Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on August 27, 2021 Maxim Healthcare Services 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 state re-licensure survey conducted on August 27, 2021, Maxim Healthcare Services 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
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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 personnel files (PF) and an interview with the administrator, prior to hiring or rostering a direct care worker, the agency did not (1) Conduct a face-to-face interview with the individuals for two (2) of seven (7) PF's: PF#3 and PF#5 and (2) Did not obtain not less than two satisfactory references for the individuals for one (1) of seven (7) PF's. PF#7.
Findings include:
A review of PF's was conducted on August 27, 2021 at approximately 11:00 AM. The date of hire (DOH) is indicated below:
PF #3 DOH 03/20/2019 contained no evidence that a face to face interview was conducted prior to hiring or rostering the direct care worker.
PF #5 DOH 08/19/2019 contained no evidence that a face to face interview was conducted prior to hiring or rostering the direct care worker.
PF#7 DOH 11/20/2020 contained no evidence that references were conducted prior to hiring or rostering the direct care worker.
An interview with the administrator conducted at approximately 02:15 PM confirmed the above findings.
Plan of Correction:Updated our process for face to face interviews based on the findings. We will continue to do interviews over the phone until the PA policy requiring face to face interviews starts back up. After that, our updated process will require our HR team to audit each PF prior to making an employee active to confirm that a face to face interview is documented. HR manager is responsible for keep a spreadsheet to track all face to face interviews are completed prior to activation. HR manager and Operations Manager will meet once per week to review the spreadsheet and confirm that we are abiding by state policies. We will document in the spreadsheet for 60 days to ensure the process is being followed properly. Operations Manager met with recruitment team and had them sign off of the expectations regarding face to face interviews.
Starting immediately, HR manager will audit each PF file prior to activation to validate that all reference checks were completed per policy. We will document in a spreadsheet as a form on confirmation that the references were completed properly. We will do this for 60 days and HR manager and Operations Manager will meet once per week to review the spreadsheet. We had a meeting with all HR team members and had them sign off that they understood the expectations of the reference check policy.
611.56(a) LICENSURE
Health Screening
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(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 personnel files (PF), the Centers for Disease Control (CDC) guidelines and an interview with the administrator, the agency did not provide documentation that a staff member was screened for and free from active mycobacterium tuberculosis for one (1) of seven (7) PF's. PF#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, HCW's should receive TB screening annually. HCW's 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 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 PF's was conducted on August 27, 2021 at approximately 11:00 AM. The date of hire (DOH) is indicated below:
PF#7: DOH 11/11/2020 contained documentation of a single step TST performed on 111/15/2020. There was no second TST contained in the file.
An interview with the administrator conducted on August 27, 2021 at approximately 2:15 PM confirmed these findings.
Plan of Correction:HR Manager has been appointed to review all PF files for employees coming through the hiring process. No employee will be made active in our system of record until HR manager confirms that both TB shots have been completed. HR Manager will document on a spreadsheet for the next 60 days the results of his audits in order to further educate internal staff. HR manager held a meeting with HR team and had them sign off that they fully understand that no employee will be made active until HR manager completes his audit of the PF.
611.57(a) LICENSURE
Consumer Rights
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(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.
Observations:
Based on review of agency policies/procedures, consumer records (CR), and an interview with the administrator, the agency failed to provide services as outlined on the patient's plan of care for one (1) of three (3) CR's reviewed, (CR #1).
Findings include:
A review of agency policy "Patient/Client Scheduling" was conducted on August 27, 2021 at approximately 1:00 pm. Policy states, "Purpose: To ensure patient/client shifts are scheduled and completed according to the plan of care/plan of service...3.2 The office operations leader or designee shall ensure that adequate resources are available to provide qualified Direct Care Staff to cover scheduled and unscheduled absences so that ordered and/or authorized services are not interrupted..."
A review of CR's was conducted on August 27, 2021 at approximately 10:30 am.
CR #1, Start of Care: 10/19/11. Services are provided under the Attendant Care/Act 150 program and authorized for one hundred fifty-four (154) hours per week: Monday through Sunday from 7 am to 4 pm, 4 pm to 9 pm, and 10 pm to 6 am. Daily visit documentation from July 1, 2021 through August 21, 2021 was reviewed.
Missed shifts were documented as follows:
7/3/2021 7 am to 4 pm and 4 pm to 9 pm.
7/5/2021 7 am to 4 pm and 4 pm to 9 pm.
7/6/2021 7 am to 4 pm.
7/11/2021 10 pm to 6 am.
7/13/2021 10 pm to 6 am.
7/14/2021 12:37 am to 6 am.
7/15/2021 10 pm to 6 am.
7/16/2021 7 am to 12 pm.
7/23/2021 10 pm to 6 am.
7/24/2021 10 pm to 6 am.
8/5/2021 7 am to 4 pm.
8/7/2021 10 pm to 6 am.
8/11/2021 10 pm to 6 am.
8/15/2021 7 am to 4 pm and 4 pm to 9 pm.
8/16/2021 7 am to 3 pm.
8/21/2021 10 pm to 6 am.
An interview with the administrator conducted on August 27, 2021 at approximately 2:00 pm confirmed the above findings.
Plan of Correction:Maxim was able to locate timesheets for shifts on 7/3/21, 7/5/21, 7/13/21, 7/14/21, 7/15/21, and 8/16/21. However, we will increase our expectations to limit missed shifts. We will do that in a few different ways:
1. Maxim has increased its recruitment efforts to ensure we have staff available to cover all open shifts. Recently we hired 3 extra internal recruiters to ensure we are quickly hiring more staff to fill shifts to avoid missing patient hours.
2. We have increased the expectations for our recruitment team as all 6 of them are required to hire at least 1 new employee per week. Operations Manager will continue to monitor these numbers in a weekly recruitment meeting. This will allow us to have an additional 24 new caregivers per month in order to fill all open shifts.
3. Over the next 30 days we will send at least 5 new meet and greets to this particular client so that we have many more employees who are familiar with his care plan and to prevent not filling any future shifts.
4. Operations manager will review missed shift reports weekly to ensure that everything is being documented properly and to put in place further plans to avoid missed shifts.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on August 27, 2021 Maxim Healthcare Services was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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