Initial Comments:
Based on the findings of an unannounced, off-site complaint investigation survey completed on September 10, 2020, Gifted Hands Home & Health Care, LLC., was found not to be in compliance with the following requirements of 28 PA Code, Part IV, Health Facilities, Subpart G. Chapter 601 Home Health Care Agencies.
Plan of Correction:
601.3 REQUIREMENT
COMPLIANCE W/ FED, ST, & LOCAL LAWS
Name - Component - 00
601.3 COMPLIANCE WITH FEDERAL,
STATE AND LOCAL LAWS.
The home health agency and its staff
are in compliance with all applicable
Federal, State and Local Laws and
regulations.
Observations:
Based on review of policy/procedure, agency documentation and email correspondence with the agency administrator the agency failed to ensure employees were screened for signs/symptoms of COVID-1 including but not limited to daily temperature checks.
Findings include:
Review of agency policy/procedure completed on 8/26/2020 between approximately 9:00AM-9:30AM revealed:
Gifted Hand Home & Health Care COVID-19 Epidemic policy/procedure Manual, section II, "COVID policy/procedure state, " 1. Home care services staff experiencing symptoms consistent with COVID-19 exposed in the last 14 days to a COVID-19 positive individual, testing positive for COVID-19 in the last 14 days, or experiencing a temperature greater than or equal to 100.00 F, should not enter a client's home or the workplace. Staff who develop symptoms consistent with COVID-19 should stay home, contact their health care provider, and arrange for testing".
Documentation provided and reviewed on 8/25/2020 at 1:20PM revealed;
Employees of the agency are required to answer a questionaire within the agency's time keeping system regarding COVID sign/symptoms and exposure. No documentation was provided showing the agency conducted daily temperature checks of employees and consumers.
Email correspondence with the agency Administrator on 9/8/2020 at 9:10PM confirmed the above findings.
Plan of Correction:1) For 601.3 COMPLIANCE WITH FEDERAL, STATE AND LOCAL LAWS. The agency put in place mechanisms to ensure employees are screened for signs/symptoms of COVID-1 including but not limited to daily temperature checks as noted in the deficiency statements.
2) For the protection of the residents in their homes, the agency has put the affected caregiver on quarantine. Any caregiver who test positive will be put off the schedule until such time as is safe to resume work.
3) The facility will alter/implement the following to ensure that the problem does not recur.
a) COVID-19 questions have been created in the clocking in/out software used by the agency. Each caregiver must answer them before the system allows clocking in.
b) There is a policy to use the software. The caregivers have the motivation to use the software because the clocked in hours are the ones entered into the payroll.
c) The agency has placed a no-touch temperature checking thermometer in all the patient's homes. Each caregiver tests their temperature before answering the questions and clocking in.
4) The agency administrator is responsible to monitor the continued implementation of the plan of correction.
5) The deficient practice identified in the deficiency statements has been corrected as of 9/22/2020.
Initial Comments:
Based on the findings of an unannounced, off-site complaint investigation survey completed on September 10, 2020, Gifted Hands Home & Health Care, LLC., was found not to be in compliance with the following requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
51.3 (e) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification
(e) If a health care facility is
aware of information which shows that
the facility is not in compliance with
any of the Department's regulations
which are applicable to that health
care facility, and that the
noncompliance seriously compromises
quality assurance or patient safety,
it shall immediately notify the
Department in writing of its
noncompliance.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for the failure to comply and the
steps which the health care facility
shall take to bring it into compliance
with the regulation.
Observations:
Based on review of Pennsylvania Department of Health Event Reporting System (ERS), policy/procedures, agency documentation and email correspondence with the Administrator, it was determined that the agency failed to notify the Department of Health (DOH) of reportable incidents.
Findings include:
Review of incidents on the ERS system on August 18, 2020, prior to the survey, revealed no reported incidents.
Review of agency policy/procedure completed on 8/26/2020 between approximately 9:00AM-9:30AM revealed:
Gifted Hand Home & Health Care COVID-19 Epidemic policy/procedure Manual, section II, "COVID policy/procedure state, " 1. Home care services staff experiencing symptoms consistent with COVID-19 exposed in the last 14 days to a COVID-19 positive individual, testing positive for COVID-19 in the last 14 days, or experiencing a temperature greater than or equal to 100.00 F, should not enter a client's home or the workplace. Staff who develop symptoms consistent with COVID-19 should stay home, contact their health care provider, and arrange for testing".
Documentation provided and reviewed on 8/25/2020 at 1:20PM revealed;
Employees of the agency are required to answer a questionaire within the agency's time keeping system regarding COVID sign/symptoms and exposure. No documentation was provided showing the agency conducted daily temperature checks of employees and consumers.
Email correspondence with agency Administrator on August 31, 2020 at 1:48PM confirmed the agency was aware of an employee exposure. "We are only aware of one health worker,... who was exposed".
Plan of Correction:1) For 51.3 (e) LICENSURE, NOTIFICATION: The agency has reported the incident noted in the deficiency statements. It has been reported at
https://sais.health.pa.gov/Incidents/FacilityLogin.asp. Event number: 660692 dated 9/22/2020.
2) For the protection of the residents in their homes, the agency has put the affected caregiver on quarantine. Any caregiver who test positive will be put off the schedule until such time as is safe to resume work.
3) The facility will alter/implement the following to ensure that the problem does not recur.
a) COVID-19 questions have been created in the clocking in/out software used by the agency. Each caregiver must answer them before the system allows clocking in.
b) There is a policy to use the software. The caregivers have the motivation to use the software because the clocked in hours are the ones entered into the payroll.
c) The agency has placed a no-touch temperature checking thermometer in all the patient's homes. Each caregiver tests their temperature before answering the questions and clocking in.
4) The agency administrator is responsible to monitor the continued implementation of the plan of correction. All incidents will be reported by him/her.
5) The deficient practice identified in the deficiency statements has been corrected as of 9/22/2020.
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