Initial Comments:
Based on the findings of an onsite complaint survey completed 1/31/24, Ashton's Angels, 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 complaint survey completed 1/31/24 Ashton's Angels, 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(a) LICENSURE
Requirements for HCA and HCR
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A current copy of this Chapter shall be maintained at the home care agency or home care registry.
Observations:
Based on review of the agencies documentation, the agency did not possess a copy of the required Chapter 611, Home Care Agency and Home Care Registry regulations.
Findings include:
Interview with the Administrator on 1/31/24 confirmed she was unable to produce a copy of the required Chapter 611, Home Care Agency and Home Care Registry regulations.
Plan of Correction:Office will copy Chapter 611 in a notebook binder and place in the conference room.
Agency shall monitor during quarterly reviews that manual Home Care Registry Regulations will be in place each quarter. Tina Ashton will monitor the placement of this book. Tina Ashton will implement this poc. Manual is in place at this time 2/19/24 and ready if drop in inspection.
611.52(d) LICENSURE
Proof of Residency
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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 review of personnel files (PF) and interview with the administrator the agency failed to have 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 for one (1) of three Personal files reviewed (PF #3)
Findings Include:
Review of personnel files (PF) conducted on 1/31/24 at 1:00 PM revealed the following:
PF #3, date of hire (DOH): 9/3/22, Documentation failed to show 2 years proof of residency
Interview with the administrator on 1/31/24 at approximately 1:00 PM confirmed the above findings.
Plan of Correction:Employee's state ID card has an issue date of 2/20/21 and expires 2/28/25. Will secure from employee proof of residency prior to his September 2022 hire date.
Tina Ashton, manager will monitor closely anyone with a residency card to assure she has proof that residency provision is in place. A second person in management (assistant manager or supervisor) will check over the new employee files to double check all new employee records are correct at initial employment and quarterly.
611.56(a) LICENSURE
Health Screening
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(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 on a review of personnel files (PF), it was determined the agency failed to ensure the direct care worker, prior to consumer contact, to be screened for mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for one (1) out of three (3) personnel files (PF) reviewed (PF#3).; failed to provide annual TB screenings for two (2) of three (3) personnel files (PF#2 and PF #3).
Findings Include:
The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs with a baseline positive or newly 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; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.)
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
Personnel files were reviewed on 1/31/24 at approximately 1:00 PM revealing the following:
PF#2 (DOH: 6/1/15): There was no documentation that a TB screening had been conducted for 2022 or 2023.
PF#3 (DOH: 9/3/22): No documentation of the second TB test on hire and no documentation that a TB screening had been conducted for 2023.
An interview with the agency administrator on 1/31/24 at approximately 1:00 PM confirmed the above findings.
Plan of Correction:Employee will get a two step TB test in the next thirty days and will be in place in his file. A checklist on front of each employee file will have every required document needed before hiring. Tina Ashton, manager will put first set of checkmarks as she collects the documents. A second person (either asst. manager or supervisor)will do a second check before start date and quarterly thereafter. A two step tb for CF was there but papers were stuck together. Second person found it right after inspection.
611.57(a) LICENSURE
Consumer Rights
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(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 documentation, consumer records (CR) reviews and interview with the Administrator the agency failed to provide services with reasonable accommodation of individual needs and/or preference for three (3) of three (3) consumer records (CR) reviewed (CR#1, CR#2, CR#3).
Findings include:
Review of consumer records (CR) on 1/26/24 from 1:30 PM through 4:00 PM and 1/31/24 at 1:00 PM revealed the following:
CR#1 (the consumer alleged in the complaint). Start of services 1/7/19. The consumer is authorized for 38.5 hours of services per week.
For the week beginning 12/2/23 the consumer only received 23.25 hours of care
For the week beginning 12/9/23 the consumer only received 19.5 hours of care
For the week beginning 12/16/23 the consumer only received 25.5 hours of care
For the week beginning 12/23/23 the consumer only received 22.75 hours of care
For the week beginning 12/30/23 the consumer only received 25.75 hours of care
For the week beginning 1/6/24 the consumer only received 18 hours of care
For the week beginning 1/13/24 the consumer only received 19 hours of care
For the week beginning 1/20/24 the consumer only received 23.55 hours of care
There was no documentation the service coordinator was made aware of the missed hours.
CR#2. Start of service 12/24/20. The consumer is authorized for 49.5 hours of services per week.
For the week beginning 12/2/23 the consumer only received 34.25 hours of care
For the week beginning 12/9/23 the consumer only received 34.5 hours of care
For the week beginning 12/16/23 the consumer only received 42 hours of care
For the week beginning 12/2/23 the consumer only received 23.25 hours of care
For the week beginning 12/23/23 the consumer only received 32.5 hours of care
For the week beginning 12/30/23 the consumer only received 41.25 hours of care
For the week beginning 1/6/24 the consumer only received 35 hours of care
For the week beginning 1/13/24 the consumer only received 32.25 hours of care
There was no documentation the service coordinator was made aware of the missed hours.
CR#3 Start of service 12/24/20 CR#2. Start of service 12/24/20. The consumer is authorized for 49.5 hours of services per week.
For the week beginning 12/2/23 the consumer only received 43.25 hours of care
For the week beginning 12/9/23 the consumer only received 46.5 hours of care
For the week beginning 12/16/23 the consumer only received 45.75 hours of care
For the week beginning 12/23/23 the consumer only received 41.5 hours of care
For the week beginning 12/30/23 the consumer only received 36.5 hours of care
For the week beginning 1/6/24 the consumer only received 36 hours of care
For the week beginning 1/13/24 the consumer only received 34.25 hours of care
There was no documentation the service coordinator was made aware of the missed hours.
Interview with the administrator on 1/31/24 at approximately 1:00 PM confirmed the above findings.
Plan of Correction:Reviewed with all present clients that we are working on hiring new staff but do have a shortage of workers and cannot cover their entire shifts.
Clients #1 already has the backup agency to cover until more workers are in place and cl#1 does not want another agency at this time to cover 11:30-5pm. We will cover her 3-5.5 hours daily until we can cover these hours.
Client 2 and Client 3 have had new agency since February 12, 2024 covering all their hours. We are not accepting new clients until we get new staff trained and in place. We have contacted Client 1's service coordinator of the reduced hours we are providing daily. dew
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