Initial Comments:
Based on the findings of an onsite unannounced revisit completed August 9, 2023, Cherish Your Love Ones had corrected the deficiency cited under PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51. The deficiency was cited as a result of a state survey completed March 23, 2023.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced revisit completed August 9, 2023, Cherish Your Love Ones had not corrected the deficiencies cited under PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries. The deficiencies were cited as a result of a state survey completed March 23, 2023.
Plan of Correction:
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 for two (2) of two (2) personnel files (PF1, & PF2).
Finding included:
According to CDC guidelines "Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment." Retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6819-H.pdf
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 ... 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." Retrieved from http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf
Review of personnel files was conducted on August 9, 2023, at 10:30 a.m.
PF1 was hired on 7/24/2023 and began providing services to consumers on 8/9/2023. PF1 contained no symptom screen and no individual risk assessment.
PF2 was hired on 7/11/2023 and began providing services to consumers on 8/1/2023. PF2 contained one negative TST completed 3/21/2023 with no documented second step, no symptom screen, and no individual risk assessment.
Interview with EMP1 on August 9, 2023, at 11:30 a.m. confirmed above findings.
Plan of Correction:The agency has put in place a symptom screen questionnaire and individual TB risk assessment, according to CDC guidelines. The agency will monitor, that the screening questionnaire be done prior to hiring, and monitoring will be done on a monthly bases. The Office Manager will be responsible for for over seeing that this is done.
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 files (CF), agency information packet, and staff (EMP) interview, the agency failed to provide the consumer with required information in a format that was easily read and understood prior to commencement of services for two (2) of two (2) consumer files reviewed (CF1, & CF2).
Findings included:
Review of consumer files was conducted on August 9, 2023, at 10:30 a.m.
CF1 signed their service agreement on 6/16/2023 and services commenced on 6/26/2023, but CF1 received incorrect information as listed below.
CF2 signed their service agreement on 4/27/2023 and services commenced on 5/4/2023, but CF2 received incorrect information as listed below.
Review of agency's information packet on August 9, 2023, at 10:09 a.m. revealed it contained information that was not easily read and understood. The Department's correct hotline number was listed on one page, but an incorrect hotline number appeared on another page of the 26-page packet leaving the consumer with contradictory information that was not easily read and understood. The packet also contained the incorrect (Walnut Street) mailing address for the Department-- the Department's change of address was communicated to all agencies on May 8, 2023, via the Department of Health Message Board.
Interview with EMP1 on August 9, 2023, at 11:30 a.m. confirmed above findings.
Plan of Correction:The agency has updated the consumer packet, and has sent out the information to all consumers on the roster. The agency will monitor the the consumer packet every week and make the necessary changes to the consumer packet as needed. The Office Manager will be responsible for over seeing that this is done.
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