Initial Comments:
Based on the findings of an onsite unannounced State relicensure survey completed 10/25/2021, Arcadia Home Care & Staffing was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed 10/25/2021, Arcadia Home Care & Staffing was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.
Plan of Correction:
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 the agency policy, CDC (Center for Disease Control) guidelines, personnel files (PF), and staff interview, the agency failed to conduct tuberculosis (TB) screening in accordance with CDC guidelines and agency policy for two (2) of seven (7) PFs reviewed (PF1 and PF6).
Findings included:
A review of the agency policy on 10/25/2021 at 3:00 PM revealed: Policy "INITIAL TUBERCULOSIS SCREENING/DOCUMENTATION FORM (PA)...THIS SECTION TO BE COMPLETED BY A NURSE: TWO STEP REQUIRED FOR ALL NEW APPLICANTS..."
A review on 10/25/2021 at approximately 3:30 PM of "CDC MMWR Morbidity and Mortality Weekly Report Recommendations and Reports December 30, 2005/Vol. 54/No. RR-17 Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005" revealed "...Baseline testing for M. Tuberculosis infection is recommended for all newly hired HCWs [health care workers]...If TST [tuberculin skin testing] is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative...If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read...A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months, a single TST can be administered in the new setting...This additional TST represents the second stage of two-step testing..."
A review of PF1 was conducted on 10/25/2021 at approximately 12:35 PM revealed, date of hire 9/27/2021. Initial TST was administered on 8/27/2021, read 8/30/2021 with negative results. The agency failed to provide documentation to confirm the second TST was administered
A review of PF6 was conducted on 10/25/2021 at approximately 1:15 PM revealed, date of hire 10/29/2019. Initial TST was administered on 10/14/2019, read 10/16/2019 with negative results. The second TST was administered on 2/19/2020, read 2/21/2020 the results were negative. The agency failed to administered the second TST within a three week period from when the first TST result was read.
An interview with the director on 10/25/2021 at approximately 10:58 AM confirmed the above findings.
Plan of Correction:Staff will be re-educated on our Personnel Policy #3.8 regarding Health Screenings. The policy states, "All employees are required to obtain a Step 1 (of two steps) of TB skin test and complete the TB INITIAL SCREENING DOCUMENTATION FORM prior to client contact." The TB INITIAL SCREENING DOCUMENTATION FORM includes the screening of signs and symptoms and a risk assessment. All personnel files will be audited to ensure compliance regarding this requirement. New employee files will be reviewed by both the Office Coordinator and the Service Coordinator, using the New Hire Documentation Checklist and both parties signing off once completed, to ensure compliance, going forward.
Staff will be re-educated on our Personnel Policy #3.8 regarding Health Screenings. The policy states, "Per the directive from the PA Department of Health, initial 2-Step TB testing is required, along with an annual TB risk assessment and screening and TB education." All personnel files will be audited to ensure compliance regarding this requirement. The expiring license report, which shows the last date of the employee's TB test or screening, and will be reviewed monthly by the office staff and by the Agency Director to ensure compliance, going forward.
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 records (CR) and staff (EMP) interview, the agency failed to provide required information in writing to consumers/consumer representatives prior to the commencement of services for five (5) of seven (7) CRs reviewed (CR1-CR5).
Findings included:
A review of CR1 on 10/15/2021 at approximately 1:30 PM revealed start of services 2/3/2021. No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
A review of CR2 on 10/15/2021 at approximately 1:40 PM revealed start of services 10/14/2021. No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The identity of the direct care worker who would provide services.
2. The hours when services would be provided.
A review of CR3 on 10/15/2021 at approximately 1:42 PM revealed start of services 12/22/2020. No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
A review of CR4 on 10/15/2021 at approximately 1:50 PM revealed start of services 4/23/20219. No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided
A review of CR5 on 10/15/2021 at approximately 1:55 PM revealed start of services 1/27/2020 No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided
An interview with the director on 10/25/2021 at approximately 10:58 AM confirmed the above findings.
Plan of Correction:Staff will be re-educated regarding the requirement to provide the consumer with a completed Welcome Letter, which includes the name of the direct care worker providing services to the consumer, prior to the commencement of services. Office staff will audit all consumer files, if it is discovered that a welcome letter was not filled out completely, a new completed letter will be mailed to the consumer and a copy of that letter will be maintained in the consumer's file to include the date the letter was mailed. The Agency Director will review all new consumer files prior to commencement of services to ensure compliance, going forward.
Initial Comments:
Based on the findings of an onsite unannounced State relicensure survey completed 10/18/2021, Arcadia Home Care & Staffing was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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