QA Investigation Results

Pennsylvania Department of Health
AGAPE CARE, INC.
Health Inspection Results
AGAPE CARE, INC.
Health Inspection Results For:


There are  4 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 unannounced onsite state relicensure survey completed June 16, 2021, Agape Care, Inc. was found not to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.







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 an interview with the agency Administrator, the agency failed to ensure event reporting to the Pennsylvania (Pa.) Department of Health of employee who was diagnosed COVID-19 positive for one (1) of one (1) interviews (Interview #1).

Findings Include:

ERS (Event Reporting System) Event Reporting Related to COVID-19 (03/30/2020): "Agencies are to report all initial 'Activation of Internal/External Emergency Plan' - You may submit additional reports, as updates, if necessary".
"Agencies must report under 'Health Department Reportable Disease' all COVID-19 positive test results for staff and patients including name, date of birth, symptoms (if known) and date of test results."

Interview #1: On June 15, 2021 at approximately 11:00 a.m. a list was requested from the the agency Human Resources Director of all consumers and all employees who were diagnosed COVID-19 +. The Human Resources Director was also asked for documentation showing that all COVID-19 + consumers/employees were entered into the Pa. Event Reporting website.
The consumer/employees are listed below with their date of positive COVID-19 diagnosis:
Consumer #6: Agency documentation of COVID-19 test date of 01/09/21 with results being positive. No documentation provided of this reportable disease event being reported to the Pa. Department of Health through the ERS.

Employee #8: Agency documentation of COVID-19 test date of 01/13/21 with results being positive. No documentation provided of this reportable disease event being reported to the Pa. Department of Health through the ERS.

Employee #9: Agency documentation of COVID-19 test date of 01/11/21 with results being positive. No documentation provided of this reportable disease event being reported to the Pa. Department of Health through the ERS.

An interview conducted with the agency Administrator on June 15, 2021 at approximately 11:00 a.m. confirmed the above findings.











Plan of Correction:

1. Consumer #6, Employee #8, and Employee #9 will have their reportable disease submitted to the ERS.

2. Will conduct an audit of entire consumer files/employee files to ensure no other individuals have been affected by the same deficient practice.

3. Will create a new checklist for event reporting. Those responsible for reporting (President, Director of Human Resources, and Client Care Coordinator) will be trained on entering reports in the ERS.

4. The President will audit 10% of consumer/employee files every 6 months to monitor that the deficient practice does not recur.

5. August 13, 2021


Initial Comments:


Based on the findings of an unannounced onsite state relicensure survey completed June 16, 2021, Agape Care, Inc. 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:




611.4(b) LICENSURE
Requirements For HCA And HCR

Name - Component - 00
28 PA Code Chapter 51, applicable to all entities licensed as Health Care facilities under the Act, applies to Home Care Agencies and Home Care Registries licensed under this Chapter.

Observations:


Based upon an interview with the agency Administrator, the agency failed to be aware of Chapter 51 event reporting requirements, which requires reporting of any events which seriously compromise quality assurance and patient safety for one (1) of one (1) interviews conducted (Interview #1).

Findings include:

Interview #1: An interview was conducted with the agency Administrator on June 15, 2021 at approximately 10:05 a.m. The Administrator was asked if agency was aware of the Department of Health Event Reporting System (ERS) and what circumstances would warrant a notification to the Department. The Administrator stated "I am not aware of event reporting to the Department of Health." The Administrator was not aware of the agency username or password to enter the Department of Health ERS. A review of the Department of Health ERS showed no reports were made by the agency.

An interview conducted with the agency Administrator on June 15, 2021 at approximately 11:00 a.m. confirmed the above findings.











Plan of Correction:

1. The President, Director of Human Resources, and Client Care Coordinator will be trained on ERS.

2. An audit of client and employee files will be conducted to ensure that other individuals have not been affected by the same deficient practice.

3. Will create a new checklist for event reporting. Those responsible for reporting (President, Director of Human Resources, and Client Care Coordinator) will be trained on entering reports in the ERS.

4. The President will audit 10% of consumer/employee files every 6 months to monitor that the deficient practice does not recur.

5. August 13, 2021


611.4(c) LICENSURE
Requirements for HCA and HCR

Name - Component - 00
Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.

Observations:


Based on observations and an interview with the agency Administrator, agency failed to ensure employees were provided/have available, personal protective equipment (PPE) if required/needed, for one (1) of one (1) observations (Observation #1) and failed to ensure that everyone entering the health care facility is screened and triaged for COVID-19 for one (1) of one (1) observations (Observation#1) and one (1) of one (1) interviews conducted (Interview #1) .

Findings include:

Pennsylvania Department of Health 'Health Alert Network' 'PAHAN-492' dated 04/03/2020 section 'Universal Masking of Health Care Workers and Staff in Congregate Settings' states "Continue to utilize recommended PPE (N-95 respirator or higher, gown, gloves, and eye protection) for confirmed COVID-19 cases".

Observation #1: Interview conducted with the agency Human Resources Director on June 15, 2021 at approximately 10:00 a.m. The Human Resources Director was asked to show the state surveyor the agency PPE inventory. The agency inventory consisted of disposable gloves, disposable surgical face masks, cloth face masks, and eye protection.
The agency did not have a supply of N-95 (or approved equivalent) respirators nor gowns.


Pennsylvania Department of Health 'Health Alert Network' dated August 7, 2020 'Subject' 'Update: Interim Infection Prevention and Control Recommendations for Patients with known or Patients Under Investigation for 2019 Novel Coronavirus (COVID-19) in a Healthcare Setting' section (I) Recommended Routine Infection Prevention and Control (IPC) Practices During the COVID-19 Pandemic' (B) 'Screen and Triage Everyone Entering a Healthcare Facility for signs and symptoms of COVID-19':....symptom screening remains an important strategy to identify those who could have COVID-19 .......". "Screen everyone (patients, healthcare personnel, visitors) entering the facility for symptoms consistent with COVID-19 .....". "Actively take their temperature and document absence of symptoms consistent with COVID-19".

Observation #1: On June 15, 2021 at approximately 8:40 a.m. the state surveyor arrived at the agency office. No COVID-19 temperature screening nor symptom screening questions were conducted. The surveyor was escorted into an office area to begin the survey by the Human Resources Director.
Interview #1: On June 15, 2021 at approximately 10:45 a.m. an interview was conducted with the agency Administrator. The Administrator was asked what the agency screening protocols are for people who enter the agency office. The Administrator was not aware of the requirements to screen people who enter the agency for COVID-19.
No documentation of the Administrator, the Human Resources Director, nor the Client Care Coordinator being screened for COVID-19 upon entry into the agency office.
The agency failed to ensure adequate infection control practices by ensuring that everyone entering the health care facility is screened and triaged for COVID-19.


An interview conducted with the agency Administrator on June 15, 2021 at approximately 11:00 a.m. confirmed the above findings.










Plan of Correction:

1a. The Agency will screen and triage everyone entering the facility.

1b. The Agency will have a supply of N95 (or approved equivalent) respirators and gowns.

2a. The President will weekly check the screening log to ensure compliance.

2b. The Director of Human Resources will distribute N95 masks and gowns to staff and ensure a supply is kept at the agency.

3a.Admistrative staff will be trained to screen and triage incoming individuals. A sign will be placed on the door stating that the screening will occur upon entrance.

3b. N95 masks and gowns will be added to the PPE ordering/inventory list that will be checked monthly.

4a.The President will monitor logs weekly to ensure compliance.

4b. The President will monitor orders/supply on a quarterly basis to ensure compliance.

5a.August 13, 2021

5b. August 13, 2021


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 review of employee files and an interview with the agency Administrator, agency failed to provide documentation showing annual competency review covering all required sixteen (16) subject areas for two (2) of seven (7) employee files (EF) reviewed (EF#1, EF#2).

Findings include:

A review of EFs was conducted on June 15, 2021 at approximately 9:15 a.m. Employee date of hire (DOH) is listed below.

EF#1 DOH 01/30/20: No documentation provided of a 2021 annual competency review containing all sixteen (16) required elements.

EF#2 DOH 04/22/20: No documentation provided of a 2021 annual competency review containing all sixteen (16) required elements.


An interview conducted with the agency Administrator on June 15, 2021 at approximately 11:00 a.m. confirmed the above findings.







Plan of Correction:

1. EF#1 and EF#2 will receive the annual competency review.

2. Will conduct an audit of all employee files to ensure that the annual competency reviews have been completed.

3. Will implement a tracking system via Appointmate (scheduling/employee & client track program) that will be used to ensure deficient practice does not recur.

4. The Director of Human Resources will conduct an audit of 10% of employee files every quarter to ensure compliance.

5. August 13, 2021


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 employee files and an interview with the agency Administrator, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, was screened for and is free from active mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for seven (7) out of seven (7) employee files (EF) reviewed (EF#1-EF#7).

Findings Include:

The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs with a baseline positive or newly 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.)
*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).

A review of EFs was conducted on June 15, 2021 at approximately 9:15 a.m. Employee date of hire (DOH) is listed below.

EF#1 DOH 01/30/20: No documentation a symptom screen questionnaire nor an individual TB risk assessment being conducted.

EF#2 DOH 04/22/20: No documentation a symptom screen questionnaire nor an individual TB risk assessment being conducted.

EF#3 DOH 09/15/20: No documentation a symptom screen questionnaire nor an individual TB risk assessment being conducted.

EF#4 DOH 09/15/20: No documentation a symptom screen questionnaire nor an individual TB risk assessment being conducted.

EF#5 DOH 03/30/21: No documentation a symptom screen questionnaire nor an individual TB risk assessment being conducted.

EF#6 DOH 03/31/21: No documentation of an individual TB risk assessment being conducted.

EF#7 DOH 05/03/21: No documentation of an individual TB risk assessment being conducted.


An interview conducted with the agency Administrator on June 15, 2021 at approximately 11:00 a.m. confirmed the above findings.












Plan of Correction:

1. EF#1- Symptom Screen questionnaire and an individual TB risk assessment will be conducted.

EF#2-Symptom Screen questionnaire and an individual TB risk assessment will be conducted.

EF#3-Symptom Screen questionnaire and an individual TB risk assessment will be conducted.

EF#4-Symptom Screen questionnaire and an individual TB risk assessment will be conducted.

EF#5- Symptom Screen questionnaire and an individual TB risk assessment will be conducted.

EF#6-Individual TB Risk Assessment will be conducted.

EF#7-Individual TB Risk Assessment will be conducted

2. Will conduct an audit of all employee files to make sure no other individuals have been affected by the same deficient practice.

3. Will create tracking via Appointmate that will be used to ensure deficient practice does not occur. Annual TB education will be conducted.

4. The Director of Human Resources will audit 10% of all employee records quarterly to ensure the the deficient practice will not recur.

5. August 13, 2021


611.57(c) LICENSURE
Information to be Provided

Name - Component - 00
(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 upon review of consumer files, the consumer admission packet, and an interview with the agency Administrator, the agency failed to provide the consumer, prior to the commencement of services, the Department's complaint Hot Line (1-800-254-5164) for five (5) of five (5) consumer files (CF) reviewed (CF#1-CF#5).

Findings include:

A review of CFs was conducted on June 15, 2021 at approximately 9:15 a.m. Consumer start of service (SOS) is listed below.

CF#1 SOS 12/01/20: No documentation of providing the consumer, prior to the commencement of services, the Department's complaint Hot Line (1-800-254-5164). The consumer admission packet listed an incorrect number (1-866-826-3644).

CF#2 SOS 08/26/19: No documentation of providing the consumer, prior to the commencement of services, the Department's complaint Hot Line (1-800-254-5164). The consumer admission packet listed an incorrect number (1-866-826-3644).

CF#3 SOS 12/14/20: No documentation of providing the consumer, prior to the commencement of services, the Department's complaint Hot Line (1-800-254-5164). The consumer admission packet listed an incorrect number (1-866-826-3644).

CF#4 SOS 11/23/20: No documentation of providing the consumer, prior to the commencement of services, the Department's complaint Hot Line (1-800-254-5164). The consumer admission packet listed an incorrect number (1-866-826-3644).

CF#5 SOS 01/25/21: No documentation of providing the consumer, prior to the commencement of services, the Department's complaint Hot Line (1-800-254-5164). The consumer admission packet listed an incorrect number (1-866-826-3644).

An interview conducted with the agency Administrator on June 15, 2021 at approximately 11:00 a.m. confirmed the above findings.










Plan of Correction:

1. CF#1-CF#5 will receive a written notice with the corrected Department's Complaint Hotline.

2. An audit of all consumer files will be conducted. A written notice will be sent to all consumers with the corrected Department's Complaint Hotline.

3. The "Welcome to Agape" Packet will be updated to ensure the correct phone number. All old copies will be discarded.

4. The President will audit and update the packet annually or upon notice of a change in number by the department.

5. August 13, 2021


Initial Comments:


Based on the findings of an unannounced onsite state relicensure survey completed June 16, 2021, Agape Care, Inc. was found not to be in compliance with the requirements of 35 P.S. 448.809 (b).









Plan of Correction:




35 P. S. 448.809b LICENSURE
Photo Id Reg

Name - Component - 00
(1) The photo identification tag shall include a recent photograph of the employee, the employee's FIRST name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.



Observations:


Based upon observation of Identification badges (ID) and an interview with the agency Administrator, agency failed to format/issue ID badges per regulatory requirements for one (1) of one (1) observation (Observation #1).

Findings include:

Observation #1: Observation of employee Identification Badge (ID) on June 15, 2021 at approximately 10:30 a.m. revealed the current ID badge title did not occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge. The employee title is approximately 1/4" and is positioned towards the center of the badge.


An interview conducted with the agency Administrator on June 15, 2021 at approximately 11:00 a.m. confirmed the above findings.
Email correspondence was conducted with the Human Resources Director on June 16, 2021 at approximately 9:39 a.m. Per the Human Resources Director, there are approximately twenty-two (22) employees in the field who currently have ID badges formatted as stated above.







Plan of Correction:

1. All 22 employees will receive corrected ID Badges to reflect the Department's requirements.

2. All employees will receive a new ID Badge. Old Badges will be collected and destroyed.

3. A new ID Badge Template will be created to ensure compliance.

4. The President will ensure that updates to regulations regarding ID Badges are followed. The Director of Human Resources will ensure that future badges are compliant.

5. August 13, 2021