QA Investigation Results

Pennsylvania Department of Health
AMORE SENIOR CARE, LLC
Health Inspection Results
AMORE SENIOR CARE, LLC
Health Inspection Results For:


There are  10 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an onsite unannounced state re-licensure survey conducted on May 14, 2024, Amore Senior Care, LLC, 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 May 14, 2024, Amore Senior Care, LLC, was found to not 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

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 review of personnel files (PF) and an interview with agency administrator, the agency failed to retain documentation of face-to-face interview and/or two satisfactory references prior to hiring or rostering for five (5) of the five (5) PF's reviewed. (PF#1-5)

Findings include:
Personnel file review conducted May 14, 2024 from approximately 1:00 pm to 3:00 pm revealed the following:

PF #1, DOH 8/18/2023: Contained no documentation of two satisfactory, verified references. Contained no documentation of a face to face interview.

PF#2, DOH 10/16/2022: Contained no documentation of two satisfactory, verified references. Contained no documentation of a face to face interview.

PF #3, DOH 7/31/23: Contained no documentation of two satisfactory, verified references. Contained no documentation of a face to face interview.

PF#4, DOH 4/13/2024: Contained no documentation of two satisfactory, verified references. Contained no documentation of a face to face interview.

PF#5, DOH 3/5/2023: Contained no documentation of two satisfactory, verified references. Contained no documentation of a face to face interview.


An interview with the administrator on May 14, 2024 at approximately 4:05 pm confirmed the above findings.










Plan of Correction:

For this observation, we are reviewing all personnel files (PF) to rectify the observations that found missing references and face to face interviews documentation. Moving forward, Amore Senior Care will require a minimum of 2 verifiable references and face to face interview to be conducted prior to hiring or rostering the direct care worker. The references will be either verbal or written from a former employer or other person not related to the individual. The current employees that did not have the required references were told to have them in the office no later than the corrective action date as listed.

Our plan of prevention for future recurrences is as follows; upon inquiry of hire we will conduct a face to face interview, also obtain no less than 2 satisfactory references for the new hire. The documentation to the references and face to face interview will be kept in their personnel files (PF).


On the survey exit date we started the correction for the individuals that were found to be non compliant. In regards to new hires this will be a necessity prior to employment. Agency internal management will be holding quarterly meetings with the Administrator to discuss and review and possibly update any incidents that have occurred or to review goals and possible improvements that are needed with staff and office training in regards to issues and maintaining compliance.



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 failed to ensure documented proof of residency through submission of any 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 five (5) PFs. (PF#1 and PF#5)


Findings include:
Personnel file review conducted May 14, 2024 from approximately 1pm to 3pm revealed the following:

PF #1, DOH 8/18/2023: Contained a Pennsylvania (PA) driver's license issued 1/20/22 . No documentation to show Pa residency prior to 1/20/2022. No documentation of a Federal check.

PF#5, DOH 3/5/2023: Contained a Pennsylvania driver's license issued 1/21/22. No documentation to show Pa residency prior to 1/21/22. No documentation of a Federal check.

An interview with the adminstrator on May 14, 2024 at approximately 4:05pm confirmed the above findings.








Plan of Correction:

For this observation, we are reviewing all personnel files (PF) to rectify the observations that found missing documentation of proof of residency. For PF#1 & 5 proof of residency will be obtained from (1) Motor vehicle records, (2) Housing records, (3) Public utility records and receipts, (4) Local tax records, (5) Federal, State or local income tax return, or (6) Employment records.

All personnel files will be audited on a quarterly basis to make sure compliance is achieved. The corrective action date as listed is our projected completion date. A checklist will be made with all the steps we need to do in order to hire a direct care worker. Every time a new direct care worker is hired, the administrator will follow the checklist guidelines. The current employees that did not have the required proof of residency were told to have them in the office no later than the corrective action date as listed. An FBI background history check will be conducted for employees that do not meet the 2 year residency requirement



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 personnel files (PF), and an interview with the agency administrator, it was determined the agency failed to demonstrate, prior to assigning or referring the direct care worker to provide services to a consumer, competency by passing an initial competency examination for five (5) of five (5) PF reviewed. (PF #1-5)


Findings include:
Personnel file review conducted May 14, 2024 from approximately 1:00 pm to 3:00 pm revealed the following:

PF #1, DOH 8/18/2023: Contained no documentation showing an initial competency was completed prior to assigning or referring the direct care worker to provide services to a consumer.

PF#2, DOH 10/16/2022: Contained no documentation showing an initial competency was completed prior to assigning or referring the direct care worker to provide services to a consumer .

PF #3, DOH 7/31/23: Contained no documentation showing an initial competency was completed prior to assigning or referring the direct care worker to provide services to a consumer.

PF#4, DOH 4/13/2024: Contained no documentation showing an initial competency was completed prior to assigning or referring the direct care worker to provide services to a consumer.

PF#5, DOH 3/5/2023: Contained no documentation showing an initial competency was completed prior to assigning or referring the direct care worker to provide services to a consumer.


An interview with the administrator on May 14, 2024 at approximately 4:05 pm confirmed the above findings.







Plan of Correction:

For this observation, we are reviewing all personnel files (PF) to rectify the observations that found missing documentation of an initial competency test of direct care workers. The agency already has a policy in place that mandates all new hires must take a competency test prior to assigning or referring a direct care worker to provide services to a consumer. This policy will now be reviewed and enforced by the administrator.

If found direct care workers have completed an initial competency exam but are missing it in their personnel files it will be printed from our server and placed in their files. Any direct care worker that has not completed an initial competency test has been given till the corrective action date as listed to come in the office and complete a test. A new list is being generated with dates that will be monitored quarterly by the Administrator to keep up with current and incoming employees.


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 personnel files (PF), and an interview with the agency administrator, it was determined the agency failed to perform a competency review, which 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 for one (1) of five (5) PF reviewed. (PF#2)


Findings include:
Personnel file review conducted May 14, 2024 from approximately 1:00 pm to 3:00 pm revealed the following:

PF#2, DOH 10/16/2022: Contained no documentation for direct care worker competency to perform assigned duties through direct observation, testing, training, consumer feedback or other method approved by the Department.




An interview with the administrator on May 14, 2024 at approximately 4:05 pm confirmed the above findings.







Plan of Correction:

For this observation, we are reviewing all personnel files (PF) to rectify the observations that found missing documentation of an annual competency review of direct care workers. The agency already has a policy in place that mandates all direct care workers must take a competency test annually to provide services to a consumer. This policy will now be reviewed and enforced by the administrator.

For PF#2 documentation will be placed in the personnel files for an annual competency review. If found direct care workers have completed an annual competency exam but are missing it in their personnel files it will be printed from our server and placed in their files. All active direct care workers that have not completed an annual competency test have been given till the corrective action date as listed to come in the office and complete a test. A new list is being generated with dates that will be monitored quarterly by the Administrator to keep up with current and incoming employees.


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 CDC guidelines, personnel files (PF) and staff interview it was determined the facility failed to ensure direct care workers were screened for and free from active mycobacterium tuberculosis (TB) prior to assignment for five (5) out of five (5) files reviewed. (PF#1-5)

Findings include:

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



Findings include:
Personnel file review conducted May 14, 2024 from approximately 1:00 pm to 3:00 pm revealed the following:

PF #1, DOH 8/18/2023: Contained no documentation of any baseline testing for tuberculosis upon hire. No documentation of a competed risk assessment.

PF#2, DOH 10/16/2022: Contained no documentation of any baseline testing for tuberculosis upon hire. No documentation of a competed risk assessment.

PF #3, DOH 7/31/23: Contained no documentation of any baseline testing for tuberculosis upon hire. No documentation of a competed risk assessment.


PF#4, DOH 4/13/2024: Contained documentation of a QuanterFERON Gold dated 5/6/24, which is after the hire date.

PF#5, DOH 3/5/2023: Contained no documentation of any baseline testing for tuberculosis upon hire.

An interview with the administrator on May 14, 2024 at approximately 4:05 pm confirmed the above findings.








Plan of Correction:

For this observation, we are reviewing all personnel files (PF) to rectify the observations that found missing documentation of any baseline testing for tuberculosis upon hire of direct care workers. The agency already has a policy in place that requires direct care workers to be tested for TB prior to contacting consumers, the administrator will review and enforce this policy.

Currently of the PFs that were missing any baseline testing for tuberculosis as of the survey exit date, PF#1 & PF#2 have been tested and results have been placed in their personnel files and the agency will have a total completion by the corrective action date as listed. A TB symptom screening and risk assessment questionnaire will also be placed in the personnel files.

Ongoing, we are creating a list within our system that will be more accurate to keep up with the annual screenings. This should be up and functional by the corrective action date as listed. All personnel files will be audited on a quarterly basis to make sure compliance is achieved. The files will also be audited by the administrator.



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 on review of consumer records (CR) and an interview with the administrator, the agency failed to provide the following information to the consumer, the consumer's legal representative, or a responsible family member prior to the start of services: 1) the identity of the DCW who would be providing the services, 2) the hours when the services would be provided and 3) 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 for four (4) of four (4) consumer files: (CR#1, CF#2, CF#3, CF#4)


Findings include:
Personnel file review conducted May 14, 2024 from approximately 3pm to 4pm revealed the following:

CR#1 Start of care (SOC) 9/1/2023: Contained no documentation the identity of the DCW who would be providing the services. Contained no documentation of the the hours when the services would be provided. Contained no documentation of 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

CR#2 SOC 6/12/2023: Contained no documentation the identity of the DCW who would be providing the services. Contained no documentation of the the hours when the services would be provided. Contained no documentation of 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


CR#3 SOC 4/7//2023: Contained no documentation the identity of the DCW who would be providing the services. Contained no documentation of the the hours when the services would be provided. Contained no documentation of 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


CR#4 SOC 2/2/2023 : Contained no documentation the identity of the DCW who would be providing the services. Contained no documentation of the the hours when the services would be provided. Contained no documentation of 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



An interview with the administrator on May 14, 2024 at approximately 4:05 pm confirmed the above findings.









Plan of Correction:

For this observation, we are reviewing all consumer records (CR) to rectify the observations that found missing sections that (1) identifies the direct care worker who will be providing service to the consumer, prior to commencement of services, (2) documents the hours when the services would be provided, and (3) includes documentation of a disclosure.

The agency will edit and update the existing Service Agreement to include a section that identifies the direct care worker who will be providing service to the consumer, prior to commencement of services. The agency will edit and update the existing Service Agreement to include documentation of the hours when the services would be provided and also include documentation of a disclosure, in a format to be published by the Department in the Pennsylvania Bulletin, 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.

This updated Service Agreement will be completed by the administrator and reviewed by the Agency Owner. It will be created and implemented by the corrective action date as listed, and ongoing thereafter. All consumer records missing the required documentation will be fixed. Ongoing all consumer records will be audited on a quarterly basis by the administrator to make sure compliance is achieved.



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 review of consumer records (CR) and an interview with the administrator, the agency failed to maintain documentation on file at the agency or registry of compliance with the requirements of this section (611.57) which shall be available for Department inspection for four (4) of four (4) consumer files: (CR#1, CF#2, CF#3, CF#4)


Findings include:
Consumer record review conducted May 14, 2024 from approximately 3pm to 4pm revealed the following:


CR#1 Start of care (SOC) 9/1/2023: Contained no documentation of a service agreement or a service plan.

CR#2 SOC 6/12/2023: Contained no documentation of a service agreement or a service plan.

CR#3 SOC 4/7//2023: Contained no documentation of a service agreement or a service plan.

CR#4 SOC 2/2/2023 : Contained no documentation of a service agreement or a service plan.


An interview with the administrator on May 14, 2024 at approximately 4:05 pm confirmed the above findings.











Plan of Correction:

For this observation, we are reviewing all consumer records (CR) to rectify the observations that found missing documentation of service agreements or service plans. The agency will be getting new service agreements and service plans signed by the consumers. These documentations will be placed in their consumer records (CR).

The Service Agreement and service plan will be completed by the administrator and reviewed by the Agency Owner. It will be created and implemented by the corrective action date as listed, and ongoing thereafter. All consumer records missing the required documentation will be fixed. Ongoing all consumer records will be audited on a quarterly basis by the administrator to make sure compliance is achieved.



Initial Comments:

Based on the findings of an onsite state re-licensure survey completed May 14,2023, Amore Senior Care, LLC 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
Law amended July 11, 2022 Act 79 2022 HB 2604

(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.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(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) All other titles shall be determined by the
department. 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 on observation and interview with agency administrator/owner, the agency failed to ensure direct care workers/office staff were issued photo identification badges to include a recent photograph of the employee, the employee's name, the employees title (occupying a 1/2-inch tall strip as close as practicable to the bottom edge of the badge), and the name of the home care agency.


Findings include:
interview with administrator and staff conducted May 14, 2024 at approximately 4pm revealed the following:

Surveyor requested a copy of the badges provided to the direct care workers. The administrator provided a badge that did not meet the requirements of including a recent photograph of the employee, the employee's name, the employees title (occupying a 1/2-inch tall strip as close as practicable to the bottom edge of the badge), and the name of the home care agency.

An interview with the adminstrator on May 14, 2024 at approximately 4:05pm confirmed the above findings.









Plan of Correction:

We have completed making updated identification badges for all active employees as of the corrective action date and we will continue to issue badges for all new incoming employees. The new badges include recent photograph of the employee, the employee's name, the employees title (occupying a 1/2-inch tall strip as close as practicable to the bottom edge of the badge), and the name of the home care agency. The Administrator will monitor the employees and make sure they are wearing their identification badges while with the consumer. Badges will be replaced if lost or damaged.