QA Investigation Results

Pennsylvania Department of Health
EVERYDAY HOME CARE LLC
Health Inspection Results
EVERYDAY 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 on-site state licensure survey conducted on December 28, 2018 2018, EveryDay Home Care was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, and Subpart A.






Plan of Correction:




Initial Comments:

Based on the findings of an on-site state licensure survey conducted on December 28, 2018 2018, EveryDay Home Care was found not to be in compliance with the following requirement of Title 28 Health and Safety Part IV, Health Facilities, Subpart H. Chapter 611 Home Care Agencies and Home Care Registries.





Plan of Correction:




611.52(b) LICENSURE
State Police Criminal History Record

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

Observations:

Based on review of direct care workers files and interview with the scheduler, the agency failed to ensure Pennsylvania State Police criminal background checks were performed within 30 days of hire for five (5) of seven (7) personnel files. Personnel file # 2, 3, 4, 5, and 7.
Findings include: 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."

Review of direct care worker files on December 28, 2018 from 1:30 to 3 pm
Direct care worker file # 2 with a date of hire on November 1, 2017, no documentation of a completed Pennsylvania State Police criminal history check that was within 30 days of hire. Criminal background check was completed on May 2, 2018 (182 days after hire).
Direct care worker file # 3 with a date of hire on October 3, 2018, no documentation of a completed Pennsylvania State Police criminal history check that was within 30 days of hire. Criminal background check was completed on November 5, 2018 (33) days after hire).
Direct care worker file # 4 with a date of hire on June 29, 2016, no documentation of a completed Pennsylvania State Police criminal history check that was within 30 days of hire. Criminal background check was completed on August 8, 2016 (45 days after hire).
Direct care worker file # 5 with a date of hire on April 13, 2015, no documentation of a completed Pennsylvania State Police criminal history check that was within 30 days of hire. Criminal background check was completed on October 8, 2016 (178 days after hire).
Direct care worker file # 7 with a date of hire on January 24, 2014, no documentation of a completed Pennsylvania State Police criminal history check that was within 30 days of hire. Criminal background check was completed on March 25, 2014 (60 days after hire).
Interview with the scheduler on December 28, 2018 at 3:15 confirmed that there was no documentation of a timely criminal history check for the above employees.





Plan of Correction:

Plan of Correction:

Upon hire, HR will keep a "file check list" on all new and existing employees. This will allow HR to review each item and ensure that all required documents are submitted and in compliance with the POC

All current and future implementation of the POC on all files will be subjected to review by the Office Manager on a quarterly basis to ensure compliance with the "Act 169 of 1996 as amended by Act 13 of 1997" within the allotted time frame.




611.55(e) LICENSURE
Competency Requirements

Name - Component - 00
The competency review must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction.

Observations:

Based on a review of the direct care worker (DCW) files and an interview with the agency administrator, the agency failed to ensure that the direct care workers have an annual competency review for three (3) of seven (7) DCW. DCW # 4, 5 and 7.

Findings Include:

Review of direct care worker files on December 28, 2018 from 1:30 to 3pm
Direct care worker file # 4 with a date of hire on June 29, 2016, no documentation of an annual competency for calendar year 2017.
Direct care worker file # 5 with a date of hire on April 13, 2015, no documentation of an annual competency for calendar year 2016 and 2017.
Direct care worker file # 7 with a date of hire on January 24, 2014, no documentation of an annual competency for calendar year 2015, 2016 and 2017.

An interview with the scheduler on December 28 at 3 pm confirmed that the direct care workers did not have documentation of an annual competency review.






Plan of Correction:

Plan of Correction:

All initial competency testing will be conducted through the DPW website
services.dpw.state.pa.us upon hire.

All new and existing employee files will contain a "file check list" that will be subjected to review of initial competencies on a quarterly basis by the Office Manager to ensure all files are in compliance.

Annual competencies will be conducted and reviewed by the Office Manager through out the year on a quarterly or yearly basis (or more frequently if warranted) to ensure compliance of regulation 611.55 Competency Requirements


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 CDC [Centers for Disease Control] guidelines, direct care worker files and interview with the scheduler, the agency failed to ensure six (6) of seven (7) direct care workers files had been screened for mycobacterium tuberculosis in accordance with the CDC guidelines prior to direct consumer contact. Personnel file # 2, 3, 4, 5, 6 and 7.
Findings include:
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... "
Findings include:
A review of the Employee Handbook was conducted on December 28, 2018 at 3 pm.
Page 7, " Health Requirements " states: " Employee must submit an initial PPD (tuberculin skin test) statement ...2 step for Home Care. You are required to maintain a current PPD on file ...which is not more than one year old ... "

Review of direct care worker files on December 28, 2018 from 1:30 to 3 pm
Direct care worker file # 2 with a date of hire on November 1, 2017, contained a two-step PPD dated June 2, 2017 and June 12, 2017 which is seven months after the date of hire.
Direct care worker file # 3 with a date of hire on October 3, 2018 contained a chest x-ray dated May 2, 2017 which is not within the previous 12 months and which is seven months after the date of hire. No documentation of annual PPD screening for calendar year 2018.
Direct care worker file # 4 with a date of hire on June 29, 2016, no documentation that two-step PPD testing had been conducted on hire. No documentation of annual PPD testing for calendar year 2016 and 2018.
Direct care worker file # 5 with a date of hire on April 13, 2015, no documentation that two-step PPD testing had been conducted on hire. No documentation of annual PPD testing for calendar year 2016, 2017 and 2018.
Direct care worker file # 6 with a date of hire on April 6, 2018, no documentation that two-step PPD testing had been conducted on hire.
Direct care worker file # 7 with a date of hire on January 24, 2014, no documentation of annual PPD testing for calendar year 2018
Interview with the scheduler on December 28, 2018 at 3:15 pm confirmed that the required documentation that an annual PPD testing and a two-step PPD testing had not been conducted in the above direct care workers files.







Plan of Correction:

Plan of Correction:

Upon Hire, HR will ensure that all new employees will be subjected to comply with the requirements according to the regulations of 611.52. All newly hired employees will be required to obtain a 2 - step PPD or must have obtained a Chest X-ray within a year from the Date-of-Hire.

The Office Manager will review and maintain a checklist of all DCW files in order to ensure compliance of the implementation of the POC. All DCW files will be subjected to these reviews on a quarterly basis by the Office Manager to ensure compliance.


Initial Comments:

Based on the findings of an on-site state licensure survey was conducted on December 28, 2018 2018, EveryDay Home Care was found to be in compliance with the requirements of 35 P.S. 448.809(b).





Plan of Correction: