Initial Comments:
Based on the findings of an onsite unannounced state license survey completed April 7, 2022, Sherwood Oaks was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced state license survey completed April 7, 2022, Sherwood Oaks was found not to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.
Plan of Correction:
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 direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to obtain two satisfactory references prior to hire for two (2) of two (2) direct care worker personnel files hired since the year 2020 (PF1 & PF2).
Findings include:
Review of personnel files was conducted on April 7, 2022, at 10 a.m.
PF1 was hired on 1/16/2022 but contained no satisfactory references.
PF2 was hired on 4/12/21 but contained no satisfactory references.
Interview with EMP1 and EMP2 on April 7, 2022, at 11:30 a.m. confirmed findings.
Plan of Correction:Our Human Resource representative has obtained two personal reference contacts for each of the employees identified in this survey. These references have been completed.
An audit of all current employee files has begun and will be completed by June 1, 2022 to verify all have completed references in their files.
The manager has developed a spreadsheet of all Chapter 611 employee file requirements to ensure these are completed upon hire into the department. An audit will be conducted within two weeks of first work day to ensure all items are contained within the file. An additional audit of all files will be completed annually in January.
611.51(b) LICENSURE
Direct Care Worker Files
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Files for direct care workers employed or rostered shall include documentation of the date of the face-to-face interview with the individual and of references obtained. Direct Care Worker files also shall include other information as required by § 611.52, § 611.53, if applicable, § 611.54, § 611.55 and § 611.56 (relating to criminal background checks, child abuse clearance, provisional hiring, competency requirements; and health evaluations).
Observations:
Based on review of direct care worker personnel files (PF) and staff (EMP) interview, the agency failed to ensure direct care worker personnel files contained documentation of references obtained, and other information to show residency 611.52(d), competency 611.55(c) and health screening 611.56(a) requirements were met for two (2) of two (2) direct care worker personnel files hired after the year 2020 (PF1, & PF2).
Findings include:
Note: agency has personnel file information maintained and stored by the parent company's human resources department and some personnel file information stored onsite at the home care agency causing incomplete personnel files and or no oversite of files at home care agency.
PF1 was hired on 1/16/2022 and providing services to consumers the following week. PF1 contained no proof of residency, no references, and no mycobacterium tuberculosis (TB) screening.
PF2 was hired on 4/12/2021 and providing services to consumers on 4/20/2021. PF2 contained no references, incomplete competency exams, and incomplete TB test results. PF2's training checklist showed the following topics were checked: bathing; mouth care; ambulation/transferring; feeding; toileting; and self-administered medication. A review of PF2's competency exams did not show that PF2 was tested on the above topics to show his/her understanding of them. PF2 also contained the third page of a TB blood test but was missing pages 1 and 2 which contained the results-- not possible to determine if PF2 was free from TB with incomplete documentation.
Interview with EMP1 and EMP2 on April 7, 2022, confirmed above findings, and that PF2 is responsible for providing personnel care services.
Plan of Correction:PF1 proof of residency was collected by the organization; however, the document was not immediately accessible on the day of inspection. Verification via driver's license is now available in the employee's file.
Our Human Resources representative has obtained two personal reference contacts for PF1 & PF2. The references are completed and in each employee file. An audit of all current employee files has begun and will be completed by June 1, 2022 to verify all have completed references in their files.
The manager has developed a spreadsheet of all Chapter 611 employee file requirements to ensure these are completed upon hire into the department. An audit will be conducted within two weeks of first work day to ensure all items are contained within the file. An additional audit of all files will be completed annually in January.
PF2's onboarding medical review contained verification of a TB test completion with a negative result. The full lab result and explanation was not present in the employee's file on the day of inspection; however, the full report was obtained and placed in the file on 4/18/2022.
PF2 competency training was completed upon 2021 hire/orientation; however, the documents were not reviewed for thorough completion. The training forms have been completed for PF2 on 4/25/2022.
The manager has developed a spreadsheet of all Chapter 611 employee requirements to ensure these are completed upon hire and annually. The manager will conduct an audit within 30 days of first work day for ongoing compliance with each employee. Annual training materials will be reviewed within 30 days after the final education session to ensure all documents are thoroughly completed.
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 on review of direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to ensure one (1) of two (2) direct care worker personnel files hired since the year 2020 contained proof of residency (PF1).
Findings included:
Review of personnel files was conducted on April 7, 2022, at 10 a.m.
PF1 was hired on 1/16/2022 but contained no proof of residency.
Interview with EMP1 and EMP2 on April 7, 2022, at 11:30 a.m. confirmed findings.
Plan of Correction:PF1 proof of residency was collected by the organization; however, the document was not immediately accessible on the day of inspection. Verification via driver's license is now available in the employee's file as of 4/18/22.
The manager has developed a spreadsheet of all Chapter 611 employee requirements to ensure these are completed upon hire and annually. The manager will conduct an audit within 2 weeks of first work day to ensure all documents are present on site in the employee's file. We have at least two new hires beginning in May 2022. Their audits will be completed by June 15, 2022. An audit of all employee files will occur annually in January to ensure ongoing compliance for employee files on site.
611.56(a) LICENSURE
Health Screening
Name - Component - 00
The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.
Observations:
Based on review of direct care worker personnel files (PF), agency policy, CDC (Center for Disease Control and Prevention) guidelines and staff (EMP) interview, the agency failed to ensure one (1) of two (2) employees hired after the year 2020 were screened for mycobacterium tuberculosis (TB) (PF1).
Findings include:
Note: at this time, the two step TB test is currently waived by the Department for home care agencies due to Covid-19 pandemic. However, per EMP2 the agency's hospital-based parent company continues to require the two-step TB test in accordance with CDC guidelines because it is "more stringent."
Review of agency policy on April 7, 2022, at 11 a.m. showed, "Infection Control Policy and Procedure ... 5.1 TB EXPOSURE CONTROL ... UPMC Senior Communities Skill Nursing Facilities ... IV. HEALTHCARE WORKER (HCW) SCREENING ... 16. Following CDC recommendations for Health Care Workers, ... will have screening for TB ... either through placement of a 2 step TST or a whole-blood interferon gamma release assay (IRGA) Quanti FERRON(r)-TB Gold TEST (QFT-G)."
Per CDC Guidelines, "Updated Recommendations ... Recommendations from the 2005 CDC guidelines ... TB screening is defined as a process that includes a TB risk assessment, symptom evaluation, TB testing for M. tuberculosis infection (by either IGRA [blood test] or TST [tuberculin skin test]) for health care personnel without documented evidence of ... TB disease, ... Baseline (preplacement) screening and testing. All U.S. health care personnel should have baseline TB screening, including an individual risk assessment ... which is necessary for interpreting any test result." Retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6819a3-H.pdf
Review of PF1 on April 7, 2022, at 10 a.m. did not show that a TB screen was conducted in accordance with CDC guidelines. PF1 was hired on 1/16/2022 and providing services to consumers "the following week" according to EMP1.
Interview with EMP4 (PF1) on April 7, 2022, at 11 a.m. confirmed he/she was never screened for TB to include a blood or skin test, individual risk assessment or symptom evaluation.
Interviews with EMP1 and EMP2 on April 7, 2022, at 11 a.m. confirmed above findings.
Plan of Correction:PF1 started the 2-step TB process on 4/18/2022 and the tw0-step process was completed on 4/28/22 with negative results.
The manager has developed a spreadsheet of all Chapter 611 employee requirements to ensure these are completed upon hire and annually. The manager will conduct an audit within 2 weeks of each new employees first work day. We have at least two new hires beginning in May 2022. Their audits will be completed by June 15, 2022. All employee files will be reviewed for ongoing compliance annually in January.
Initial Comments:
Based on the findings of an onsite unannounced state license survey completed April 7, 2022, Sherwood Oaks was found to be in compliance with the requirement of 35 P.S. 448.809 (b).
Plan of Correction:
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