QA Investigation Results

Pennsylvania Department of Health
BRIGHTSTAR OF LEHIGH VALLEY
Health Inspection Results
BRIGHTSTAR OF LEHIGH VALLEY
Health Inspection Results For:


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Initial Comments:


Based on the findings of an announced onsite state re-licensure survey completed November 8, 2022, Brightstar of Lehigh Valley was found to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.





Plan of Correction:




Initial Comments:


Based on the findings of an announced onsite state re-licensure survey completed November 8, 2022, Brightstar of Lehigh Valley 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

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 a review of employee files and an interview with the agency Owner, the agency failed to obtain not less than two satisfactory references prior to hire, for seven (7) out of seven (7) employee files (EF) reviewed (EF#1-EF#7).

Findings include:

A review of EFs was conducted on November 8, 2022 at approximately 9:45 a.m. Employee date of hire (DOH) is listed below.

EF#1 DOH 07/25/22: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable) prior to hire.

EF#2 DOH 07/29/22: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable) prior to hire.

EF#3 DOH 01/19/22: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable) prior to hire.

EF#4 DOH 09/27/22: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable) prior to hire.

EF#5 DOH 08/08/22: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable) prior to hire.

EF#6 DOH 01/15/21: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable) prior to hire. Documentation provided of one reference being obtained on 01/19/21.

EF#7 DOH 03/01/21: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable) prior to hire.


An interview conducted with agency Owner on November 8, 2022 at approximately 1:00 p.m. confirmed the above findings.









Plan of Correction:

For EF#1- EF#7 will obtain at least 2 positive, verifiable references for each employee. These references will be from either a former employer or other person not related to the individual that affirms the ability of the person to provide home care services.

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

Will create a reference checklist to ensure that the employee file contains at least 2 positive, verifiable references and the manner in which it was collected.

The operations manager will audit 10% of charts monthly reviewing the checklists to ensure no other individuals are affected by this same deficient practice in the future.



611.52(a) LICENSURE
Criminal Background Checks

Name - Component - 00
The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.

Observations:


Based on a review of employee files and an interview with the agency Owner, the agency failed to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application for one (1) out of seven (7) employee files (EF) reviewed (EF#6).

Findings include:

A review of EFs was conducted on November 8, 2022 at approximately 9:45 a.m. Employee date of hire (DOH) is listed below.

EF#6 DOH 01/15/21: No documentation provided of criminal history report being obtained at the time of application or within 1 year (365 days) immediately preceding the date of application. Documentation provided of obtaining a Pennsylvania State Police criminal history report late on 03/17/22.

An interview conducted with agency Owner on November 8, 2022 at approximately 1:00 p.m. confirmed the above findings.









Plan of Correction:

For EF#6 a criminal background check was found to be missing during an internal audit of the employee files. A state police background was run at that time.

An audit of all employees hired since this internal audit in March of 2022 will be conducted to ensure that no other employees have been affected by this same deficient practice.

A spreadsheet was set up to track all employees to ensure timely background checks. The spreadsheet contains the date of the check and the result number obtained from that check. The results of these background reports are then uploaded in the electronic onboarding software and the paper copy is stored in the employee file.

The operations manager will audit the spreadsheet on a quarterly basis to ensure no other individuals are affected by this same deficient practice in the future.



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 employee files and an interview with the agency Owner, agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for two (2) out of seven (7) employee files (EF) reviewed (EF#1, EF#2).

Findings include:

A review of EFs was conducted on November 8, 2022 at approximately 9:45 a.m. Employee date of hire (DOH) is listed below.

EF#1 DOH 07/25/22: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Drivers License issued 10/01/20 with an expiration date of 01/30/25. 'Application for Employment' record was reviewed. Employer listed with no complete address with 'Dates Employed' "From' "09/14" 'To' "Present."
No proof of Pa. residency from 07/25/20-10/01/20.

EF#2 DOH 07/29/22: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Identification Card issued 03/11/21 with an expiration date of 03/31/25. 'Application for Employment' record was reviewed. Employer listed with no complete address with 'Dates Employed' "From' "Oct 2020." The 'To' section was scribbled out and not legible.
No proof of Pa. residency from 07/29/20-03/11/21.


An interview conducted with agency Owner on November 8, 2022 at approximately 1:00 p.m. confirmed the above findings.













Plan of Correction:

For EF#1- Employee will be asked to provide proof that they have been a PA resident for 2 years immediately preceding hire date.
For EF#2- Employee will be asked to provide proof that they have been a PA resident for 2 years immediately preceding hire date.

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

A verification of residency form will be added to the onboarding package to ensure that no other employees will be affected by this same deficient practice. If residency cannot be established an FBI background check will be initiated and the results will be entered into the employee file.

The hiring manager will review new hire paperwork at on boarding to ensure no other individuals are affected by this same deficient practice in the future.





611.55(a) LICENSURE
Compentency 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 upon a review of employee files and an interview with the agency Owner, the agency failed to ensure documentation showing direct care workers, prior to providing services to consumers, completed/demonstrated an initial competency training covering all required sixteen (16) subject areas for seven (7) of ten (10) employee files (EF) reviewed (EF#1 - EF#7).

Findings include:

A review of EFs was conducted on November 8, 2022 at approximately 9:45 a.m. Employee date of hire (DOH) is listed below.

EF#1 DOH 07/25/22: Documentation provided of a written test being completed on 07/25/22. No documentation provided of initial competency training covering all required sixteen (16) subject areas (No hair care, mouth care, shaving, nor toileting).

EF#2 DOH 07/29/22: Documentation provided of a written test being completed (undated). No documentation provided of initial competency training covering all required sixteen (16) subject areas (No hair care, mouth care, shaving, nor toileting).

EF#3 DOH 01/19/22: No documentation provided of initial competency training covering all required sixteen (16) subject areas.

EF#4 DOH 09/27/22: No documentation provided of initial competency training covering all required sixteen (16) subject areas.

EF#5 DOH 08/08/22: Documentation provided of a written test being completed on 08/08/22 with the 'Score' section marked "Failed." No documentation provided of initial competency training covering all required sixteen (16) subject areas (No hair care, mouth care, shaving, nor toileting).

EF#6 DOH 01/15/21: No documentation provided of initial competency training covering all required sixteen (16) subject areas.

EF#7 DOH 03/01/21: Documentation provided of a written test being completed on 03/01/21. No documentation provided of initial competency training covering all required sixteen (16) subject areas (No hair care, mouth care, shaving, nor toileting).


An interview conducted with agency Owner on November 8, 2022 at approximately 1:00 p.m. confirmed the above findings.











Plan of Correction:

For EF#1, EF#2 and EF#7 Will have these employee complete an updated competency training covering all 16 subject areas ensuring that it includes the 4 missing areas of hair care, mouth care, shaving and toileting.

For EF#3, EF#4 and EF#6 Will have these employee complete an updated competency training that will include all 16 of the required subject areas.

For EF#5 - Will have this employee complete an updated competency training covering all 16 of subject areas with a passing grade.

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

Will revise the competency training to ensure that all 16 subject areas are covered.

The hiring manager will review new hire paperwork at on boarding to ensure no other individuals are affected by this same deficient practice in the future.



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 a review of employee files and an interview with the agency Owner, the agency failed to ensure competency review, covering all required sixteen (16) subject areas, occurred at least once per year after initial competency is established, for two (2) of two (2) employee files (EF) annual documentation reviewed (EF#6, EF#7).

Findings include:

A review of EFs was conducted on November 8, 2022 at approximately 9:45 a.m. Employee date of hire (DOH) is listed below.

EF#6 DOH 01/15/21: No documentation provided of an annual 2022 competency review, covering all required sixteen (16) subject areas.

EF#7 DOH 03/01/21: No documentation provided of an annual 2022 competency review, covering all required sixteen (16) subject areas.


An interview conducted with agency Owner on November 8, 2022 at approximately 1:00 p.m. confirmed the above findings.








Plan of Correction:

For EF#6 and EF#7 Will have these employee complete a competency review training covering all 16 subject areas.

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

Will add annual competency training to our employee chart audit check list to ensure that the deficient practice does not recur.

The office manager will audit 10% of charts monthly reviewing the checklists to ensure no other individuals are affected by this same deficient practice in the future.




611.56(a) LICENSURE
Health Screening

Name - Component - 00
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.

Observations:


Based on a review of employee files and an interview with the agency Owner, 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) EFs 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 November 8, 2022 at approximately 9:45 a.m. Employee date of hire (DOH) is listed below.

EF#1 DOH 07/25/22: No documentation provided of an individual TB risk assessment upon hire.
EF#2 DOH 07/29/22: No documentation provided of an individual TB risk assessment upon hire.
EF#3 DOH 01/19/22: No documentation provided of an individual TB risk assessment upon hire.
EF#4 DOH 09/27/22: No documentation provided of an individual TB risk assessment upon hire.
EF#5 DOH 08/08/22: No documentation provided of an individual TB risk assessment upon hire.
EF#6 DOH 01/15/21: No documentation provided of an individual TB risk assessment upon hire.
EF#7 DOH 03/01/21: No documentation provided of an individual TB risk assessment upon hire.

An interview conducted with agency Owner on November 8, 2022 at approximately 1:00 p.m. confirmed the above findings.








Plan of Correction:

For EF#1- EF#7 will obtain a TB risk assessment for these employees.

All other rostered employees will be given the TB risk assessment to ensure no other employees have been affected by this same deficient practice.

A TB risk assessment will be added to the onboarding process to ensure that no other employees will be been affected by this same deficient practice.

The hiring manager will review all incoming new hires as they are on boarded to ensure no other individuals are affected by this same deficient practice in the future.




611.56(b) LICENSURE
Health Screening

Name - Component - 00
(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.

Observations:


Based on a review of employee files and an interview with the agency Owner, agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, were provided with annual mycobacterium tuberculosis education, for two (2) of two (2) employee files (EF) annual documentation reviewed (EF#6, EF#7).

Findings Include:

The CDC (Center for Disease and Control) 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. ........ 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 November 8, 2022 at approximately 9:45 a.m. Employee date of hire (DOH) is listed below.

EF#6 DOH 01/15/21: No documentation provided of annual 2022 TB education.

EF#7 DOH 03/01/21: No documentation provided of annual 2022 TB education.


An interview conducted with agency Owner on November 8, 2022 at approximately 1:00 p.m. confirmed the above findings.








Plan of Correction:

For EF#6 will provide annual TB education for this employee for 2022.

For EF#7 will provide annual TB education for this employee for 2022

All other rostered employees will be given the TB annual education to ensure no other employees have been affected by this same deficient practice.

A TB education will be added to the onboarding process as well as implemented annually to ensure that no other employees will be affected by this same deficient practice.

The hiring manager will review all incoming new hires and will audit 25% of employee charts quarterly to ensure no other individuals are affected by this same deficient practice in the future.




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 a review of consumer files, the consumer admission packet, and an interview with the agency Owner, the agency failed to provide the consumer, prior to the commencement of services, the identity of the direct care worker who will provide the services, for five (5) out of five (5) consumer files (CF) reviewed (CF#1 - CF#5).

Findings include:

A review of CFs was conducted on November 8, 2022 at approximately 9:45 a.m. Consumer start of service (SOS) is listed below.

CF#1 SOS 09/12/22: No documentation provided of the agency providing the consumer, prior to the commencement of services, the identity of the direct care worker who will provide the services.

CF#2 SOS 08/01/22: No documentation provided of the agency providing the consumer, prior to the commencement of services, the identity of the direct care worker who will provide the services.

CF#3 SOS 08/02/22: No documentation provided of the agency providing the consumer, prior to the commencement of services, the identity of the direct care worker who will provide the services.

CF#4 SOS 08/01/22: No documentation provided of the agency providing the consumer, prior to the commencement of services, the identity of the direct care worker who will provide the services.

CF#5 SOS 05/23/22: No documentation provided of the agency providing the consumer, prior to the commencement of services, the identity of the direct care worker who will provide the services.


An interview conducted with agency Owner on November 8, 2022 at approximately 1:00 p.m. confirmed the above findings.






Plan of Correction:

For CF#1 located the text messages that were exchanged with the authorized representative for the client. It was determined that this was done via a phone conversation. We have entered a note to that effect into the client record in our enterprise computer system.

For CF#2 The identity of the direct care worker was discussed in person at our initial meeting with the client on July 29th and was documented in our enterprise computer system. Subsequent text messages were also sent regarding the start of care.

For CF#3 Located the text messages that were exchanged with the authorized representative for the client. We did identify the name of the DCW that was to be sent to start services. We have entered a note into the client record in our enterprise computer system to document this.

For CF#4 The identity of the direct care worker was discussed at our initial meeting with the client on July 25th and was documented in our enterprise computer system as part of the initial setup. Subsequent text messages were also sent regarding the start of care.

For CF#5 The identity of the direct care workers was sent via an email and text messages to the authorized representative. The client had already been using our services for another family member and so some of the direct care workers were already known to the family. This has been documented in our enterprise computer system.

Will conduct an audit of all client files to make sure no other clients have been affected by this same deficient practice.

Will educate our customer care manager on the importance of this step and documenting this interaction with the clients in our enterprise computer system to ensure that the deficient practice does not recur.

The operations manager will review all client start of care documents to ensure no other individuals are affected by this same deficient practice in the future.




Initial Comments:


Based on the findings of an announced onsite state re-licensure survey completed November 8, 2022, Brightstar of Lehigh Valley was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: