Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey conducted on April 10, 2025, Helping Hand Nurse, LLC, 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 unannounced onsite state re-licensure survey conducted on April 10, 2025, Helping Hand Nurse, LLC, 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:
611.53(a) LICENSURE
Child Abuse Clearances
Name - Component - 00
A home care agency or home care registry that serves persons under 18 years of age shall require each applicant for employment or referral as a direct care worker, each applicant for employment as a member of the agency or registry office staff to request a ChildLine verification regarding whether the applicant is named in the Statewide Central Register as the perpetrator of a founded or indicated report of child abuse as defined at 55 Pa. Code § 3490.4 (relating to definitions).
Observations:
Based upon review of personnel files (PFs) and an interview with the agency's Senior Operations Manager, the agency failed to require each applicant for employment or referral as a direct care worker and/or each applicant for employment as a member of the agency or registry office staff to request a ChildLine verification for two (2) out of the seven (7) personnel files reviewed (PF#4 and PF#7).
Personnel file review conducted April 10, 2025, from approximately 2:30 pm to 4:10 pm revealed the following:
PF#4 Date of hire (DOH) 5/30/24: Agency failed to provide documentation of a Childline verification being conducted upon application for employment, due to the agency providing services to persons less than 18 years of age. Childline verification on file is dated 11/14/19, Four (4) years and six months before the application date.
PF#7 DOH 10/5/23: Agency failed to provide documentation of a Childline verification being conducted upon application for employment, due to the agency providing services to persons less than 18 years of age. Childline verification on file dated 10/13/23.
An interview with the Senior Operations Manager conducted on April 10, 2025 at approximately 4:15PM confirmed the above findings.
Plan of Correction:Helping Hand Nurse will address the deficiency related to obtaining a Childline Verification for employees servicing persons under the age of 18. All active employee files will also be reviewed to ensure compliance with regulation.
An in-service will be conducted with the Human Resources (HR) department by June 5th, 2025, reinforcing the requirement that all new hires servincing persons under the age of 18 must obtain a Childline Verification before their start date.
To ensure understanding and compliance with this requirement, the HR Manager and Administrator is responsible for implementing these corrective actions, and compliance will be monitored continuously to prevent recurrence.
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 review of personnel files (PF), the Centers for Disease Control Guidelines, and an interview with the agency Senior Operations Manager, it was determined the agency failed to ensure direct care workers were screened for and were free from active mycobacterium tuberculosis prior to assignment with clients for five (5) out of seven (7) direct personnel files reviewed. (PF #1, PF#2, PF #4, PF #6, and PF#7).
Findings include:
In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: receive baseline tuberculosis screening upon hire by using: a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB), or a negative chest x-ray to test for infection with tuberculosis. 2. Completion of a tuberculosis symptom questionnaire. And 3. Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCWs should receive TB education annually. HCWs with a baseline 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;(5-16-19)
Personnel file review conducted April 10, 2025, from approximately 2:30 pm to 4:10 pm revealed the following:
PF #1 Date of hire (DOH) 10/20/23: Did not contain documentation of a completed tuberculosis test. One (1) TST dated 10/13/23 on file. No documentation of a second TST on file.
PF#2 DOH 11/20/23: Did not contain documentation of a completed tuberculosis (TB) test. One (1) TST dated 5/30/23 on file. No documentation of a second TST on file.
PF#4 DOH 5/30/24: : Did not contain documentation of a TB test.
PF#6 DOH 1/19/25: Did not contain documentation of a completed tuberculosis (TB) test. One (1) TST dated 12/20/24 on file. No documentation of a second TST on file.
PF#7 DOH 10/5/23 Did not contain documentation of a completed tuberculosis (TB) test. One (1) TST dated 9/27/22 on file. No documentation of a second TST on file.
An interview with the Senior Operations Manager conducted on April 10, 2025 at approximately 4:15PM confirmed the above findings.
Plan of Correction:Helping Hand Nurse will address the deficiency related to tuberculosis (TB) screening. Employee PF#6 will complete the second step of the two-step tuberculin skin test by June 5th, 2025. Employee PF#1, PF#2, PF#4 and PF#7 will complete a new TB testing using a two-step tuberculin skin test or a single blood assay to test for infection with tuberculosis by June 5th, 2025.
An inservice will be conducted for all HR and scheduling staff reinforcing the requirement that TB testing using a two-step tuberculin skin test or a single blood assay must be completed before direct care. HR will conduct periodic audits to ensure ongoing compliance. The Administrator and HR Manager will oversee these actions and ensure full implementation.
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 a review of consumer files (CF) and an interview with the agency 's Senior Operations Manager, the agency failed to provide the following information to the consumer, the consumer's legal representative, or a responsible family member prior to the start of services: (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 for three (3) of the seven (7) CF's reviewed. (CF#2-4)
Findings include:
A review of consumer files (CF) was conducted on April 10, 2025, from approximately 1:15PM pm to 2:30pm revealed the following:
CF#2 Start of care (SOC) 11/20/23: Contained no documentation that prior to the start of services, the consumer, the consumer's legal representative, or a responsible family member received the following: (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. The Service agreement on file was signed on 12/6/23, after the start of services.
CF#3 SOC 3/18/24: Contained no documentation that prior to the start of services, the consumer, the consumer's legal representative, or a responsible family member received the following: (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. No evidence of a service agreement on file.
CF#4 SOC 5/22/24: Contained no documentation that prior to the start of services, the consumer, the consumer's legal representative, or a responsible family member received the following: (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. Service agreement on file without a date.
An interview with the Senior Operations Manager conducted on April 10, 2025 at approximately 4:15PM confirmed the above findings.
Plan of Correction:Helping Hand Nurse will ensure all consumers receive complete and accurate information packets before the commencement of services Consumer File CF# 2, CF#3 and CF#4 who did not receive a fully documented information packet, will receive a packet by the completion date.
A full review of all active consumer files will be conducted by the completion date, to verify that every consumer has received the updated information packet.
An in-service session will be conducted for care coordinators by the completion date, to reinforce the importance of properly documenting and distributing consumer information packets prior to the commencement of services. A new tracking system will be implemented to prevent future occurrences. The Administrator and HR Manager will oversee these actions and ensure full implementation.
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey conducted on April 10, 2025, Helping Hand Nurse, LLC, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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