QA Investigation Results

Pennsylvania Department of Health
CARING BASED HEALTH CARE SERVICES
Health Inspection Results
CARING BASED HEALTH CARE SERVICES
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted on October 25, 2022, Caring Based Health Care Services, 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 unannounced home care agency state re-licensure survey conducted on October 25, 2022, Caring Based Health Care Services, 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 seven (7) of seven (7) PF's, (PF #1, 2, 3, 4, 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 October 25, 2022, from approximately 10:00 am to 10:45 am.

PF #1, Date of Hire: 9/9/16, 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 #2, Date of Hire: 1/29/2021, 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 #3, Date of Hire: 8/15/2022, 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 #4, Date of Hire: 11/18/2021, 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: 8/18/17, 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 #6, Date of Hire: 1/18/2022, 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: 8/9/2022, 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 October 25, 2022, at approximately 11:00 am confirmed the above findings.








Plan of Correction:

A phone request will be sent to all employees who did not submit neither their vaccination cards nor their exemption certificates yet.
All covid-19 vaccination cards that were kept electronically will be printed out and put into employees' files.
From now on, all vaccination cards and Exemption certificate will be kept on employees' files physically and electronically.

Vaccination card policy will be updated.
Vaccination Cards and Exemption Certificate will be incorporated into the lists of required documents for new Hires.
This Corrective Action will be monitored during Quarterly Internal-Audit.
Person Responsible: Administrator
Tools: Covid-19 Vaccination Policy
Date: November 30th, 2022.





611.51(a) LICENSURE
Hiring or Rostering Prerequisites

Name - Component - 00
Prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. (3) Require the individual to submit a criminal history report, in accordance with the requirements of 611.52 (relating to criminal background checks), and a ChildLine verification, if applicable, in accordance with the requirements of 611.53 (relating to child abuse clearance).

Observations:


Based on a review of personnel files (PF) and an interview with the administrator, the agency failed to provide documentation that an interview was conducted with the individual for seven (7) of seven (7) PF's reviewed, (PF #1, 2, 3, 4, 5, 6, and 7); and obtain at least two satisfactory and verifiable references for one (1) of seven (7) PF's, (PF #6).

Findings include:

A review of PF's was conducted on October 25, 2022 from approximately 10:00 am to 10:45 am.

PF #1, Date of Hire: 9/9/16, did not contain any documentaton of an interview conducted.

PF #2, Date of Hire: 1/29/2021, did not contain any documentaton of an interview conducted.

PF #3, Date of Hire: 8/15/2022, did not contain any documentaton of an interview conducted.

PF #4, Date of Hire: 11/18/2021, did not contain any documentaton of an interview conducted.

PF #5, Date of Hire: 8/18/17, did not contain any documentaton of an interview conducted.

PF #6, Date of Hire: 1/18/2022, did not contain any documentaton of an interview conducted and did not contain any documentation at least two satisfactory and verifiable references.

PF #7, Date of Hire: 8/9/2022, did not contain any documentaton of an interview conducted.

An interview with the administrator on October 25, 2022 at approximately 11:00 am confirmed the above findings.










Plan of Correction:

An Interview Evaluation Form will be created.
This form will be completed for each employee.
This completed form will be included into every employee's file.
That item will be highlighted in Employees' files checklist sheet.
Monthly check of all employees' files will be done, and any discrepancies will be addressed.
Administrator
Interview Evaluation Form.
November 7th,2022.





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 personnel files (PF) and an interview with the administrator, the agency failed to provide documentation of a Federal Bureau of Investigation criminal history report for one (1) of seven (7) PF's reviewd, (PF #3).

Findings include:

Pennsylvania Act 169 of 1996 as amended by Act 13 of 1997 requires an applicant/ employee who has not been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application for employment or currently lives out-of-state, in addition to the Pennsylvania State Police Criminal History Check, the applicant/employee will also need to obtain an FBI Criminal History Check and letter of determination from the Department of Aging within ninety (90) days of employment. An employee is defined as any applicant or new employee hired after July 1, 1998. The definition of employee includes contract employees who have direct contact with residents or unsupervised access to their personal living quarters.


A review of PF's was conducted on October 25, 2022 from approximately 10:00 am to 10:45 am.

PF #3, Date of Hire: 8/15/2022 did not contain any documentation of a Federal Bureau of Investigation criminal history report. File contained a copy of a North Carolina driver's license issued 12/14/19.

An interview with the administrator on October 25, 2022 at approximately 11:00 am confirmed the above findings.










Plan of Correction:

The applicant will be contacted to find out about her process of obtaining the FBI fingerprinted background check.
All new applicants will be scrutinized to determine potential candidate for FBI fingerprinted background checks. The Coordinator and Administrative Assistants' knowledge of the company's recruiting policy will be reinforced.
Monthly Check of all employees' files.
November 30th, 2022
Administrator




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 one (1) of seven (7) PF's reviewed, (PF #1).

Findings include:

A review of PF's was conducted on October 25, 2022 from approximately 10:00 am to 10:45 am.

PF #1, Date of Hire: 9/9/16, did not contain any documentation of an annual competency evaluation for 2021 or 2022.

An interview with the administrator on October 25, 2022 at approximately 11:00 am confirmed the above findings.











Plan of Correction:

A competency review for the identified employees will be conducted.
Ensure all employees attend the required competency review every year.
Continue the practice of organizing multiple training sessions throughout the year and send the training session dates to all employees.
Quarterly Self-Audit
November 30th, 2022
Administrator



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 on a review of personnel files (PF), Centers for Disease Control Guidelines, and an interview with the administrator, the agency failed to provide documentation that the individual has completed a tuberculosis symptom questionnaire and risk assessment upon hire for two (2) of seven (7) PF's, (PF #3 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, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. 2. Completion of a tuberculosis symptom questionnaire. 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 October 25, 2022 from approximately 10:00 am to 10:45 am.

PF #3, Date of Hire: 8/15/2022, did not contain any documentation of a completed symptom questionnaire and risk assessment upon hire.

PF #7, Date of Hire: 8/9/2022, did not contain any documentation of a completed symptom questionnaire and risk assessment upon hire.

An interview with the administrator on October 25, 2022 at approximately 11:00 am confirmed the above findings.






Plan of Correction:

The Company's TB test form will be updated by including a TB risk assessment Questionnaire.
Double-check all employees' TB test result to identify discrepancies.
Remove the previous TB test form from the company's Application Package.
Quarterly Self-Audit
November 15th, 2022
Tools: Staff Health Certificate Form
Person responsible: Administrator



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 for five (5) of five (5) CF's, (CF # 1, 2, 3, 4, and 5).


Findings include:

A review of CF's was conducted on October 25, 2022 from approximately 9:50 am to 10:00 am.

CF #1, Start of Care: 1/22/2022, 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.

CF #2, Start of Care: 11/14/17, 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.

CF #3, Start of Care: 8/15/2022, 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.

CF #4, Start of Care: 8/18/2022, 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.

CF #5, Start of Care: 3/3/2020, 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.

An interview with the administrator on October 25, 2022 at approximately 11:00 am confirmed the above findings.







Plan of Correction:

A paragraph containing the phone number to contact for information about licensure requirements for Home Care Agency will be incorporated into the Patient Orientation Booklet.
An updated version of the Patient Orientation Booklet will be sent to all participants.
Remove the previous Patient Orientation Booklet from the Company's Admission Package.
Quarterly self-audit
November 30th, 2022
Administrator



Initial Comments:

Based on the findings of an onsite home care agency state re-licensure survey conducted on October 25, 2022, Caring Based Health Care Services, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: