QA Investigation Results

Pennsylvania Department of Health
ADWA HOME CARE, INC.
Health Inspection Results
ADWA HOME CARE, INC.
Health Inspection Results For:


There are  6 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted on November 10, 2022, Adwa Home Care, Inc., was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.



Plan of Correction:




51.3 (g)(1-14) LICENSURE
NOTIFICATION

Name - Component - 00
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.


Observations:



Based on review of agency personnel files (PF), Department of Health (DOH) Event Reporting system (ERS), and an interview with the administrator, the agency did not report any events in the ERS system.

Findings include:

Per the Pennsylvania Department of Health Event Reporting System Manual, "...Purpose: To provide a system to enter events per 28 PA Code - 51.3 that is readily available to all appropriate PA-DOH [Pennsylvania Department of Health] facilities, a simple process to insure consistent data entry and submission, and a source for quick and meaningful feedback on event notification submissions...All facilities are required to submit notification of events as defined in 28 Pa Code Chapter 51 to the Department of Health within 24 hours of occurrence or discovery. The Electronic Event Reporting System [ERS] is the mechanism the Department will use to meet this regulatory requirement..."

A review of the ERS on November 9, 2022 at 1:00 PM revealed that the agency had never reported any incidents in the system since its opening in 2014.

An interview with the administrator on November 10, 2022 at approximately 2:00 PM stated not being aware of the above reporting requirement.





Plan of Correction:

1. Agency has been reporting all events/critical incidents in the EIM system.

2. Agency will set up an account with the Department of Health (DOH) Event Reporting system (ERS).

3. Starting 12/1/22, the agency will record new events in this system.


Initial Comments:

Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on November 10, 2022, Adwa Home Care, 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

Name - Component - 00
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 a review of personnel files (PF), the Philadelphia Department of Public Health, Division of COVID-19 Containment Health Alert Dated 10/14/2021, and an interview with the administrator, the agency failed to provide documentation employees were either vaccinated against COVID-19 or received testing as required for four (4) of ten (10) PF's, (PF #2, 5, 6, and 7).

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.
Accommodations for Exemptions
Healthcare Institutions must instruct exempted workers to comply with, and such workers must comply with, one of the following options for accommodation:
1. Routine Testing: Exempt individuals must be tested by a PCR test or an antigen test for COVID-19 at least twice (2x) per week. The two tests should be spread out appropriately over the week, but there is not a required time interval to account for varying schedules. If the individual ' s test is within 72 hours of their work shifts for the week, one test may suffice.
2. Virtual accommodation: If possible, the Healthcare Institution can create a fully virtual option for the individual."

A review of PF's was conducted on November 10, 2022, from approximately 11:10 am to 1:15 pm.

PF #2, Date of Hire: 10/31/2020, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption or documentation of testing as required.

PF #5, Date of Hire: 12/17/19, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption or documentation of testing as required.

PF #6, Date of Hire: 10/4/17, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption or documentation of testing as required.

PF #7, Date of Hire: 11/9/18, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption or documentation of testing as required.

An interview with the administrator conducted on November 10, 2022, at approximately 2:00 pm confirmed the above findings.










Plan of Correction:

1. HR Department had a copy of the four (4) PF's COVID-19 vaccination cards, but they were scanned & stored using our own software system.

2. Copies of their vaccination cards were made and placed in their personnel file.

3. Agency can provide copies of the COVID-19 vaccination cards during the follow-up visit.




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 a review of personnel files (PF) and an interview with the administrator, the agency failed to provide documentation of an annual competency evaluation for five (5) of ten (10) PF's reviewed, (PF #2, 5, 6, 7, and 9).

Findings include:

A review of PF's was conducted on November 10, 2022 from approximately 11:10 am to 1:15 pm.

PF #2, Date of Hire:10/31/2020, did not contain any documentation of an annual competency evaluation for 2021.

PF #5, Date of Hire: 12/17/19, did not contain any documentation of an annual competency evaluation for 2021.

PF #6, Date of Hire: 10/4/17, did not contain any documentation of an annual competency evaluation for 2021 or 2022.

PF #7, Date of Hire: 11/9/18, did not contain any documentation of an annual competency evaluation for 2021.

PF #9, Date of Hire: 9/1/2021, did not contain any documentation of an annual competency evaluation for 2022.

An interview with the administrator on November 10, 2022 at approximately 2:00 pm confirmed the above findings.











Plan of Correction:

1. Caregivers are unable to complete an annual competency evaluation through the website that the surveyor suggested. However, caregivers have completed their annual competency courses through our internal software system. Their certifications have been recorded on our system, but were not placed in their respective personnel files

2. Agency will show training certifications during the surveyor's follow-up visit.

3. Every quarter, the HR Director (Bao Huynh) or assigned associate will select 5 random caregiver files for review to ensure that they've completed the annual competency training and their certifications have been placed in the personnel files.

4. For the next audit, we will ensure that all caregivers' training certification stays in the personnel file for the auditor/surveyor to review.


611.56(b) LICENSURE
Health Screening

Name - Component - 00
(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.

Observations:



Based on review of personnel files (PFs), the Centers for Disease Control guidelines, and interview with the administrator, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, were provided with annual mycobacterium tuberculosis education for four (4) of ten (10) PF's reviewed, (PF# 1, 2, 5, and 7).

Findings include:

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 November 10, 2022 between approximately 11:10 am to 1:15 pm.

PF #1, Date of Hire: 5/1/18, did not contain any documentation of annual tuberculosis education provided for 2021 or 2022.

PF #2, Date of Hire: 10/31/2020, did not contain any documentation of annual tuberculosis education provided for 2021.

PF #5, Date of Hire: 12/17/19, did not contain any documentation of annual tuberculosis education provided for 2021.

PF #7 Date of Hire: 11/9/18, did not contain any documentation of annual tuberculosis education provided for 2021.

An interview with the administrator conducted on October 21, 2021 at approximately 2:00 pm confirmed the above findings.







Plan of Correction:

1. HR Dept has updated the employment application packet to include an annual TB screening questionnaire.

2. This form was given to the four (4) PFs. They reviewed and signed the form.

3. Agency will show these forms to the surveyor during the follow-up visit.

4. This form will be given to all existing and new direct care workers / caregivers.



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 files (CF) and an interview with the administrator, the agency failed to provide documentation that the consumer received information stating: who to contact at the Department (717) 783-1379 for information about licensure requirements for the agency and the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry, for eleven (11) of eleven (11) CF's, (CF # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11).


Findings include:

A review of CF's was conducted on November 10, 2022 from approximately 10:40 am to 11:40 am.

CF #1, Start of Care: 2/19/2022, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency and the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.

CF #2, Start of Care: 11/3/2021, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency and the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.

CF #3, Start of Care: 10/21/2020, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency and the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.

CF #4, Start of Care: 7/11/2022, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency and the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.

CF #5, Start of Care: 6/11/2022, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency and the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.

CF #6, Start of Care: 12/21/2021, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency and the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.

CF #7, Start of Care: 8/10/2022, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency and the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.

CF #8, Start of Care: 10/17/2022, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency and the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.

CF #9, Start of Care: 8/17/2020, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency and the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.

CF #10, Start of Care: 8/30/2022, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency and the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.

CF #11, Start of Care: 2/6/2021, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency and 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 administrator on November 10, 2022 at approximately 2:00 pm confirmed the above findings.






Plan of Correction:

1. Administrator notified RN to use the updated Welcoming & Participant's packet effective immediately 11/10/2022.

2 RN updated the Welcoming & Participant Packets to include the following information:

* Hiring requirements/competency training for direct care workers.

* Licensing information: Contact the Pennsylvania Department of Health. Quality Assurance Complaint Hotline: 1-800-254-5164. Pennsylvania Department of Health: 717-783-1379

3. This form will be given to all existing and new participants.


Initial Comments:

Based on the findings of an onsite home care agency state re-licensure survey conducted on November 10, 2022, Adwa Home Care, Inc., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: