Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on 02/20/2024, Brightstar Care of South Bucks and Southeast Montgomery County, was found to not be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A
Plan of Correction:
51.3 (e) LICENSURE
NOTIFICATION
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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), agency incident reports, and staff interview, it was determined that the agency failed to notify the Department of Health (DOH) of reportable incidents for one (1) of six (6) months.
Findings include:
1) Review of incidents on the ERS system on 02/20/2024 at approximatley 8:00 am prior to the survey, revealed no reported incidents.
2) Facility incident reports were requested on 02/20/2024 at approximately 2:00 pm. Staff provided an incident report dated 11/14/2023, reported "client weak and fell again". This incident was not reported to ERS system.
An interview on 02/20/2024 at approximately 3:30 pm with the administrator and staff, confirmed the above findings.
Plan of Correction:The Director of Nursing has gained access to the ERS system and reviewed the training and reporting requirements as of 03/08/2024. On an ongoing basis, the Director of Nursing understands requirements and will submit incidents as per PA DOH guidelines. The leadership team which includes at a minimum the Owner, Director of Nursing, and Branch Manager will conduct a quarterly review of any incidents founded by or reported to our agency to be sure proper reporting was completed in ERS as well. Agency will include ERS reporting training to any internal nursing staff (Director of Nursing, Assistant Director of Nursing, etc) that would be responsible for this in the future or in the event of staffing changes. Training is being created by the Director of Nursing and Branch Manager, and will be implemented for leadership staff and any new hires to the leadership staff within the agency. This training program is to be completed by 03/21/2024. This will be added to our internal policies and procedures under sections pertaining to staff education by 3/21/2024 as well.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on 02/20/2024, Brightstar Care of South Bucks and Southeast Montgomery County, was found to not 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:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
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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 agency policies/procedures and personnel files (PF), and interview with the administrator, the agency failed to ensure the two (2) satisfactory references were obtained for five (5) of eight (8) PF (PF#1, PF#3, PF#4, PF#5, PF#6)
Findings include:
A review of the personnel files (PF) was conducted on 02/20/2024 between approximately 1:15 pm and 3:15 pm.
PF#1 Date of hire (DOH) 02/15/2024, contained no documentation that two satisfactory verifiable references were obtained.
PF#3 DOH 07/21/2016, contained no documentation that two satisfactory verifiable references were obtained.
PF#4 DOH 01/08/2024, contained no documentation that two satisfactory verifiable references were obtained.
PF#5 DOH 01/06/2012, contained no documentation that two satisfactory verifiable references were obtained.
PF#6 DOH 08/12/2019, contained no documentation that two satisfactory verifiable references were obtained.
An interview on 02/20/2024 at approximately 3:30 pm with the administrator and staff, confirmed the above findings.
Plan of Correction:Agency will adopt a new employment verification form, to be electronically submitted by all applicants, and to be verified by HR administrator before orientation/date of hire. The form will be available in paper format in the event of any technological issues. This form will include Signature of employee as well as the Reference/Company Name, Phone Number, and Address. It will also include a section to verify dates of employment and work history/recommendation. The document will be signed and dated by the HR administrator upon verification. This new and improved verification method will be implemented as of 03/11/2024 and ongoing. The reference form will be kept in the employee record. The Branch Manager will perform a quarterly audit to ensure verifications are being obtained and verified correctly and adequately. The findings of this internal quarterly audit will be documented, signed, and dated by Branch Manager once each quarter.
611.56(a) LICENSURE
Health Screening
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(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 CDC guidelines, personnel files (PF) and staff interview it was determined the facility failed to ensure direct care workers were screened for and were free from active mycobacterium tuberculoses prior to assignment with clients for four (4) out of eight (8) files reviewed. (PF#4, PF#5, PF#7, and PF#8)
Findings include:
The CDC guidelines state that all Health Care Workers (HCW) should received baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screen annually. HCWs with a baseline 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.
Review of personnel files on 02/20/2024 between approximately 1:15 pm and 3:30 pm revealed:
PF#4: Date of Hire (DOH): 01/08/2024 No documentation of a TB risk or screening on file.
PF#5: DOH: 01/06/2012, No documentation of an annual TB risk or screening on file.
PF#7: DOH: 02/20/2023, No documentation of a tuberculin test performed. No documentation of a TB risk or screening on file.
PF#8: DOH: 02/20/2023, No documentation of a tuberculin test performed. No documentation of a TB risk or screening on file.
An interview on 02/20/2024 at approximately 3:30 pm with the administrator and staff, confirmed the above findings.
Plan of Correction:Agency will implement and ensure proper baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis including all agency personnel, office and field staff alike. This screening will be enforced by the HR Administrator and will be in compliance with PA DOH guidelines. Annual screening for TB will be completed for all staff. Agency staff with a baseline positive test for tuberculosis infections will receive one chest radiograph result to exclude tuberculosis disease. The Branch Manager will conduct an internal audit of all personnel files to be sure TB testing has been properly obtained for each active employee and will have screenings completed by 04/02/2024 for any incomplete screenings on existing staff.
611.57(c) LICENSURE
Information to be Provided
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(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 on review of the consumer information packet/files and interview with the administrator, the home care agency failed to provide the consumer with the identity of the direct care worker who would be providing the services in seven (7) of seven (7) consumers files reviewed. (Consumer files # 1, #2, #3, #4, #5, #6 and #7).
Findings include:
Review of the agency' service agreement and consumer files on 02/20/2024 between approximately 11:45 pm to 1:15 pm revealed.
CF# 1, Start of service date: 10/25/2023, no identity of the direct care worker documented in the service agreement packet on file prior to the commencement of services.
CF# 2, Start of service date: 02/12/2024, no identity of the direct care worker documented in the service agreement packet on file prior to the commencement of services.
CF# 3, Start of service date: 06/14/2022, no identity of the direct care worker documented in the service agreement packet on file prior to the commencement of services.
CF# 4, Start of service date: 03/12/2021, no identity of the direct care worker documented in the service agreement packet on file prior to the commencement of services.
CF# 5, Start of service date: 06/24/2020, no identity of the direct care worker documented in the service agreement packet on file prior to the commencement of services.
CF# 6, Start of service date: 02/13/2024, no identity of the direct care worker documented in the service agreement packet on file prior to the commencement of services.
CF# 7, Start of service date: 02/02/2024, no identity of the direct care worker documented in the service agreement packet on file prior to the commencement of services.
An interview on 02/20/2024 at approximately 3:30 pm with the administrator and staff, confirmed the above findings.
Plan of Correction:The agency will create an addendum to the existing client Service Agreements, that will be entered into the client's record/chart, identifying the direct care worker who will be/is providing services. This will be completed by the Branch Manager by 03/25/2024.
The agency will edit and update the existing Service Agreement to include a section that identifies the direct care worker who will be providing service to the consumer, prior to commencement of services. This updated Service Agreement will be completed by the Branch Manager and reviewed by the Agency Owner. It will be implemented by 03/19/2024, and ongoing thereafter.
Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on 02/20/2024, Brightstar Care of South Bucks and Southeast Montgomery County, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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