Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed March 19, 2024, Effraim Home Care Agency, Llc. was found to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed March 19, 2024, Effraim Home Care Agency, 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:
611.51(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 review of employee files and an interview with the agency Operations Manager, the agency failed to obtain not less than two satisfactory references, not related to the individual, prior to hire, for one (1) out of five (5) employee files (EF) reviewed (EF#4).
Findings include:
A review of EFs was conducted on March 19, 2024 at approximately 9:45 a.m. Employee date of hire (DOH) is listed below.
EF#4 DOH 05/12/23: Documentation provided of a reference by (family member) obtained on 04/21/23. Documentation provided of a reference by (family member) obtained on 05/11/23.
An interview conducted with the agency Operations Manager on March 19, 2024 at approximately 11:30 a.m. confirmed the above findings.
Plan of Correction:The agency shall follow Policy # HR-1.0 Selecting and Hiring Personnel that requires that all direct care workers must have at least two (2) satisfactory references from a former employer or other person not related to the applicant documented in their personnel file.
A mandatory inservice will be held for all administrative and human resources management staff by 04/10/2024 to educate them to the need to follow the state requirement and the agency's policy for the documentation of two satisfactory references in the employee's personnel file from a former employer or other person not related to the applicant and to document this reference check form on the personnel file checklist.
Staff sign-in sheet, agenda and training documentation will be available on site.
Employee file # 4 will have two satisfactory reference checks completed and documented from a former employer or other person not related to the applicant and this will be documented on the reference check form. These will be placed in the personnel file, noting that these items were corrected as a result of a survey deficiency and have been placed in the file late to correct the deficiency. All documents will be noted on the personnel file checklist once completed. This will be completed by 03/29/2024 by the Operations Manager or designee.
In order to avoid this deficiency in the future, this element will be added to the agency's Quality Management Plan effective 04/01/2024: 25% of the direct care worker's personnel files will be audited quarterly to verify that two positive verifiable references from two individuals who are either former employers or other people not related to the individual are completed prior to hire and are part of the personnel file for each direct care worker. Target Threshold = 100%.
The Operations Manager is responsible.
Corrective Action Completion Date: 04/16/2024
611.52(c) LICENSURE
Federal Criminal History Record
Name - Component - 00
If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code § 15.144(b) (relating to procedure).
Observations:
Based on a review of employee files and an interview with the agency Operations Manager, agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for four (4) out of five (5) employee files (EF) reviewed (EF#1, EF#2, EF#4, EF#5).
Findings include:
A review of EFs was conducted on March 19, 2024 at approximately 9:45 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 03/02/23: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Drivers License issued 12/06/22 with an expiration date of 12/13/26. 'Application for Employment' record was reviewed. No employment history listed for the previous two years prior to hire. No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 03/02/21-12/06/22.
EF#2 DOH 04/28/23: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Drivers License issued 06/09/22 with an expiration date of 12/01/25. 'Application for Employment' record was reviewed. Prior employer with a Pa. address was listed with incomplete dates 'From:' "2021-2022." No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 04/28/21-06/09/22.
EF#4 DOH 05/12/23: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Drivers License issued 10/20/21 with an expiration date of 07/31/24. 'Application for Employment' record was reviewed. Prior employer with a Pa. address was listed with dates 'From:' "03/15/2022" 'To:' "Until Now." No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 05/12/21-10/20/21.
EF#5 DOH 05/12/20: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Drivers License issued 03/14/20 with an expiration date of 08/04/23. 'Application for Employment' record was reviewed. Prior employer with an incomplete address was listed with dates 'From:' "09/2019" 'To:' "01/2020." No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 05/12/18-03/14/20.
An interview conducted with the agency Operations Manager on March 19, 2024 at approximately 11:30 a.m. confirmed the above findings.
Plan of Correction:The agency will follow the agency policy # HR-8.0—Employee Background Checks which includes the requirement that the individual must provide proof of residency in Pennsylvania (Pa.) for the 2 years immediately preceding application for employment and if not a PA resident for two years must provide an FBI Background Check and a letter of Determination from the PA Department of Aging.
A mandatory inservice for all administrative and management staff will be held by 04/10/2024 to educate staff to the need to follow the state requirement and agency's policy that prior to being hired, all employees must follow policy # HR-8.0—Employee Background Checks which includes the requirement that the individual being hired must provide proof of Pennsylvania residency for the 2 years immediately preceding application for employment. If there is no proof of continuous residency in PA, the employee must provide an FBI Background Check and a letter of Determination from the PA Department of Aging. 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).
Staff attendance sheets, agenda and training documentation will be available on site.
Employees #1, 2, 4 and 5 will have their FBI background check and a letter of Determination from the PA Department of Aging run immediately to bring their records into compliance per regulatory guidelines.
By 04/01/24, the Operations Manager will initiate quarterly audits of 25% of the employee files as part of the agency's Quality Management Plan to verify that:
1.Staff have provided proof of residency in Pennsylvania for the 2 years immediately preceding application for employment
a.) If no proof of residency in PA, an FBI Background Check and a letter of Determination from the PA Department of Aging has been run for the employee
b.) If the employee has proof of PA residency, a Pennsylvania Criminal Background Check--PATCH has been run
c.) A ChildLine Verification will be completed, as appropriate, if the direct care workers is in a home where there is likelihood of contact with children.
Target Threshold = 100%.
The Operations Manager is responsible.
Completion Date = 04/16/2024
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 employee files and an interview with the agency Operations Manager, agency failed to provide documentation showing annual competency review covering all required sixteen (16) subject areas for two (2) of five (5) employee files (EF) reviewed (EF#3, EF#5).
Findings include:
A review of EFs was conducted on March 19, 2024 at approximately 9:45 a.m. Employee date of hire (DOH) is listed below.
EF#3 DOH 08/09/22: No documentation provided of a 2023 annual competency review containing all sixteen (16) required elements.
EF#5 DOH 05/12/20: No documentation provided of a 2023 annual competency review containing all sixteen (16) required elements.
An interview conducted with the agency Operations Manager on March 19, 2024 at approximately 11:30 a.m. confirmed the above findings.
Plan of Correction:The agency will follow the Department of Health guidelines and the agency Policy: HR # 4.0--Competency Requirements including the Competency Test and Competency and Performance Evaluation Checklist effective 03/21/2024 covering all required sixteen (16) subject areas at least once per year, after initial competency is established, and more frequently when discipline or other sanctions, including, for example, a verbal warning or suspension, is imposed because of a quality of care infractions. Furthermore:
The employees noted under EF#3 and EF #5 will complete the agency Competency Test and/or the Competency and Performance Evaluation Checklist will be completed with them to verify their competency for 2023 no later than 04/01/2024.
A mandatory inservice for all administrative and management staff will be held by 04/10/2024 to educate current staff to the need to follow the state requirement and agency's policy that all direct care workers must have a competency review, covering all required sixteen (16) subject areas, at least once per year after initial competency is established.
Staff sign-in sheets, agenda and training documentation will be available on site.
In order to avoid this deficiency in the future, effective 04/01/2024, the Operations Manager will add this element to the agency's Quality Management Plan with 25% of the direct care worker's personnel files audited quarterly to ensure completion of annual direct care staff competency with documentation on the competency evaluation checklist to comply with this element of the PA regulations. Target Threshold = 100%.
The Operations Manager is responsible.
Completion Date: 04/16/2024
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 employee files and an interview with the agency Operations Manager, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, was screened for and is free from active mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for five (5) out of five (5) employee files (EF) reviewed (EF#1-EF#5).
Findings Include:
The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs with a baseline positive or newly 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; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.)
*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. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
A review of EFs was conducted on March 19, 2024 at approximately 9:45 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 03/02/23: No documentation provided of an individual TB risk assessment, containing all three required questions, upon hire.
EF#2 DOH 04/28/23: No documentation provided of an individual TB risk assessment, containing all three required questions, upon hire.
EF#3 DOH 08/09/22: No documentation provided of an individual TB risk assessment, containing all three required questions. Documentation provided of a one step TB skin test conducted on 07/23/22. No documentation provided of obtaining the second step TB skin test.
EF#4 DOH 05/12/23: No documentation provided of an individual TB risk assessment, containing all three required questions, upon hire.
EF#5 DOH 05/12/20: No documentation provided of an individual TB risk assessment, containing all three required questions, upon hire.
An interview conducted with the agency Operations Manager on March 19, 2024 at approximately 11:30 a.m. confirmed the above findings.
Plan of Correction:The agency shall follow the state guidelines to verify that all direct care staff, other office staff or contractors with direct consumer contact, are screened for and are free from active mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines and per the agency policy HR-6.0 Tuberculosis Screening using the updated agency Tuberculosis Risk Assessment Questionnaire with the required three questions.
An updated Tuberculosis Risk Assessment Questionnaire with the correct language for the required three questions will be completed on EF's # 1, 2, 3, 4 and 5.
For EF # 3—documentation of the employee's second step TB test that occurred after July 2022 and prior to June 23, 2023, will be found; or the employee will have another 2-step TB test completed now and placed in their personnel file by 04/16/2024.
A mandatory inservice for all management and human resources staff is to be held by 04/10/2024 to educate personnel to the need to follow the state requirement and the agency's policy that all direct care staff, other office staff or contractors with direct consumer contact, must complete the Tuberculosis Risk Assessment Questionnaire with the three required questions at hire prior to consumer contact and on an annual basis thereafter.
Staff sign-in sheets, agenda and training documentation will be available on site.
In order to avoid this deficiency in the future, this element will be added to the agency's Quality Management Plan effective 04/01/2024 with 25% of the direct care worker's personnel files audited quarterly to verify that the TB Risk Assessment Questionnaire has been completed prior to consumer contact at hire and annually thereafter for all direct care workers, office staff and contractors. Target Threshold = 100%
The Operations Manager is responsible.
Completion Date: 04/16/2024
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 on a review of employee files and an interview with the agency Operations Manager, agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, were provided with annual mycobacterium tuberculosis education, for two (2) of two (2) employee files (EF) annual documentation reviewed (EF#3, EF#5).
Findings Include:
The CDC (Center for Disease and Control) guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. ........ HCWs with a baseline positive or newly 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; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.)
*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. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
A review of EFs was conducted on March 19, 2024 at approximately 9:45 a.m. Employee date of hire (DOH) is listed below.
EF#3 DOH 08/09/22: No documentation provided of 2023 annual TB education.
EF#5 DOH 05/12/20: No documentation provided of 2023 annual TB education.
An interview conducted with the agency Operations Manager on March 19, 2024 at approximately 11:30 a.m. confirmed the above findings.
Plan of Correction:The agency will follow the state guidelines and ensure each direct care worker, other office staff or contractors with direct consumer contact are provided with annual mycobacterium tuberculosis education.
The staff persons noted under EF# 3 and #5 will receive the 2023 annual mycobacterium tuberculosis education that was missed by 04/05/2024.
A mandatory inservice will be held for all management and human resources staff by 04/10/2024 to educate current staff to the need to follow the state requirement related to the need for all direct care workers, other office staff or contractors with direct consumer contact to annually receive mycobacterium tuberculosis education.
Staff sign-in sheets, agenda and training documentation will be available on site.
In order to avoid this deficiency in the future, this element will be added to the agency's Quality Management Plan effective 04/01/2024 with 25% of the direct care worker's personnel files audited quarterly to verify that: all direct care workers, other office staff or contractors with direct consumer contact received their annual mycobacterium tuberculosis (TB) education.
Target Threshold = 100%.
The Operations Manager is responsible.
Completion Date 04/16/2024
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, the consumer admission packet, and an interview with the agency Operations Manager, the agency failed to provide the consumer, prior to the commencement of services, the hours when the services will be provided, for one (1) out of four (4) consumer files (CF) reviewed (CF#1).
Findings include:
A review of CFs was conducted on March 19, 2024 at approximately 9:45 a.m. Consumer start of service (SOS) is listed below.
CF#1 SOS 03/02/23: No documentation provided of the agency providing the consumer with the hours when the services will be provided.
An interview conducted with the agency Operations Manager on March 19, 2024 at approximately 11:30 a.m. confirmed the above findings.
Plan of Correction:The following steps have been taken with the consumer affected by this deficiency:
CF#1 has been updated to reflect the hours the services to be provided to the consumer and a new consumer service agreement is being provided to the consumer to sign by 04/01/2024.
An inservice education session will be held with all Management Staff by 04/10/2024 to review the state requirements relative to what must be provided to the consumer on admission relative to the consumer service agreement with particular emphasis on including the hours of service to be provided to the consumer. This inservice education will include training on the new consumer service agreement which has been created for "Direct Care Workers" which will be used on all admissions effective 04/01/2024.
In order to avoid this deficiency in the future, this element will be added to the agency's Quality Management Plan effective 04/01/2024, with 25% of the client records reviewed each quarter as supervisory visits occur to have the consumers sign new consumer service agreements in order to replace the prior consumer service agreements with the new agreements that note the home care is provided by "direct care workers".
The Operations Manager is responsible.
Completion Date 04/16/2024
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed March 19, 2024, Effraim Home Care Agency, Llc. was found not to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
35 P. S. § 448.809b LICENSURE
Photo Id Reg
Name - Component - 00
Law amended July 11, 2022 Act 79 2022 HB 2604
(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.
(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.
(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.
(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.
Observations:
Based on observation of Identification badges (ID) and an interview with the agency Operations Manager, agency failed to format/issue ID badges per regulatory requirements for one (1) of one (1) observation (Observation #1).
Findings include:
Observation #1: Observation of employee Identification Badge (ID) on March 19, 2024 at approximately 10:45 a.m. revealed the current ID badge employee title does not occupy the bottom 1/2" of the badge, as large as possible. The employee title is incorrectly labeled as "Caregiver" (the actual employee title is 'Direct Care Worker') and is approximately 1/4" tall and is located above the bottom 1/2" of the badge.
An interview conducted with the agency Operations Manager on March 19, 2024 at approximately 11:30 a.m. confirmed the above findings.
Plan of Correction:For all current direct care workers, the agency shall create a photo identification badge with the employee title 'Direct Care Worker', occupying the bottom 1/2" tall strip of the badge, as large as possible in block letters by 04/16/2024. Each employee will receive a signature sheet to confirm that they received a new photo identification badge with their correct name and title listed on it and it will be placed in their personnel file.
For each new employee upon hire a form shall be created in order to verify that new employee ID badge has the correct employee name and title for the ID badge, so the employee can sign off on the form to verify that their name and title as noted in their signed job description matches their photo ID badge which will be created per the above specifications.
The Operations Manager is responsible.
Completion Date is 04/16/2024
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