QA Investigation Results

Pennsylvania Department of Health
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Initial Comments:


Based on the findings of an onsite unannounced State relicensure survey completed on January 31, 2020, Harmony Home Care 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 on January 31, 2020, Harmony Home Care was found not to be in compliance with the 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(c) LICENSURE
Federal Criminal History Record

Name - Component - 00
If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code 15.144(b) (relating to procedure).

Observations:


Based on a review of agency personnel files (PF) and staff (EMP) interview it was determined the agency failed to obtain a federal criminal history record for three (3) of five (5) PF who had not been a resident of the Commonwealth for the 2 years immediately preceding the date of the request. (PF2,4,6)


Findings Included:


Review of PF completed on January 31, 2020 between approximately 10:00 a.m. and 2:30 p.m. revealed:

PF2, date of hire (DOH) 2/21/18, PF contained a Pennsylvania driver's license issued 5/12/15. PF did not contain evidence employee had been a resident of the Commonwealth for the 2 years immediately preceding the date of hire. PF contained a Pennsylvania State Police Background Check dated 1/22/18. PF did not contain evidence of a Federal criminal history report.

PF4, DOH 5/28/19, PF contained a Pennsylvania driver's license issued 5/16/17. PF did not contain evidence employee had been a resident of the Commonwealth for the 2 years immediately preceding the date of hire. PF contained a Pennsylvania State Police Background Check dated 5/7/19. PF did not contain evidence of a Federal criminal history report.

PF6, DOH 8/7/19, PF contained a Pennsylvania driver's license issued 6/28/17. PF did not contain evidence employee had been a resident of the Commonwealth for the 2 years immediately preceding the date of hire. PF contained a Pennsylvania State Police Background Check dated 7/22/19. PF did not contain evidence of a Federal criminal history report.


Interview completed on January 31, 2020 at approximately 3:00 p.m. with director and client services manager confirmed the findings.









Plan of Correction:


0320 The credentialing procedure will be revised by the Client Services Manager or her designee by 3/30/20.The revised procedure will eliminate 3rd party verification and will utilize an alternate approved form of identification as listed in the regulations for those employees who have lived in Pa. for less than two years. If unable to obtain an acceptable alternate ID then a federal criminal history report sensitive to the Department of Aging criteria will be obtained. Applicants will not be hired if unable to verify criminal history for both PA and FBI . All current employee files will be assessed & updated with the required information by 3/30/20.

A pre-hire checklist will be developed to include residency verification and follow-up related to the required FBI electronic fingerprint by the Client Services Manager or her designee to be used for audit internal audit purposes by 3/30/20. This checklist will be utilized by the credentialing specialist before completion of all hires to assure that all required items are completed including the Dept of Aging determination letter if needed. These documents will be obtained & scanned into the software system. The checklist will be audited quarterly by the Director of Quality & Education



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 staff (EMP) interviews it was determined the agency failed to ensure a competency review occurred at least once per year after initial competency was established for three (3) of three (3) PF reviewed who had more than 12 months of employment. (PF1, 2, 3)


Findings Included:


Review of PF completed on January 31, 2020 between approximately 10:00 a.m. and 2:30 p.m. revealed:

PF1, date of hire (DOH) /21/18, PF did not contain evidence of annual competencies for 2018 or 2019.

PF2, DOH 2/21/18, PF PF did not contain evidence of annual competencies for 2019.

PF3, DOH 12/12/28, PF did not contain evidence of required annual competencies for 2019. No evidence of competencies for the following required areas: Recognizing changes in patient condition, Universal Precautions, Documentation, Meal prep and feeding, and Assistance with self administered medications.


Interview completed on January 31, 2020 at approximately 3:00 p.m. with director and client services manager confirmed the findings.


Repeat Deficiency: Previously cited 1/18/17







Plan of Correction:


0621 An "Initial"(at orientation) & "Annual" exam will be developed to include all required areas per the regulations by the Director of Education & Quality to assess competency of all PCA's at Harmony Homecare by 3/30/20.This exam will include all required topics per state regulations & will be given at time of hire and annually thereafter.

The initial exam will be given in orientation & the annual test will be s completed by each employee yearly upon their date of hire by the credentialing specialist. The test will be returned & graded by the Director of Quality & Education. A passing grade of 70% will be accepted. If the test is not passed- education will be provided by the Director of Quality & Education & the employee will be able to retake the exam. The tests will be sent to all current employees and completed by 3/30/20.

A report will be run monthly by the credentialing specialist to determine who is due for testing that month based on hire date.

All test results will be uploaded into Clearcare/software and tracked by the credentialing specialist on an ongoing basis with a sample quarterly audit for compliance by Director of Education & Quality or designee.








Initial Comments:


Based on the findings of an onsite unannounced State relicensure survey completed on January 31, 2020, Harmony Home Care was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: