 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. .

4. Review of consumer record #4, SOC 02/20/2016, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ), the consumer had not been advised of the Department's complaint Hot Line (1-800-254-5164), and had not received contact information to 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. Review of consumer record #5, SOC 11/19/2015, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ), the consumer had not been advised of the Department's complaint Hot Line (1-800-254-5164), and had not received contact information to 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.

6. Review of consumer record #6, SOC 01/01/2016, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ), the consumer had not been advised of the Department's complaint Hot Line (1-800-254-5164), and had not received contact information to 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. .

7. Review of consumer record #7, SOC 02/25/2016, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ), the consumer had not been advised of the Department's complaint Hot Line (1-800-254-5164), and had not received contact information to 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.

An interview with the agency administrator at approximately 1500 confirmed the above findings.
















Plan of Correction:

The information packet will be revised and updated and will include the Dept. of Health #, Area Agency on Aging (AAA) program phone # as well. Also, along with the formal letter delivered to the clients, their individual SOC information will be provided to them for their records by 5/16/16.

Moving forward The agency's Intake Supervisor will have a detailed consultation where she will go over the agreement and paperwork, indicating that the consumer is aware of these guidelines. Only when the consumer have been fully verbally briefed will the Intake Supervisor receive a signature indicating that he/she understands these laws and guidelines. The signature shows that the consumer is aware and understands this information.