Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed June 3, 2021, Elderschoice, Inc. was found to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed June 3, 2021, Elderschoice, Inc. 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:
611.52(a) LICENSURE
Criminal Background Checks
Name - Component - 00
The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.
Observations:
Based upon review of employee files and an interview with the agency Administrator, agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging at the time of application or within 1 year immediately preceding the date of application for one (1) out of seven (7) employee files (EF) reviewed (EF#3).
Findings include:
A review of EFs was conducted on June 3, 2021 at approximately 12:00 p.m. Employee date of hire (DOH) is listed below.
EF#3 DOH 04/10/2021: Documentation provided shows the applicant was not a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging at the time of application or within 1 year immediately preceding the date of application. Documentation provided of a federal criminal history record obtained on 02/25/20 (410 days prior to hire).
An interview conducted with the agency Administrator on June 3, 2021 at approximately 2:30 p.m. confirmed the above findings.
Plan of Correction:1. EF#3 will obtain a new FBI print. A Determination letter will be given to EldersChoice by EF#3 and placed in DCW's file.
2. All other caregiver files will be audited and reviewed by the Administrator to ensure all state and federal criminal history records and letters of determination from the Department of Aging are placed in direct care worker's file.
3. The Administrator will create a chart in Excel on the agency computer tracking and documenting the completion date of all direct workers PA State Police background checks and FBI prints. Also, a form will be filled out by the Administrator titled "Caregiver Background Checks Completed for State Police and FBI". The form will have the caregivers name, the date when the state police report and FBI prints were completed along with the PA Department of Aging Determination letter and date of placement. This form will be placed in the direct care worker's file.
4. Agency Administrator will review files every six months to ensure compliance with 611.52(a) licensure for criminal background checks. To ensure compliance, the Administrator will initial and date on the "Caregiver Background Checks" form documenting every six months a review was completed for each direct care worker's file.
5.The Plan of Correction for 611.52(a) licensure will be submitted to the Pennsylvania Department of Health on Monday, July 26, 2021.
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 upon review of employee files and an interview with the agency Administrator, the agency failed to ensure documentation showing direct care workers, prior to providing services to consumers, completed/demonstrated an initial competency training covering all required sixteen (16) subject areas for four (4) of seven (7) employee files (EF) reviewed (EF#1, EF#3, EF#4, EF#6).
Findings include:
A review of EFs was conducted on June 3, 2021 at approximately 12:00 p.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 06/22/20: No documentation provided of initial competency training covering all required sixteen (16) subject areas. 'Recognizing and Reporting Neglect' was not included in the competency examination.
EF#3 DOH 04/10/21: No documentation provided of initial competency training covering all required sixteen (16) subject areas. 'Recognizing and Reporting Neglect' was not included in the competency examination.
EF#4 DOH 02/20/21: No documentation provided of initial competency training covering all required sixteen (16) subject areas. 'Recognizing and Reporting Neglect' was not included in the competency examination.
EF#6 DOH 06/05/20: No documentation provided of initial competency training covering all required sixteen (16) subject areas. 'Recognizing and Reporting Neglect' was not included in the competency examination.
An interview conducted with the agency Administrator on June 3, 2021 at approximately 2:30 p.m. confirmed the above findings.
Plan of Correction:1. EF#1, EF#3, EF#4, EF#6 will take an initial competency training that EldersChoice, Inc. developed on "Recognizing and Reporting Neglect and Abuse to comply with 611.55(a) licensure competency requirements and placed in direct care workers files when completed.
2. All the direct care worker's files will be audited and reviewed by the Administrator to ensure that other individual files have not been affected by the same deficient practice.
3. The agency will create a chart in Excel in the agency computer tracking and documenting the completion date of all direct care workers completing the initial competency training requirement and annual competency trainings. The new training on "Recognizing and Reporting Neglect and Abuse" will be placed in the Initial Competency Training exam. For the annual reviews, the agency will ensure that the trainings cover all 16 subject areas required by 611.55(a) licensure. Also, the Administrator will fill out a form titled "Caregiver Competency Tests" with the direct care workers name, date of the initial competency test along with the direct care workers referral date to a case. Annual competency reviews will be conducted for each direct care worker, documented, dated and placed in DCW file.
4. Agency Administrator will review files every six months to ensure compliance with 611.55(a) licensure for competency requirements. Every six months, the agency Administrator will also initial and date on the "Caregiver Competency Test Form" that all trainings were completed and up to date.
5. The Plan of Correction for 611.55(a)licensure will be submitted to the Pennsylvania Department of Health on Monday, July 26, 2021.
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 employee files and an interview with the agency Administrator, agency failed to provide documentation showing annual competency review covering all required sixteen (16) subject areas for one (1) of seven (7) employee files (EF) reviewed (EF#5).
Findings include:
A review of EFs was conducted on June 3, 2021 at approximately 12:00 p.m. Employee date of hire (DOH) is listed below.
EF#5 DOH 08/07/18: No documentation provided of a 2019 nor a 2020 annual competency review containing all sixteen (16) required elements.
An interview conducted with the agency Administrator on June 3, 2021 at approximately 2:30 p.m. confirmed the above findings.
Plan of Correction:1. EF#5 will take an annual competency exam to comply with 611.55(e).
2. Agency Administrator will review and audit files to ensure that all current caregivers have completed annual competency reviews containing all (16) required elements.
3. The agency will develop a chart in Excel on the agency computer tracking and documenting the completion of all direct care workers annual competency reviews. Also, the completion of annual reviews will be dated and documented on the "Caregiver Competency Exam Form".
4. Agency Administrator will review direct care worker files every six months to ensure compliance with 611.55(e) licensure for annual competency reviews. Every six months, the Administrator will initial and date on the "Caregiver Competency Form that all annual competency reviews were completed.
5. The Plan of Correction for 611.55(e) licensure will be submitted to the Pennsylvania Department of Health on Monday, July 26, 2021.
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 upon review of employee files and an interview with the agency Administrator, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, was screened for and is free from active mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for three (3) out of seven (7) employee files (EF) reviewed (EF#1, EF#6, EF#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. 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.)
*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).
A review of EFs was conducted on June 3, 2021 at approximately 12:00 p.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 06/22/20: No documentation provided of an individual TB risk assessment upon hire.
EF#6 DOH 06/05/20: No documentation provided of an individual TB risk assessment upon hire.
EF#7 DOH 07/10/20: No documentation provided of an individual TB risk assessment upon hire.
An interview conducted with the agency Administrator on June 3, 2021 at approximately 2:30 p.m. confirmed the above findings.
Plan of Correction:1. EF#1, EF#6, EF#7 will complete, sign and date an Individual TB Risk Assessment form from the CDC and placed in the direct care worker's file to comply with 611.56(a).
2. Agency Administrator will review and audit files to ensure that all current direct care workers per CDC guidelines filled out a pre-placement Individual TB risk assessment screening. Also, all DCW's were screened for tuberculosis using a two-step tuberculin skin test or a single blood test IGRA) or chest x-ray when applicable. Also, the Administrator will ensure that a TB symptom screening questionnaire is completed by all the direct care workers upon hire and annually. All documentation will be placed in the direct care workers files.
3. The agency will create a chart in Excel on the agency computer tracking and documenting the completion of a baseline individual TB risk assessment form, TB symptom screening questionnaire form and either a two- step TB skin test (TST), IGRA or a chest x-ray when direct care worker has a positive skin test. Direct care workers will also receive TB screenings and TB symptom questionnaires annually. This documentation will be documented on the "Caregiver PPD form in DCW file.
4. The Administrator will review direct care worker files every six months to comply with 611.56(a) and ensure that all assessments, screenings, and testing are documented on the "Caregiver PPD Document" and placed in file. The Administrator will initial and date very six months that the file was reviewed.
5. The Plan of Correction for 611.56(a) licensure will be submitted to the Pennsylvania Department of Health on Monday, July 26, 2021.
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 upon review of employee files and an interview with the agency Administrator, 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 one (1) of seven (7) employee files (EF) reviewed (EF#5).
Findings Include:
The CDC (Center for Disease and Control) 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).
A review of EFs was conducted on June 3, 2021 at approximately 12:00 p.m. Employee date of hire (DOH) is listed below.
EF#5 DOH 08/07/18: No documentation provided of 2019 nor 2020 annual TB education.
An interview conducted with the agency Administrator on June 3, 2021 at approximately 2:30 p.m. confirmed the above findings.
Plan of Correction:1. EF#5 will be given Tuberculosis education to comply with 611.56(b).
2. Administrator will conduct an audit of direct care worker files to ensure no other files have been affected by the same deficient practice.
3. The agency will create a chart in Excel program tracking and documenting the completion of annual Tuberculosis education for direct care workers. Also, on the "Caregiver PPD Form", the Administrator will document annually when TB education has been completed.
4. Agency Administrator will review files every six months to ensure compliance with 611.56(b), Tuberculosis education. The Administrator will initial on the "Caregiver PPD form" that the annual TB education was completed.
5. The Plan of Correction for 611.56(b) will be submitted to the Pennsylvania Department of Health on Monday, July 26,, 2021.
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed June 3, 2021, Elderschoice, Inc. was found not to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
35 P. S. § 448.809b LICENSURE
Photo Id Reg
Name - Component - 00
(1) The photo identification tag shall include a recent photograph of the employee, the employee's FIRST name, the employee's title and the name of the health care facility or employment agency.
(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.
(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.
(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.
Observations:
Based upon observation of Identification badges (ID) and an interview with the agency Administrator, agency failed to format/issue ID badges per regulatory requirements for one (1) of one (1) observation (Observation #1).
Findings include:
Observation #1: Observation of employee Identification Badge (ID) on June 3, 2021 at approximately 11:45 a.m. revealed the current ID badge title did not occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge. The employee title is approximately 1/8" and is not positioned in the bottom 1/2" of the badge.
An interview was conducted with the agency Administrator on June 3, 2021 at approximately 11:45 a.m. Per the Administrator, there are approximately twenty-two (22) employees in the field who currently have ID badges formatted as stated above.
An interview conducted with the agency Administrator on June 3, 2021 at approximately 2:30 p.m. confirmed the above findings.
Plan of Correction:1. Agency Administrator will create 23 new badges to comply with 35 P.S.448.809b.
2. Administrator will conduct an audit of files to ensure all Direct Care Workers and agency staff receive new identification badges.
3. The Administrator will create in agency computer through the Publisher Program, 23 updated identification badges. The updated ID badges will have a recent photo of the individual, name, title and the name of the healthcare facility or employment agency. For Direct Care Workers, the title "Direct Care Worker" will be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.
4. The Administrator will audit charts every six months to ensure that all current staff and DCW's have updated ID badges and new staff and direct care workers receive updated ID badges prior to employment or placement. A paper copy of the badge will be placed in personnel and direct care worker's files.
5. The Plan of Correction for 35 P.S.448.809(b) will be submitted to the Pennsylvania Department of Health on Monday, July 26, 2021.
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