Initial Comments:
An offsite follow up survey completed on March 18, 2024 found that Fountain of Life Home Care, Llc. had not corrected the deficiencies cited under the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries. The deficiencies were cited as a result of a state re-licensure survey completed on December 27, 2023 and an offsite follow-up survey completed on January 26, 2024.
Plan of Correction:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
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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 the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure a review of the entire agency's employee personnel files was conducted, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/18/2024 at approximately 1:00 p.m., approved by the Department on 02/12/2024, revealed the following:
"To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files including and specifically personnel file, interview process and documentation process as directed by Citation 0200. ......"
Corrective action date: 03/11/2024.
Documentation review #1: No documentation provided of stated ".... the Administrator has reviewed the entire Agency's employee personnel files."
Plan of Correction documentation was requested on 03/11/24 at approximately 3:30 p.m. Agency sent Plan of Correction documentation on 03/16/24 at approximately 3:00 a.m. Requested above missing documentation on 03/18/24 at approximately 2:58 p.m. and agency was given until 03/19/24 the end of business day to submit the missing documentation. As of 03/21/24, the missing documentation has not been submitted.
Email correspondence on March 18, 2024 at approximately 2:58 p.m. with the agency Administrator confirmed the above findings.
Plan of Correction:To ensure this Agency is in compliance with the approved Plan of Correction from the Department dated 3/18/24, the Administrator ("Admin") has reviewed the entire Agency's employee personnel files including and specifically personnel file, interview process and documentation process as directed by Citation 0200; and upon request from the Department, the Admin will forward over via email documented proof of this review.
611.52(a) LICENSURE
Criminal Background Checks
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The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.
Observations:
Based on a review of the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure a review was conducted of the entire Agency's employee personnel files, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/18/2024 at approximately 1:00 p.m., approved by the Department on 02/12/2024, revealed the following:
"To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files including and specifically Personnel files as directed by Citation 0300...... "
Corrective action date: 03/11/2024.
Documentation review #1: No documentation provided of stated ".... the Administrator has reviewed the entire Agency's employee personnel files....."
Plan of Correction documentation was requested on 03/11/24 at approximately 3:30 p.m. Agency sent Plan of Correction documentation on 03/16/24 at approximately 3:00 a.m. Requested above missing documentation on 03/18/24 at approximately 2:58 p.m. and agency was given until 03/19/24 the end of business day to submit the missing documentation. As of 03/21/24, the missing documentation has not been submitted.
Email correspondence on March 18, 2024 at approximately 2:58 p.m. with the agency Administrator confirmed the above findings.
Plan of Correction:To ensure this Agency is in compliance with the approved Plan of Correction from the Department dated 3/18/24, the Administrator ("Admin") has reviewed the entire Agency's employee personnel files as outlined by the Citation 0300; and upon request from the Department, the Admin will forward over via email documented proof of this review.
611.52(c) LICENSURE
Federal Criminal History Record
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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 the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure the Administrator conducted a review of the entire agency's employee personnel files, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/18/2024 at approximately 1:00 p.m., approved by the Department on 02/12/2024, revealed the following:
"To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files ......"
Corrective action date: 03/11/2024.
Documentation review #1: No documentation provided of stated "......the Admin has reviewed the entire Agency's employee personnel files ..."
Plan of Correction documentation was requested on 03/11/24 at approximately 3:30 p.m. Agency sent Plan of Correction documentation on 03/16/24 at approximately 3:00 a.m. Requested above missing documentation on 03/18/24 at approximately 2:58 p.m. and agency was given until 03/19/24 the end of business day to submit the missing documentation. As of 03/21/24, the missing documentation has not been submitted.
Email correspondence on March 18, 2024 at approximately 2:58 p.m. with the agency Administrator confirmed the above findings.
Plan of Correction:To ensure this Agency is in compliance with the approved Plan of Correction from the Department dated 3/18/24, the Administrator ("Admin") has reviewed the entire Agency's employee personnel files as outlined by the Citation 0320; along with obtaining all related missing documents and clearances.
And upon request from the Department, the Admin will forward over via email documented proof of this Employee Personnel File Review and related personnel missing documents.
611.55(a) LICENSURE
Competency Requirements
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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 a review of the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure the Administrator conducted a review of the entire agency's employee personnel files, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/18/2024 at approximately 1:00 p.m., approved by the Department on 02/12/2024, revealed the following:
"To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files ...."
Corrective action date: 03/11/2024.
Documentation review #1: No documentation provided of stated "Administrator conducting a review of the entire Agency's employee personnel files...."
Plan of Correction documentation was requested on 03/11/24 at approximately 3:30 p.m. Agency sent Plan of Correction documentation on 03/16/24 at approximately 3:00 a.m. Requested above missing documentation on 03/18/24 at approximately 2:58 p.m. and agency was given until 03/19/24 the end of business day to submit the missing documentation. As of 03/21/24, the missing documentation has not been submitted.
Email correspondence on March 18, 2024 at approximately 2:58 p.m. with the agency Administrator confirmed the above findings.
Plan of Correction:To ensure this Agency is in compliance with the approved Plan of Correction from the Department dated 3/18/24, the Administrator ("Admin") has reviewed the entire Agency's employee personnel files as outlined by the Citation 0600; along with obtaining all related missing documents and clearances.
And upon request from the Department, the Admin will forward over via email documented proof of this Employee Personnel File Review and related personnel missing documents.
611.55(e) LICENSURE
Competency Requirements
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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 the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure the Administrator conducted a review of the entire agency's employee personnel files and the Administrator has obtained the required documentation for ..... employee#1....", as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/18/2024 at approximately 1:00 p.m., approved by the Department on 02/12/2024, revealed the following:
"To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files ...... the Admin has obtained the required documentation for employees' personnel in EF#1, DOH 06/30/21...."
Corrective action date: 03/11/2024.
Documentation review #1: No documentation provided of stated "....the Administrator conducted a review of the entire agency's employee personnel files and the Administrator has obtained the required documentation for ..... employee #1...."
Plan of Correction documentation was requested on 03/11/24 at approximately 3:30 p.m. Agency sent Plan of Correction documentation on 03/16/24 at approximately 3:00 a.m. Requested above missing documentation on 03/18/24 at approximately 2:58 p.m. and agency was given until 03/19/24 the end of business day to submit the missing documentation. As of 03/21/24, the missing documentation has not been submitted.
Email correspondence on March 18, 2024 at approximately 2:58 p.m. with the agency Administrator confirmed the above findings.
Plan of Correction:To ensure this Agency is in compliance with the approved Plan of Correction from the Department dated 3/18/24, the Administrator ("Admin") has reviewed the entire Agency's employee personnel files as outlined by the Citation 0621; along with obtaining all related missing documents and clearances.
And upon request from the Department, the Admin will forward over via email documented proof of this Employee Personnel File Review and related personnel missing documents.
611.56(a) LICENSURE
Health Screening
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(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 the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure the Administrator conducted a review of the entire Agency's employee personnel files and the Administrator has contacted the identified employees (EF# 1, 2, 3 and 4) and requested all employees complete the required documentation for the mycobacterium tuberculosis symptom screen questionnaire and an individual TB risk assessment, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/18/2024 at approximately 1:00 p.m., approved by the Department on 02/12/2024, revealed the following:
"....... the Admin has reviewed the entire Agency's employee personnel files the Admin has contacted the identified employees' and (EF# 1, 2, 3 and 4) and requested all employees' complete the required documentation for the mycobacterium tuberculosis symptom screen questionnaire and an individual TB risk assessment....."
Corrective action date: 03/11/2024.
Documentation review #1: No documentation provided of stated "Administrator conducted a review of the entire Agency's employee personnel files and the Administrator has contacted the identified employees' and (EF# 1, 2, 3 and 4) and requested all employees' complete the required documentation for the mycobacterium tuberculosis symptom screen questionnaire and an individual TB risk assessment...."
Plan of Correction documentation was requested on 03/11/24 at approximately 3:30 p.m. Agency sent Plan of Correction documentation on 03/16/24 at approximately 3:00 a.m. Requested above missing documentation on 03/18/24 at approximately 2:58 p.m. and agency was given until 03/19/24 the end of business day to submit the missing documentation. As of 03/21/24, the missing documentation has not been submitted.
Email correspondence on March 18, 2024 at approximately 2:58 p.m. with the agency Administrator confirmed the above findings.
Plan of Correction:To ensure this Agency is in compliance with the approved Plan of Correction from the Department dated 3/18/24, the Administrator ("Admin") has reviewed the entire Agency's employee personnel files as outlined by the Citation 0700; along with obtaining all related missing documents and clearances.
And upon request from the Department, the Admin will forward over via email documented proof of this Employee Personnel File Review and related personnel file missing documents.
611.56(b) LICENSURE
Health Screening
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(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 the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure the Administrator conducted a review of the entire agency's employee personnel files and providing all employees' with annual mycobacterium tuberculosis education especially (employee#1), as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/18/2024 at approximately 1:00 p.m., approved by the Department on 02/12/2024, revealed the following:
"...... the Admin has reviewed the entire Agency's employee personnel files.... We have also provided all employees' with annual mycobacterium tuberculosis education especially (EF#1 DOH 06/30/21)....."
Corrective action date: 03/11/2024.
Documentation review #1: No documentation provided of stated "the Administrator conducting a review of the entire agency's employee personnel files nor providing all employees' with annual mycobacterium tuberculosis education especially (employee#1)."
Plan of Correction documentation was requested on 03/11/24 at approximately 3:30 p.m. Agency sent Plan of Correction documentation on 03/16/24 at approximately 3:00 a.m. Requested above missing documentation on 03/18/24 at approximately 2:58 p.m. and agency was given until 03/19/24 the end of business day to submit the missing documentation. As of 03/21/24, the missing documentation has not been submitted.
Email correspondence on March 18, 2024 at approximately 2:58 p.m. with the agency Administrator confirmed the above findings.
Plan of Correction:o ensure this Agency is in compliance with the approved Plan of Correction from the Department dated 3/18/24, the Administrator ("Admin") has reviewed the entire Agency's employee personnel files as outlined by the Citation 0710; along with obtaining all related missing documents and clearances.
And upon request from the Department, the Admin will forward over via email documented proof of this Employee Personnel File Review and related personnel file missing documents.
Initial Comments:
An offsite follow up survey completed on March 18, 2024 found that Fountain of Life Home Care, Llc. had corrected the deficiency cited under the requirements of 35 P.S. 448.809 (b). The deficiency was cited as a result of a state re-licensure survey completed on December 27, 2023 and an offsite follow up survey completed on January 26, 2024.
Plan of Correction:
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