QA Investigation Results

Pennsylvania Department of Health
CONCORDIA PRIVATE CARE
Health Inspection Results
CONCORDIA PRIVATE CARE
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced state license survey completed June 3, 2021, Concordia Private Care 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 June 3, 2021, Concordia Private Care was found not to be in compliance with the following requirements 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 consumer information packet, direct care worker (DCW) personnel files (PF), and staff (EMP) interviews, the agency failed to obtain two satisfactory references, and a criminal history report for six (6) of 10 personnel files reviewed (PF1, PF2, PF4, PF5, PF9, & PF10).

Findings included:

Review of consumer information packet on June 2, 2021, at 9:35 a.m. showed, "D. HIRING AND COMPETENCY REQUIREMENTS FOR DIRECT CARE WORKERS: The direct care worker(s) who will be providing services has met the hiring requirements in accordance with Pennsylvania's home care licensure regulations. The direct care worker's criminal background checks have been completed and cleared."

Review of DCW personnel files was conducted on June 2, 2021, from 11 a.m. to 1:45 p.m. with EMP1 (administrator) and EMP4 (human resources).

PF1 was hired on 1/28/2019. The file did not contain two satisfactory references.

PF2 was hired on 11/21/2020. The file did not contain two satisfactory references. The criminal history report was not requested until 11/27/2020 (not prior to hire).

PF4 was hired on 11/2/2020. The file contained only one satisfactory reference completed prior to hire.

PF5 was hired on 11/21/2020. The file did not contain two satisfactory references.

PF9 was also hired on 11/21/2020. The file contained only one satisfactory reference completed prior to hire.

PF10 was also hired on 11/21/2020. The file contained only one satisfactory reference completed prior to hire.

Interviews with EMP1 and EMP2 on June 2, 2021, at 11:50 a.m. and 1:45 p.m. confirmed above findings.















Plan of Correction:

1. How the Agency will correct the deficiency: 2 satisfactory reference checks were completed and placed in employee files for PF1, PF2, PF4, PF5, PF9 & PF10 on 6/7/2021.
2. Measures or systems the Agency will alter to ensure the problem does not reoccur: A pre-visit checklist was created for human resources and private duty leadership to utilize to validate that all necessary documentation related to two satisfactory references and criminal history report are completed prior to permanently hiring a direct care worker. The checking will also validate that the first step TB and competency evaluation have been completed prior to direct care worker (DCW) providing services to the consumer.
3. Plans to monitor the Agency's performance to ensure solutions are sustained: For three months starting after 7/3/2021 all new hire DCW files will be audited to validate that two satisfactory reference checks have been completed and documented prior to the DCW providing consumer services.
4. Action to protect patients in a similar situation: Education related to obtaining two satisfactory reference checks and criminal background checks for all new DCW will be provided to human resources staff and private duty leadership. Human resources and private duty leadership will utilize the pre-visit checklist to ensure all necessary documentation related to two satisfactory reference checks have been completed prior to permanently hiring the DCW.




611.51(b) LICENSURE
Direct Care Worker Files

Name - Component - 00
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 agency policy, direct care worker (DCW) personnel files, staff (EMP) interviews, and an email, the agency failed to ensure DCW personnel files included information as required by 611.56 relating to health evaluations for two (2) of 10 personnel files reviewed (PF2, & PF9).

Findings included:

Review of DCW personnel files was conducted on June 2, 2021, from 11 a.m. to 1:45 p.m. with EMP1 (administrator) and EMP4 (human resources).

PF2 was hired on 11/21/2020 and began providing services to a consumer on 12/2/2020. PF2 was not screened for TB prior to consumer contact-- no negative TB test until 1/2/2021.

Interviews with EMP1 and EMP2 on June 2, 2021, at 11:50 a.m. and 1:45 p.m. confirmed above findings.

On June 3, 2021, at 10:59 a.m., EMP3 provided additional information via email for PF2 that was not contained in PF2 at the time of the above review with EMP1 and EMP3. The documentation showed PF2 was screened for TB on 10/8/2019 when PF2 had been working for another agency subsequently acquired by Concordia.

PF9 was hired on 11/20/2020 and began providing services to a consumer on 12/1/2020. PF9 was not screened for TB prior to consumer contact-- no negative TB test until 12/3/2020.

Interviews with EMP1 and EMP2 on June 2, 2021, at 11:50 a.m. and 1:45 p.m. confirmed above findings.

On June 3, 2021, at 10:59 a.m., EMP3 provided additional information via email for PF9 that was not contained in PF9 at the time of the above review with EMP1 and EMP3. The documentation showed PF9 was screened for TB on 10/15/2019 when PF9 had been working for another agency subsequently acquired by Concordia.












Plan of Correction:

1. How the Agency will correct the deficiency: The initial two-step TB test that was completed 1/4/2019, for PF 2 was added to the employee's personnel file. PF2 also had a TB screening completed on 10/8/2019, which was placed in the employee's file. PF9 had TB screening completed on 10/15/2019, which was placed in the employee's file.
2. Measures or systems the Agency will alter to ensure the problem does not reoccur: A pre-visit checklist has been created for human resources and private duty leadership to utilize to validate that all necessary documentation related to TB screenings have been completed prior to direct care worker providing services to the consumer.
3. Plans to monitor the Agency's performance to ensure solutions are sustained: For three months starting after 7/3/21, all new hire direct care worker files will be audited to validate that appropriate health evaluations have been completed and documented prior to the direct care worker providing consumer services.
4. Action to protect patients in a similar situation: Education related to appropriate TB screenings will be provided to human resources staff and private duty leadership. Human resources and private duty leadership will utilize a pre-visit checklist to ensure all necessary documentation related to TB screenings have been completed prior to the direct care worker providing services to the consumer.




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 agency policy, consumer information packet, direct care worker (DCW) personnel files (PF), and staff (EMP) interviews, the agency failed to ensure the DCW had demonstrated competency for two (2) of 10 personnel files reviewed (PF1, & PF2).

Findings included:

Review of agency policy on June 2, 2021, at 2 p.m. showed, "I. Policy Concordia Care is committed to ensuring that all staff have the relevant knowledge, skill and expertise to consistently perform their work to high standards and will comply with all training requirements necessary to maintain Pennsylvania Department of Health Home Care Licensure. II. Procedure A. Prior to providing service to consumers, staff members will be trained regarding how to provide service according to the consumer's service agreement."

Review of consumer information packet on June 2, 2021, at 9:35 a.m. showed, "D. HIRING AND COMPETENCY REQUIREMENTS FOR DIRECT CARE WORKERS: The direct care worker(s) who will be providing services has met the hiring requirements in accordance with Pennsylvania's home care licensure regulations. ... the direct care worker(s), through competency examination and/or training program, has successfully completed the competency requirements."

Review of DCW personnel files was conducted on June 2, 2021, from 11 a.m. to 1:45 p.m. with EMP1 (administrator) and EMP5 (IT supervisor).

PF1 was hired on 1/28/2019 and began providing services to a consumer on 1/29/2019. PF1 did not complete agency's competency program until 1/30/2019.

PF2 was hired on 11/21/2020 and began providing services to a consumer on 12/2/2020. PF2 did not complete agency's competency program until 12/20/2020.

Interviews with EMP1 and EMP5 on June 2, 2021, at 1:45 p.m. confirmed findings.











Plan of Correction:

1. How the Agency will correct the deficiency: PF1 completed competency evaluation on 1/30/2019. PF2 completed competency evaluation on 12/20/2020.
2. Measures or systems the Agency will alter to ensure the problem does not reoccur: A pre-visit checklist was developed for human resources and private duty leadership to utilize to validate that all necessary documentation related to competency evaluations have been completed prior to direct care worker providing services to the consumer.
3. Plans to monitor the Agency's performance to ensure solutions are sustained: For three months starting after 7/3/21, all new hire direct care worker files will be audited to validate that competency evaluation has been completed and documented prior to the direct care worker providing consumer services.
4. Action to protect patients in a similar situation: Education related to competency requirements will be provided to all staff. Human resources and private duty leadership will utilize a checklist to ensure all necessary documentation related to competency evaluation has been completed prior to the direct care worker providing services to the consumer.



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 agency policy, direct care worker (DCW) personnel files (PF), and staff (EMP) interviews, the agency failed to ensure, prior to consumer contact, that the DCW had been screened for and free from active mycobacterium tuberculosis (TB) for two (2) of 10 personnel files reviewed (PF1, & PF7).

Findings included:

Review of agency policy on June 2, 2021, at 2 p.m. showed, "Tuberculosis (TB) Infection Control ... If a new employee does not have any documentation of a negative TB test or their documentation is more than twelve (12) months old, they must have a two-step TB test before they are allowed to work with consumers. If the first step of the two-step comes back negative, the new employee may work with consumers while they wait two to three weeks for the second step to be completed."

Review of DCW personnel files was conducted on June 2, 2021, from 11 a.m. to 1:45 p.m. with EMP1 (administrator) and EMP5 (IT supervisor).

PF1 was hired on 1/28/2019 and began providing services to a consumer on 1/29/2019. PF1 was not screened for TB prior to consumer contact-- no negative TB test until 1/30/2019.

PF7 was hired on 7/27/2020 and began providing services to a consumer on 8/10/2020. PF7 was not screened for TB prior to consumer contact-- no negative TB test until 11/21/2020.

Interviews with EMP1 and EMP5 on June 2, 2021, at 1:45 p.m. confirmed findings.










Plan of Correction:

1. How the Agency will correct the deficiency: PF1 had negative TB test completed on 1/30/2019. PF7 had negative TB test completed on 11/21/2020.
2. Measures or systems the Agency will alter to ensure the problem does not reoccur: A pre-visit checklist has been developed for human resources and private duty leadership to utilize to validate that all necessary documentation related to TB screening has been completed prior to direct care worker providing services to the consumer.
3. Plans to monitor the Agency's performance to ensure solutions are sustained: For three months starting after 7/3/21, all new hire direct care worker files will be audited to validate that appropriate TB screening has been completed and documented prior to the direct care worker providing consumer services.
4. Action to protect patients in a similar situation: Education related to TB Screening requirements will be provided to all staff. Human resources and private duty leadership will utilize a pre-visit checklist to ensure all necessary documentation related to TB Screening has been completed prior to the direct care worker providing services to the consumer.



Initial Comments:

Based on the findings of an onsite unannounced state license survey completed June 3, 2021, Concordia Private Care was found to be in compliance with the requirement of 35 P.S. 448.809 (b).





Plan of Correction: