Initial Comments:
Based on the findings of an onsite unannounced survey completed January 24, 2024, Gina's Care Llc was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced survey completed January 24, 2024, Gina's Care Llc was found not to be in compliance with the following requirements of PA Code, 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(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 direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to ensure two (2) of five (5) personnel files contained proof of residency (PF1, & PF3).
Findings included:
Review of personnel files was conducted on January 24, 2024, at 10 a.m.
PF1 was hired on 1/13/2023. PF1 contained no proof of residency, and no other documentation to show this requirement was met.
PF3 was hired on 2/15/2023. PF3 contained a PA driver's license but the license was issued on 3/8/2023 (not 2 years preceding the date of hire). PF3 contained no other documentation to show this requirement was met.
Interview with EMP1 (administrator) on January 24, 2024, at 1 p.m. confirmed above findings.
Plan of Correction:Def #1 S0330; 611.52(d) Proof of Residency
1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Administrator will update PF#1 and PF#3 with Proof of Residency that meets the requirements at 611.52(d). If Proof of Residency cannot be obtained, staff will not be allowed to continue employment.
2. How the facility will act to protect patients in similar situations
The Administrator will audit 100% of Personnel files within the next 30 days to ensure that the requirements at 611.52(d), Proof of Residency is obtained. Threshold is 100%. If threshold is not met, the Administrator will contact personnel who are out of compliance to obtain compliant Proof of Residency. If Proof of Residency cannot be obtained, staff will not be allowed to continue employment.
3.Measures the facility will take or the systems it will alter to ensure that the problem does not recur
Administrator will educate staff on 611.52(d) Proof of Residency requirements to include:
The home care agency 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
Staff will verbalize understanding.
Agency will conduct personnel file audits on 100% of new hires within 30 days of employment to ensure 611.52(d) Proof of Residency requirements are on file.
4. Plans to monitor performance to make sure that solutions are sustained
The Administrator will audit 100% of newly hired Personnel files monthly for one quarter to ensure requirements are met at 611.52(d) Proof of Residency. Threshold is 100%. Once threshold is met for one quarter, the agency will continue to audit 100% of personnel files within 30 days of hire to ensure that there is compliance with 611.52(d). If there is noncompliance, agency will re-educate staff on Proof of Residency requirements and staff non-compliant will not be allowed to continue employment.
The Administrator will monitor all the audits and education findings and will report results to the Governing Body annually and as needed. The Governing Body will identify if trends exist and what action is recommended to achieve and maintain 100% compliance.
5. Date when corrective action plan will be completed
02/23/2024
611.55(a) LICENSURE
Competency 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 review of direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to ensure the direct care worker completed a competency program that contained all necessary subjects prior to providing services to a consumer for five (5) of five (5) personnel files reviewed (PF1-PF5).
Findings included:
Review of personnel files was conducted on January 24, 2024, at 10 a.m.
PF1 completed a competency exam on 1/13/2023 and began providing services to consumers on 2/11/2023.
PF2 completed a competency exam on 11/30/2023 and began providing services to consumers on 12/1/2023.
PF3 completed a competency program on 9/5/2022 and began providing services to consumers on 2/15/2023.
PF4 completed a competency program on 2/16/2023 and began providing services to consumers on 6/9/2023.
PF5 completed a competency exam on 8/26/2023 and began providing services to consumers on 8/29/2023.
A review of the agency's competency exam on January 24, 2024, at 11:45 a.m., and completed by PF1-PF5, did not show it covered the subjects of consumer control and the independent living philosophy, recognizing and reporting abuse or neglect, and assistance with self-administered medications.
Interview with EMP1 (administrator) on January 24, 2024, at 1 p.m. confirmed above findings.
Plan of Correction:Def #2 S0600; 611.55(a) Competency Requirements
1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Administrator will update the competency program to include the required elements of the subjects of consumer control and the independent living philosophy, recognizing and reporting abuse or neglect, and assistance with self-administered medications.
The Administrator will then complete the competency program for the employee for PF#1-PF#5. Employee will not be allowed to provide direct care unless competency program is passed.
2. How the facility will act to protect patients in similar situations
The Administrator will audit 100% of direct care workers personnel files to ensure that 611.55(a) Competency Requirements are met. Threshold is 100%. If the threshold is not met, agency will not allow those employees to provide direct care until all elements are successfully passed.
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Administrator will train all staff on 611.55(a) Competency Requirements that are to be met in that, prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency 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 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 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.
Staff will verbalize understanding.
The Administrator will audit 100% of newly hired direct care worker's Personnel files prior to assigning services to a consumer to ensure the Competency Requirements are met.
4. Plans to monitor performance to make sure that solutions are sustained
The Administrator will audit 100% of newly hired Personnel files monthly for one quarter to ensure requirements are met at 611.55(a) Competency Requirements Threshold is 100%. Once threshold is met for one quarter, the Administrator will continue to audit 100% of newly hired direct care worker's Personnel files prior to assigning services to a consumer to ensure the Competency Requirements are met. If there is a noncompliance, agency will re-educate staff on Competency Requirements and staff non-compliant will not be allowed to continue employment.
The Administrator will monitor all the audits and education findings and will report results to the Governing Body annually and as needed. The Governing Body will identify if trends exist and what action is recommended to achieve and maintain 100% compliance.
5. Date when corrective action will be completed
02/23/2024
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 CDC (Center for Disease Control and Prevention) guidelines, direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to ensure each direct care worker was screened for mycobacterium tuberculosis (TB) in accordance with CDC guidelines prior to consumer contact for five (5) of five (5) personnel files (PF1-PF5).
Finding included:
According to CDC guidelines "the 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include 1) TB screening with an individual risk assessment and symptom evaluation at baseline." Retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6819-H.pdf
Review of personnel files was conducted on January 24, 2024, at 10 a.m.
PF1 began providing services to consumers on 2/11/2023. PF1 contained no TB individual risk assessment.
PF2 began providing services to consumers on 12/1/2023. PF2 contained no TB individual risk assessment.
PF3 began providing services to consumers on 2/15/2023. PF3 contained no TB individual risk assessment.
PF4 began providing services to consumers on 6/9/2023. PF4 contained no TB individual risk assessment.
PF5 began providing services to consumers on 8/29/2023. PF5 contained no TB individual risk assessment.
Interview with EMP1 (administrator) on January 24, 2024, at 1 p.m. confirmed above findings.
Plan of Correction:Def #3 S0710; 611.56(a) Health Screening
1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Administrator will update PF#1-PF#5 that includes a TB individual risk assessment and symptom evaluation.
2. How the facility will act to protect patients in similar situations
The Administrator will audit 100% of direct care workers personnel files to ensure that the requirements of 611.56(a) Health Screening that includes a TB individual risk assessment and symptom evaluation is met. Threshold is 100%. If the threshold is not met, the agency will not allow those employees to provide direct care until the TB individual risk assessment and symptom evaluation is completed.
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Administrator will train all staff on the requirements of 611.56(a) Health Screening, in that 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 start date.
Specifically, TB screening must be conducted with an individual risk assessment and symptom evaluation at baseline.
Staff will verbalize understanding.
The Administrator will audit 100% of newly hired direct care worker's Personnel files prior to assigning services to a consumer to ensure a TB screening was conducted with an individual risk assessment and symptom evaluation at baseline.
4. Plans to monitor performance to make sure that solutions are sustained
The Administrator will audit 100% of newly hired Personnel files monthly for one quarter to ensure requirements are met at 611.56(a) Health Screening. Threshold is 100%. Once threshold is met for one quarter, the Administrator will continue to audit 100% of personnel files prior to assigning services to a consumer to ensure that there is compliance with 611.55(a). If there is non-compliance, agency will re-educate staff on Competency Requirements and staff non-compliant will not be allowed to continue employment.
The Administrator will monitor all the audits and education findings and will report results to the Governing Body annually and as needed. The Governing Body will identify if trends exist and what action is recommended to achieve and maintain 100% compliance.
5. Date when corrective action will be completed
02/23/2024
Initial Comments:
Based on the findings of an onsite unannounced survey completed January 24, 2024, Gina's Care Llc was found to be in compliance with the requirement of 35 P.S. 448.809 (b).
Plan of Correction:
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