Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on January 23, 2024, Word Of Life International, 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 state re-licensure survey conducted on January 23, 2024, Word Of Life International, 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:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
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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 interview with the administrator, it was determined that personnel files did not include documentation of two (2) positive, verifiable references (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, prior to hiring or rostering direct care workers for five (5) of six (6) personnel files reviewed. (PF1, PF3, PF4, PF5, and PF6)
Findings Include:
Review of personnel files (PF), was conducted on 1/23/2024 from approximately 9:33AM until approximately 10:45AM revealed:
PF1: DCW for CR2 - (Date of Hire): 6/10/2023 - File did not contain documentation of two (2) verified references.
PF3: DCW for CR3 - (Date of Hire): 9/25/2021 - File did not contain documentation of two (2) verified references.
PF4: DCW for CR4 - (Date of Hire): 12/12/2022 - File did not contain documentation of two (2) verified references.
PF5: DCW for CR1 - (Date of Hire): 1/1/2019 - File did not contain documentation of two (2) verified references.
PF6: (Date of Hire): 2/1/2023 - File did not contain documentation of a face-to-face interview or two (2) verified references.
Interview with administrator on 1/23/2024 at approximately 12:00PM confirmed the above findings.
Plan of Correction: The hiring coordinator will begin documenting the date the references will be called. The HR department is currently creating a form that will be given out for each reference to fill out before completing the hiring process.
611.52(b) LICENSURE
State Police Criminal History Record
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If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.
Observations:
Based on review of personnel files (PF), and interview with the administrator, it was determined that personnel files did not include documentation of a State Police Criminal History report on hire for two (2) of six (6) personnel files reviewed. (PF3 and PF5)
Findings Include:
Review of personnel files (PF), was conducted on 1/23/2024 from approximately 9:33AM until approximately 10:45AM revealed:
PF3: DCW for CR3 - (Date of Hire): 9/25/2023 - File did not contain a Pennsylvania Access To Criminal History report (PATCH) on hire or thereafter.
PF5: DCW for CR1 - (Date of Hire): 1/1/2019 - File contained a Pennsylvania Access To Criminal History report (PATCH) dated 5/16/2019 which was four (4) months after hire.
Interview with administrator on 1/23/2024 at approximately 12:00PM confirmed the above findings.
Plan of Correction:PF3 criminal background check (PATCH) was requested from PATCH on 1/29/2024 and received on 02/02/2024. This have been added to PF3 file.
PF5 background check have been updated and added to PF5 file.
Criminal background check is included in the prerequisite requirement to the hiring process.
Secondly, the Administrator will continue conducting monthly background check for all staff and document them to ensure State compliance. The various sites are being used for this which includes: Medicheck, PA, Sam.gov and LEIE.
611.55(e) LICENSURE
Competency Requirements
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(e) The home care agency or home care registry also shall include documentation in the direct care worker's file that the agency or registry has reviewed the individual's competency to perform assigned duties through direct observation, testing, training, consumer feedback or other method approved by the Department or through a combination of methods.
Observations:
Based on review of personnel files (PF), and interview with the administrator, it was determined that the agency failed to ensure personnel files included documentation that the home care agency or home care registry reviewed the individual ' s competency to perform assigned duties through direct observation, testing, training, consumer feedback or other method approved by the Department or through a combination of methods, prior to assigning direct care workers to consumers, for five (5) of six (6) personnel files reviewed. (PF1, PF2, PF3, PF4, and PF5)
Findings Include:
Review of personnel files (PF), was conducted on 1/23/2024 from approximately 9:33AM until approximately 10:45AM revealed:
PF1 - (Date of Hire): 6/10/2021 - File did not contain documentation that the home care agency evaluated direct care worker ' s competency on hire.
PF2 - (Date of Hire): 2/23/2023 - File did not contain documentation that the home care agency evaluated direct care worker ' s competency on hire.
PF3 - (Date of Hire): 9/25/2023 - File did not contain documentation that the home care agency evaluated direct care worker ' s competency on hire.
PF4 - (Date of Hire): 12/12/2022 - File did not contain documentation that the home care agency evaluated direct care worker ' s competency on hire.
PF5 - (Date of Hire): 1/1/2019 - File did not contain documentation that the home care agency evaluated direct care worker ' s competency on hire.
Interview with administrator on 1/23/2024 at approximately 12:00PM confirmed the above findings.
Plan of Correction:Word of Life International Inc Administrator is in the process of creating a Competency documentation that will be used to evaluate Direct care workers to perform assigned duties during the hiring process before assigning the staff to work with a consumer.
A competency/skills evaluation will be completed for the files reviewed (PF1, PF2, PF3, PF4 and PF5) and all other Direct care workers to ensure State compliance.
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 review of personnel files (PF), and interview with the administrator, it was determined that personnel files did not include documentation that TB testing, TB risk assessments, or TB symptom screens were conducted at time of hire or prior to assigning direct care workers (DCW) and staff to consumers, for five (5) of six (6) personnel files reviewed. (PF1, PF2, PF3, PF4, and PF5)
Findings Include:
"Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019 - Historically, U.S. health care personnel were at increased risk for latent TB infection (LTBI) and TB disease from occupational exposures, but recent data suggest that this is no longer the case. CDC and the National Tuberculosis Controllers Association have updated the 2005 CDC recommendations for testing health care personnel. The update includes 1) TB risk assessment, symptom screening, and TB testing upon hire with a TB blood test (e.g., interferon-gamma release assay) or tuberculin skin test for those without documented prior TB or LTBI; 2) no annual TB testing for most health care personnel without a known exposure or ongoing transmission; 3) for health care personnel with LTBI treatment is strongly encouraged; 4) annual symptom screening for health care personnel with untreated LTBI; and 5) annual TB education for all health care personnel. These recommendations apply to health care personnel and volunteers in all health care settings. However, state and local TB screening and testing regulations may have different requirements."
Review of personnel files (PF), was conducted on 1/23/2024 from approximately 9:33AM until approximately 10:45AM revealed:
PF1: DCW for CR2 - (Date of Hire): 6/10/2021 - File did not contain documentation that a TB risk assessment or TB symptom screen were conducted at time of hire or prior to assigning direct care worker (DCW) to consumers, and there was no documentation that annual TB education was provided in 2022 or 2023.
PF2: DCW for CR5 - (Date of Hire): 2/2/2023 - File contained results of a Chest X-ray dated 4/6/2023, which was 2 months after hire. File did not contain documentation that a TB risk assessment or TB symptom screen were conducted at time of hire or prior to assigning direct care worker (DCW) to consumers.
PF3: DCW for CR3 - (Date of Hire): 9/25/2023 - File contained a 1-Step PPD skin test dated 8/16/2023, however, file did not contain documentation of the second PPD. File did not contain documentation that a TB risk assessment or TB symptom screen were conducted at time of hire or prior to assigning direct care worker (DCW) to consumers.
PF4: DCW for CR4 - (Date of Hire): 12/12/2022 - File contained a 1-Step PPD skin test dated 5/10/2022, however, file did not contain documentation of the second PPD. File did not contain documentation that a TB risk assessment or TB symptom screen were conducted at time of hire or prior to assigning direct care worker (DCW) to consumers, and there was no documentation that annual TB education was provided in 2023.
PF5: DCW for CR1 - (Date of Hire): 1/1/2019 - File contained results of a Chest X-ray dated 8/26/2022, which was 3 years and 7 months after hire. File did not contain documentation that a TB risk assessment or TB symptom screen were conducted at time of hire or prior to assigning direct care worker (DCW) to consumers, and there was no documentation that annual TB education was provided in 2020, 2021, 2022, and 2023.
Interview with administrator on 1/23/2024 at approximately 12:00PM confirmed the above findings.
Plan of Correction:The Hiring coordinator have created document(s) that are included in the hiring package to indicate the TB screening/assessment process are completed prior to hiring.
A TB symptom screen/assessment will be conducted for (PF1, PF2, PF3, PF4, and PF5) and all other Direct Care workers to maintain compliance.
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 agency documentation, visit calendars, and interview with the administrator, it was determined that the agency failed to ensure that consumer ' s rights were protected by providing the correct number of hours for home care services, for one (1) of five (5) consumer records (CR) reviewed. (CR1)
Findings Include:
Reviewed agency ' s consumer and personnel binder on 1/23/2024 at approximately 11:00AM. The binder included the name of each consumer, the number of hours that each consumer will receive caregiver services, and the name of the consumer ' s Director Care Worker (DCW). Agency ' s documentation revealed:
CR1 - (Start of Care): 1/1/2019 - Receives personal assistance services for fifty-four hours per week.
Review of visit calendar on 1/23/2024 at approximately 11:10AM, revealed the agency did not provide caregiver services for the correct number of hours as documented in the agency ' s binder. The agency ' s binder indicates that the consumer receives fifty-four (54) hours per week. However, the consumer ' s visit calendar shows the following visits for the month of December 2023:
12/1/2023 - 12/25/2023: Services provided for twelve (12) hours each day.
12/26/2023 - 12/31/2024: Services were not provided for any of these days.
An interview with the agency ' s Human Resources (HR) staff member on 1/23/2024 at approximately 11:50AM revealed, the correct number of hours that the consumer receives caregiver services is fifty-four (54) hours per week, and not eighty-four (84) hours per week as indicated on the visit calendar. The HR staff member stated that the Direct Care Worker (DCW) " entered the wrong times " on the visit calendar. There was no documentation available for review during the survey that outlined the details for the visit calendar discrepancy.
Interview with administrator on 1/23/2024 at approximately 12:00PM confirmed the above findings.
Plan of Correction:HHA exchange corrected the discrepancies.
Allocated hours from December 1-31 were 246 hours. Billing was mistakenly done for 240hrs from December 1-20 instead of December 31, but the agency was not paid for the excess hours. This has been corrected on the master calendar as of January 2024.
Moving forward, Word of Life International Inc will work with HHA exchange to ensure that the hours entered are accurate.
611.57(b) LICENSURE
Prohibitions
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(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.
Observations:
Based on review of agency documentation, and interview with the administrator, it was determined that the agency failed to ensure that consumers were informed that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry, and that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry, for five (5) of five (5) consumer records (CR) reviewed (CR1, CR2, CR3, CR4, and CR5).
Findings include:
On 1/23/2024 at approximately 10:55AM, the surveyor requested to review consumer records. The administrator indicated that the agency ' s intake coordinator had abruptly resigned and deleted/destroyed all consumer records. Therefore, consumer records were not available for review during the survey. Instead, the agency provided a personnel/consumer binder that included the name of each consumer, the number of hours that each consumer will receive caregiver services, and the name of the consumer ' s Director Care Worker (DCW).
Review of consumer documentation was conducted on 1/23/2024 at approximately 11:00AM revealed:
CR1 - (Start of Care): 1/1/2019 - There was no documentation available for review during the survey to confirm that consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry, and that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.
CR2 - (Start of Care): 6/6/2021 - There was no documentation available for review during the survey to confirm that consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry, and that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.
CR3 - (Start of Care): 7/20/2021 - There was no documentation available for review during the survey to confirm that consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry, and that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.
CR4 - (Start of Care): 9/4/2021 - There was no documentation available for review during the survey to confirm that consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry, and that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.
CR5 - (Start of Care): 2/23/2023 - There was no documentation available for review during the survey to confirm that consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry, and that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.
Interview with administrator on 1/23/2024 at approximately 12:00PM confirmed the above findings.
Plan of Correction:Word of Life International Inc has already created a documentation to ensure that the consumer is informed that the home care agency cannot be the Power of Attorney or Guardianship over a consumer utilizing the services of Word of Life international Inc.
Moving forward, consumers (CR1, CR2, CR3, CR4, and CR5) will receive the updated documentation that was missing during the survey and that the signed documentation will be included in their records. All other consumer records will also be reviewed/ audited for compliance.
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 review of agency documentation and interview with the administrator, it was determined that the agency failed to ensure that consumer, consumer ' s legal representative or responsible family member, were provided an information packet that included the following: (1) A listing of services that will be provided to the consumer by the Direct Care Worker (DCW), (2) The hours when those services will be provided, (4) Who to contact at the Department for information about licensure requirements for home care agency or home care registry, (5) The Department ' s complaint Hot Line phone number and Ombudsman Program located in the Local Area Agency on Aging (AAA), (6) The hiring and competency requirements for the agency ' s Direct Care Workers (DCW), and (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, for five (5) of five (5) consumer records (CR) reviewed. (CR1, CR2, CR3, CR4, and CR5)
Findings Include:
On 1/23/2024 at approximately 10:55AM, the surveyor requested to review consumer records. The administrator indicated that the agency ' s intake coordinator had abruptly resigned and deleted/destroyed all consumer records. Therefore, consumer records were not available for review during the survey. Instead, the agency provided a binder that included the name of each consumer, the number of hours that each consumer will receive caregiver services, and the name of the consumer ' s Director Care Worker.
Review of consumer documentation was conducted on 1/23/2024 at approximately 11:00AM revealed:
CR1 - (Start of Care): 1/1/2019 - There was no documentation available for review during the survey to confirm that consumer, consumer ' s legal representative or responsible family member were provided an information packet that included, a listing of services that the consumer will receive, the number of hours when those services would be provided by a DCW, who to contact at the Department about licensure requirements, the Department ' s Hot Line number, the Ombudsman Program and Local Area Agency on Aging (AAA), the agency ' s hiring and competency requirements for DCWs, and the DCW disclosure status form. There also was no documentation of a signed consumer consent agreement.
CR2 - (Start of Care): 6/6/2021 - There was no documentation available for review during the survey to confirm that consumer, consumer ' s legal representative or responsible family member were provided an information packet that included, a listing of services that the consumer will receive, the number of hours when those services would be provided by a DCW, who to contact at the Department about licensure requirements, the Department ' s Hot Line number, the Ombudsman Program and Local Area Agency on Aging (AAA), the agency ' s hiring and competency requirements for DCWs, and the DCW disclosure status form. There also was no documentation of a signed consumer consent agreement.
CR3 - (Start of Care): 720/2021 - There was no documentation available for review during the survey to confirm that consumer, consumer ' s legal representative or responsible family member were provided an information packet that included, a listing of services that the consumer will receive, the number of hours when those services would be provided by a DCW, who to contact at the Department about licensure requirements, the Department ' s Hot Line number, the Ombudsman Program and Local Area Agency on Aging (AAA), the agency ' s hiring and competency requirements for DCWs, and the DCW disclosure status form. There also was no documentation of a signed consumer consent agreement.
CR4 - (Start of Care): 9/4/2021 - There was no documentation available for review during the survey to confirm that consumer, consumer ' s legal representative or responsible family member were provided an information packet that included, a listing of services that the consumer will receive, the number of hours when those services would be provided by a DCW, who to contact at the Department about licensure requirements, the Department ' s Hot Line number, the Ombudsman Program and Local Area Agency on Aging (AAA), the agency ' s hiring and competency requirements for DCWs, and the DCW disclosure status form. There also was no documentation of a signed consumer consent agreement.
CR5 - (Start of Care): 2/23/2023 - There was no documentation available for review during the survey to confirm that consumer, consumer ' s legal representative or responsible family member were provided an information packet that included, a listing of services that the consumer will receive, the number of hours when those services would be provided by a DCW, who to contact at the Department about licensure requirements, the Department ' s Hot Line number, the Ombudsman Program and Local Area Agency on Aging (AAA), the agency ' s hiring and competency requirements for DCWs, and the DCW disclosure status form. There also was no documentation of a signed consumer consent agreement.
Interview with administrator on 1/23/2024 at approximately 12:00PM confirmed the above findings.
Plan of Correction:Information packet containing all of the required information have been submitted to the Individual and their representatives and they have already signed the packet.
Corrected.
All of the consumers including the files that were not reviewed, have been audited and provided the information packets for review and signing to meet compliance requirements.
Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on January 23, 2024, Word Of Life International, Inc., was found to be in compliance with the requirements of 35 P.S. 448.809(b).
Plan of Correction:
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