Initial Comments:
Based on the findings of an onsite home care agency re-licensure survey conducted on November 13, 2024, Always Best Care 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 home care agency state re-licensure survey conducted on November 13, 2024, Always Best Care 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:
611.52(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 personnel records (PF) and staff interview, the agency failed to obtain a Federal criminal history check for employees who were not a Pa resident for two (2) years preceding the date of hire for two (2) out of the seven (7) PFs reviewed. (PF#1 and PF#3)
Findings include:
Personnel file review conducted November 13, 2024 from approximately 2 pm to 4pm, revealed the following:
PF#1, Date of hire (DOH) 12/21/23: Contained a Pennsylvania drivers license issued on 12/20/23, which fails to ascertain PA residence of two (2) or more years. No other documentation on file to establish proof of residency. No documentation of a federal criminal history check performed.
PF#3 DOH 10/31/22: Contained a US passport, which fails to ascertain PA residence of two (2) or more years. No other documentation on file to establish proof of residency. No documentation of a federal criminal history check performed.
An interview with the administrator on November 13, 2024 at approximately 4:30pm confirmed the above findings.
Plan of Correction:WHAT CORRECTIVE ACTION WILL BE ACCOMPLISHED FOR THOSE INDIVIDUALS AND/OR PRACTICES IDENTIFIED IN THE DEFICIENCY STATEMENT?
The agency will review the file of PF#1 & PF#3 and obtain the Federal criminal history record requirement to be in compliance with 611.52(c).
HOW WILL YOU IDENTIFY OTHER INDIVIDUALS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE?
An immediate file audit of all new hires will be for missing Federal criminal history record requirement, to ensure that the agency is in compliance with 611.52(c)
WHAT MEASURES (ACTIONS/FORMS/SYSTEM CHANGES ETC) WILL BE PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR?
A check list will become a part of each employee's file, and upon hire Human Resources will ensure that every item listed on the check list is in the file.
HOW WILL THE CORRECTIVE ACTION BE MONITORED TO ENSSURE THAT THE DEFICIENT PRACTICE WILL NOT RECUR, I.E. WHAT QUALITY ASSURANCE PROGRAMS WILL BE ESTABLISHED/FOLLOWED?
A monthly file audit will be performed with no less than 10% of random personnel files of which all will be audited for missing references until all files are done to ensure that the agency is in compliance with 611.52(c).
IDENTIFY BY POSITION WHO WILL BE RESPONSIBLE FOR SUCH MONITORING AND WHAT FORMS OR TOOLS WILL BE COMPLETED/RETAINED TO MEASURE/SUSTANTIATE THE MONITORING PERFORMED AND FREQUENCY OF MONITORING?
The Human Resources Manager or designee will review the findings of the quarterly internal audit and document the review.
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 personnel files (PF) and an interview with the administrator, the agency did not obtain proof of residency in order to request/obtain a criminal history record through the 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 for two (2) of seven (7) PF's: PF#1 and PF#3)
Findings include:
Personnel file review conducted November 13, 2024 from approximately 2 pm to 4pm, revealed the following:
PF#1 Date of hire (DOH) 12/21/23: Contained a Pennsylvania drivers license issued on 12/20/23, which fails to ascertain PA residence of two (2) or more years. No other documentation on file to establish proof of residency.
PF#3 DOH 10/31/22: Contained a US passport, which fails to ascertain PA residence of two (2) or more years. No other documentation on file to establish proof of residency.
An interview with the administrator on November 13, 2024 at approximately 4:30pm confirmed the above findings.
Plan of Correction:WHAT CORRECTIVE ACTION WILL BE ACCOMPLISHED FOR THOSE INDIVIDUALS AND/OR PRACTICES IDENTIFIED IN THE DEFICIENCY STATEMENT?
The agency will review the files of PF#1 & PF#3, and obtain proof of PA residency of two (2) years or more to be in compliance with 611.52(d).
HOW WILL YOU IDENTIFY OTHER INDIVIDUALS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE?
An immediate file audit of all new hires will be for missing proof of PA residency, to ensure that the agency is in compliance with 611.52(d)
WHAT MEASURES (ACTIONS/FORMS/SYSTEM CHANGES ETC) WILL BE PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR?
A check list will become a part of each employee's file, and upon hire Human Resources will ensure that every item listed on the check list is in the file.
HOW WILL THE CORRECTIVE ACTION BE MONITORED TO ENSSURE THAT THE DEFICIENT PRACTICE WILL NOT RECUR, I.E. WHAT QUALITY ASSURANCE PROGRAMS WILL BE ESTABLISHED/FOLLOWED?
A monthly file audit will be performed with no less than 10% of random personnel files of which all will be audited for missing references until all files are done to ensure that the agency is in compliance with 611.52(d).
IDENTIFY BY POSITION WHO WILL BE RESPONSIBLE FOR SUCH MONITORING AND WHAT FORMS OR TOOLS WILL BE COMPLETED/RETAINED TO MEASURE/SUSTANTIATE THE MONITORING PERFORMED AND FREQUENCY OF MONITORING?
The Human Resources Manager or designee will review the findings of the quarterly internal audit and document the review.
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 review of personnel files (PF), the Centers for Disease Control Guidelines, and an interview with the agency administrator, it was determined the agency failed to ensure direct care workers were screened for and were free from active mycobacterium tuberculosis prior to assignment with clients for six (6) out of seven (7) personnel files reviewed. (PF #2, PF #3, PF #4, PF#5, PF#6, PF#7)
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).
Findings include:
Personnel file review conducted November 13, 2024 from approximately 2 pm to 4pm, revealed the following:
PF#2 Date of hire (DOH) 5/9/24: Did not contain any documentation of TB testing performed upon date of hire or within one year preceding the hire date.
PF#3 DOH 10/31/22: Did not contain a baseline risk and symptom questionaire upon hire.
PF#4 DOH 12/22/21: Contained a 2 step TST dated 8/30/22 and 9/13/22, which is after the hire date.
PF#5 DOH 5/2/24: Did not contain any documentation of a TB test performed upon hire or within one year preceding the hire date. Also did not contain a baseline risk and symptom questionaire upon hire.
PF#6 DOH 8/3/23: Did not contain any documentation of a TB test performed upon hire or within one year preceding the hire date. Also did not contain a baseline risk and symptom questionaire upon hire.
PF#7 DOH 7/19/24: Did not contain a completed TB test. TST dated 1/27/24. No documentation that a second step was performed.
An interview with the administrator on November 13, 2024 at approximately 4:30pm confirmed the above findings.
Plan of Correction:WHAT CORRECTIVE ACTION WILL BE ACCOMPLISHED FOR THOSE INDIVIDUALS AND/OR PRACTICES IDENTIFIED IN THE DEFICIENCY STATEMENT?
The agency will review the files of PF #2, PF #3, PF #4, PF#5, PF#6, & PF#7 and we will perform the symptom questionnaires and risk assessments even though it was not at hire and will follow the CDC guidelines every year thereafter.
HOW WILL YOU IDENTIFY OTHER INDIVIDUALS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE?
A quarterly file audit will be performed with no less than 10% of random personnel files of which all will be audited for missing Annual Competency Evaluations, to ensure that the agency is in compliance with 611.56(a).
WHAT MEASURES (ACTIONS/FORMS/SYSTEM CHANGES ETC) WILL BE PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR?
A check list will become a part of each employee's file, and upon hire Human Resources will ensure that every item listed on the check list is in the file.
HOW WILL THE CORRECTIVE ACTION BE MONITORED TO ENSSURE THAT THE DEFICIENT PRACTICE WILL NOT RECUR, I.E. WHAT QUALITY ASSURANCE PROGRAMS WILL BE ESTABLISHED/FOLLOWED?
A monthly file audit will be performed with no less than 10% of random personnel files of which all will be audited for missing references until all files are done to ensure that the agency is in compliance with 611.56(a).
IDENTIFY BY POSITION WHO WILL BE RESPONSIBLE FOR SUCH MONITORING AND WHAT FORMS OR TOOLS WILL BE COMPLETED/RETAINED TO MEASURE/SUSTANTIATE THE MONITORING PERFORMED AND FREQUENCY OF MONITORING?
The Human Resources Manager or designee will review the findings of the quarterly internal audit and document the review.
Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on November 13, 2024, Always Best Care was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
|