QA Investigation Results

Pennsylvania Department of Health
CARING FRIENDS HOME CARE
Health Inspection Results
CARING FRIENDS HOME CARE
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite unannounced state re-licensure survey conducted on December 14, 2022, and concluded off-site on December16, 2022, Caring Friends Home Care 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 December 14, 2022, and concluded off-site on December 16, 2022, Caring Friends Home Care 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 direct care worker personnel files (PF) and interview with the agency Executive Director, the agency failed to document interviews and/or two (2) satisfactory references prior to employment for six (6) of seven (7) PF reviewed. (PF #1, 3, 4, 5, 6, and 7).

Findings Include:

A review of PF's conducted on December 14, 2022, from approximately 10:45 A.M. to 11:30 A.M. and December 16, 2022, from approximately 2:15 P.M to 2:45 P.M. revealed the following:

PF #1, date of hire May 15, 2022, contained no documentation of two (2) satisfactory references obtained prior to employment.

PF #3, date of hire September 30, 2021, contained no documentation of two (2) satisfactory references obtained prior to employment.

PF #4, date of hire October 8, 2021, contained no documentation of two (2) satisfactory references obtained prior to employment.

PF #5, date of hire April 1, 2022, contained documentation of only one (1) satisfactory references obtained prior to employment.

PF #6, date of hire April 29, 2022, contained documentation of only one (1) satisfactory references obtained prior to employment.

PF #7, date of hire May 5, 2020, contained no documentation of an interview and no documentation of two (2) satisfactory references obtained prior to employment.

An interview with the agency Executive Director on December 14, 2022, at approximately 11:45 A.M. and a follow-up email on December 16, 2022, at approximately 2:15 P.M. confirmed the above findings.













































Plan of Correction:

Caring Friends staff will conduct a full audit of all active caregivers to identify deficiencies. Then staff will follow up with each employee to complete outstanding items. Caring Friends staff will adhere to the hiring policy to ensure a face-to-face interview is conducted with each candidate being considered for hire. Prior to hire, Caring Friends staff will complete 2 satisfactory references with a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. Caring Friends staff will ensure criminal background checks are completed for each new hire in accordance with 611.52. The audit and reconciliation process will be monitored by the Sr. Compliance Manager. We will complete the full audit and reconciliation by February 14, 2023. Thereafter, employee files will be audited at a rate of 10% of active employees audited per quarter to ensure continued compliance.


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 review of direct care worker personnel files (PF) and an interview with the agency Executive Director, it was determined that the agency failed to ensure criminal background checks were obtained at the time of application for employment or within one year immediately preceding the date of application for six (6) of seven (7) PF reviewed. (PF# 1, 3, 4, 5, 6, and 7)

Findings include:

A review of PF's conducted on December 14, 2022, from approximately 10:45 A.M. to 11:30 A.M. and December 16, 2022, from approximately 2:15 P.M to 2:45 P.M. revealed the following:

PF #1, date of hire May 15, 2022, contained a background check completed by IntelliCorp that did not contain a Pennsylvania State Police (PATCH) background check.

PF #3, date of hire September 30, 2021, contained a background check completed by IntelliCorp that did not contain a Pennsylvania State Police (PATCH) background check.

PF #4, date of hire October 8, 2021, contained a background check completed by IntelliCorp that did not contain a Pennsylvania State Police (PATCH) background check.

PF #5, date of hire April 1, 2022, contained a background check completed by IntelliCorp that did not contain a Pennsylvania State Police (PATCH) background check.

PF #6, date of hire April 29, 2022, contained a background check completed by IntelliCorp that did not contain a Pennsylvania State Police (PATCH) background check.

PF #7, date of hire May 5, 2020, contained no documentation of a Pennsylvania State Police (PATCH) background check.

An interview with the agency Executive Director on December 14, 2022, at approximately 11:45 A.M. and a follow-up email on December 16, 2022, at approximately 2:15 P.M. confirmed the above findings.















































Plan of Correction:

Caring Friends will audit all current employee files to ensure compliance with 611.52, and obtain any missing background checks. Caring Friends Criminal Background Check Policies are part of the Hiring Policy Caring Friends staff will conduct criminal background checks, including Pa PATCH reports, for each new hire. The audit and reconciliation process will be monitored by the Sr. Compliance Manager. We will complete the full audit and reconciliation by February 14, 2023. Thereafter, employee files will be audited at a rate of 10% of active employees audited per quarter to ensure continued compliance.


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 direct care worker personnel files (PF) and an interview with the agency Executive Director, the agency failed to ensure initial and annual competency reviews were conducted for two (2) of six (6) PF reviewed. (PF # 4 and 7).

Findings include:

A review of PF's conducted on December 14, 2022, from approximately 10:45 A.M. to 11:30 A.M. and December 16, 2022, from approximately 2:15 P.M to 2:45 P.M. revealed the following:

PF #4, date of hire October 8, 2021, contained no documentation of an annual competency review in 2022.

PF #7, date of hire May 5, 2020, contained no documentation of an initial competency review upon hire and annual competency reviews in 2021 and 2022.

An interview with the agency Executive Director on December 14, 2022, at approximately 11:45 A.M. and a follow-up email on December 16, 2022, at approximately 2:15 P.M. confirmed the above findings.


































































Plan of Correction:

All new hires will satisfactorily complete an initial competency exam upon hire. Caring Friends will audit all current employee files, and ensure each employee is in compliance with Annual Competency Trainings. Caring Friends will conduct Annual Competency Trainings each year to ensure employee receive ongoing support and remain in compliance. The audit and reconciliation process will be monitored by the Sr. Compliance Manager. We will complete the full audit and reconciliation by February 14, 2023. Thereafter, employee files will be audited at a rate of 10% of active employees audited per quarter to ensure continued compliance.





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 upon review of personnel files (PF) and an interview with the agency Executive Director, the agency failed to ensure tuberculosis (TB) screening/and or testing, a symptom screen questionnaire, and/or an individual TB risk assessment, and /or annual TB education was conducted for seven (7) of seven (7) PF reviewed. (PF#1, 2, 3, 4, 5, 6, and 7).

Findings Include:

The CDC (Centers for Disease Control and Prevention) guidelines state baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or tuberculin skin test (TST), shall include a symptom screen questionnaire and an individual tuberculosis (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 PF's conducted on December 14, 2022, from approximately 10:45 A.M. to 11:30 A.M. and December 16, 2022, from approximately 2:15 P.M to 2:45 P.M. revealed the following:

PF #1, date of hire May 15, 2022, contained documentation of a single TST conducted on November 3, 2022, six months after date of hire. There was no documentation of a second-step TST conducted, and no documentation of an individual TB risk assessment completed upon hire.

PF #2, date of hire June 24, 2022, contained no documentation of an individual TB risk assessment completed upon hire.

PF #3, date of hire September 30, 2021, contained no documentation of a symptom screening questionnaire and an individual TB risk assessment completed upon hire. There was no documentation of annual TB education.

PF #4, date of hire October 8, 2021, contained documentation of a single TST conducted on October 28, 2020. There was no documentation of a second-step TST and an individual TB risk assessment completed upon hire. There was no documentation of annual TB education.

PF #5, date of hire April 1, 2022, contained no documentation of a symptom screening questionnaire and an individual TB risk assessment completed upon hire.

PF #6, date of hire April 29, 2022, contained no documentation of a symptom screening questionnaire and an individual TB risk assessment completed upon hire.

PF #7, date of hire May 5, 2020, contained no documentation of an IGRA or TST, a symptom screening questionnaire and an individual TB risk assessment completed upon hire. There was no documentation of annual TB education.

An interview with the agency Executive Director on December 14, 2022, at approximately 11:45 A.M. and a follow-up email on December 16, 2022, at approximately 2:15 P.M. confirmed the above findings.

























Plan of Correction:

Caring Friends staff will audit each file and, if missing, collect documentation that each individual candidate has been screened for and is free from active mycobacterium tuberculosis. Going forward, the TB Symptoms Screening and Risk Assessment Form will be completed with each new candidate upon hire. Caring Friends staff will provide Annual TB Education to all active employees. The TB screening and annual education process will be monitored by the Sr. Compliance Manager. We will complete the full audit and reconciliation by February 14, 2023. Thereafter, employee files will be audited at a rate of 10% of active employees audited per quarter to ensure continued compliance.

Tuberculosis Symptom Screening and Risk Assessment
Employee Name: (Print)_________________________________ Assigned Office: _____________

Step 1: Screening for TB symptoms
 Are you experiencing any of the following symptoms?
 If there are significant TB symptoms, TB testing will be required prior to attending orientation.
 If there are no symptoms recorded continue to Step 2.
Those with a history of testing positive will be required to provide
 Documentation of the positive Tb history and a negative chest x-ray/clinical clearance
 We will also accept documentation of previous treatment for the disease
Symptoms YES NO
Prolonged, Productive Cough (for 3 weeks or more)
Bloody Sputum, Hemoptysis
Chest Pain
Malaise (general weakness)
Unexplained Rapid Weight Loss
Fever ( > 100.5 degrees or longer than 2 days)
Chills
Night Sweats
Fatigue
Anorexia
Step 2: TB Risk Assessment
☐ Born or Lived in a Country with an elevated TB rate
 Includes any country other than the United States, Canada, Australia, New Zealand, or a county in
western or northern Europe
 If resources require prioritization within this group, prioritize patients with at least one medical risk for
progression (See User Guide for list)
 Interferon Gamma Release Assay (IGRA) is preferred over Tuberculin Skin Test (TST) for Foreign-born
persons > 2 yrs. old. The TST is an acceptable test for all ages when administered and read correctly.
☐ Immunosuppression, current or planned
 HIV infection, organ transplant recipient, treated with TNF-alpha antagonists, steroids, or other
immunosuppressive medications.
☐ Close Contact to someone sick with infectious TB disease (since last TB risk Assessment)
☐ Previously tested positive for TB test or had TB disease
☐ None of the above Low Risk
By signing below, I am acknowledging the information I have provided above is true and correct.
Employee Signature: _________________________________________ Date: ____________


Initial Comments:


Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on December 14, 2022, and concluded off-site on December 16, 2022, Caring Friends Home Care was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: