Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on March 25, 2024, Mother's Love Home Health Care Assistance 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 onsite unannounced home care agency state re-licensure survey conducted on March 25, 2024, Mother's Love Home Health Care Assistance Inc. 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 direct care worker personnel files (PF) and interview with the agency staff, the agency failed to document face-to-face interviews and/or two (2) satisfactory references prior to employment for seven (7) of seven (7) PF reviewed. (PF #1, 2, 3, 4, 5, 6, and 7).
Findings Include:
A review of PF's conducted on March 25, 2024, from approximately 1:30 P.M. to 2:30 P.M. revealed the following:
PF #1, date of hire November 12, 2022, contained no documentation of two (2) satisfactory references obtained prior to employment.
PF #2, date of hire June 26, 2023, contained no documentation of two (2) satisfactory references obtained prior to employment.
PF #3, date of hire February 1, 2012, contained no documentation of a face-to-face interview and no documentation of two (2) satisfactory references obtained prior to employment.
PF #4, date of hire March 11, 2022, contained no documentation of a face-to-face interview and no documentation of two (2) satisfactory references obtained prior to employment.
PF #5, date of hire May 19, 2022, contained no documentation of a face-to-face interview and no documentation of two (2) satisfactory references obtained prior to employment.
PF #6, date of hire March 9, 2019, contained documentation of only one (1) satisfactory reference obtained prior to employment.
PF #7, date of hire July 19, 2016, contained no documentation of a face-to-face interview and no documentation of two (2) satisfactory references obtained prior to employment.
An interview with the agency Office Manager on March 25, 2024, at approximately 2:30 P.M. confirmed the above findings.
Plan of Correction:All missing interviews will be conducted as well as references and put into caregivers folders. Since the missing interviews and references were to have been completed prior to the current office managers hire date they will have to be redone to insure proper documentation is complete. Moving forward all interview paperwork will be given to all employees prior to hire date and will be kept in employee file. Quarterly file audits will be performed by office manager to insure that all paperwork including interview and reference sheets are present
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 an interview with the agency staff, the agency failed to retain documentation of proof of residency for the two years immediately preceding the date of hire for seven (7) of seven (7) PF reviewed. (PF # 1, 2, 3, 4, 5, 6, and 7).
Findings include:
A review of PF's conducted on March 25, 2024, from approximately 1:30 P.M. to 2:30 P.M. revealed the following:
PF #1, date of hire November 12, 2022, contained a Pennsylvania driver's license issued September 16, 2022. There was no documentation that the applicant resided in Pennsylvania for the two (2) years immediately preceding the date of hire.
PF #2, date of hire June 26, 2023, contained a Pennsylvania driver's license issued April 27, 2022. There was no documentation that the applicant resided in Pennsylvania for two (2) years immediately preceding the date of hire.
PF #3, date of hire February 1, 2012, contained no documentation that the applicant resided in Pennsylvania for the two (2) years immediately preceding the date of hire.
PF #4, date of hire March 11, 2022, contained a Pennsylvania driver's license issued June 29, 2020. There was no documentation that the applicant resided in Pennsylvania for the two (2) years immediately preceding the date of hire.
PF #5, date of hire May 19, 2022, contained a Pennsylvania driver's license issued November 22, 2022. There was no documentation that the applicant resided in Pennsylvania for the two (2) years immediately preceding the date of hire.
PF #6, date of hire March 9, 2019, contained a Pennsylvania driver's license issued March 5, 2019. There was no documentation that the applicant resided in Pennsylvania for the two (2) years immediately preceding the date hire.
PF #7, date of hire July 19, 2016, contained a Pennsylvania driver's license issued April 20, 2016. There was no documentation that the applicant resided in Pennsylvania for the two (2) years immediately preceding the date of hire.
An interview with the agency Office Manager on March 25, 2024, at approximately 2:30 P.M. confirmed the above findings.
Plan of Correction:Office Manager will supply paperwork for the caregivers who are listed to be missing the proof of residency for 2 years prior to hire date. They will complete this paperwork and return it to the office where it will be placed in the file no later than 4/20. All new hire employees will be instructed to produce proof of residency for at least 2 years prior to hire date and will need to supply that to our agency prior to the hire date. Moving forward this will be done for every employee and quarterly audits of files will be preformed to make sure this is properly documented and kept in the employee file.
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 review of direct care worker personnel files (PF) and an interview with the agency staff, the agency failed to ensure initial and annual competency reviews were conducted for seven (7) of seven (7) PF reviewed. (PF # 1, 2, 3, 4, 5, 6, and 7).
Findings include:
A review of PF's conducted on March 25, 2024, from approximately 1:30 P.M. to 2:30 P.M. revealed the following:
PF #1, date of hire November 12, 2022, contained no documentation of an initial competency evaluation upon hire.
PF #2, date of hire June 26, 2023, contained no documentation of an initial competency evaluation upon hire.
PF #3, date of hire February 1, 2012, contained no documentation of an initial competency evaluation upon hire. There was no annual competency evaluation or training documented from 2013 through 2022.
PF #4, date of hire March 11, 2022, contained no documentation of an initial competency evaluation upon hire. There was no annual competency evaluation or training documented in 2023.
PF #5, date of hire May 19, 2022, contained no documentation of an initial competency evaluation upon hire.
PF #6, date of hire March 9, 2019, contained no documentation of an initial competency evaluation upon hire. There was no annual competency evaluation or training documented in 2020, 2021, and 2022.
PF #7, date of hire July 19, 2016, contained no documentation of an initial competency evaluation upon hire. There was no annual competency or training documented in 2017 through 2021, and 2023.
An interview with the agency Office Manager on March 25, 2024, at approximately 2:30 P.M. confirmed the above findings.
Plan of Correction:Current Employees that are listed to be missing a initial competency test will be given one and asked to have it completed no later than 4/20. It will be placed in the files. All new hire employees will be instructed to conduct a competency test prior to hire. Moving forward this will be completed for every employee prior to hire date and quarterly audits of files will be performed to make sure this is properly documented and kept in the employee file.
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 upon review of direct care worker personnel files (PF) and an interview with agency staff, the agency failed to ensure that baseline (preplacement) screening and testing was completed for three (3) of seven (7) PF reviewed PF #2, 3, and 5), and a symptom screen questionnaire, and/or an individual TB risk assessment and/or annual TB education was conducted for seven (7) of seven (7) PF reviewed. (PF# 1, 2, 3, 4, 5, 6, and 7).
Findings Include:
The CDC (Centers for Disease and Control and Prevention) guidelines state baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or tuberculin skin test (TST), shall include a symptom screen questionnaire and an individual tuberculosis (TB) risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
A review of PF's conducted on March 25, 2024, from approximately 1:30 P.M. to 2:30 P.M. revealed the following:
PF #1, date of hire November 12, 2022, contained no documentation that a symptom screen questionnaire and an individual TB risk assessment were completed upon hire.
PF #2, date of hire June 26, 2023, contained no documentation that baseline (preplacement) testing and an individual TB risk assessment were completed upon hire.
PF #3, date of hire February 1, 2012, contained no documentation that baseline (preplacement) testing was completed upon hire. There was no documentation that a symptom screen questionnaire and an individual TB risk assessment were completed .
PF #4, date of hire March 11, 2022, contained no documentation that a symptom screen questionnaire and an individual TB risk assessment were completed upon hire.
PF #5, date of hire May 19, 2022, contained no documentation that baseline (preplacement) testing and an individual TB risk assessment were completed upon hire.
PF #6, date of hire March 9, 2019, contained no documentation that a symptom screen questionnaire and an individual TB risk assessment were completed.
PF #7, date of hire July 19, 2016, contained no documentation that a TB risk assessment was completed.
An interview with the agency Office Manager on March 25, 2024, at approximately 2:30 P.M. confirmed the above findings.
Plan of Correction:2, 3, and 5 will be notified that they have to complete a TB screening test no later than 4/20/24. They will not be able to continue work with us if this is not completed correctly by the given date. Also moving forwards.
All missing TB paperwork including TB screening questionnaire, risk assessment and fact sheet will be provided to PF#1 and will be given to all new hire from here on.. Office Manager will closely monitor and make sure all proper documentations are collected from caregivers upon hire to ensure compliance moving forward. Quarterly file audits will be performed by office manager to make sure that moving forward all proper documentation will be completed and collected and kept in files.
611.56(b) LICENSURE
Health Screening
Name - Component - 00
(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.
Observations:
Based upon review of direct care worker personnel files (PF) and an interview with the agency staff, the agency failed to ensure annual TB education was conducted for six (6) of seven (7) PF reviewed. (PF# 1, 3, 4, 5, 6, and 7).
Findings Include:
The CDC (Centers for Disease and Control and Prevention) guidelines state baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or tuberculin skin test (TST), shall include a symptom screen questionnaire and an individual tuberculosis (TB) risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
A review of PF's conducted on March 25, 2024, from approximately 1:30 P.M. to 2:30 P.M. revealed the following:
PF #1, date of hire November 12, 2022, contained no documentation of annual TB education for 2023.
PF #3, date of hire February 1, 2012, contained no documentation of annual TB education for 2019 through 2024.
PF #4, date of hire March 11, 2022, contained no documentation of annual TB education completed for 2023 and 2024.
PF #5, date of hire May 19, 2022, contained no documentation of annual TB education completed for 2023.
PF #6, date of hire March 19, 2019, contained no documentation of annual TB education completed for 2020 through 2024.
PF #7, date of hire July 19, 2016, contained no documentation of annual TB education completed for 2019 through 2023.
An interview with the agency Office Manager on March 25, 2024, at approximately 2:30 P.M. confirmed the above findings.
Plan of Correction:Yearly TB education will be provided for all current and new hire employees. Documentation of this will be kept and placed in individual employee files. Also during quarterly audits office manager will make note to make sure this is occurring and proper docummenation of it is kept.
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 review of the agency's consumer information packet, consumer records (CR) and interview with the agency staff, the agency failed to provide documentation that the consumer was informed that 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 and that 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 for five (5) of five (5) CR reviewed. (CR#'s 1, 2, 3, 4, and 5)
Findings include:
Review of CR conducted on March 25, 2024, from approximately at 12:45 P.M. to 1:30 P.M. revealed the following:
CR #1, start of care October 3, 2023, did not contain documentation that the consumer was informed that 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 and that 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.
CR #2, start of care July 16, 2023, did not contain documentation that the consumer was informed that 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 and that 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.
CR# 3, start of care May 11, 2022, did not contain documentation that the consumer was informed that 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 and that 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.
CR# 4, start of care December 15, 2021, did not contain documentation that the consumer was informed that 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 and that 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.
CR# 5, start of care January 18, 2022, did not contain documentation that the consumer was informed that 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 and that 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.
An interview with the agency Office Manager on March 25, 2024, at approximately 2:30 P.M. confirmed the above findings.
Plan of Correction:Our client agreement will be updated to include 611.57(b) to be in regulation with Chapter 611 no late then 5/20/24.For CR 1, 2, 3, 4, 5, will be given a new copy of the updated agreement to include this and moving forward all new clients will be given the new agreement with the following statement added.
Quarterly Audits completed by the office manager will be completed on all client files to make sure that proper documentation is completed.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on March 25, 2024, Mother's Love Home Health Care Assistance Inc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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