Initial Comments:
Based on the findings of an onsite unannounced complaint survey conducted on February 29, 2024 and completed on March 15, 2024, Sarahcare Home Care Agency, was found to not be in compliance with the requirements 28 Pa.Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
51.3 (f) LICENSURE
NOTIFICATION
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51.3 Notification
(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.
Observations:
Based on review of the Department of Health Event Reports for this agency, and interview with the administrator, it was determined that the agency does not report to the ERS system.
Findings include:
Review on February 29, 2024, of the Department of Health, Division of Home Health's Event Reporting System manual, last revised December 2014, as a part of pre-survey preparation, further defines timeframe's for reporting of events as "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 is the mechanism the Department will use to meet this regulatory requirement."
Review of incidents on the ERS system on February 29, 2024 prior to the survey, revealed no reported incidents from this agency.
An interview with the administrator was conducted on February 29, 2024, between approximately 11:00 am and 4:00 pm. The administrator stated that she was not aware of the need to report in the Department of Health Event Reporting System. The administrator stated that she was only aware of having to report to the Department of Human Services.
An interview with the administrator on February 29, 2024, at approximately 4:00 pm confirmed the above findings.
Plan of Correction:Access to ERS obtained and reporting to Event Reporting System to begin (4-3-2024).
SarahCare Administrator to report all incidents in Event Reporting System within 24 hours of occurrence.
Monthly audit to occur to ensure all recorded incidents have been reported to Event Reporting System will be completed by administrator/designee.
Initial Comments:
Based on the findings of an onsite unannounced complaint survey conducted on February 29,2024 and off site on March 15, 2024, Sarahcare Home Care Agency, was found to not 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:
611.51(b) LICENSURE
Direct Care Worker Files
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Files for direct care workers employed or rostered shall include documentation of the date of the face-to-face interview with the individual and of references obtained. Direct Care Worker files also shall include other information as required by § 611.52, § 611.53, if applicable, § 611.54, § 611.55 and § 611.56 (relating to criminal background checks, child abuse clearance, provisional hiring, competency requirements; and health evaluations).
Observations:
Based on review of personnel files (PF), and an interview with the agency administrator, it was determined the agency failed to to provide documentation of two references obtained for three (3) of eight (8) direct care worker PFs. (PF#2, PF#3, PF#4).
Findings Include:
A review of PF conducted on February 29, 2024 between approximately 11:00 am and
4:00 pm revealed the following:
PF #2, DOH 2/05/2024: Did not contain documentation of two (2) references.
PF #3, DOH 1/24/2024: Did not contain documentation of two (2) references.
PF #4, DOH 1/08/2024: Did not contain documentation of two (2) references.
An interview with the agency administrator on February 29, 2024 at approximately 4:00 pm confirmed the above findings.
Plan of Correction:Human Resources Manager/designee to ensure that a face-to-face interview along with the appropriate documentation is completed for each potential employee. Human Resources assistant to ensure that at least 2 references are submitted with each application for review during the application/onboarding process.
Human Resources manager to complete random monthly audits to ensure compliance with regulation.
611.52(a) LICENSURE
Criminal Background Checks
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The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.
Observations:
Based on a review of personnel files (PF), and an interview with the agency administrator, the agency failed to provide documentation of a Pennsylvania State Police Criminal Background Check (PATCH) at the time of application or within 1 year immediately preceding the date of application for six (6) of ten (10) PF reviewed. (PF #1, PF#3, PF#4, PF #6, PF#8 and PF#9)
Findings include:
Personnel file review conducted February 29, 2024 from approximately 11:00 am to 4:00 pm revealed the following:
PF #1, Date of Hire (DOH) 1/18/2024: PATCH on file dated 1/23/2024, which is after the date of hire.
PF #3, DOH 1/24/2024: PATCH on file dated 1/24/2024, which is after the date of hire.
PF #4, DOH 1/08/2024: PATCH on file dated 1/09/2024, which is after the date of hire.
PF #6, DOH 12/13/2023: PATCH on file dated 12/18/2023, which is after the date of hire.
PF #8, DOH 12/01/2023: PATCH on file dated 12/11/2023, which is after the date of hire.
PF #9, DOH 4/17/2023: PATCH on file dated 05/22/2023, which is after the date of hire.
An interview with the agency administrator on February 29,2024 at approximately 4:00 pm confirmed the above findings.
Plan of Correction:Human Resources manager to ensure that all new hires shall have a criminal background check completed prior to start of care by using PATCH, FBI and Child Line (if appropriate).
Human Resources manager to complete monthly random audits that show application date vs first work date to ensure compliance.
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 an interview with the agency administrator, it was determined the agency failed to obtain proof of residency for six (6) of ten (10) PF reviewed. (PF #2, PF #4, PF #6, PF #7, PF #8 and PF #10)
Findings include:
A review of PF conducted on February 29, 2024 between approximately 11:00 am and
4:00 pm revealed the following:
PF #2, Date of Hire (DOH) 2/05/2024: Pennsylvania ( Pa) state identification (ID) #28221326 issued 3/23/2023, expires 2/28/2026 does not cover required two year proof of Pa residency. No Federal check on file.
PF #4, DOH 1/08/2024: Pa state ID#34587973 issued 1/24/2023, expires 12/19/2024, which does not cover two year proof of Pa residency. No Federal check on file.
PF #6, DOH 12/13/2023: Pa state drivers license (DL)#34587973 issued 12/08/2022, expires 2/06/2025, which does not cover two year proof of Pa residency. No Federal check on file.
PF #7, DOH 1/31/2024: Pa state ID#24296480 issued 9/23/2022, expires 8/30/2026, which does not cover two year proof of Pa residency. No Federal check on file.
PF #8, DOH 12/01/2023: United States Passport #C32979244 issued 7/6/2023, expires 7/05/2033, which does not cover two year proof of Pa residency. No Federal check on file.
PF #10, DOH 12/20/2023: NJ state ID in file. No Federal check on file.
An interview with the agency administrator on February 29, 2024 at approximately 4:00 pm confirmed the above findings.
Plan of Correction:Human Resources team to ensure that FBI clearances are scheduled and we obtain documents that establish Proof of Residency for each new hire.
Human Resources manager/designee to complete monthly audits to ensure compliance.
611.55(a) LICENSURE
Competency Requirements
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Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.
Observations:
Based on review of personnel files (PF), and an interview with the agency administrator, it was determined the agency failed to demonstrate, prior to assigning or referring the direct care worker to provide services to a consumer, competency by passing an initial competency examination for two (2) of ten (10) PF reviewed. (PF#1 and PF#4)
Findings include:
A review of PF conducted on February 29, 2024 between approximately 11am and 4 pm revealed the following:
PF #1, Date of Hire (DOH) 1/23/2024; Competency exam with 76% grade on file without a date on test.
PF #4, Date of Hire (DOH) 1/08/2024; no documentation showing an initial competency was completed prior to assigning or referring the direct care worker to provide services to a consumer.
An interview with the agency administrator on February 29, 2024 at approximately 4 pm confirmed the above findings.
Plan of Correction:Competency test form amended to show date of testing. (4-1-2024)
Audit to be completed by Human Resources manager/designee to ensure that all forms are dated.
611.56(a) LICENSURE
Health Screening
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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 personnel files (PF) and an interview with the administrator, the agency did not conduct screening for mycobacterium tuberculosis in accordance with the Centers for Disease (CDC) guidelines for ten (10) of ten (10) PFs (PF#1, PF#2, PF#3, PF#4, PF# 5, PF#6, PF# 7, PF# 8, PF#9 and PF# 10)
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).
A review of PF conducted on February 29, 2024 between approximately 11:00 am and
4:00 pm revealed the following:
PF #1, Date of Hire (DOH) 1/18/2024: Did not contain a tuberculosis symptom screen questionnaire and an individual TB risk assessment.
PF #2, DOH 2/05/2024: Did not contain a tuberculosis symptom screen questionnaire and an individual TB risk assessment.
PF #3, DOH 1/24/2024: Did not contain a tuberculosis symptom screen questionnaire and an individual TB risk assessment.
PF #4, DOH 1/08/2024: Did not contain a tuberculosis symptom screen questionnaire and an individual TB risk assessment.
PF #5, DOH 1/17/2024: Did not contain a tuberculosis symptom screen questionnaire and an individual TB risk assessment.
PF #6, DOH 12/13/2023: Did not contain a tuberculosis symptom screen questionnaire and an individual TB risk assessment. QuanterFERON was drawn 12/19/2023, after DOH.
PF #7, DOH 1/31/2024: Did not contain a tuberculosis symptom screen questionnaire and an individual TB risk assessment.
PF #8, DOH 12/01/2023: Did not contain a tuberculosis symptom screen questionnaire and an individual TB risk assessment.
PF #9, DOH 4/17/2023: T-spot dated 5/09/2023 with a negative result was on file, which is after the hired date
PF #10, DOH 12/20/2023: Did not contain a tuberculosis symptom screen questionnaire and an individual TB risk assessment.
An interview with the agency administrator on February 29, 2024 at approximately 4:00 pm confirmed the above findings.
Plan of Correction:Screening for active TB shall be conducted for each employee upon hire using : risk assessment form, symptom screening form and TB testing (Quanteferon/skin test).
Human Resources manager/designee to perform random monthly employee file audits to ensure compliance.
Annual TB education for TB to be completed for each employee based on date of hire.
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