Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed December 6, 2019, Senior Pride Adult Day Care LLC, 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 December 6, 2019, Senior Pride Adult Day Care LLC, 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(b) LICENSURE
State Police Criminal History Record
Name - Component - 00
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 interview with the administrator, and review of personnel files, it was determined the agency failed to ensure that all agency employees obtained criminal background checks for seven, (7) of ten (10) Direct care Worker files reviewed. (DCW #2, 3, 4, 5, 6, 7, and 8).
Findings included:
1. On December 6, 2019, a review DCW #3, at approximately 11:40 a.m. revealed a date of hire on October 23, 2019. There was no evidence that a Pennsylvania State Police Criminal Background Check, or Federal Bureau of Investigation check had been conducted by the agency.
2. On December 6, 2019, a review DCW #3, at approximately 11:50 a.m. revealed a date of hire on February 1, 2017. There was no evidence that a Pennsylvania State Police Criminal Background Check, or Federal Bureau of Investigation check had been conducted by the agency.
3. On December 6, 2019, a review DCW #4, at approximately 12:00 p.m. revealed no date of hire. There was no evidence that a Pennsylvania State Police Criminal Background Check, or Federal Bureau of Investigation check had been conducted by the agency.
4. On December 6, 2019, a review DCW #5, at approximately 12:10 p.m. revealed a date of hire on July 10, 2016. There was no evidence that a Pennsylvania State Police Criminal Background Check, or Federal Bureau of Investigation check had been conducted by the agency.
5. On December 6, 2019, a review DCW #6, at approximately 12:20 p.m. revealed a date of hire on July 11, 2018. There was no evidence that a Pennsylvania State Police Criminal Background Check, or Federal Bureau of Investigation check had been conducted by the agency.
6. On December 6, 2019, a review DCW #7, at approximately 12:30 p.m. revealed a date of hire on October 18, 2018. There was no evidence that a Pennsylvania State Police Criminal Background Check, or Federal Bureau of Investigation check had been conducted by the agency.
7. On December 6, 2019, a review DCW #8, at approximately 12:40 p.m. revealed a date of hire on June 4, 2018. There was no evidence that a Pennsylvania State Police Criminal Background Check, or Federal Bureau of Investigation check had been conducted by the agency.
In an interview with agency's administrative personnel conducted on December 6, 2019 at approximately 2:30 p.m., it was confirmed that there was no record of a Pennsylvania State Police Criminal Background Check, or Federal Bureau of Investigation check for seven employees in contact with Clients.
Plan of Correction:1. Under this deficiency our agency will comply to the following: corrections under this act will be rectified immediately by having all employees and new hires have criminal background will be performed before or within 2-5 days of hire as well as having employees
to ensure that all employees have them completed we will conduct a QM meeting to review all employee files. Those who have not have them completed or if they were incomplete, we will immediately run checks for them.
Our agency will have a current checklist for new hires that we will follow for provisional hiring that includes all state and federal background checks to be completed within 2-5 days of new hiring.
611.55(e) LICENSURE
Competency Requirements
Name - Component - 00
(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, and interview with the Administrator, it was determined that the agency failed to include documentation in the direct care worker's file that the agency or registry had reviewed the individual's competency through direct observation, testing, training, or other combinations approved by the Department for ten, (10) of ten, (10) Direct Care Worker, (DCW), personnel files reviewed. (DCW #1, 2, 3, 4, 5, 7, 8, 9, and 10).
Findings included:
1. Review of personnel files on December 6, 2019, at approximately 11:30 a.m. revealed that DCW #1 was hired on May 30, 2017. A competency test located in the file, revealed no evidence of a test result, name of person tested, or the date test was administered. There was no evidence of the individual's competency to perform assigned duties.
2. Review of personnel files on December 6, 2019, at approximately 11:40 a.m. revealed that DCW #2 was hired on October 23, 2019. A competency test located in the file, revealed no evidence of a test result, name of person tested, or the date test was administered. There was no evidence of the individual's competency to perform assigned duties.
3. Review of personnel files on December 6, 2019, at approximately 11:50 a.m. revealed a that DCW #3 was hired on February 1, 2017. A competency test located in the file, revealed no evidence of a test result, name of person tested, or the date test was administered. There was no evidence of the individual's competency to perform assigned duties.
4. Review of personnel files on December 6, 2019, at approximately 12:00 p.m. revealed that DCW #4 was hired on October 21, 2019. A competency test located in the file, revealed no evidence of a test result, name of person tested, or the date test was administered. There was no evidence of the individual's competency to perform assigned duties.
5. Review of personnel files on December 6, 2019, at approximately 12:10 p.m. revealed that DCW #5 was hired on July 10, 2016. A competency test located in the file, revealed no evidence of a test result, name of person tested, or the date test was administered. There was no evidence of the individual's competency to perform assigned duties.
6. Review of personnel files on December 6, 2019, at approximately 12:20 p.m. revealed that DCW #6 was hired on July 11, 2018. There was no evidence of a competency throughout year 2018.
7. Review of personnel files on December 6, 2019 at approximately 12:30 p.m. revealed that DCW # 7 was hired on October 18, 2018. A competency test located in the file, revealed no evidence of a test result, name of person tested, or the date test was administered. There was no evidence of the individual's competency to perform assigned duties.
8. Review of personnel files on December 6, 2019 at approximately 12:40 p.m. revealed that DCW # 8 was hired on June 4, 2018. A competency test located in the file, revealed no evidence of a test result, name of person tested, or the date test was administered. There was no evidence of the individual's competency to perform assigned duties.
9. Review of personnel files on December 6, 2019, at approximately 12:50 p.m. revealed that DCW #9 was hired on January 29, 2018. A competency test located in the file, revealed no evidence of a test result, name of person tested, or the date test was administered. There was no evidence of the individual's competency to perform assigned duties.
10. Review of personnel files on December 6, 2019, at approximately 1:00 p.m. revealed that DCW #10 was hired on April 7, 2018. A competency test located in the file, revealed no evidence of a test result, name of person tested, or the date test was administered. There was no evidence of the individual's competency to perform assigned duties.
In an interview on December 6, 2019, with the Administrator at approximately 2:30 p.m., it was confirmed that ten DCW competency exams, were not identified, scored or dated by the agency.
Plan of Correction:Under this deficiency our agency will review and include all documentation regarding competency exams of our agency's DCW. This will include current workers as well as DCWs that are new hires. This documentation will include a review of our DCWs to perform assigned duties through testing, training as well as consumer feedback.
Testing, training and consumer feedback documentation will be reviewed by the agency's office administrator upon initial DCW hiring/screening as well as annually. This documentation will also be included each individual DCW files.
so that this problem will not reoccur, an audit sheet will be kept for all DCWs and reviewed by our agency's office administrator, noting that the competency exams/testing was completed with dates of completion for initial testing as well as annual testing.
this will be completed by 2/6/2020
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 personnel files, and interview with the acting Administrator, it was determined that the agency failed to administer annual competency reviews for seven, (7), of ten (10) Direct Care Worker, (DCW), personnel files reviewed, (DCW# 1, 5, 6, 7, 8, 9, and 10).
Findings Included:
1. Review of personnel files on December 6, 2019, at approximately 11:30 a.m. revealed that DCW #1 was hired on May 30, 2017. There was no evidence of an annual competency for the years 2018 and 2019.
2. Review of personnel files on December 6, 2019, at approximately 12:10 p.m. revealed that DCW #5 was hired on July 10, 2016. There was no evidence of an annual competency for the years 2017, 2018 and 2019.
3. Review of personnel files on December 6, 2019, at approximately 12:20 p.m. revealed that DCW #6 was hired on July 11, 2018. There was no evidence of an annual competency for the year 2019.
4. Review of personnel files on December 6, 2019 at approximately 12:30 p.m. revealed that DCW #7 was hired on October 18, 2018. There was no evidence of an annual competency for the year 2019.
5. Review of personnel files on December 6, 2019 at approximately 12:40 p.m. revealed that DCW #8 was hired on June 4, 2018. There was no evidence of an annual competency for the year 2019.
6. Review of personnel files on December 6, 2019, at approximately 12:50 p.m. revealed that DCW #9 was hired on January 29, 2018. There was no evidence of an annual competency for the year 2019.
7. Review of personnel files on December 6, 2019, at approximately 1:00 p.m. revealed that DCW #10 was hired on April 7, 2018. There was no evidence of an annual competency for the year 2019.
In an interview on December 6, 2019, with the Administrator at approximately 2:30 p.m., it was confirmed that seven DCW files did not contain annual competencies.
Plan of Correction:Under this deficiency our agency will conduct competency testing, and/or training prior to hiring/ or DCW receiving an agency consumer.
DCW that were found to not have exams in their files will have this performed and reviewed by the office administrator.
Our agency will keep an audit sheet that will show each DCW initial competency documentation (testing, training, or consumer feedback) requirements, as well as annual competency requirements with dates of when this testing or training was performed.
This will also be reviewed by our agency's office administrator.
Competency exams will be kept in individual DCW files for review for auditing and updating as needed.
Our DCW that were found not have these competency requires will have them performed immediately for this current year.
Our exams that are conducted initially and annually of our DCW and will be reviewed by the office administrator so that our agency does not have this reoccurring issue as well as having a audit sheet for our records for review initially and annually.
this will be completed by 2/6/2020
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 the Center for Disease Control, (CDC) guidelines, employee files, and administrator interview, it was determined the facility failed to ensure that Direct Care Workers, (DCW) were screened and free from active mycobacterium tuberculosis (TB), (an infectious bacterial disease characterized by the growth of nodules (tubercles) in the tissues, especially the lungs), prior to assignment to clients. Review of personnel files revealed that this did not occur for ten, (10), of ten, (10), DCW's reviewed. (DCW # 1, 2,3,4,5,6,7,8,9, and 10)
Findings include:
CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005; (RR-17), revealed that, "all Health Care Workers (HCW) should receive a baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST), or a test with an interferon-gamma release assay, (IGRA), for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, health care workers should receive a TB risk assessment screen annually if determined to be in a low risk area. Health care workers with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease." (MMWR Morb Mortal Wkly Rep 2019;68:439-443. DOI: http://dx.doi.org/10.15585/mmwr.mm6819a3external icon )
1. Review of personnel files on December 6, 2019, at approximately 11:30 a.m. revealed that DCW #1 was hired on May 30, 2017. A two step TST was completed on May 3, 2018, and May 10, 2018. There was no evidence that an annual risk assessment screen was conducted for the year 2019.
2. Review of personnel files on December 6, 2019, at approximately 11:40 a.m. revealed that DCW #2 was hired on October 23, 2019. There was no documented evidence that a baseline TST, Chest X-ray, or blood assay had been conducted to exclude tuberculosis disease.
3. Review of personnel files on December 6, 2019, at approximately 11:50 a.m. revealed a that DCW #3 was hired on February 1, 2017. A two step TST was completed on July 31, 2017, and August 14, 2017. There was no evidence that an annual risk assessment screen was conducted for the years 2018, and 2019.
4. Review of personnel files on December 6, 2019, at approximately 12:00 p.m. revealed that DCW #4 was hired on October 21, 2019. One TST was conducted on October 21, 2019. There was no evidence or documentation that a second step TST had occurred.
5. Review of personnel files on December 6, 2019, at approximately 12:10 p.m. revealed that DCW #5 was hired on July 10, 2016. A Two-step TST was conducted on July 25, 2016 and November 23, 2016. There was no evidence of further testing or that an annual risk assessment screen was conducted for the years 2017, 2018, and 2019.
6. Review of personnel files on December 6, 2019, at approximately 12:20 p.m. revealed that DCW #6 was hired on July 11, 2018. There was no evidence that a Two-Step TST, Chest X-Ray, single blood Essay, or that an annual risk assessment screen was conducted during the year 2018, or to date for 2019.
7. Review of personnel files on December 6, 2019 at approximately 12:30 p.m. revealed that DCW # 7 was hired on October 18, 2018. There was no evidence that a Two-Step TST, Chest X-Ray, single blood Essay was conducted. There was no evidence that an annual risk assessment screen was conducted to date for 2019.
8. Review of personnel files on December 6, 2019 at approximately 12:40 p.m. revealed that DCW # 8 was hired on June 4, 2018. There was no evidence that a Two-Step TST, Chest X-Ray, single blood assay was conducted during year 2018, and to date for 2019.
9. Review of personnel files on December 6, 2019, at approximately 12:50 p.m. revealed that DCW #9 was hired on January 29, 2018. A two step TST was completed on January 22, 2018, and March 2, 2018. There was no evidence that an annual risk assessment screen was conducted to date for the year 2019.
10. Review of personnel files on December 6, 2019, at approximately 1:00 p.m. revealed that DCW #10 was hired on April 7, 2018. One TST was conducted on March 2, 2018. To date, there was no evidence or documentation that a second step TST had occurred.
There was no evidence that an annual risk assessment screen was conducted to date for the year 2019.
In an interview on December 6, 2019, with the Administrator at approximately 2:30 p.m., it was confirmed that ten DCW files did not contain evidence that individuals were screened and free from active mycobacterium tuberculosis.
Plan of Correction:Under this deficiency our agency DCWs that were found to not have updated TB testing since the on-site visit, have all completed and submitted current TB testing documentation for the year of 2019.
So that this deficiency will not reoccur, our agency will implement an audit sheet that will list our agency's DCWs names, dates of last TB testing results, as well as when their next TB testing is required. With this audit sheet, our Office administrator will review and notify individual DCWs 2 weeks prior to the date that their TB testing is to be done yearly.
Our agency will also include these testing results in our DCWs individual files.
These results will be scanned and sent on-site reviewer for confirmation that all of the DCWs under our agency has had this completed for the year 2019 audit.
Initial Comments:
Based on the findings of an onsite unannounced relicensure survey completed December 6, 2019, Senior Pride Adult day Care LLC, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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