Initial Comments:
Based on the findings of an onsite unannounced survey completed September 20, 2023, Just For You, 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 survey completed September 20, 2023, Just For You, 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:
611.51(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 review of direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to, prior to hire, conduct interviews, obtain two satisfactory references, and initiate criminal history reports in accordance with 611.52 (State Police criminal history record) for six (6) of six (6) personnel files reviewed (PF1-PF6).
Findings included:
Review of personnel files was conducted on September 9, 2023, at 10 a.m.
PF1 was hired on 8/10/2023 and providing services on 8/11/2023 but the criminal history report was not initiated until 8/22/2023 (late and not prior to hire). PF1 contained an undated and incomplete interview and no satisfactory references.
PF2 was hired on 7/21/2023. PF2 contained no satisfactory references.
PF3 was hired on 7/5/2023 and providing services on 7/8/2023 but the criminal history report was not initiated until 7/21/2023. PF3 contained an undated interview and no satisfactory references.
PF4 was hired on 7/25/2022 and providing services on 8/5/2022 but the criminal history report was not initiated until 9/22/2022. PF4 contained no interview and no satisfactory references.
PF5 was also hired on 7/25/2022 and contained no interview and no satisfactory references.
PF6 was hired on 7/5/2023 and contained an undated interview and no satisfactory references.
Interview with EMP1 on September 20, 2023, at 12 p.m. confirmed above findings.
Plan of Correction:Just For You, LLC Human Resource Coordinator will conduct all interviews, obtain two verifiable references that will be documented and signed by the Human Resource Coordinator and placed in each employee's file. Human Resource Coordinator will ensure criminal history reports are obtained prior to hiring of all employees. When there are children living in the home, employees will be required to obtain a ChildLine verification, FBI fingerprinting and a criminal background check. Our Administrator has completed a file review and audited all employee files to ensure the hiring process is being followed. Files will be monitored on a monthly basis. Corrective action plan is currently in place and being followed.
611.52(d) LICENSURE
Proof of Residency
Name - Component - 00
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 direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to ensure three (3) of five (5) personnel files contained proof of residency (PF3-PF5).
Findings included:
Review of personnel files was conducted on September 20, 2023, at 10 a.m.
PF3 was hired on 7/5/2023. PF3 contained a PA driver's license but the license was issued on 6/14/2023 (not 2 years preceding the date of hire). PF3 contained no other documentation to show this requirement was met.
PF4 was hired on 7/25/2022. PF4 contained a PA driver's license but the license was issued on 5/27/2022. PF4 contained no other documentation to show this requirement was met.
PF5 was also hired on 7/25/2022. PF5 contained a PA driver's license but the license was issued on 7/27/21. PF5 contained no other documentation to show this requirement was met.
Interview with EMP1 on September 20, 2023, at 12 p.m. confirmed above findings.
Plan of Correction:Just For You, Human Resource Coordinator will ensure proof of residency hiring requirements are met prior to employees having contact or working a consumer. Human Resource Coordinator will ensure 611.52(D) is being met by employees who will be required to submit documents such as driver's license/state identification, housing records, tax records, or employment/unemployment records.
Just for You, LLC Administrator has completed a file review and audited all employee files to ensure the hiring process is being followed. Files will be monitored on a monthly basis. Corrective action plan is currently in place and being followed as of 11/30/2023
611.55(a) LICENSURE
Competency Requirements
Name - Component - 00
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 direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to ensure the direct care worker had successfully completed a training program that met the requirements of subsection (b) and (c) prior to being assigned to a consumer for six (6) of six (6) personnel files reviewed (PF1-PF6).
Findings included:
Review of personnel files was conducted on September 20, 2023, at 10 a.m.
PF1 was hired on 8/10/2023 and providing services on 8/11/2023. PF1 contained an exam that was not complete (not all questions answered), not dated, and not graded to show competency was achieved..
PF2 was hired on 7/21/2023 and providing services on 7/24/2023. PF2 contained an exam but the exam was not graded to show competency was achieved..
PF3 was hired on 7/5/2023 and providing services on 7/8/2023. PF3 contained an exam but the exam was not graded to show competency was achieved.
PF4 was hired on 7/25/2022 and providing services on 8/5/2022. PF4 contained a certificate for a training program titled "ADULT RESIDENTIAL LICENSING ... Direct Care Staff Training Course" prior to consumer contact, but the training course did not include the required subjects of: Confidentiality; Consumer control and the independent living philosophy; Recognizing changes in the consumer that need to be addressed; Shaving and mouth care; Assistance with ambulation and transferring; Feeding; Toileting; and Assistance with self-administered medications.
PF5 was also hired on 7/25/2022 and providing services on 8/2/2022. PF5 contained a certificate for a training program titled "ADULT RESIDENTIAL LICENSING ... Direct Care Staff Training Course" prior to consumer contact, but the training course did not include the required subjects of: Confidentiality; Consumer control and the independent living philosophy; Recognizing changes in the consumer that need to be addressed; Shaving and mouth care; Assistance with ambulation and transferring; Feeding; Toileting; and Assistance with self-administered medications.
PF6 was hired on 7/5/2023 and providing services on 7/6/2023. PF6 contained an exam but the exam was not graded to show competency was achieved.
Interview with EMP1 on September 20, 2023, at 12 p.m. confirmed above findings.
Plan of Correction:Just For You, LLC Human Resource Coordinator will ensure all direct care workers successfully complete our training program and meet the requirements of 611.55(a) prior to working at a consumer's home. Human Resource Coordinator will document the successful completion of testing results in the employee file. No employee will have contact or work with a consumer without successful completion of the training requirements.
Just for You, LLC Administrator has completed a file review and audited all employee files to ensure the hiring process is being followed. Files will be monitored on a monthly basis. Corrective action plan is currently in place and being followed as of 11/30/2023
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 direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to conduct a competency review at least once per year for two (2) of two (2) personnel files who were eligible for an annual review (PF4, & PF5).
Findings included:
Review of personnel files was conducted on September 20, 2023, at 10 a.m.
PF4 was hired on 7/25/2022 and providing services on 8/5/2022. PF4 contained a training certificate dated 7/14/2022 but no annual competency review completed thereafter.
PF5 was also hired on 7/25/2022 and providing services on 8/2/2022. PF5 contained a training certificate dated 7/13/2022 but no annual competency review completed thereafter.
Interview with EMP1 on September 20, 2023, at 12 p.m. confirmed above findings.
Plan of Correction:Our Human Resource Coordinator will ensure all employees successfully complete a competency review annually.
Just for You, LLC Administrator will ensure the annual competency training is being followed by auditing employee files monthly. Just for You, LLC Administrator has completed a file review and audited all employee files to ensure the hiring process is being followed. Corrective action plan is currently in place and being followed as of 11/30/2023
611.56(a) LICENSURE
Health Screening
Name - Component - 00
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 CDC (Center for Disease Control and Prevention) guidelines, direct care worker personnel files, and staff (EMP) interview, the agency failed to ensure each direct care worker was screened for free from active mycobacterium tuberculosis (TB) in accordance with CDC (Center for Disease and Control) guidelines prior to consumer contact for six (6) of six (6) personnel files (PF1-PF6).
Findings included:
According to CDC guidelines "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." Retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6819-H.pdf
According to the "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005," "Baseline testing for M. Tuberculosis infection is recommended for all newly hired HCWs [health care workers] ... If TST [tuberculin skin testing] is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative ... A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST result within the previous 12 months, a single TST can be administered in the new setting ... This additional TST represents the second stage of the two-step testing." Retrieved from http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf
Review of personnel files was conducted on September 20, 2023, at 10 a.m.
PF1 was hired on 8/10/2023 and providing services on 8/11/2023. PF1 contained no TB symptom screen, and no individual risk assessment.
PF2 was hired on 7/21/2023 and providing services on 7/24/2023. PF2 contained no TB symptom screen, and no individual risk assessment.
PF3 was hired on 7/5/2023 and providing services on 7/8/2023. PF3 contained no two-step skin test, no TB symptom screen, and no individual risk assessment.
PF4 was hired on 7/25/2022 and providing services on 8/5/2022. PF4 contained no TB symptom screen, and no individual risk assessment.
PF5 was also hired on 7/25/2022 and providing services on 8/2/2022. PF5 contained no TB symptom screen, and no individual risk assessment.
PF6 was hired on 7/5/2023 and providing services on 7/6/2023. PF6 contained no TB symptom screen, and no individual risk assessment.
Interview with EMP1 on September 20, 2023, at 12 p.m. confirmed above findings.
Plan of Correction:Just For You, LLC Human Resource Coordinator has created a symptom screen questionnaire and individual risk assessment form that all employees have to sign to ensure all employees are free from active mycobacterium tuberculosis (TB) prior to being assigned to a consumer's home.
Just for You, LLC Administrator will ensure all employees have a signed a system screen questionnaire and induvial risk assessment form process is being followed by auditing employee files monthly. Just for You, LLC Administrator has completed a file review and audited all employee files to ensure the hiring process is being followed. Files will be monitored on a monthly basis. Corrective action plan is currently in place and being followed as of 11/30/2023
611.56(b) LICENSURE
Health Screening
Name - Component - 00
(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.
Observations:
Based on review of Centers for Disease Control and Prevention (CDC) guidelines, direct care worker personnel files (PF) and staff (EMP) interview, the agency failed to ensure two (2) of two (2) eligible employees received annual mycobacterium tuberculosis (TB) education (PF4, & PF5).
Findings included:
According to CDC guidelines "Serial screening and testing not routinely recommended. Annual TB education is recommended." Retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6819-H.pdf
Review of personnel files was conducted on September 20, 2023, at 10 a.m.
PF4 was hired on 7/25/2022 and providing services on 8/5/2022. PF4 contained no annual TB education.
PF5 was also hired on 7/25/2022 and providing services on 8/2/2022. PF5 contained no annual TB education.
Interview with EMP1 on September 20, 2023, at 12 p.m. confirmed above findings.
Plan of Correction:Just For You, Human Resource Coordinator LLC will ensure employees receive mycobacterium tuberculosis (TB) education annually. Each employee will have to sign acknowledging they have read and received education.
Just for You, LLC Administrator will ensure all employees have received and signed TB education annually and that it runs from the date of the last evacuation by auditing employee files monthly. Just for You, LLC Administrator has completed a file review and audited all employee files to ensure the hiring process is being followed. Files will be monitored on a monthly basis. Corrective action plan is currently in place and being followed as of 11/30/2023
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 review of consumer files (CF), agency information packet, and staff (EMP) interview, the agency failed to provide the consumer with required information in a format that was easily read and understood prior to commencement of services for five (5) of five (5) consumer files reviewed (CF1-CF5).
Findings included:
Review of consumer files was conducted on September 20, 2023, at 11 a.m.
CF1 signed their service agreement on 7/5/2023 and services commenced on 7/6/2023. CF1's service agreement did not contain the hours the services would be provided nor the correct hotline number.
CF2 signed their service agreement on 8/8/2023 and services commenced on 8/22/2023. CF2's service agreement did not contain the identity of the direct care worker who would provide the services, or the hours when those services will be provided.
CF3 signed their service agreement on 8/4/2023 and services commenced on 8/11/2023. CF3's service agreement did not contain the identity of the direct care worker who would provide the services or the hours when those services will be provided.
CF4 contained and undated service agreement but services commenced on 9/25/2023. There was nothing contained in CF4 to show the consumer received any of the required information prior to commencement of services.
Additionally, a review of agency's information packet containing the service agreement provided to consumers prior to start of services, and received by CF1-CF5, did not show it contained the Department's complaint Hot Line (1-800-254-5164). The packet listed 866-826-3644 which is not the Department's Hotline number.
Interview with EMP1 on September 20, 2023, at 12:30 p.m. confirmed above findings.
Plan of Correction:Just For You LLC, Human Resource Coordinator has revised our consumer packet and will now provide the consumer with all the required information in a format that is easy to read and understood prior to the start of their services per 611.57(c).Will also correct the Complaint Hotline Number, make sure all packets have the direct care worker's name who is providing services, the hours, and services being provided.
Just for You, LLC Administrator has completed a file review and audited all employee files to ensure the hiring process is being followed. Files will be monitored on a monthly basis. Corrective action plan is currently in place and being followed as of 11/30/2023
Initial Comments:
Based on the findings of an onsite unannounced survey completed September 20, 2023, Just For You, Llc was found to be in compliance with the requirement of 35 P.S. 448.809 (b).
Plan of Correction:
|