Initial Comments:
Based on the findings of an onsite unannounced relicensure survey conducted 7/21/2017, Bayada Home Health Care Inc. 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 conducted 7/21/2017, Bayada Home Health Inc. 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:
611.52(d) LICENSURE
Proof of Residency
Name - Component - 00
The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation
Observations:
Based on a review of agency policy, personnel files (PFs) and staff interview, it was determined the agency failed to verify proof of residency in this Commonwealth for the 2 years preceding the date of hire (DOH) in three (3) of seven (7) PFs reviewed (PF4, PF6 and PF7).
Findings include:
A review of agency policy on 7/21/2017 at approximately 12:20 PM revealed: "0-17105 Criminal Background checks, clearances, and required screenings-PA offices...4.1.2 Home Care Licensure (non-medical). Proof of residency may be requested from the prospect in order to obtain a criminal history record ...4.2 FBI Check through the PA Department of Aging-Employees who have lived out of state within 2 years prior to orientation..."
PF #4 DOH 3/6/2017, documentation revealed a Pennsylvania driver's license with an issue date of 5/11/2016. There was no additional documentation in PF to show agency verified proof of residency in this Commonwealth for two (2) years immediately preceding the date of hire.
PF #6 date of hire (DOH) 3/24/2017, documentation revealed a Pennsylvania driver's license with an issue date of 12/30/2016. There was no additional documentation in PF to show agency verified proof of residency in this Commonwealth for two (2) years immediately preceding the date of hire.
PF #7 DOH 2/16/2016 documentation revealed a Pennsylvania driver's license with an issue date of 4/4/2015. There was no additional documentation in PF to show agency verified proof of residency in this Commonwealth for two (2) years immediately preceding the date of hire.
An interview with the director and associate director on 7/21/2017 at approximately 4:32 PM confirmed the above findings.
Plan of Correction:0330
Based on an analysis of the specific deficiencies cited, the corrective plan and actions taken are to address the lack of demonstrated knowledge resulting in failure to obtain documented evidence of proof of residency in the Commonwealth for two years preceding the date of the request for a criminal history report. The plan of correction will be completed through comprehensive focused education and re- instruction.
Employee #4 is not currently on the active employee roster. If this employee returns to work at this agency, proof of residency, as outlined in 611.52(d), will be collected at that time.
Employee #6 is not currently on the active employee roster and will not return to work at this Agency.
Employee #7 is not currently on the active employee roster and will obtain a Federal criminal history record as outlined in 611.52(c) prior to returning to work as this employee is not able to provide any of the documents listed in 611.52(d) dating back two years prior to the date of request for the criminal history report.
On 8/18/2017, the Director completed an audit of all existing employees who were hired two years prior to the date of the survey (7/21/2017) for documented evidence of proof of residency in the Commonwealth for two years preceding the date of the request for a criminal history report. By 9/20/2017, evidence of proof of residency, as outlined in 611.52(d), will be obtained for all employees identified as not having documented evidence of residence. Any employee unable to provide documented evidence of residence, or any employee identified as not being a resident of the Commonwealth for the two years preceding the date of the request for a criminal history report, will have a federal background check conducted as outlined in 611.53(c) by 9/20/2017.
All applicants will be notified at inquiry that they must provide proof of residence for two years preceding the date of the request for a criminal history report.
On 8/18/2017, the Director educated all office staff on the requirement to obtain proof of residency for two years preceding the date of the request for a criminal history report for all prospective employees utilizing one of the following that clearly demonstrates length of residency:
(1) Motor vehicle records, such as a valid driver's license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it.
(6) Employment records, including records of unemployment compensation.
Education will also include that if any of the above information is not able to be obtained, the prospective employee will obtain a Federal criminal history record as outlined in 611.52(c).
Effective 8/18/2017 for three months, the Director/designee will review all prospective hires paperwork for documentation of proof of residency for two years preceding the date of the request for a criminal history report utilizing one of the forms of documentation listed in 611.52(d), or for the completion of a federal criminal history report if proof of residence is not present. If during the review any discrepancies are found, corrections will be made and the employee responsible will be counseled. Sustained improvement and compliance will be monitored through periodic review conducted by organizational Quality Assurance audits.
The Director has overall responsibility for implementation and oversight of the plan.
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 guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings, 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 (PF4 and PF6).
Findings include:
A review of agency policy on 7/21/2017 at approximately 12:38 PM revealed: Policy, "0-1999 TB Exposure Plan ...2.0 Administration, Reading and Interpreting results of Mantoux Tuberculin Skin Test (PPD/TST)...2.3 Reading the Mantoux Tuberculin Skin Test (PPD/TST)2.3.1 The results of the Mantoux (PPD/TST) must be read by a qualified, licensed health care professional...48-72 hours after the test was administer...2.3.4 A positive Mantoux (PPD/TST) is based on the presence of induration (raised redness) at the injection site. If induration is present, it should be measured transverse to the long axis of the forearm and the measurement recorded in millimeters. If the reaction is negative, that is, no induration is found, it should be documented as "0 mm". 2.3.5 If an employee fails to show up for the scheduled reading, a positive reaction may still be measurable up to one week after testing, However, if the employee who fails to return within 72 hours has a negative test, the PPD/TST must be repeated."
A review on 7/28/2017 at approximately 9:30 AM 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 the second stage of two-step testing. ... The need for serial follow-up screening for groups of HCWs with negative test results for M. tuberculosis infection an institutional decision that is based on the setting's risk classification. This decision and changes over time based on updated risk assessments should be official and documented."
A review of personnel files was conducted on 7/21/2017 approximately between 2:42PM to 4:10 PM.
PF #4 date of hire 3/6/2017 The initial TST was administered on 1/6/2017, and read on 1/10/2017. The second TST was administered on 1/17/2017, and read on1/19/2017. The results were negative. The agency failed to read the results prior to 72 hours after the test was administer.
PF #6 date of hire 3/24/2017, The initial TST screening was 1/28/2016 and read 1/31/2016 with the test result of 7 mm. The next TST screening was conducted on 2/9/2017 and read 2/11/2017 with the test results 4 mm. No additional documentation was provided to confirm the DCW was free from TB prior to the start of services or additional testing was completed within a 12 month period. Start of services with a consumer was 3/24/2017. Screening not completed per CDC guidelines or company policy.
An interview with the director and associate director on 7/21/2017 at approximately 4:32 PM confirmed the above findings.
Plan of Correction:
0701
Based on an analysis of the specific deficiencies cited, the corrective plan and actions taken are to address the lack of demonstrated knowledge resulting in failure to conduct TB screening in accordance with CDC guidelines and agency policy. The plan of correction will be completed through comprehensive focused education and re- instruction.
An audit was completed on 8/17/2017of all active employees for the following:
1. To ensure all TB screening readings were completed within the appropriate timeframe as outlined in CDC guidelines and agency policy 0-1999 - TB EXPOSURE PLAN;
2. To ensure the completion of a two-step PPD at hire as well as the completion of an annual PPD within a 12 month timeframe.
Employee #4 is currently out of state and not working but will receive one Mantoux and have it read within the appropriate timeframe as outlined in CDC guidelines and agency policy 0-1999 - TB EXPOSURE PLAN prior to returning to work.
A critical review of employee #6 PPD documentation revealed completion of a one-step PPD on 2/9/2017 with a reading of 4mm and this agency's failure to administer a second step as per agency policy 0-1999 - TB EXPOSURE PLAN.
Employee #6 no longer works for this agency.
Employee #6 brought documentation demonstrating completion of a one-step PPD on 2/9/2017. This agency failed to perform the second step as per agency policy 0-1999 - TB EXPOSURE PLAN.
By 8/17/17, the Director/designee will re-educate all office staff on the requirements to conduct TB screening in accordance with CDC guidelines and agency policy 0-1999 - TB EXPOSURE PLAN, including reading the first step of the test within 72 of it being administered as well as performing a second step when the employee presents documentation of a previously completed one-step PPD.
Effective 8/17/17 for three months, the Director/designee will monitor the employee files of all new employees for the completion of the required two step TB screening procedure at hire, including the timely reading of each step as outlined in CDC guidelines and policy 0-1999 - TB EXPOSURE PLAN. Monitoring will also include a review of timely completion of the two-step at hire as well as the completion of an annual PPD within a 12 month timeframe. If during the record review any discrepancies are found, corrections will be made and the employee responsible will be counseled. Sustained improvement and compliance will be monitored through record review conducted by organizational Quality Assurance audits.
The Director has overall responsibility for implementation and oversight of the plan.
611.57(a) LICENSURE
Consumer Rights
Name - Component - 00
(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 a review of agency policy, consumer records (CR) and staff interview, the agency failed to involved the consumer in the service planning process and to receive services with reasonable accommodation of individual needs and preferences for one (1) of ten (10) CR reviewed (CR2).
Findings include:
A review of agency policy on 7/21/2017 at approximately 12:20 PM revealed: "Admission Booklet, page 7, Your rights and responsibilities...Decision-making, Jointly participate with ...in the initial planning of your care (including the care to be provided and the schedule) and in any change to the care plan before the change is made...Be notified in writing of the care to be provided, the type of ...caregiver who will provide this care, and the frequency and duration of the visits."
A review of CR2 on 7/21/2017 at approximately 12:44 PM, start of services 11/27/2016 revealed: No agency service agreement was available in the CR to show that the agency had met with consumer/consumer representative to discuss individual service planning needs and preferences. The surveyor asked the director of the agency at the exit interview for any additional documentation that would be available, no other documentation was provided.
An interview with the director and associate director on 7/21/2017 at approximately 4:32 PM confirmed the above findings.
Plan of Correction:Based on an analysis of the specific deficiencies cited, the corrective plan and actions taken are to address the lack of demonstrated knowledge resulting in failure to involve the consumer in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, specifically, by not reviewing and completing a service agreement with the consumer. The plan of correction will be completed through comprehensive focused education and re- instruction.
by 8/21/17, service agreement/form 0-5035 - CLIENT AGREEMENT FORM SUPPLEMENT - PA HOME CARE (NON-MEDICAL) will be reviewed and completed with client #2 and entered into their file. A coordination of services note was also added detailing that the client participated in directing service hours/frequency of care.
On 8/7/17, an audit of 100% client charts was conducted to ensure each client has a completed service agreement/form 0-5035 - CLIENT AGREEMENT FORM SUPPLEMENT - PA HOME CARE (NON-MEDICAL) present in their file.
By 8/10/17, the Director/designee will re-educate all office staff on the requirement to include the client in the service planning process, specifically by reviewing and completing with the client service agreement/form 0-5035 - CLIENT AGREEMENT FORM SUPPLEMENT - PA HOME CARE (NON-MEDICAL).
Effective 8/10/17, the Director will review weekly for three months, the records of all new admissions for the presence of a service agreement/form 0-5035 - CLIENT AGREEMENT FORM SUPPLEMENT - PA HOME CARE (NON-MEDICAL). If during the record review any discrepancies are found, corrections will be made and the employee responsible will be counseled. Sustained improvement and compliance will be monitored through record review conducted by organizational Quality Assurance audits.
The Director has overall responsibility for implementation and oversight of the plan.
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 the agency policy, consumer records (CR) and staff interview, the agency failed to provide required information in writing to the consumers/consumer representatives prior to the commencement of services for six (6) of ten (10) CRs reviewed (CR2, CR5, CR7, CR8, CR9 and CR10).
Findings include:
A review of agency policy on 7/21/2017 at approximately 12:20 PM revealed: "Admission Booklet, page 7, Your rights and responsibilities...Decision-making, Jointly participate with ...in the initial planning of your care (including the care to be provided and the schedule) and in any change to the care plan before the change is made...Be notified in writing of the care to be provided, the type of...caregiver who will provide this care, and the frequency and duration of the visits."
A review of CR #2 on 7/21/2017 at approximately 12:44 PM revealed start of services 11/27/2016. No documentation was made available to show the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
2. Who to contact at the Department of Health for information about regulations and/or home care agency/registry compliance.
3. The Department of Health's complaint hotline.
4. The local Area Agency on Aging's Ombudsman Program telephone number.
5. The hiring and competency requirements of direct care workers.
6. The consumer disclosure notice regarding employee or independent contractor status of direct care workers and the resultant tax and insurance obligations and other responsibilities.
A review of CR #5 on 7/21/2017 at approximately 1:13 PM revealed start of services 6/11/2017. No documentation was made available to show the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
A review of CR #7 on 7/21/2017 at approximately 1:48 PM revealed start of services 7/5/2015. No documentation was made available to show the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
2. The consumer disclosure notice regarding employee or independent contractor status of direct care workers and the resultant tax and insurance obligations and other responsibilities.
A review of CR #8 on 7/21/2017 at approximately 1:52 PM revealed start of services 1/29/2017. No documentation was made available to show the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
A review of CR #9 on 7/21//2017 at approximately 1:58 PM revealed start of services 6/12/2016. No documentation was made available to show the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
A review of CR #10 on 7/21/2017 at approximately 2:06 PM revealed start of services 2/19/2017. No documentation was made available to show 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. Who to contact at the Department of Health for information about regulations and/or home care agency/registry compliance.
3. The Department of Health's complaint hotline.
4. The local Area Agency on Aging's Ombudsman Program telephone number.
5. The hiring and competency requirements of direct care workers.
6. The consumer disclosure notice regarding employee or independent contractor status of direct care workers and the resultant tax and insurance obligations and other responsibilities.
An interview with the director and associate director on 7/21/2017 at approximately 4:32 PM confirmed the above findings.
Plan of Correction:Based on an analysis of the specific deficiencies cited, the corrective plan and actions taken are to address the lack of demonstrated knowledge resulting in failure to provide required information in writing to the consumer/consumers representative prior to the commencement of services. The plan of correction will be completed through comprehensive focused education and re- instruction.
By 8/21/17, form 0-5035 - CLIENT AGREEMENT FORM SUPPLEMENT - PA HOME CARE (NON-MEDICAL) will be completed and reviewed with client #2 and entered into their file. This form contains the hours services are provided, who to contact at the Department of Health for information about regulations and home care agency/registry compliance, the Department of Health's complaint hotline, the local Area Agency on Aging's Ombudsman Program phone number, hiring and competency requirements of direct care workers, and the consumer disclosure notice regarding employee or independent contractor status of direct care workers and the resultant tax and insurance obligations and other responsibilities.
By 8/21/17, form 0-5035 - CLIENT AGREEMENT FORM SUPPLEMENT - PA HOME CARE (NON-MEDICAL) will be completed and reviewed with client #5 and entered into their file. This form contains the hours services are provided.
By 8/21/17, form 0-5035 - CLIENT AGREEMENT FORM SUPPLEMENT - PA HOME CARE (NON-MEDICAL) will be completed and reviewed with client #7 and entered into their file. This form contains the hours services are provided and the consumer disclosure notice regarding employee or independent contractor status of direct care workers and the resultant tax and insurance obligations and other responsibilities.
By 8/21/17, form 0-5035 - CLIENT AGREEMENT FORM SUPPLEMENT - PA HOME CARE (NON-MEDICAL) will be completed and reviewed with client #8 and entered into their file. This form contains the hours services are provided.
By 8/21/17, form 0-5035 - CLIENT AGREEMENT FORM SUPPLEMENT - PA HOME CARE (NON-MEDICAL) will be completed and reviewed with client #9 and entered into their file. This form contains the hours services are provided.
By 8/21/17, form 0-5035 - CLIENT AGREEMENT FORM SUPPLEMENT - PA HOME CARE (NON-MEDICAL) will be completed and reviewed with client #10 and entered into their file. This form contains the hours services are provided, who to contact at the Department of Health for information about regulations and home care agency/registry compliance, the Department of Health's complaint hotline, the local Area Agency on Aging's Ombudsman Program phone number, hiring and competency requirements of direct care workers, and the consumer disclosure notice regarding employee or independent contractor status of direct care workers and the resultant tax and insurance obligations and other responsibilities.
On 8/7/17, an audit of 100% client charts was conducted to ensure each client has form 0-5035 - CLIENT AGREEMENT FORM SUPPLEMENT - PA HOME CARE (NON-MEDICAL) completed and present in their file.
By 8/10/17, the Director/designee will re-educate all office staff on the requirement to provide required information in writing to the consumer/consumers representative prior to the commencement of services, specifically by completing, reviewing with and providing to the client form 0-5035 - CLIENT AGREEMENT FORM SUPPLEMENT - PA HOME CARE (NON-MEDICAL).
Effective 8/10/17, the Director will review weekly for three months, the records of all new admissions for the presence of the completed form 0-5035 - CLIENT AGREEMENT FORM SUPPLEMENT - PA HOME CARE (NON-MEDICAL). If during the record review any discrepancies are found, corrections will be made and the employee responsible will be counseled. Sustained improvement and compliance will be monitored through record review conducted by organizational Quality Assurance audits.
The Director has overall responsibility for implementation and oversight of the plan.
Initial Comments:
Based on the findings of an unannounced state relicensure survey conducted on 7/21/2017, Bayada Home Health Care Inc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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