QA Investigation Results

Pennsylvania Department of Health
CHRISTIAN COMPANION SENIOR CARE-CUMBERLAND PA
Health Inspection Results
CHRISTIAN COMPANION SENIOR CARE-CUMBERLAND PA
Health Inspection Results For:


There are  7 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 on-site state re-licensure survey conducted on April 8, 2021, Christian Companion Senior Care-Cumberland Pa, 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 unannounced on-site state re-licensure survey conducted on April 8, 2021, Christian Companion Senior Care-Cumberland Pa, 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:




611.4(c) LICENSURE
Requirements for HCA and HCR

Name - Component - 00
Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.

Observations:


Based observations and an interview with the agency administer (EMP# 1), it was determined the agency failed to ensure that everyone entering the health care facility is screened and triaged for COVID-19 for one (1) of one (1) observations (Observation #1) and one (1) of one (1) interviews (Interview #1).

Findings Include:

Pennsylvania Department of Health 'Health Alert Network' dated August 7, 2020 'Subject' 'Update: Interim Infection Prevention and Control Recommendations for Patients with known or Patients Under Investigation for 2019 Novel Coronavirus (COVID-19) in a Healthcare Setting' section (I) Recommended Routine Infection Prevention and Control (IPC) Practices During the COVID-19 Pandemic' (B) 'Screen and Triage Everyone Entering a Healthcare Facility for signs and symptoms of COVID-19':....symptom screening remains an important strategy to identify those who could have COVID-19 .......". "Screen everyone (patients, healthcare personnel, visitors) entering the facility for symptoms consistent with COVID-19 .....". "Actively take their temperature and document absence of symptoms consistent with COVID-19".

Observation #1: No screening process noted upon entry to the office building. On April 8, 2021 at approximately 10:00 a.m. the state surveyor began the onsite survey. The state surveyor was not screened in any manner for COVID-19. The state surveyor was escorted by EMP# 1 to an office area to begin the survey process.
Interview #1: At approximately 10:02 a.m. an interview was conducted with EMP# 1. The state surveyor asked EMP# 1 if they conducted COVID-19 symptoms screenings and if they were aware of the HAN (Health Alert Network) COVID-19 notification. EMP# 1 replied, "No, what is that?" The state surveyor showed him a copy of the HAN COVID-19 and EMP# 1 made a copy of it. Then EMP# 1 stated, "Our caregivers do screenings with the consumers-that is more important than anyone that comes here."

An interview conducted with EMP# 1 on April 8, 2021 at approximately 2:45 p.m. confirmed the above findings.





Plan of Correction:

Everyone entering the CCSC office area is now being presented with a list of Covid 19 symptom/screening questions to be completed upon entry to the office. This screening is dated and signed by person completing form. The Temperature of the person is recorded on this form as well.
Screening forms will be kept in the CCSC office indefinitely and will be available for review as needed.


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 personnel files (PFs) and interview with agency administrator (EMP #1), it was determined agency failed to maintain documentation of a face-to-face interview for one (1) of seven (7) PFs reviewed (PF# 6); failed to maintain documentation of two satisfactory references prior to hiring or rostering direct care workers for one (1) of seven (7) PFs reviewed. (PF# 6)
Findings include:
Review of PFs conducted on April 8, 2021 between approximately 11:00 a.m. and 11:58 a.m. revealed the following:
PF# 6, Date of Hire (DOH), 11/10/2020: No documentation of a face-to-face interview prior to hiring or rostering direct care worker. No documentation of two references being verified prior to hiring or rostering direct care worker.
An interview conducted with EMP# 1 on April 8, 2021 at approximately 2:45 p.m. confirmed the above findings.

Repeat Deficiency from 6/7/2017







Plan of Correction:

PF#6 Proper documentation of the face to face interview was added to this employee's file.
We will audit files of current employees to be sure that the new hire check list is completed, including a date of face to face interview.
We currently use a check list paper for all the information necessary for a new hire.
In the future the new hire employee folders will not be considered completed until all necessary information on this checklist has not only been obtained, but documented fully.
The person responsible for hiring a person is responsible for making sure that all prerequisites are completed and documented.


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 upon review of personnel files (PFs) and interview with agency administrator (EMP #1), it was determined agency failed to 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) for two (2) of seven (7) PFs reviewed. (PF# 3 and #5)

Findings include:
Review of PFs conducted on April 8, 2021 between approximately 11:00 a.m. and 11:58 a.m. revealed the following:

PF# 3, Date of Hire (DOH), 10/10/19: No Federal criminal history record and/or a letter of determination obtained from the Department of Aging.
PF# 5, DOH, 6/20/19: No Federal criminal history record and a letter of determination obtained from the Department of Aging.
An interview conducted with EMP# 1 on April 8, 2021 at approximately 2:45 p.m. confirmed the above findings.






Plan of Correction:

We will request PF#3 obtain a Federal Criminal History record and present us with a Letter of Determination from the Office of Aging.

PF #5 will furnish us with documentation of proof of residency, 2017 Federal Income tax return or utility bill.

We will audit all current active employee files to make sure that proof of residency in state of PA and appropriate criminal background checks on file.

We will implement a new hire practice of reviewing all necessary paperwork and requesting additional information upon hire when deemed necessary.


611.52(d) LICENSURE
Proof of Residency

Name - Component - 00
The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation

Observations:


Based upon review of personnel files (PFs) and interview with agency administrator (EMP #1), it was determined agency failed to ensure proof of residency for two (2) of seven (7) PFs. (PF# 3 and #5)

Findings include:
Review of PFs conducted on April 8, 2021 between approximately 11:00 a.m. and 11:58 a.m. revealed the following:

PF# 3, Date of Hire (DOH), 10/10/19: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained Pa. Drivers License issued 9/10/2020-5/29/2024.
PF# 5, DOH, 6/20/19: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained Pa. Drivers License issued 1/21/18-1/20/22.
An interview conducted with EMP# 1 on April 8, 2021 at approximately 2:45 p.m. confirmed the above findings.


Repeat Deficiency from 6/7/2017




Plan of Correction:

PF #3 will obtain a Federal Criminal History record and provide the letter of determination from the department of aging.

PF#5 Will provide proof of residency in the form of either 2017 federal income tax form or utility records.

We will audit all active employee files to insure that they have appropriate proof of residency and background checks, both state and Federal if necessary.

All newly hired employees will be required to submit proof of residency
and appropriate background checks. This will be made part of their permanent employee file.


611.55(a) LICENSURE
Compentency Requirements

Name - Component - 00
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 review of personnel files (PFs) and interview with agency administrator (EMP #1), it was determined agency failed to demonstrate, prior to assigning or referring a direct care worker to provide services to a consumer, competency by passing a competency examination for two (2) of seven (7) PFs reviewed. (PF# 1 and # 2).
Findings include:
Review of PFs conducted on April 8, 2021 between approximately 11:00 a.m. and 11:58 a.m. revealed the following:
PF# 1, Date of Hire (DOH), 12/18/19: No documentation showing an initial competency completed prior to assigning or referring a direct care worker to provide services to a consumer. Competency exam dated 3/30/2020, 86 days after initial worked shift on 1/4/2020.
PF# 2, DOH, 12/7/18: No documentation showing an initial competency completed prior to assigning or referring a direct care worker to provide services to a consumer. Competency exam dated 1/15/19, 36 days after initial worked shift on 12/10/19.

An interview conducted with EMP# 1 on April 8, 2021 at approximately 2:45 p.m. confirmed the above findings.







Plan of Correction:

PF #1 Manager will review Competency exam with this Caregiver to be sure that she meets/understands standards necessary to provide home care. Manager will document this meeting.

PF #2 Manager will review Competency exam with this Caregiver to be sure that she meets/understands standards necessary to provide homecare. Manager will document this meeting

Staff will audit all active caregiver files to be sure that completed competency test was received prior to initial assignment. Any found deficient will also undergo review of competency test with Manager.

A New Hire check list will include date of completion of Competency test and score.
The Competency Test will be distributed at the new hire orientation meeting with instructions that it must be returned to manager prior to assigning them as a direct care worker.

Manager will periodically review employee records to be sure that Competency testing is completed prior to first day of direct care.


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 review of personnel files (PFs) and interview with agency administrator (EMP #1), it was determined agency failed to conduct competency reviews at least once per year after initial competency was established for two (2) of seven (7) PFs reviewed. (PF#1 and #4)
Findings include:
Review of PFs conducted on April 8, 2021 between approximately 11:00 a.m. and 11:58 a.m. revealed the following:
PF# 1, Date of Hire (DOH), 12/18/19: No documentation of annual competency for year 2020.
PF# 4, DOH, 2/26/19: No documentation of annual competency for year 2020.

An interview conducted with EMP# 1 on April 8, 2021 at approximately 2:45 p.m. confirmed the above findings.


Repeat Deficiency from 6/7/2017





Plan of Correction:

PF #1 and PF #4 will be brought in to review the annual competency test for 2020.

Going forward active employee files will be audited for current competency reviews.

The review is to be signed and dated by the reviewer and made part of the employee file.

All active employees files will reviewed periodically to assure that annual reviews are up to date.



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 review of personnel files (PFs) and interview with agency administrator (EMP #1), it was determined agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, were screened for and free from active mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for seven (7) of seven (7) PFs reviewed. (PF# 1-#7)
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. 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).
Review of PFs was conducted on April 8, 2021 between approximately 11:00 a.m. and 11:58 a.m. revealed the following:
PF# 1, Date of Hire (DOH), 12/18/2019: No documentation provided of a completed symptom screen questionaire and an individual TB risk assessment upon hire.
PF# 2, DOH, 12/7/2018: No documentation of 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. TB vial used to give 1st TB (5/3/19-5/5/19) and 2nd step (5/12/19-5/15/19) was expired. Lot # C5570AA Expiration Date: 4/15/19. No documentation provided of a completed symptom screen questionaire and an individual TB risk assessment upon hire.

PF# 3, DOH, 10/10/2019: No documentation provided of a completed symptom screen questionaire and an individual TB risk assessment upon hire.

PF# 4, DOH, 2/26/2019: No documentation provided of a completed symptom screen questionaire and an individual TB risk assessment upon hire.

PF# 5, DOH, 6/20/2019: No documentation provided of a completed symptom screen questionaire and an individual TB risk assessment upon hire.

PF# 6, DOH, 11/10/2020: No documentation of 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. One TST completed: 11/20/2020-11/23/2020. No documentation provided of a completed symptom screen questionaire and an individual TB risk assessment upon hire.

PF# 7, DOH, 3/19/2019: No documentation provided of a completed symptom screen questionaire and an individual TB risk assessment upon hire.

An interview conducted with EMP# 1 on April 8, 2021 at approximately 2:45 p.m. confirmed the above findings.









Plan of Correction:

PF # 1,2,3,4,5,6,7 should have been given risk assessment upon hire, however in the future risk assessment will be completed annually by the employee.

PF#2 did not present 2 step TB test at hire date 12/7/2018, however 2 step was completed in May 2019 and records are in her employee file.

PF#6 did get a 2 step it was not received by CCSC from UPMC office. It is now part of her file.

We are currently giving all current active employees the TB risk assessment screening at this time. We have added a line at the bottom of the risk assessment for the caregiver to initial that they have received the TB education information.

CCSC will include the TB risk assessment and TB education information, now used annually, in the new hire information packet and reviewed at the new hire orientation meeting.







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 review of personnel files (PFs) and interview with agency administrator (EMP #1), it was determined 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 six (6) of seven (7) PFs reviewed. (PF# 1, 2, 3, 4, 5, and 7)
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. 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).
Review of PFs conducted on April 8, 2021 between approximately 11:00 a.m. and 11:58 a.m. revealed the following:
PF# 1, Date of Hire (DOH), 12/18/2019: No documentation provided of annual 2020 TB education.
PF# 2, DOH, 12/7/2018: No documentation provided of annual 2020 TB education.

PF# 3, DOH, 10/10/2019: No documentation provided of annual 2020 TB education.

PF# 4, DOH, 2/26/2019: No documentation provided of annual 2020 TB education.

PF# 5, DOH, 6/20/2019: No documentation provided of annual 2020 TB education.

PF# 7, DOH, 3/19/2019: No documentation provided of annual 2020 TB education.

An interview conducted with EMP# 1 on April 8, 2021 at approximately 2:45 p.m. confirmed the above findings.


Repeat Deficiency from 6/19/2014






Plan of Correction:

PF #1-7 will be provided a CDC fact sheet named TB Elimination, Tuberculosis: General Information, to act as TB Education form.

All active employees will be provided the same TB Education form.

TB Education sheet will be included with the TB Risk Assessment and provided both upon hire and annually for all active employees. The caregivers will initial at the bottom of the TB Risk Assessment letter showing that they received the TB Education information.

Going forward all active employee files will be audited annually to insure TB education for has been issued.


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 upon review of consumer files (CFs) and an interview with agency administrator (EMP #1), it was determined agency failed to provide an information packet, prior to the commencement of services to the consumer containing the identity of the direct care worker who will provide the services to ten (10) of ten (10) CFs reviewed (CF#1-10); failed to provide the hiring and competency requirements applicable to direct care workers employed by the home care agency for ten (10) of ten (10) CFs reviewed (CF#1-10)
Findings include:
Review of CFs conducted on April 8, 2020 at approximately between 12:01 p.m. to 12:45 p.m. revealed the following:
CF# 1, Start of Service (SOS), 10/18/2019: No documentation of providing the consumer the identity of direct care worker who will provide services and providing the hiring and competency requirements applicable to direct care workers employed by the home care agency.
CF# 2, SOS, 1/28/2018: No documentation of providing the consumer the identity of direct care worker who will provide services and providing the hiring and competency requirements applicable to direct care workers employed by the home care agency.
CF# 3, SOS, 8/20/2019: No documentation of providing the consumer the identity of direct care worker who will provide services and providing the hiring and competency requirements applicable to direct care workers employed by the home care agency.
CF# 4, SOS, 12/12/2020: No documentation of providing the consumer the identity of direct care worker who will provide services and providing the hiring and competency requirements applicable to direct care workers employed by the home care agency.
CF# 5, SOS, 10/3/2018: No documentation of providing the consumer the identity of direct care worker who will provide services and providing the hiring and competency requirements applicable to direct care workers employed by the home care agency.
CF# 6, SOS, 10/30/2020: No documentation of providing the consumer the identity of direct care worker who will provide services and providing the hiring and competency requirements applicable to direct care workers employed by the home care agency.
CF# 7, SOS, 11/28/2018: No documentation of providing the consumer the identity of direct care worker who will provide services and providing the hiring and competency requirements applicable to direct care workers employed by the home care agency.
CF# 8, SOS, 12/4/2019: No documentation of providing the consumer the identity of direct care worker who will provide services and providing the hiring and competency requirements applicable to direct care workers employed by the home care agency.
CF# 9, SOS, 11/11/2020: No documentation of providing the consumer the identity of direct care worker who will provide services and providing the hiring and competency requirements applicable to direct care workers employed by the home care agency.
CF# 10, SOS, 8/3/2020: No documentation of providing the consumer the identity of direct care worker who will provide services and providing the hiring and competency requirements applicable to direct care workers employed by the home care agency.
An interview conducted with EMP# 1 on April 8, 2021 at approximately 2:45 p.m. confirmed the above findings.

Repeat Deficiency from 5/24/2011 and 6/7/2017




Plan of Correction:

CF # 1-10 The current Client Rights and Responsibility form that the client and or their family member or responsible party signs prior to the commencement of services contains the following :

The identity of the initial direct care giver will be added to the Clients Rights & Responsibility form and provided to the client prior to the commencement of services.
The initial direct caregiver will be introduced to the client/family prior to the first scheduled appointment and documented accordingly and added to clients folder.

We will modify the current Rights and Responsibility form to include the initial direct caregiver identity for future printings.

Rights and Responsibility form will also include the following:
To be assured that the personnel who provide care are qualified through training and experience and are tested upon hire and annually thereafter to meet competency requirements in order to carry out the services for which they are responsible and appropriately supervised.


Initial Comments:


Based on the findings of an unannounced on-site, state re-licensure home care agency survey conducted on April 8, 2021, Christian Companion Senior Care- Cumberland Pa, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: