Initial Comments:
Based on the findings of an unannounced on-site state home care agency re-licensure survey conducted on August 28, 2024, Ageless Senior 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 August 28, 2024, Ageless Senior 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(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 review of direct care worker (DCW) personnel files (PF), facility policy and procedure, employee handbook and staff/employee (EMP) interview, the agency failed to ensure two (2) of seven (7) DCW personnel files reviewed contained proof of residency. (PF#1 & PF#3)
Findings include:
A review of employee handbook policy for facility was conducted on August 28, 2024 at approximately 11:00 am revealed... "Enclosed in this booklet, you will find information that will need to be completed before you first shift of work."..."What you will need to complete (within 7 days of hire): ... 2 Step series Tuberculosis Test... Two- year proof of PA Residency - Old W-2 form - Older utility bill, carinsurance, leasing agreement, etc. - Driver's license IF has exactly 2 years or more on the Issued Date... Competency Test."
A review of DCW personnel files was conducted on August 28, 2024, between 12:15 p.m. and 1:30 p.m. revealed the following:
PF1 was hired on September 7, 2023 and contained a PA Driver's license but the license was expired on June 30, 2022; facility did obtain valid identification due to expiration preceding the date of hire. PF1 contained no other documentation to show requirement was met.
PF3 was hired on November 4, 2022, and contained a PA Driver's license but the license was issued on August 11, 2021; not 2 years preceding the date of hire. PF3 contained no other documentation to show requirement was met
Interview with EMP 1 on August 28, 2024 at approximately 1:45 p.m. confirmed the above findings.
Plan of Correction:To correct this in the future, Ageless Senior In Home Care, Inc will provide a more thorough explanation to DCW to show proof of two years of PA Residency.
1. Motor Vehicle License
Ageless Senior will collect driver's license, current and expired that prove 2 years of residency
2. House Hold Records
Mortgage records and rent receipts which prove out 2 year residency...
3. Public Utility records
Collect historic electric bills, etc. to prove 2 years residency.
4. Taxes
Tax bills in the name of the employee that prove the two year residency.
5. Federal State or Local Taxes
6. Employment records of employment compensation
If unable to provide two years proof of PA Residency, then we will have DCW go to IdentoGo to get an FBI Check. Our Provisional Hiring policy will go into effect. If the DCW refuses, then DCW will not be scheduled for any work, until the required documentation is submitted.
This will be monitored by the DCW manager and During a monthly audit of new hires, an office manager will complete a sign off sheet for monthly audits for new hires
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 review of direct care worker (DCW) personnel files (PF), policy and procedure review and staff (EMP) interview, the agency failed to ensure, prior to assigning a direct care worker to provide services to a consumer, the DCW met minimum competency requirements for two (2) of seven (7) personnel files reviewed (PF#2 & PF#4).
Findings include:
A review of employee handbook policy for facility was conducted on August 28, 2024 at approximately 11:00 am revealed... "Enclosed in this booklet, you will find information that will need to be completed before you first shift of work."..."What you will need to complete (within 7 days of hire): ... 2 Step series Tuberculosis Test... Two- year proof of PA Residency - Old W-2 form - Older utility bill, car insurance, leasing agreement, etc. - Driver's license IF has exactly 2 years or more on the Issued Date... Competency Test."
A review of DCW personnel files was conducted on August 28, 2024 between 12:15 p.m. and 1:30 p.m.
PF#2 was hired on March 28, 2024 and began providing services to consumers upon hire. PF contained no proof of competency completed prior to providing services to consumers.
PF#4 was hired on April 13, 2023 and began providing services to consumers upon hire. PF contained no proof of competency completed prior to providing services to consumers.
Interview with EMP1 on August 28, 2024 at approximately 2:00 p.m. confirmed findings.
Plan of Correction:All files from this point forward will be audited and signed off on before the start of a new employee.
We will ensure that all employees either have a current license (CNA, LPN, RN etc) or complete our initial assessment test to prove that they are competent to provide services to the consumer. Tests will be checked immediately with the score clearly written on the top of the test and manager initials beside them. Review of missed questions will take place before the start of the first shift.
The files of those pulled by the inspector have been corrected as per the deficiencies identified and they have been corrected and brought to the standard of our policies will be adjusted to clarify this requirements moving forward within 30 days.
The office manager will be responsible for the monitoring moving forward.
611.56(c) LICENSURE
Health Screening
Name - Component - 00
(c) A direct care worker employed by a home care agency or rostered by the home care registry on December 12, 2009, shall achieve compliance with the health evaluation requirements imposed by this chapter by September 1, 2010.
Observations:
Based on review of the facility employee handbook policy, direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to ensure screenings for mycobacterium tuberculosis (TST-Tuberculosis Screening Testing) were conducted in accordance with facility policy for five (5) of seven (7) direct care worker personnel files reviewed (PF#2, PF#3, PF#5, PF#6 and PF#7).
Findings Include:
A review of employee handbook policy for facility was conducted on August 28, 2024 at approximately 11:00 am revealed... "Enclosed in this booklet, you will find information that will need to be completed before you first shift of work."..."What you will need to complete (within 7 days of hire): ... 2 Step series Tuberculosis Test... Two- year proof of PA Residency - Old W-2 form - Older utility bill, car insurance, leasing agreement, etc. - Driver's license IF has exactly 2 years or more on the Issued Date... Competency Test."
A review DCW of personnel files was conducted on August 28, 2024 between 12:15 p.m. and 1:30 p.m.
PF#2 was hired on March 28, 2024. PF contained a negative TST result dated April 3, 2024 but did not contain documentation that the second-step was initiated or completed.
PF#3 was hired on November 4, 2022. PF did not contain documentation that the TST was initiated or completed.
PF#5 was hired on April 4, 2022. PF did not contain documentation that the TST was initiated or completed.
PF#6 was hired on August 16, 2022. PF did not contain documentation that the TST was initiated or completed.
PF#7 was hired on September 14, 2023. PF contained a negative TST result dated September 16, 2023 but did not contain documentation that the second-step was initiated or completed.
Interview with EMP1 on August 28, 2024 at approximately 2:00 p.m. confirmed findings.
Plan of Correction:Ageless Senior will assure that ALL Health Screening requirements will be met as stated in the employee handbook.
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.
The office manager will be required to keep records on when the second step of the TB is required by and follow up accordingly. If the employee is only required to have a yearly due to a two step already being complete, the two step will also be obtained and filed.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on August 28, 2024, Ageless Senior Care, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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