Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on February 23, 2024, God's Glory, Inc., 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 home care agency state re-licensure survey conducted on February 23, 2024, God's Glory, Inc. 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:
611.4(c) LICENSURE
Requirements for HCA and HCR
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Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.
Observations:
Based on review of personnel files (PF), and the Philadelphia Department of Public Health, Division (PDPH) of COVID-19 Containment Health Alert Dated 10/14/2021, the agency failed to provide documentation that four (4) of five (5) PF's (PF#1, 2, 4, 5) employees were vaccinated against COVID-19 or received a medical/religious exemption.
Findings include:
Philadelphia Department of Public Health, Division of COVID-19 Containment Health Alert Dated 10/14/2021, states "Exemptions: An individual may not simply opt out of vaccination. They must submit a medical or religious exemption to the Healthcare Institution where such individual works according to the policies set by the institution. The Institution will determine if an exemption applies. Healthcare Institutions and organizations that are granting exemptions must create appropriate exemption policies to implement this regulation. Institutions may establish stricter vaccination policies for their workers, contractors, and volunteers that exceed the requirements of the Vaccine Mandate Regulation, to the extent
otherwise permitted by applicable law.
A Healthcare Worker or Healthcare Institution Worker who is granted an exemption must strictly follow the applicable accommodation, including documenting their participation in the accommodation process that their employer or institution has agreed upon. Healthcare Institutions are required to keep records of vaccination status of all vaccinated individuals, exemptions requested and granted, and participation in accommodations granted. Records must be made available to PDPH upon request.
Self-employed Healthcare Workers must carefully document the need for exemption and ongoing compliance with routine testing as set forth below under " Accommodations for Exceptions. "
Medical
The Healthcare Worker or Healthcare Institution Worker may request an exemption by submitting a certification from a licensed healthcare provider to the appropriate Healthcare Institution. Medical exemptions must include a statement signed by a licensed healthcare provider that states the exemption applies to the specific individual submitting the certification because the COVID-19 vaccine is medically contraindicated for the individual. The certification must also be signed by the Healthcare Worker or Healthcare Institution Worker. For the purposes of the Vaccine Mandate Regulation a licensed healthcare provider means a physician, nurse practitioner, or physician assistant licensed by an authorized state licensing board.
Religious
The Healthcare Worker or Healthcare Institution Worker may request an exemption by submitting a signed statement in writing that the individual has a sincerely held religious belief that prevents them from receiving the COVID-19 vaccination. An institution may request the worker explain in the certification why the worker ' s religious belief prevents them receiving the COVID-19 vaccine. Philosophical or moral exemptions are not permitted.
A review of PF's was conducted on February 23, 2024, from approximately 10:00 am to 11:15 am.
PF #1, Date of Hire: 4/1/2011, did not contain any documentation that the employee received COVID-19 vaccination(s). The employee's file did not contain any documentation of exemption present to determine compliance with the PDPH COVID-19 guidelines. DCW caring for consumers who live in Phila?
PF #2, DCW for CR1, CR2, and CR3, Date of Hire: 6/22/2023, did not contain any documentation that the employee received COVID-19 vaccination(s). The employee's file did not contain any documentation of exemption present to determine compliance with the PDPH COVID-19 guidelines. DCW is caring for consumers who live in Philadelphia.
PF #4, DCW for CR1, CR2, and CR3, Date of Hire: 1/21/2024, did not contain any documentation that the employee received COVID-19 vaccination(s). The employee's file did not contain any documentation of exemption present to determine compliance with the PDPH COVID-19 guidelines. DCW is caring for consumers who live in Philadelphia.
PF #5, DCW for CR 5, Date of Hire: 9/25/2018, did not contain any documentation that the employee received COVID-19 vaccination(s) in addition, the employee's file did not contain any documentation of exemption present to determine compliance with the PDPH COVID-19 guidelines. DCW is caring for consumers who live in Philadelphia.
An interview with the CEO/ President conducted on February 23, 2024, at approximately 1:30 pm confirmed the above findings.
Plan of Correction:*Plan of Correction for 611.4(c) LICENSURE - Requirements for HCA and HCR:*
**Objective:** To ensure compliance with applicable environmental, health, sanitation, and professional licensure standards related to COVID-19 vaccination for home care agency personnel.
**Actions:**
1. **Immediate Compliance:**
- Obtain and document the COVID-19 vaccination status or exemptions for the employees identified in the citation (PF#1, PF#2, PF#4, PF#5).
- For any unvaccinated employees, initiate the process for obtaining a medical or religious exemption, as per the guidelines provided by the Philadelphia Department of Public Health (PDPH).
- Keep records of vaccination status, exemptions requested and granted, and participation in accommodations.
2. **Review and Update Policies:**
- Review and update agency policies to align with the requirements outlined in the Philadelphia Department of Public Health, Division of COVID-19 Containment Health Alert Dated 10/14/2021.
- Clearly define the process for obtaining and documenting medical or religious exemptions, including the involvement of licensed healthcare providers.
3. **Employee Education:**
- Conduct training sessions for all agency employees to ensure awareness of COVID-19 vaccination requirements, exemptions, and documentation procedures.
- Emphasize the importance of compliance with the Vaccine Mandate Regulation and PDPH guidelines.
4. **Regular Audits and Record Keeping:**
- Implement a regular auditing process to ensure ongoing compliance with COVID-19 vaccination documentation requirements.
- Maintain accurate and up-to-date records of employee vaccination status and exemptions, accessible for inspection by PDPH upon request.
5. **Communication with Employees:**
- Communicate the updated policies and procedures to all employees promptly.
- Provide a clear channel for employees to seek clarification and guidance on COVID-19 vaccination-related matters.
**Timeline:**
- *Immediate:* Initiate the process to obtain vaccination documentation or exemptions for identified employees.
- *By April 23rd:* Complete the review and update of agency policies. Conduct training sessions for employees.
- *Ongoing:* Implement regular audits and maintain up-to-date records.
**Responsibility:** The CEO/President will oversee the implementation of this plan, with support from the Human Resources department and designated compliance officers.
**Verification:** The agency will conduct internal audits and maintain documentation to demonstrate compliance with the plan of correction.
611.55(e) LICENSURE
Competency Requirements
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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 personnel files (PF) and an interview with the President/ CEO, the agency failed to ensure that an annual competency was performed for one (1) of five (5) PF's reviewed: PF #3.
Findings include:
A review of personnel files was conducted on February 23, 2024 starting at 10:00 AM.
PF#3 Date of hire 09/23/2022. PF #3, did not have an annual competency indicated within the file.
An interview with the CEO/ President and Human Resources representative on February 23, 2024 starting at 1:30 PM, acknowledged that an annual competency was not conducted for 2023.
Plan of Correction:**Objective:** To ensure compliance with the competency requirements outlined in 611.55(e), specifically the annual competency review for all personnel.
**Actions:**
1. **Immediate Competency Review:**
- Conduct an immediate competency review for PF #3, including an assessment of the skills and knowledge required for their role.
- Document the results of the competency review and ensure it is filed appropriately in PF #3.
2. **Catch-up Competency Reviews:**
- Identify any other personnel for whom the annual competency review was due in the past 12 months.
- Conduct competency reviews for the identified personnel, documenting the results and ensuring compliance with the annual competency requirements.
3. **Review and Update Competency Review Procedures:**
- Review existing competency review procedures and update them to clearly outline the process and timeline for annual competency reviews.
- Clearly define the consequences for not conducting timely competency reviews, including disciplinary actions.
4. **Employee Training:**
- Provide training to relevant personnel, including supervisors and Human Resources, on the importance of annual competency reviews and the updated procedures.
- Emphasize the need for timely and accurate documentation of competency reviews.
5. **Establish a Monitoring System:**
- Implement a monitoring system to track and ensure timely completion of annual competency reviews for all personnel.
- Set up reminders and notifications to prompt the HR department and supervisors when competency reviews are due.
**Timeline:**
- *Immediate:* Conduct a competency review for PF #3.
- *By April 23rd:* Identify and conduct competency reviews for any other personnel for whom the annual competency review was due. Review and update competency review procedures. Provide training to relevant personnel.
- *Ongoing:* Establish and implement the monitoring system.
**Responsibility:** The Human Resources department will take the lead in implementing this plan, with support from supervisors and managers.
**Verification:** Regular internal audits will be conducted to ensure compliance with the competency review procedures. Human Resources will maintain records of competency reviews, and the CEO/President will review the results periodically.
611.56(a) LICENSURE
Health Screening
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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 personnel files (PF), the Centers for Disease Control Guidelines, and an interview with the CEO/President, the agency failed to provide documentation of an initial tuberculosis screening for four (4) of five (5) PF's reviewed, (PF #1, 2, 4, and 5).
Findings:
In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: receive baseline tuberculosis screening upon hire by using: a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB), or a negative chest x-ray to test for infection with tuberculosis. 2. Completion of a tuberculosis symptom questionnaire. And 3. Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCWs should receive TB education 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;(5-16-19)
A review of PF's was conducted on February 23, 2024 from approximately 10:00 am to 11:15 am.
PF #1 Date of Hire 4/1/11, contained documentation of a Chest X-Ray dated for 4/20/2021. No documentation of an initial TB screening was found. File did not contain documentation of annual TB education and no Risk Assessments in the PF.
PF #2 Date of Hire 6/22/2023, contained documentation of a one-step tuberculosis skin test dated 6/15/2023, however, file did not contain documentation of the second tuberculosis skin test. File did not contain documentation that a TB risk assessment or TB symptom screen was conducted at time of hire or prior to assigning direct care worker (DCW) to consumers.
PF #3 Date of Hire 9/23/2022, contained documentation of a Chest X-Ray 12/8/2020. No initial TB Risk Assessment/ Symptom Screen. File did not contain documentation of annual TB education and no Risk Assessments in the PF.
PF #4 Date of Hire 1/21/2024, contained results of a Chest X-ray dated 1/18/2024. File did not contain documentation that a TB risk assessment or TB symptom screen was conducted at time of hire or prior to assigning direct care worker (DCW) to consumers.
PF #5 Date of Hire 9/25/2018, contained documentation of only a one-step tuberculosis skin test dated 6/18/2018. No initial TB Risk Assessment/ Symptom Screen and documentation that a 2 step PPD was administered. QuantiFERON Gold test was found dated for 2/20/2023 but no annual TB education and no Risk Assessment found in the PF.
Interview with President/ CEO on February 23, 2024 at approximately 1:30PM confirmed the above findings.
Plan of Correction:**Objective:** To ensure compliance with CDC guidelines for tuberculosis screening for all personnel, as outlined in 611.56(a).
**Actions:**
1. **Immediate Health Screening:**
- Conduct an immediate tuberculosis screening for PF #1, PF #2, PF #3, PF #4, and PF #5, using the appropriate method (two-step tuberculin skin test, single blood assay, or chest x-ray).
- Document the results of the screenings in the respective personnel files.
2. **Catch-up Tuberculosis Testing:**
- Identify any other personnel for whom the initial tuberculosis screening is overdue.
- Conduct the appropriate tuberculosis testing for identified personnel, ensuring compliance with CDC guidelines.
- Document the results and update personnel files accordingly.
3. **Review and Update Health Screening Procedures:**
- Review existing health screening procedures and update them to align with CDC guidelines for tuberculosis screening.
- Clearly outline the process and documentation requirements for initial and annual tuberculosis screenings.
4. **Employee Education:**
- Provide training to relevant personnel, including HR staff and supervisors, on the importance of complying with tuberculosis screening guidelines.
- Emphasize the need for accurate and timely documentation of screening results and related information.
5. **Establish a Monitoring System:**
- Implement a monitoring system to track and ensure timely completion of initial and annual tuberculosis screenings for all personnel.
- Set up reminders and notifications to prompt HR and supervisors when screenings are due.
**Timeline:**
- *Immediate:* Conduct tuberculosis screenings for PF #1, PF #2, PF #3, PF #4, and PF #5.
- *By April 23rd:* Identify and conduct screenings for any other personnel for whom tuberculosis screening is overdue. Review and update health screening procedures. Provide training to relevant personnel.
- *Ongoing:* Establish and implement the monitoring system.
**Responsibility:** The Human Resources department will take the lead in implementing this plan, with support from supervisors and managers.
**Verification:** Regular internal audits will be conducted to ensure compliance with the updated health screening procedures. Human Resources will maintain records of screenings, and the CEO/President will review the results periodically.
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 consumer records (CR), and interview with the President/ CEO, it was determined that the agency failed to ensure that consumer's rights were protected by not providing home care services according to service plan for three (3) (CR#1, CR#2, CR#3) of four (4) consumer records (CR) reviewed.
Findings Include:
Review of consumer records (CR), was conducted on 2/23/2024 at approximately 11:15 am, revealed:
CR1 - (Start of Care): 6/13/2023 - Receives personal assistance services for twenty-four hours per week for seven (7) days per week.
Review of visit calendar on 2/23/2024 starting at approximately 12:00PM, revealed the agency did not provide caregiver services for the full shift of twenty-four (24) hours per day for seven (7) days per week on the following dates for the timeframe of 1/1/2024 through 2/22/2024 per service agreement:
1/13/2024: Services provided for fifteen (15) hours and one-half (.5) hour. The agency did not provide services for the remaining eight (8) hours and one-half (.5) hour.
2/1/2024: Services provided for twenty-two (22) hours. The agency did not provide services for the remaining two (2) hours.
2/8/2024: Services provided for twenty-two (22) hours. The agency did not provide services for the remaining two (2) hours.
2/15/2024: Services provided for twenty-two (22) hours. The agency did not provide services for the remaining two (2) hours.
CR2 - (Start of Care): 1/18/2024 - Receives personal assistance services for twenty-four hours per week for seven (7) days per week.
Review of visit calendar on 2/23/2024 starting at approximately 12:00PM, revealed the agency did not provide caregiver services for the full shift of twenty-four (24) hours per day for seven (7) days per week on the following dates for the timeframe of 1/18/2024 through 2/22/2024 per service agreement:
1/13/2024: Services provided for fifteen (15) hours and one-half (.5) hour. The agency did not provide services for the remaining eight (8) hours and one-half (.5) hour.
2/4/2024: Services provided for twelve (12) hours and one-half (.5) hours. The agency did not provide services for the remaining eleven (11) hours and one-half (.5) hours.
2/9/2024: Services provided for seventeen (17) hours. The agency did not provide services for the remaining seven (7) hours.
2/11/2024: Services provided for twenty-three (23) hours and fifteen (15) minutes. The agency did not provide services for the remaining forty-five (45) minutes.
2/15/2024: Services provided for twenty-two (22) hours and one-half (.5) hours. The agency did not provide services for the remaining one (1) hour and one-half (.5) hours.
CR3 (Start of Care): 6/13/2023-
2/9/2024: Services provided for twenty (20) out of the twenty-four (24) hours indicated. The agency did not provide services for the remaining four (4) hours.
2/15/2024: Services provided for twenty-one (21) out of the 24 hours indicated. The agency did not provide services for the remaining three (3) hours.
2/16/2024: Services provided for twenty-two (22) and one-half (.5) hours out of the 24 hours indicated. The agency did not provide services for the remaining one (1) hour and one-half (.5) hours.
Interview with President/ CEO on February 23, 2024 at approximately 1:30PM confirmed the above findings.
Plan of Correction:*Objective:* To ensure compliance with consumer rights by providing home care services according to the service plan.
*Actions:*
1. *Immediate Service Plan Review:*
- Conduct an immediate review of the service plans for CR#1, CR#2, and CR#3 to identify any discrepancies or issues.
- Ensure that the service plans are clear, comprehensive, and reflect the consumer's needs and preferences.
2. *Corrective Services:*
- Address the missed hours and discrepancies identified in the consumer records (CR#1, CR#2, and CR#3) immediately.
- Conduct a comprehensive retraining program for all staff, emphasizing the critical importance of adhering to punctual clock-in and clock-out procedures to accurately reflect the coverage of services provided.
3. *Review and Strengthen Scheduling Procedures:*
- Review and update scheduling procedures to ensure that caregiver services are provided according to the service plan.
- Implement measures to prevent scheduling errors and ensure adequate coverage for all consumers.
4. *Employee Training:*
- Conduct training sessions for relevant staff, including scheduling coordinators and caregivers, on the importance of adherence to service plans.
- Emphasize the rights of consumers to receive services as per their agreed-upon schedules.
5. *Establish Monitoring and Reporting System:*
- Implement a monitoring system to track and ensure that caregiver services are provided according to the service plans.
- Set up regular reporting mechanisms to identify and address any deviations promptly.
*Timeline:*
- *Immediate:* Review service plans for CR#1, CR#2, and CR#3. Address and compensate for missed hours.
- *By April 23rd:* Review and update scheduling procedures. Conduct training sessions for relevant staff.
- *Implement the monitoring system and reporting mechanisms.*
- *Ongoing:* Continuously monitor and adjust scheduling procedures as needed.
*Responsibility:* The HR Director will be responsible for implementing and overseeing this plan. The CEO/President will provide support and ensure ongoing compliance.
*Verification:* Regular internal audits will be conducted to verify adherence to service plans, and consumer records will be periodically reviewed to ensure that services are provided as scheduled.
611.57(c) LICENSURE
Information to be Provided
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(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 (CF) and an interview with the President/ CEO, the agency failed to provide documentation that the consumer received (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. 6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. for one (1) of the four (4) CF's reviewed, (CF#4).
Findings include:
A review of CF's was conducted on February 23, 2024 from approximately 11:15 pm to 1:15 pm.
CR#4 (Start of Care): 9/24/2018 - Consumer record did not contain documentation of the following: A listing of the available home care services that will provided to the consumer by the direct care worker and the identity of the direct care worker who will provide services. Hours when the services will be provided. No signed service agreement on file. The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.
An interview with the President/CEO on February 23, 2024 at approximately 1:30 pm confirmed the above findings.
Plan of Correction:*Objective:* To ensure compliance with the requirement of providing comprehensive information to consumers prior to the commencement of services.
*Actions:*
1. *Immediate Information Delivery:*
- Immediately provide the missing information to the consumer, CF#4, as outlined in 611.57(c).
- Ensure the consumer receives a complete information packet including details on available home care services, the identity of the direct care worker, service hours, hiring and competency requirements, and any other relevant information.
2. *Review and Update Informational Procedures:*
- Review and update the agency's procedures for providing information packets to consumers.
- Implement measures to ensure that all necessary information is consistently and comprehensively provided to consumers before the commencement of services.
3. *Document Compliance:*
- Establish a system for documenting the delivery of information packets to consumers.
- Ensure that each consumer's file contains signed documentation indicating receipt of the required information.
4. *Staff Training:*
- Conduct training sessions for relevant staff, including intake coordinators and caregivers, on the importance of providing comprehensive information to consumers.
- Emphasize the necessity of ensuring that consumers understand the details of the home care services they will receive.
5. *Regular Audits:*
- Implement a regular auditing system to review consumer files and ensure compliance with information delivery requirements.
- Conduct periodic internal audits to verify that all consumers receive the necessary information packets.
*Timeline:*
- *Immediate:* Provide missing information to CF#4. Review and update informational procedures.
- *By April 23rd:* Implement a documentation system for information packet delivery. Conduct staff training sessions.
- Conduct the first round of internal audits.
- *Ongoing:* Continue regular audits to ensure ongoing compliance.
*Responsibility:* The HR Director will be responsible for implementing and overseeing this plan. The CEO/President will provide support and ensure ongoing compliance.
**Verification:** Regular internal audits will be conducted to verify compliance with the information delivery requirements. Consumer files will be periodically reviewed to ensure that all necessary information is consistently provided.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on February 23, 2024, God's Glory, Inc, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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