Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on February 21, 2020, Home Health Care Plus, LLC, 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 February 21, 2020, Home Health Care Plus, LLC, 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:
611.52(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 review of personnel files (PFs) and interview with the agency's administrator, the agency failed to ensure that a criminal background check was completed prior to employment for two (2) of four (4) PFs reviewed. (PF #1 and 4).
Findings include:
Act 169 of 1996 as amended by Act 13 of 1997 states: "If the applicant/employee has been a resident of the Commonwealth of Pennsylvania for 2 or more years prior to application for employment, the applicant will need to obtain a clearance from the Pennsylvania State Police. This clearance is obtained by doing the following: Request for Criminal Record Check Form (SP4-164)." "When the applicant/employee 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. Facilities are defined by the act to include: Domiciliary Care Homes, Home Health Care Agency, Nursing Facility (licensed by the Department of Aging), and Personal Care Home (licensed by the Department of Public Welfare). A Home Health Care Agency is further defined to include those agencies licensed by the Department of Health and any public or private organization which provides care to a care-dependent individual in their place of residence." "If entities run into special circumstances where they need to hire an employee before the results of their record checks are returned, there is a provision in CPSL that allows for a provisional hiring period. The period is to not exceed 30 days for in state residents and 90 for out of state residents."
Findings:
A review of the PFs was conducted on February 21, 2020 between approximately 1:00 PM - 3:00 PM revealed the following:
PF #1 Date of Hire (DOH): 10/9/2014 - There was documentation that a Pennsylvania State Police Criminal Background Check was conducted on 12/7/2015, which was fourteen (14) months after date of hire.
PF #4 DOH: 11/22/2016 - There was documentation that a Pennsylvania State Police Criminal Background Check was conducted on 1/6/2017, which was two (2) months after date of hire.
Interview with the adminstrator on February 21, 2020 at approximately 2:30 PM confirmed the above findings.
Plan of Correction:Plan of Correction for PF# 1, and PF# 4
The Office Administrator and/ or HR Director shall review all current personnel files and ensure future hires files reflect the recruitment, screening and hiring policy requiring all articles to be completed in the file and supported by a completed signature and date.
HR Director shall revise checklist identifying requirements for hiring and training. The checklist will be attached to the DCW file and signed off by Human Resources. The checklist will include a Criminal Background Check selection. DCW who are missing said check will be completed, documented on revised checklist and will be reviewed by corrective action date and triannual thereafter.
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 personnel files (PFs) and an interview with agency's administrator, it was determined the agency failed to demonstrate initial or annual competency by passing a competency examination for four (4) of four (4) PFs reviewed. (PF #1 - 4).
Findings include:
Review of PFs was conducted on February 21, 2020 between approximately 1:00 PM - 3:00 PM revealed the following:
PF#1 Date of Hire (DOH): 10/9/2014 - File contained documentation that initial competency was completed on 10/9/2014. There was no documentation indicating annual competency for 2015, 2017 and 2018.
PF#2 (DOH): 3/4/2016 - File contained documentation that initial competency was completed on 3/14/2016. There was no documentation indicating annual competency for 2018 and 2019.
PF#3 (DOH): 4/4/2016 - File contained documentation that initial competency was completed on 1/11/2016. There was no documentation indicating annual competency for 2018 and 2019.
PF#4 (DOH): 11/22/2016 - File contained documentation that initial competency was completed on 11/21/2016. There was no documentation indicating annual competency for 2017, 2018 and 2019.
An interview with the administrator on February 21, 2020 at 2:30 PM confirmed the above findings.
Plan of Correction:Plan of Correction for PF# 1, PF# 2, PF# 3, and PF# 4
HR Director and/or Administrator will monitor the initial competency training/testing for DCW staff upon initial hiring orientation and annually.
The Office Administrator and/ or HR Director shall review all current personnel files and ensure future hires files reflect the recruitment, screening and hiring policy requiring all articles to be completed in the file and supported by a completed signature and date.
HR Director shall revise checklist identifying requirements for hiring and training. The checklist will be attached to the DCW file and signed off by Human Resources.The checklist will include a Competency test selection. DCW who are missing said test will be issued the test, documented on revised checklist and will be reviewed by corrective action date and triannual thereafter.
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 review of personnel files (PF), Centers for Disease Control guidelines, and administrator interview, it was determined the agency failed to ensure that direct care workers were screened for and were free from active mycobacterium tuberculosis prior to assignment with clients. Review of personnel files revealed that four (4) of four (4) direct care workers were not screened for mycobacterium tuberculosis per CDC guidelines. (PF #1 - 4).
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) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screen 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;(RR-17)
http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.
A review of PFs was conducted on February 21, 2020 from approximately 1:00 PM - 3:00 PM revealed the following:
PF #1 Date of Hire (DOH): 10/9/2014 - did not contain annual TB screening for 2019 and contained a one step TST dated 2/11/2020 that did not include results.
PF #2 DOH: 3/4/2016: There was no documentation of annual TB screening for 2017, 2018 and 2019.
PF #3 DOH: 4/4/2016: There was no documentation of annual TB screening for 2017, 2018 and 2019.
PF #4 DOH: 11/22/2016: There was no documentation that a two step TST, Quantiferon or chest x-ray occurred prior to date of hire.
An interview with the administrator on February 21, 2020 at 2:30 PM confirmed the above findings.
Plan of Correction:Plan of Correction for PF# 1, PF# 2, PF# 3, and PF# 4
DCW was given 30 days (due by 03/22/2020) to provide evidence of 2-Step PPD or an annual TB screening for the current year.
The Office Administrator and/ or HR Director shall review all current personnel files and ensure future hires files reflect the recruitment, screening and hiring policy requiring all articles be completed in the file and supported by a completed signature and date.
HR Director shall revise checklist identifying requirements for hiring and training also implement an Annual TB Questionnaire and TB Education Sheet which will be attached to DCW file and signed off by DCW and Human Resources.The checklist will include a TB Test selection. DCW who are missing said tests will be given a deadline of March 27,2020 to have the test completed, it will be documented on revised checklist and will be reviewed by corrective action date and triannual thereafter.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on February 21, 2020, Home Health Care Plus, LLC was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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