Initial Comments:
An offsite follow up survey completed on February 15, 2024 found that Lehigh Home Health Care and Staffing Agency, Inc. had not corrected the deficiency cited under the requirements of 28 Pa. Code, Part IV, Health Facilities, Subpart G. Chapter 601. The deficiency was cited as a result of a state re-licensure survey conducted January 5, 2024.
Plan of Correction:
601.35(a) REQUIREMENT
SELECTION OF AIDES
Name - Component - 00
601.35(a) Selection of Aides. Home
health aides are selected on the basis
of such factors as sympathetic
attitude toward the care of the sick,
ability to read, write, and carry out
directions, and maturity and ability
to deal effectively with the demands
of the job. Aides are carefully
trained in assisting patients to
achieve maximum self-reliance,
principles of nutrition and meal
preparation, the aging process and
emotional problems of illness,
maintaining a clean, healthful, and
pleasant environment, changes in
patient's condition that should be
reported, work of the agency and the
health team, ethics and
confidentiality, and recordkeeping.
Home Health Aid Training. All home
health aides have completed a minimum
of 60 hours of classroom instruction
prior to or during the first 3 months
of employment.
They are closely supervised to assure
their competence in providing care.
Observations:
Based on a review of the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure their home health aides competency/training was completed, 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 02/15/2024 at approximately 1:00 p.m., approved by the Department on 01/18/2024, revealed the following:
'1. Elements detailing how the facility will correct the deficiency as it relates to the individual:
The Administrator & Alt Admin will audit personnel files for EF (employee) #6 & EF #8 for compliance with 601.35(a), Selection of Aides, ..... The training documents that are incomplete will be completed according to the revised organized training material in Compliance with the Dept of Health guidelines, including the test dates, Procedure Evaluation Checklists, .......
2. How the facility will act to protect patients in similar situations:
.........The Administrator/Alt Admin will audit 100% of active HHA's personnel files to ensure that the requirements of 601.35(a) and a minimum of 60 hours of classroom instruction have been successfully provided. The active HHA's that are found to not have proper documentation, after personnel file audits, on the requirements of 601.35(a) and a minimum of 60 hours of classroom instruction will be removed from the field until all required elements have been met. "
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur:
........The agency will revise the policy and procedures for the HHA Training Program to ensure Compliance with the Dept of Health guidelines .......... '
Corrective action date: 02/09/2024.
Documentation review #1: Initial Plan of Correction documentation was requested on February 12, 2024 at approximately 8:35 a.m. Agency submitted documentation. A second request was made for missing Plan of Correction documentation on February 14, 2024 at approximately 1:31 p.m. Agency submitted documentation. A third request was made for missing Plan of Correction documentation on February 14, 2024 at approximately 3:49 p.m. Agency submitted documentation.
No documentation provided of stated "Procedure Evaluation Checklists' being completed for EF#6 and EF#8, of an "audit 100% of active HHA's personnel files to ensure that the requirements of 601.35(a) and a minimum of 60 hours of classroom instruction" being conducted, nor of the agency "revising the policy and procedures for the HHA Training Program ."
Email correspondence on February 15, 2024 at approximately 2:00 p.m. with the agency Administrator at confirmed the above findings.
Plan of Correction:The Administrator & Alt Admin will audit personnel files for EF #6 & EF #8 for compliance with 601.35(a), Selection of Aides, that is: Home health aides are selected on the basis of such factors as sympathetic attitude toward the care of the sick, ability to read, write, and carry out directions, and maturity and ability to deal effectively with the demands of the job. Aides are carefully trained in assisting patients to achieve maximum self-reliance, principles of nutrition and meal preparation, the aging process and emotional problems of illness, maintaining a clean, healthful, and pleasant environment, changes inpatient's condition that should be reported, work of the agency and the health team, ethics and confidentiality, and record keeping. Home Health Aid Training: All home health aides have completed a minimum of 60 hours of classroom instruction prior to or during the first 3 months of employment. They are closely supervised to assure their competence in providing care.
1) The training documents that are incomplete will be completed according to the revised organized training material in Compliance with the Dept of Health guidelines, including the test dates, Procedure Evaluation Checklists, and Handouts. All active HHAs will be reeducated for the missing training and the documents will be maintained in the office logs.
2) The Administrator/Alt Admin will audit 100% of active HHA's personnel files to ensure that the requirements of 601.35(a) and a minimum of 60 hours of classroom instruction have been successfully provided.
3) The agency will revise the policy and procedures for the HHA Training Program to ensure Compliance with the Dept of Health guidelines.
4) The Administrator will audit 100% of newly hired HHA personnel files that are provided training through the agency's HHA Training Program within 3 months of employment to ensure 100% of compliance is met.
The HHA Training Program requirements of: Home health aides are selected on the basis of such factors as sympathetic attitude toward the care of the sick, ability to read, write, and carry out directions, and maturity and ability to deal effectively with the demands of the job. Aides are carefully trained in assisting patients to achieve maximum self-reliance, principles of nutrition and meal preparation, the aging process and emotional problems of illness, maintaining a clean, healthful, and pleasant environment, changes inpatient's condition that should be reported, work of the agency and the health team, ethics and confidentiality, and recordkeeping.
Home Health Aide Training: all home health aides have completed a minimum of 60 hours of classroom instruction prior to or during the first 3 months of employment. They are closely supervised to assure their competence in providing care.
|