Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey completed on 8/6/24, Aggie Home Care, Inc, 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 re-licensure survey completed on 8/6/24, Aggie Home Care, Inc, was found not to be in compliance with the 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 a review of agency personnel files (PF) and staff (EMP) interview, it was determined the agency failed to provide evidence of a face-to-face interview for five (5) of five (5) PF reviewed (PF1-5). The agency also failed to obtain two satisfactory references for two (2) of five (5) PF reviewed (PF3 & 5).
Findings included:
Review of PF completed on August 6, 2024, at approximately 10:20am revealed:
PF1, date of hire (DOH) 6/24/23, start of service (SOS) 6/24/23. PF failed to include evidence of face-to-face interview.
PF2, DOH 7/24/23, 7/25/23. PF failed to include evidence of face-to-face interview.
PF3, DOH 4/5/24, SOS 4/17/22. PF failed to include evidence of face-to-face interview. PF included evidence of one satisfactory reference.
PF4, DOH 7/24/23, SOS 7/26/23. PF failed to include evidence of face-to-face interview.
PF5, DOH 6/11/24, SOS 7/23/24. PF failed to include evidence of face-to-face interview. PF failed to include evidence of 2 satisfactory references.
Exit interview with Administrator, Office Manager, and Head Supervisor on August 6, 2024, at approximately 2:00pm confirmed findings.
Repeat deficiency, previously cited 7/9/12, 3/5/19, 8/15/19, and 7/7/21.
Plan of Correction:The documentation of the face to face completed and the 3 references completed and mailed out. Forms are placed in files and scanned in the computer and retained in employee file. these are the steps we will be putting into place.
After the finding of no face-to-face interview, the company is now going over the policy of hiring with all of office staff. The office staff will be re-educated on all the steps of hiring with an interview sign off form.
The Administrator will review the applicant's information, and make sure it is all satisfactory.
An audit will be performed on all paperwork to make sure it is all acceptable before the applicant is given a schedule and then audited every 2 months there out to make sure all information is still correct.
611.52(b) LICENSURE
State Police Criminal History Record
Name - Component - 00
If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.
Observations:
Based on a review of agency personnel files (PF) and staff (EMP) interview, it was determined the agency failed to request a State Police criminal history record for two (2) of five (5) PF reviewed (PF1 & 3).
Findings included:
Review of PF completed on August 6, 2024, at approximately 10:20am revealed:
PF1, date of hire (DOH) 6/24/23, start of service (SOS) 6/24/23. PF contained State police criminal history record dated 1/3/18. At this time Office Manager reported that this was from a previous period of employment with the agency. No State police criminal history record available to review that aligned with reviewed date of hire.
PF3, DOH 4/5/24, SOS 4/17/22. PF contained State police criminal history record dated 7/19/24, 106 days after hire.
Exit interview with Administrator, Office Manager, and Head Supervisor on August 6, 2024, at approximately 2:00pm confirmed findings.
Plan of Correction:The company is addressing the policy of a Criminal Background Clearance at the time of an interview with the office staff. The staff will be updated and educated on the policy of taking the proper steps at the time of interview to also do a Criminal Background Check.
If a Criminal Background Clearance is not returned in a proper time, then the new hire will be put on hold until the report is returned an audit will be done at the completion of the application by the head supervisor and documented and signed off by office director.
All information will be scanned into the computer system and then a paper copy in their files in the office.
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 a review of agency personnel files (PF) and staff (EMP) interview, it was determined the agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for three (3) of three (3) PF reviewed that were void of proof of residency (PF2, 4, & 5).
Findings included:
Review of PF completed on August 6, 2024, at approximately 10:20am revealed:
PF2, date of hire (DOH) 7/24/23, start of service (SOS) 7/25/23. PF failed to contain a federal criminal history record and a letter of determination from the Department of Aging.
PF4, DOH 7/24/23, SOS 7/26/23. PF failed to contain a federal criminal history record and a letter of determination from the Department of Aging.
PF5, DOH 6/11/24, SOS 7/23/24. PF failed to contain a federal criminal history record and a letter of determination from the Department of Aging.
Exit interview with Administrator, Office Manager, and Head Supervisor on August 6, 2024, at approximately 2:00pm confirmed findings.
Repeat deficiency, previously cited 6/4/19 and 8/15/19.
Plan of Correction:Office staff will be updated and educated on the policy of having proper residential address verification. After the office staff is done with their updated training, they will sign off on a document for stating the training they received.
All applicants must have 2 forms of their residency. These form of such will be scanned into the computer system with their application and then also in their folder in the office.
If applicant cannot provide such information, the Office Manager will request for a Federal Background Check to be done. Upon receiving said information it will be added to the file and entered into the computer. The supervisor will audit the file on a as completed basis and the office manager will do a monthly audit
611.52(d) LICENSURE
Proof of Residency
Name - Component - 00
The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation
Observations:
Based on a review of agency personnel files (PF) and staff (EMP) interview, it was determined the agency failed to require applicants to furnish proof of residency for three (3) of five (5) PF reviewed (PF2, 4, & 5).
Findings included:
Review of PF completed on August 6, 2024, at approximately 10:20am revealed:
PF2, date of hire (DOH) 7/24/23, start of service (SOS) 7/25/23. PF contained Pennsylvania State driver's license issued 2/28/22.
PF4, DOH 7/24/23, SOS 7/26/23. PF contained Pennsylvania State driver's license issued 11/5/22.
PF5, DOH 6/11/24, SOS 7/23/24. PF contained Pennsylvania State driver's license issued 11/22/22.
Exit interview with Administrator, Office Manager, and Head Supervisor on August 6, 2024, at approximately 2:00pm confirmed findings.
Repeat deficiency, previously cited 3/15/19.
Plan of Correction:An approved Plan of Correction is not on file.
611.55(a) LICENSURE
Competency 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 a review of agency personnel files (PF) and staff (EMP) interview, it was determined the agency failed to ensure direct care workers established competency prior to consumer contact for five (5) of five (5) PF reviewed (PF 1-5).
Findings included:
Review of PF completed on August 6, 2024, at approximately 10:20am revealed:
PF1, date of hire (DOH) 6/24/23, start of service (SOS) 6/24/23. PF failed to contain evidence of competency prior to consumer contact. Pennsylvania Homecare Association video log contained in file void of dates of completion.
PF2, DOH 7/24/23, SOS 7/25/23. PF failed to contain evidence of competency prior to consumer contact. Pennsylvania Homecare Association video log contained in file void of dates of completion.
PF3, DOH 4/5/24, SOS 4/17/22. PF failed to contain evidence of competency prior to consumer contact. No competency documentation available to review.
PF4, DOH 7/24/23, SOS 7/26/23. PF failed to contain evidence of competency prior to consumer contact. Pennsylvania Homecare Association video log contained in file void of dates of completion.
PF5, DOH 6/11/24, SOS 7/23/24. PF failed to contain evidence of competency prior to consumer contact. No competency documentation available to review.
Exit interview with Administrator, Office Manager, and Head Supervisor on August 6, 2024, at approximately 2:00pm confirmed findings.
Repeat deficiency, previously cited 3/15/19, 8/15/19, and 7/7/21.
Plan of Correction:Office staff is being updated on the competency testing with an applicant. Office staff will be updated and trained and sign an acknowledgement form.
A competency test will be given at the time of the 2 second interview. This test will consist of a video testing and then a paper answer form. Tests will go over the 16 direct care topics. Once test is completed applicant must score an 85% or higher before given a schedule.
The Office Manager will audit the test scores, and then applicant will be retested yearly. A calendar will be made to keep records of the due dates for the retesting.
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 a review of agency personnel files (PF) and staff (EMP) interview, it was determined the agency failed to ensure direct care worker competency review occurred annually for two (2) of three (3) PF reviewed having greater than 12 months of employment (PF 2 & 4).
Findings included:
Review of PF completed on August 6, 2024, at approximately 10:20am revealed:
PF2, date of hire (DOH) 7/24/23, start of service, (SOS)7/25/23. PF failed to contain evidence of annual competency for 2024.
PF4, DOH 7/24/23, SOS 7/26/23. PF failed to contain evidence of annual competency for 2024.
Exit interview with Administrator, Office Manager, and Head Supervisor on August 6, 2024, at approximately 2:00pm confirmed findings.
Plan of Correction:Office staff is updating the policy of the competency testing system and when to retest. Once office staff is trained and educated, they will do a form stating of such.
Once an applicant is hired, their hire date will be added to the system and to the calendar so that they can be retested annually. Retests will come in different forms, such as video, paper, or combination.
This will be audited by the head supervisor. And will be done semimonthly.
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 a review of agency personnel files (PF), CDC guidance, and staff (EMP) interview, it was determined the agency failed to ensure direct care workers had been screened for and free from active mycobacterium tuberculosis (TB) prior to consumer contact for three (3) of five (5) PF reviewed (PF 1,3, & 5).
Findings included:
Review of PF completed on August 6, 2024, at approximately 10:20am revealed:
PF1, date of hire (DOH) 6/24/23, start of service (SOS) 6/24/23. PF failed to contain evidence of TB screening.
PF3, DOH 4/5/24, SOS 4/17/24. PF failed to contain evidence of TB screening prior to consumer contact. Documentation in PF of TB read 4/24/24, 7 days after consumer contact.
PF5, DOH 6/11/24, SOS 7/23/24. PF failed to contain evidence of TB screening.
Exit interview with Administrator, Office Manager, and Head Supervisor on August 6, 2024, at approximately 2:00pm confirmed findings.
Repeat deficiency, previously cited 3/5/19 and 8/15/19.
Plan of Correction:Office staff will be going over and updating the policy of TB screening. Once office staff is educated and trained, they will fill out the document of training.at this time the supervisor will audit to make certain that all files have brought up to new standards.
An applicant will be given a 2 step TB test at the time of the 2nd interview. Applicant must have one negative reading before being given a schedule. The applicant will be educated annually and given information on TB screening. The office manager will audit
the completed file and setup anniversary date for retesting the head supervisor will keep all documentation of the test dates and the results of the testing. This will also be audited by the Office Manager to make sure all are correct and current, also to be reaudited annually from hire date.
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 a review of agency personnel files (PF), CDC guidance, and staff (EMP) interview, it was determined the agency failed to ensure direct care workers were screened in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis(TB) in health care settings for three (3) of five (5) PF reviewed (PF1, 3, & 5).
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 ... A second TST 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 TST result within the previous 12 months, a single TST can be administered in the new setting ... This additional TST represents the second stage of the two-step testing." Retrieved from http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf
Review of PF completed on August 6, 2024, at approximately 10:20am revealed:
PF1, date of hire (DOH) 6/24/23, start of service (SOS) 6/24/23. PF failed to include evidence of 2-step TB screening.
PF3, DOH 4/5/24, SOS 4/17/24. PF included documentation of 1-step TB screening dated 4/24/24 and placement of second step dated 5/29/24. documentation faxed from medical office stated that on 6/3/24 employee "did not come back" to have TB read.
PF5, DOH 6/11/24, SOS 7/23/24. PF failed to include evidence of 2-step TB screening.
Exit interview with Administrator, Office Manager, and Head Supervisor on August 6, 2024, at approximately 2:00pm confirmed findings.
Repeat deficiency, previously cited 7/9/12, 3/5/19 and 8/15/19.
Plan of Correction:Office staff will be going over and updating the policy of TB screening. Once office staff will be educated and trained, they will fill out the document of training.
An applicant will be given a form for a 2 step TB test at the time of the 2nd interview. Applicant must have one negative reading before being hired. The applicant will be educated on all the CDC guidelines annually and tested. Test will be in the form of a paper copy will placed in the applicant's folder in office.
The head supervisor will keep all documentation of the test dates and the results of the testing. This will also be audited by the Office Manager to make sure all are correct and current, also reaudited on their hire date anniversary.
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 on a review of agency personnel files (PF), CDC guidance, and staff (EMP) interview, it was determined the agency failed to ensure direct care workers received annual tuberculosis (TB) education for three (3) of five (5) PF reviewed having greater than 12 months of employment (PF1, 2, & 4).
Findings included:
The CDC guidelines state that 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).
Review of PF completed on August 6, 2024, at approximately 10:20am revealed:
PF1, date of hire (DOH) 6/24/23, start of service (SOS) 6/24/23. PF failed to include evidence of TB education for 2024.
PF2, DOH 7/24/23, SOS 7/25/23. PF failed to include evidence of TB education for 2024.
PF4, DOH 7/24/23, SOS 7/26/23. PF failed to include evidence of TB education for 2024.
Exit interview with Administrator, Office Manager, and Head Supervisor on August 6, 2024, at approximately 2:00pm confirmed findings.
Repeat deficiency, previously cited 3/5/19 and 8/15/19.
Plan of Correction:Office staff is updating the policy of the TB education testing. Once the office staff is trained and educated, they will sign off on a document and audited by the head supervisor at the time of completion.
The TB education will be done annually in the form of a video and then a 15-question sheet afterwards. Staff must score an 85% on the test. After test is done and audited by the office manager, they will receive a certificate that will be placed in their folder in the office. Auditing of this process will be done by the supervisor on a monthly basis.
The head supervisor will keep records of the dates each staff member will be due to be retested, and auditing over such will be done on a case-by-case basis by the office manager to make sure information is correct and current.
611.57(d) LICENSURE
Documentation
Name - Component - 00
(d) The home care agency or home care registry shall maintain documentation on file at the agency or registry of compliance with the requirements of this section which shall be available for Department inspection.
Observations:
Based on a review of agency consumer files (CF) and staff (EMP) interview, it was determined the agency failed to maintain documentation on file at the agency for three (3) of five (5) CF reviewed (CF1, 3, & 5).
Findings included:
Review of CF completed on August 6, 2024, at approximately 11:40am revealed:
CF1, start of service (SOS) 2/4/22. CF failed to contain evidence of start of service paperwork. Not available for review.
CF3, SOS 8/2/22. CF failed to contain evidence of start of service paperwork. Not available for review.
CF5, SOS 6/20/24. CF failed to contain evidence of start of service paperwork. Not available for review.
Exit interview with Administrator, Office Manager, and Head Supervisor on August 6, 2024, at approximately 2:00pm confirmed findings.
Repeat deficiency, previously cited 8/15/19.
Plan of Correction:Office staff will be updated and trained on the policy of the consumer information. Once they have completed the training, they will sign documentation showing their training was completed.
All consumer's files will be updated and rechecked bi-monthly for any changes. Consumers files will have a check list placed in the front of each folder of all information that is requested by pa department of licensing, insurances, and office staff for any changes. Each consumer is given a welcome packet that tells them of their rights and addressing the care from the company. Consumer will have a copy in a folder in their home and signed by them and supervisor at the time of opening a case, there will also be a copy in their file in office.
Office manager and head supervisor will be doing all updates and will be auditing the folders bi-monthly from the start date of services.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey completed on 8/6/24, Aggie Home Care, Inc, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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