QA Investigation Results

Pennsylvania Department of Health
AMERICARE STAFFING OF WESTERN PENNSYLVANIA
Health Inspection Results
AMERICARE STAFFING OF WESTERN PENNSYLVANIA
Health Inspection Results For:


There are  17 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:


Based on the findings of an onsite unannounced complaint survey completed February 19, 2020, Americare Staffing of Western Pennsylvania was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.














Plan of Correction:




51.3 (f) LICENSURE
NOTIFICATION

Name - Component - 00
51.3 Notification

(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.

Observations:



Based on a review of the Pennsylvania Department of Health Event Reporting System Manual, the facility's submissions to the Department's online event reporting system, consumer file (CF) reviews and staff interview (EMP), the facility failed to comply with the notification requirements of Chapter 51 which applies to home care agencies and home care registries licensed under Chapter 611. Specifically, the facility failed to report to the Department in writing one (1) consumer complaint to agency of misappropriation of resident/patient property for consumer file reviewed (CF1).

Findings included:

A review of the Pennsylvania Department of Health Event Reporting System Manual, on 2/19/2020 at approximately 10:00 a.m. revealed the following statement: "..Purpose: To provide a system to enter events per 28 PA Code - 51.3 that is readily available to all appropriate PA-DOH [Pennsylvania Department of Health] facilities, a simple process to insure consistent data entry and submission, and a source for quick and meaningful feedback on event notification submissions...All facilities are required to submit notification of events as defined in 28 Pa Code Chapter 51 to the Department of Health within 24 hours of occurrence or discovery. The Electronic Event Reporting System (ERS) is the mechanism the Department will use to meet this regulatory requirement...The following is a list of all Categories that should be submitted:.."Misappropriation of resident/patient property..."

On 2/10/2020 at approximately 9:00 a.m. (pre-survey preparation) the Department of Health (DOH) Event Reporting System (ERS) was reviewed and revealed no events had been reported to the DOH by the facility.

During an entrance conference on 2/19/2020, at approximately 10:00 a.m. agency community outreach intake coordinator/office lead employee stated that she "did not know about ERS."

Review of CF1 on 2/19/2020 at approximately 10:30 AM, Start of Service 10/11/19 revealed agency incident report forms that documented the following:
1/2/2020- CF1 said that she "couldn't find a gift card she had received for Christmas." Agency community outreach intake coordinator/office lead employee stated "the client has to report it to the police and she never did."

An exit interview on 2/19/2020 at approximately 2:30 p.m. directly with agency operations officer, community outreach intake coordinator/office lead and staffing coordinator confirmed agency was not reporting events to the DOH ERS system.


Repeat deficiency 8/30/17.








Plan of Correction:

To comply with Regulation 51.3 Licensure notification, Americare staffing has contacted the department to get login credentials for the Health Event Reporting system. Americare will report all critical incidents; injury, hospitalization, death,abuse neglect and loss of property to the ERS system to be reviewed by the department within 24 hours of notification. Americare will review all incdidents during monthly audits and quarterly quality assurance meetings in accordance with our quality assurance policy to be assured that all incidents were resolved and properly reported.


Initial Comments:


Based on the findings of an onsite unannounced complaint survey completed February 19, 2020, Americare Staffing of Western Pennsylvania 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 personnel files (PF) and interview with agency staff (EMP), the agency failed to obtain no less than two satisfactory references for two (2) of four (4) direct care worker (DCW) personnel files reviewed (PF2, PF3), and/or conduct a face to face interview with the individual for two (2) of four (4) DCW personnel files reviewed (PF2, PF3).

Findings included:

Personnel file (PF) reviews conducted on 2/19/2020 between approximately 11:30 a.m. to 2:30 p.m. revealed:

PF2, Date of hire 12/9/19. Start of service 12/10/19. PF revealed two references checks dated 10/10/18 and face to face interview dated 10/9/18.

PF3, Date of hire 12/19/19. Start of service 2/13/2020. There was no documented evidence of at least two satisfactory references completed. PF revealed face to face interview dated 11/1/17.

An exit interview on 2/19/2020 at approximately 2:30 p.m. directly with agency operations officer, community outreach intake coordinator/office lead and staffing coordinator confirmed the above findings.


Repeat Deficiency 8/30/17.


























































































Plan of Correction:

In order to comply with regulation 611.51 hiring or rostering prerequisites. Americare staffing will treat all re hires as new hires and renew all hiring prerequisites including face to face interviews, obtain 2 new satisfactory references.
As a quality assurance measure President and operations managers will sign off on all new hires prior to them being assigned to a case to work with consumers. To assure that face to face interviews were completed and that satisfactory references have been verified signed, dated and are in the DCW file.

Correction:
Americare staffing will conduct an Audit of all employee files to be completed by march 31. Audit checklist will verify that each current staff member has had 2 satisfactory references and a face to face interview audit sheet will include the date that each document was completed to assure date was before first date of service.
Staff education will include new policy and procedure that will list the regulation that requires the policy to be implemented.

To prevent this issue from happening again the president or operation manager will sign off on each employee file prior to them going into the field to work with consumers to assure they comply with regulation 611.51 hiring or rostering prerequisites.

Following the audit of all current staff to take place prior to March 31 , and audit of new hires will be conducted each month to assure that all new staff were signed off on prior to working and that the new policy concerning hiring is being followed as explained in the corrective action.


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 on review of personnel files (PF) and interview with agency staff (EMP), the agency failed to obtain criminal background checks at the time of application or within one year immediately preceeding the date of application for two (2) of four (4) direct care worker (DCW) personnel files reviewed (PF2, PF3).

Findings included:

Personnel file (PF) reviews conducted on 2/19/2020 between approximately 11:30 a.m. to 2:30 p.m. revealed:
PF2, Date of hire 12/9/19. Start of service 12/10/19. PF revealed criminal background check dated 10/29/18.

PF3, Date of hire 12/19/19. Start of service 2/13/2020. PF revealed a criminal background check dated 11/1/17.
An exit interview on 2/19/2020 at approximately 2:30 p.m. directly with agency operations officer, community outreach intake coordinator/office lead and staffing coordinator confirmed the above findings.

Repeat deficiency 12/10/12, 7/9/19.














































































Plan of Correction:

In order to comply with regulation 611.52 hiring or rostering prerequisites. Americare staffing will treat all re hires as new hires and renew all hiring prerequisites including running a state wide police background check or accept a state police background check from no more than 12 months from the hiring date. If the background check is not returned instantly americare will determine the need and may chose to hire the individual under provisional hiring practices and will supervise and document such supervision in accordance Regulation 611.54 Provisional hiring .

Americare staffing will conduct an Audit of all employee files to be completed by March 31. Audit checklist will verify that each current staff member has had a criminal background check at the time of hire or in the 12 months preceding hire and that the criminal history does not contain any of the prohibited offenses listed in the regulations.
Audit sheet will include the date the face to face interview was completed and the first date of service to assure criminal history was ran at the time of orientation or in the 12 months leading up.
Staff education will include training on new policy and procedure that will list the regulation that requires the policy to be implemented.

To prevent this issue from happening again the president or operations manager will sign off on each employee prior to them going into the field to work with consumers.

Following the audit of all current staff to take place prior to March 31 , and audit of new hires will be conducted each month to assure that all new staff were signed off on prior to working and that the new policy concerning hiring is being followed as explained in the corrective action.



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 (PF), and interview with agency staff (EMP), the agency failed to ensure direct care workers (DCW) met minimum competency requirements prior to assigning DCWs to provide services to a consumer for two (2) of four (4) direct care worker personnel files reviewed (PF2, PF3).

Findings included:

Personnel file (PF) reviews conducted on 2/19/2020 between approximately 11:30 a.m. to 2:30 p.m. revealed:
PF2, Date of hire 12/9/19. Start of service 12/10/19. PF revealed a completed competency exam dated 10/10/18.

PF3, Date of hire 12/19/19. Start of service 2/13/2020. PF revealed a completed competency exam dated 11/1/17.

An exit interview on 2/19/2020 at approximately 2:30 p.m. directly with agency operations officer, community outreach intake coordinator/office lead and staffing coordinator confirmed the above findings.

Repeat deficiency 12/26/17.




































Plan of Correction:

In order to comply with regulation 611.55 Competency requirements. Americare staffing will require all applicants whether new hire or rehire to complete a new competency test, orientation, and the department approved MY LEARNING CENTER Modules if they have not done so in the preceding 12 months prior to completing. Additionally all of our rostered staff are required to complete and demonstrate competency annually via consumer feedback, and in service to comply with Licensure competency requirements.



The System Americare will implement is a new hiring policy or Final check to completed by President and Operations Manager this policy will require each new employee to have their file reviewed for elements listed in this corrective action plan prior to be placed on assignment with a consumer.

Each month an audit of all New employees will be conducted and verified by President and Operations Manager to make sure that the new hire was reviewed by President or Operations manager prior to hiring. This monthly audit will be conducted on during the last week of the month but prior to the 30th and 31st. It will be done each month and documented in a binder where the chapter of our regulations are maintained. So that each regulation can be read and President and Operations manager will be assured that all regulation are being followed.

Staff training will include a review of the entire 611.51-55 so that the regulation is understood clearly, review our policy to follow the regulation and our procedure and quality assurance measure to assure that Americare is following the standard set forth in chapter 611.

All employee files will be audited no later that March 31st and and Audit checklist will be included in each file to verify the date that it was completed. This will also be signed off on by President and Operations manager. Any files that are found to be out of compliance, the employee will be brought in and retrained and documentation will be completed to bring the file into compliance .


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 personnel file (PF) reviews, review of Centers for Disease Control (CDC) guidelines and interviews with agency staff (EMP), it was determined that the agency failed to ensure each direct care worker, in accordance with CDC guidelines, had been screened for and was free from active mycobacterium tuberculosis (TB) for one (1) of four (4) direct care worker personnel files reviewed (PF3).

Findings Included:

According to the "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005," "...Baseline testing for M. Tuberculosis infection is recommended for all newly hired HCWs [health care workers]...If TST [tuberculin skin testing] is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative...If the first-step TB result is negative, the second-step TB should be administered 1--3 weeks after the first TB result was read...A second TB is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TB result within the previous 12 months, a single TB can be administered in the new setting...This additional TB represents the second stage of the two-step testing...".

Personnel file (PF) reviews conducted on 2/19/2020 between approximately 11:30 a.m. to 2:30 p.m. revealed:
PF3, Date of hire 12/19/19. Start of service 2/13/2020. There was documentation of a negative result TST completed on 7/3/19. There was no documentation of a second step TST completed. Initial screening was not completed in accordance with CDC guidelines.

An exit interview on 2/19/2020 at approximately 2:30 p.m. directly with agency operations officer, community outreach intake coordinator/office lead and staffing coordinator confirmed the above findings.
Repeat deficiency 12/10/12, 8/30/17, 1/18/19.


































































Plan of Correction:

To comply with 611.56A Licensure Health Screening, Americare Staffing will require documentation of a two step TB that must have been within one year with both steps having been administered within 1-3 weeks of each other. If a DCW new hire or rehire does not have evidence of a 2 step that is at most 12 months preceding date of hire. Americare will not accept valid one step or questionnaire. A new 2 Step TB will be required prior to sending a DCW into the field to work with Participants.


The System Americare will implement is a new hiring policy or Final check to completed by President and Operations Manager this policy will require each new employee to have their file reviewed for elements listed in this corrective action plan prior to be placed on assignment with a consumer.

Each month an audit of all New employees will be conducted and verified by President and Operations Manager to make sure that the new hire was infact reviewed by President or Operations manager prior to hiring. This monthly audit will be conducted on during the last week of the month but prior to the 30th and 31st. It will be done each month and documented in a binder where the chapter of our regulations are maintained. So that each regulation can be read and President and Operations manager will be assured that all regulation are being followed.

Staff training will include a review of the entire 611.51-56A so that the regulation is understood clearly, review our policy to follow the regulation and our procedure and quality assurance measure to assure that Americare is following the standard set forth in chapter 611.

All employee files will be audited no later that March 31st and and Audit checklist will be included in each file to verify the date that it was completed. This will also be signed off on by President and Operations manager. Any files that are found to be out of compliance, the employee will be brought in and retrained and documentation will be completed to bring the file into compliance .


Initial Comments:


Based on the findings of an onsite unannounced complaint survey completed February 19, 2020, Americare Staffing of Western Pennsylvania was found to be in compliance with the requirements of 35 P.S. 448.809 (b).












Plan of Correction: