QA Investigation Results

Pennsylvania Department of Health
ACT HOME HEALTH SERVICES, INC.
Health Inspection Results
ACT HOME HEALTH SERVICES, INC.
Health Inspection Results For:


There are  16 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an unannounced onsite Medicare recertification survey conducted April 27, 2021 through April 29, 2021, Act Home Health Services, Inc., was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.




Plan of Correction:




484.80(d) STANDARD
12 hours inservice every 12 months

Name - Component - 00
Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient.

Observations:


Based on a review of personnel files (PF), interview with agency staff, and review of agency documentation of in-service education, the agency failed to provide documentation of annual number of in-service hours for two (2) of two (2) home health aide (HHA) PF reviewed (PFs # 1 & 2).

Findings Include:

Review of agency policy titled, "Staff Training Policy" on 4/29/21 at approximately 10:30 AM stated, "Home Health aides will receive twelve (12) in-service trainings as required by Federal/State/Joint Commission regulations and standards...Agency-wide meetings/in-service trainings will be scheduled one (1) in the springtime and another one (1) in the fall season yearly...Home Health aides will be required to complete at least three (3) or more in-services every quarter until twelve (12) in-services trainings are completed."

Review of agency document titled "General Staff meeting topic receipt form 5/22/20" on 4/28/21 at approximately 10 AM contains the following topics "Covid-19 Info related to symptoms, caring for a person at home with covid-19, ACT organizational chart, MEGA HIPPA law, ACT Integrity program..., Abuse, Neglect and Exploitation, Incident Management, Emergency Preparedness plan, Patient's concerns and grievances, patients with hearing impairment/nursing responsibilities, patients with visual and speech impairment, policy on use of restraints, policy on reporting unauthorized restrictive interventions, policy and procedures on how to handle patients with behavior problems, safety in the home and infection control, Division of Intellectual Disability Services (ID) Beliefs/Values, ACT Quality Improvement, policy on transporting patients/family members, Documentation requirements- compliance with medication/treatment administration record, call out and cancellation policy, compliance with authorized hours and others"

An interview with the administrator on 4/29/21 at approximatley 11 AM stated the topics in the General Staff meeting are not meant for the Home Health aides 12 hours of inservice, this is a meeting with all disciplines as a lot of the topics are meant for the nurses. It was also stated that this meeting is conducted in one day.

Review of personnel files conducted on 4/28/21, at approximately 12:00 P.M. revealed the following:

PF #1, Date of Hire: 2/7/19, revealed a document showing attendance at general staff meeting in 2019 and 2020 Document did not contain how many hours of in-services were conducted.

PF #2, Date of Hire: 10/19/18, revealed a document showing attendance at general staff meeting in 2019 and 2020 Document did not contain how many hours of in-services were conducted.



Interview with the administrator and human resources manager on 4/29/21, at approximately 1:00 P.M. confirmed the above findings.







Plan of Correction:

The Human Resources Manager had revised the scheduling of the home health aides in-services for the year 2021. The aides received their 3 modules for the first quarter (May 2021), with each module equals to an hour to complete. and by the end of the 2nd quarter (June 2021) they will be receiving 3 additional modules (each module = 1 hour).

Each quarter till December 2021, the aides will receive 3 modules each for 3rd and 4th quarters to complete 12 hours of in-services.

The Human Resources Coordinator will ensure that all the aides will receive 12 hours of in-services for the year 2021.

The Human Resources Manager will oversee the compliance of this process.


484.105(b)(1)(iv) ELEMENT
Ensure that HHA employs qualified personnel

Name - Component - 00
(iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies.

Observations:


Based on a review of personnel files (PFs), review of policies and procedures, and an interview with the Administrator, the agency did not conduct testing for mycobacterium tuberculosis according to the Center for Disease Control guidelines for six (6) of nine (9) personnel files reviewed. (PFs # 1, 2, 3, 5, 6, 7 ) and the agency did not maintain current CPR certification for all clinical staff for two (2) of nine (9) PF reviewed of clinical staff (PFs # 1 & 7) and personnel files did not contain a signed job description on hire for five (5) of nine (9) personnel files reviewed (PFs #1, 2, 3, 5, 7) and agency did not obtain Child Abuse Clearance every five years for two (2) of nine (9) personnel files (PFs # 8 & 9).


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) of 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.

Review of Pennsylvania's Child Welfare Information Solution website on 4/29/21 at approxmiatley 3PM revealed that "Beginning July 1, 2015, certifications (child abuse clearances) must be obtained every 60 months.Any employee with current certification issued prior to July 1, 2015, that is older than 60 months must renew their certificate by December 31, 2015. If an individual or agency elects to renew all required employment certifications at the same time, the date of the oldest certification, rather than the most recent, is the date to be used for the renewal date"


Review of Policies occurred on 4/29/21 at approximately 10:00 A.M.

Policy titled, "Child Abuse Clearance" reviewed and does not mention the requirement to obtain an updated clearance every five (5) years.

Job descriptions for Registered Nurse, Licensed Practical Nurse and Home Health aide revealed "Competency/skill requirement: CPR certified."

Surveyor asked for TB testing policy and agency unable to obtain a copy to give to surveyor.



A review of the personnel files was conducted on 4/28/21 at approximately 12 PM.

PF#1, Date of Hire (DOH): 2/7/19. File did not contain a copy of a signed job description on hire. File contained TB screening questionaire completed on 2/7/19. There was no documentation of a two-step TST and/or chest x-ray. In addition, there was no TB screening completed in 2020. File also did not contain CPR certification.

PF#2, DOH: 10/19/18. File did not contain a copy of a signed job description on hire.. File did not contain TB screening completed in 2020.

PF#3, DOH: 11/28/18. File did not contain a copy of a signed job description on hire. File contained TB screening questionaire completed in 2018, a 1 step TST complied on 8/12/18 and a doctors note which stated history of positive testing. There was no documentation of a Chest X-ray completed. In addition, there was no TB screening completed in 2019 and 2020.

PF#5, DOH: 7/27/18. File did not contain a copy of a signed job description on hire. File contained TB screening questionaire completed in 2018. There was no documentation of a two-step TST and/or chest x-ray completed.

PF#6, DOH: 11/2/18. File did not contain documentation of TB screening completed in 2020.

PF#7, DOH: 10/16/17. File did not contain a copy of a signed job description on hire. File did not contain documentation of TB screening completed in 2019 and 2020.

PF#8, DOH: 2/14/05. File contained Child Abuse Clearance obtained in 2005 and was not renewed until 4/28/21.

PF#9, DOH: 12/23/08. File contained Child Abuse Clearance obtained in 2008 and was not renewed until 4/29/21.



Interview with the Administrator on 4/29/21 at approximately 1:00 PM confirmed the above findings.









Plan of Correction:

1) The agency had always follows it's policy and procedures based on Center for Disease Control guidelines with regards to Tuberculosis testing for employees and all staff working with the agency.

During the survey, the entire chapter for Employee Health was missing from the main Human Resources Department binder. Luckily, the policy and procedures were saved in the agency computer system and were printed out after the survey. The policy and procedures for Employee Health was also being revised due to the current Center for Disease Control guidelines on TB monitoring at the time of the survey that resulted it to be not available to the surveyor.

As soon as the survey was over, May 01, 2021, The Human Resources Manager revised the policy in monitoring Tuberculosis testing/ monitoring by using the tuberculosis questionnaire to be sent to all current and active staff for the agency including but not limited to all office employees. For newly hired or contracted staff, they will still be required to get the 2 step tuberculosis testing or presentation of a current chest x-ray report for those testing positive with the purified protein derivatives (PPD).

2) The Human Resources Manager with his staff continue to contact the nurses and aides regarding their CPR certification. Since there are no current classes being offered by the agency in the office due to the current pandemic, the agency provided information on how to obtain the re-certification on- line.

The Human Resources Coordinator will monitor compliance on CPR certification and will report to the Human Resources Manager quarterly.

3) All newly hired or contracted employee/ staff will be given their job description prior to starting their position or case. A copy of the job description will included in the orientation packet.

The Human Resources Manager will monitor and ensure compliance.

4) The two (2) files that dis not have the updated Child Abuse clearance were process immediately by the Human Resources Manager. As of May 7, 2021, one had received her clearance and original submitted to Human Resources Department while the other employee still awaiting results at this time.

The Human Resources Coordinator will review the staff files monthly to make sure everyone's Child Abuse Clearance will be update every 5 years.

The Human Resources Manager will ensure compliance annually.


Initial Comments:


Based on the findings of an onsite unannounced medicare recertification survey conducted on April 27, 2021 through April 29, 2021, Act Home Health Services, Inc., was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.



Plan of Correction:




484.102(d)(2) STANDARD
EP Testing Requirements

Name - Component - 00
416.54(d)(2), 418.113(d)(2), 441.184(d)(2), 460.84(d)(2), 482.15(d)(2), 483.73(d)(2), 483.475(d)(2), 484.102(d)(2), 485.68(d)(2), 485.625(d)(2), 485.727(d)(2), 485.920(d)(2), 491.12(d)(2), 494.62(d)(2).

*[For ASCs at 416.54, CORFs at 485.68, OPO, "Organizations" under 485.727, CMHCs at 485.920, RHCs/FQHCs at 491.12, and ESRD Facilities at 494.62]:

(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:

(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.


*[For PRFTs at 441.184(d), Hospitals at 482.15(d), CAHs at 485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.

*[For PACE at 460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.

*[For LTC Facilities at 483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.

*[For ICF/IIDs at 483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.

*[For HHAs at 484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.

*[For OPOs at 486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

*[ RNCHIs at 403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.

Observations:



Based on interview with the administrator, the review of the agency's emergency preparedness plan, the agency failed to include sufficient documentation for an unannounced drill, tabletop exercise, emergency drills or participate in a full-scale community-based exercise.

Findings:
A review of the agency emergency preparedness plan was conducted on 4/28/21 at approximately 11:00 A.M.
There was documentation of an active shooter drill on 1/23/19 and a fire drill that was conducted on 12/10/19 . There was no documentation of exercises to test the emergency plan at least annually.


Interview with the administrator on 4/29/21 at approximately 1:00 P.M confirmed the above findings.






















Plan of Correction:

The Administrator reviewed the agency's Emergency Preparedness Policy and Procedures to meet the regulations and guidelines.

The agency will continue to have fire drills and active shooter's drill in the office.

The Administrator meets the Staffing Department weekly with the Clinical Nursing Manager(s) present as well. Part of the meeting especially in the winter time, the protocols for patients services in the event of a snow storm. The standard procedures and responsibilities from each schedulers including the Clinical Managers were discussed. The past winter , the agency needed to institute the protocols including but not limited to the steps needed to maintain continuous care especially for the 24 hours per day patients and patients with high maintenance respiratory equipment like the ventilators.
For the event of a snow storm or blizzard: 1) Prioritized all high risks patients with ventilators, etc.;
2) patient(s) requiring 24hors per day with no caregiver present to assist in the event of call-outs; 3) confirmed with nurses on the shifts the possibility of being stuck in the patient's home; 4) preparing the nurses, preparing them for the worse and asking them to bring extra clothes and food if necessary;
5) talking to the parents/caregivers/patients to allow their nurses to stay in the home if needed to prevent open shifts and asking them to have back-ups in the event the staff is unable to come;
6) making sure that all cellphones are charged and operational.
7) All schedulers and other pertinent staff must have a reliable cellphones for communication.
8) provision of electronic devices aside cellphones to schedulers, like laptops, tablets for the use while working from home.
The process and procedures are regularly review (at least monthly)to meet the needs and circumstances during a snow storm or blizzard.

With the COVID-19 pandemic, the Management and the Governing Body meet at least monthly to discuss from the last year's event to the present on what to do if an outbreak happened in the office from the employees. The process was implemented when the exposure happened to the key staff of the Finance Department during the payroll week.

The Administrator will be responsible in ensuring compliance with this regulations and standards. The plan will be reviewed every annually by the Management Team of the agency.



Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted on April 27, 2021 through April 29, 2021, Act Home Health Services, Inc., was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health facilities, Subpart G. Chapter 601.



Plan of Correction:




601.21(f) REQUIREMENT
PERSONNEL POLICIES

Name - Component - 00
601.21(f) Personnel Policies.
Personnel practices and patient care
are supported by appropriate, written
personnel policies. Personnel records
include qualifications, licensure,
performance evaluations, health
examinations, documentation of
orientation provided, and job
descriptions, and are kept current.

Observations:


Based on a review of personnel files (PFs), review of policies and procedures, and an interview with the Administrator, the agency did not conduct testing for mycobacterium tuberculosis according to the Center for Disease Control guidelines for six (6) of nine (9) personnel files reviewed. (PFs # 1, 2, 3, 5, 6, 7 ) and the agency did not maintain current CPR certification for all clinical staff for two (2) of nine (9) PF reviewed of clinical staff (PFs # 1 & 7) and personnel files did not contain a signed job description on hire for five (5) of nine (9) personnel files reviewed (PFs #1, 2, 3, 5, 7) and agency did not obtain Child Abuse Clearance every five years for two (2) of nine (9) personnel files (PFs # 8 & 9).


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) of 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.

Review of Pennsylvania's Child Welfare Information Solution website on 4/29/21 at approxmiatley 3PM revealed that "Beginning July 1, 2015, certifications (child abuse clearances) must be obtained every 60 months.Any employee with current certification issued prior to July 1, 2015, that is older than 60 months must renew their certificate by December 31, 2015. If an individual or agency elects to renew all required employment certifications at the same time, the date of the oldest certification, rather than the most recent, is the date to be used for the renewal date"


Review of Policies occurred on 4/29/21 at approximately 10:00 A.M.

Policy titled, "Child Abuse Clearance" reviewed and does not mention the requirement to obtain an updated clearance every five (5) years.

Job descriptions for Registered Nurse, Licensed Practical Nurse and Home Health aide revealed "Competency/skill requirement: CPR certified."

Surveyor asked for TB testing policy and agency unable to obtain a copy to give to surveyor.



A review of the personnel files was conducted on 4/28/21 at approximately 12 PM.

PF#1, Date of Hire (DOH): 2/7/19. File did not contain a copy of a signed job description on hire. File contained TB screening questionaire completed on 2/7/19. There was no documentation of a two-step TST and/or chest x-ray. In addition, there was no TB screening completed in 2020. File also did not contain CPR certification.

PF#2, DOH: 10/19/18. File did not contain a copy of a signed job description on hire.. File did not contain TB screening completed in 2020.

PF#3, DOH: 11/28/18. File did not contain a copy of a signed job description on hire. File contained TB screening questionaire completed in 2018, a 1 step TST completed on 8/12/18 and a doctor's note which stated history of positive TB testing. There was no documentation of a Chest X-ray completed. In addition, there was no TB screening completed in 2019 and 2020.

PF#5, DOH: 7/27/18. File did not contain a copy of a signed job description on hire. File contained TB screening questionaire completed in 2018. There was no documentation of a two-step TST and/or chest x-ray completed.

PF#6, DOH: 11/2/18. File did not contain documentation of TB screening completed in 2020.

PF#7, DOH: 10/16/17. File did not contain a copy of a signed job description on hire. File did not contain documentation of TB screening completed in 2019 and 2020.

PF#8, DOH: 2/14/05. File contained Child Abuse Clearance obtained in 2005 and was not renewed until 4/28/21.

PF#9, DOH: 12/23/08. File contained Child Abuse Clearance obtained in 2008 and was not renewed until 4/29/21.



Interview with the Administrator on 4/29/21 at approximately 1:00 PM confirmed the above findings.













Plan of Correction:

1) The Human Resources Manager reviewed and revised the policy and procedures for tuberculosis testing for all employees and contractual staff to comply with the Center for Disease Control guidelines, Federal and State guidelines.

The agency will continue its policy on all staff to have annual tuberculosis testing or use a questionnaire to be completed annually by all staff.

The Human Resources Coordinator will review and monitor compliance and will report monthly and quarterly to the Human Resources Manager .

The Humana Resources Manager will ensure compliance of the tuberculosis testing.

2) The Human Resources Coordinator reviewed staff list regarding CPR compliance. E-mail notifications were sent out to the staff and information of on-line CPR certification since in person is not possible at this this time.

3) Job descriptions for newly hired and contractual staff will be given to them where they will have to sign it of as received. The job description for the staff will also be included in their orientation packet(s).

4) The two nursing employees were given their child abuse clearance forms for completion and submission to the Department of Aging as of May 01, 2021. One of the two had received the clearances and was submitted to Human Resources. The other nurse is still waiting for his results at this time.

The Human Resources Manager will ensure that compliance of the above will be done regularly/ annually.


Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted on April 27, 2021 through April 29, 2021, Act Home Health Services, 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 state re-licensure survey conducted on April 27, 2021 through April 29, 2021, Act Home Health Services, Inc., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: