QA Investigation Results

Pennsylvania Department of Health
ANGEL COMPANIONS
Health Inspection Results
ANGEL COMPANIONS
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted on May 30, 2024, Angel Companions was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.




Plan of Correction:




Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on May 30, 2024, Angel Companions 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:




611.51(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 a review of direct care worker personnel files (PF) and interview with the agency Branch Manager, the agency failed to document two (2) satisfactory references prior to employment for one (1) of nine (9) PF reviewed. (PF #2).

Findings Include:

A review of PF's conducted on May 30, 2024, from approximately 11:15 P.M. to 12:45 P.M. revealed the following:

PF #2, date of hire December 21, 2023, contained no documentation of two (2) satisfactory references obtained prior to employment.

An interview with the agency Branch Manager on May 30, 2023, at approximately 1:00 P.M. confirmed the above findings.
























































Plan of Correction:

Brach Manager immediately spoke with HR Department regarding findings from survey. HR Department reached out to direct care worker to obtain proper documentation for direct care worker to continue working.

HR Department will audit direct care worker files more thoroughly before direct care worker is permitted to start work with agency.

HR Department will also continue conducting routine audits of direct care worker files.

All should be completed no later than 6/30/2024


611.52(c) LICENSURE
Federal Criminal History Record

Name - Component - 00
If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code 15.144(b) (relating to procedure).

Observations:


Based on review of direct care worker personnel files (PF) and an interview with the agency Branch Manager, the agency failed to obtain a Federal criminal background check for one (1) of nine (9) PF reviewed. (PF #2)

Findings include:

Review of PF on May 30, 2024, from approximately 11:15 A.M. to 12:45 P.M. revealed the following:

PF #2, date of hire December 21, 2023, contained documentation of a United States work authorization issued August 21, 2023. There was documentation of a Covid-19 vaccine given in Haiti on March 13, 2023. There was no documentation of residency prior to August, 2023. There was no documentation of a Federal criminal background check completed upon hire.

An interview with the agency Branch Manager on May 30, 2023, at approximately 1:00 P.M. confirmed the above findings.
























































Plan of Correction:

Branch Manager immediately spoke with HR Department after deficient findings occurred from audit.

Direct care worker was contacted immediately and agency put steps in place to obtain criminal background check.

Moving forward HR Department will thoroughly review direct care worker files to make sure all documentation is properly obtained before direct care worker is permitted to work.

Direct care worker files will also be audited by HR Department on a routine basis to make sure this does not occur in the future.




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 personnel files (PF) and an interview with the agency Branch Manager, the agency failed to ensure baseline (preplacement) tuberculosis (TB) screening/and or testing and/or a symptom screen questionnaire and/or an individual tuberculosis (TB) risk assessment was conducted in accordance with CDC (Centers for Disease Control and Prevention) guidelines for four (4) of nine (9) PF reviewed. (PF# 2, 5, 6, and 8).

Findings Include:

"The CDC guidelines state baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or tuberculin skin test (TST), shall include a symptom screen questionnaire and an individual tuberculosis (TB) risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended."

"Baseline Pre-Screening and Testing: ... (1). The risk assessment and symptom evaluation help guide decisions when interpreting test results. For example, health care personnel with a positive test who are asymptomatic, unlikely to be infected with M. tuberculosis, and at low risk for progression on the basis of their risk assessment should have a second test (either an IGRA or a TST) as recommended in the 2017 TB diagnostic guidelines of the American Thoracic Society, Infectious Diseases Society of America, and CDC (16). In this example, the health care personnel should be considered infected with M. tuberculosis only if both the first and second tests are positive."
(CDC/MMWR/May 17, 2019/Vol. 68/No. 19).

Review of PF's conducted on May 30, 2024, from approximately 11:15 A.M. to 12:45 P.M. revealed the following:

PF #2, date of hire December 21, 2023, contained documentation of a Quantiferon Gold TB test completed on September 11, 2023. The result of the test was positive. A TB symptom screening questionnaire and a TB risk assessment were completed. The employee did not have any symptoms of TB. The employee did reside outside of the United States in a country with high risk for TB infection, and did have a BCG (bacillus Calmette-Guvaccine. There was no follow-up testing documented to confirm that the employee was free from TB.

PF #5, date of hire May 30, 2023, contained no documentation of preplacement testing. The PF contained a TB risk assessment that was not completed upon hire.

PF #6, date of hire February 7, 2023, contained documentation of a single TST completed on February 28, 2023. There was no documentation of second TST or a TB risk assessment completed upon hire.

PF #, date of hire October 17, 2022, contained documentation of a single TST conducted on October 17, 2022. There was no documentation of a second TST conducted.

An interview with the agency Branch Manager on May 30, 2024, at approximately 1:00 P.M. confirmed the above findings.






Plan of Correction:

Branch Manager discussed audit deficient results with HR Department as soon as audit ended.

HR Department reached out to all direct care workers missing TB Documentation and Risk Assessment information to obtain immediately. Branch Manager also received information from direct care workers who were getting testing done immediately.

Going forward HR Department will review direct care worker files thoroughly to make sure all information is obtained and appropriate before direct care worker is permitted to start care.

HR Department will also continue to routinely audit direct care worker files to make sure this does not occur for any other direct care workers.

POC to be completed no later than 6/30/2024




Initial Comments:

Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on May 30, 2024, Angel Companions was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: