QA Investigation Results

Pennsylvania Department of Health
AMADA SENIOR CARE OF GREATER PITTSBURGH
Health Inspection Results
AMADA SENIOR CARE OF GREATER PITTSBURGH
Health Inspection Results For:


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Initial Comments:



Based on the findings of an unannounced onsitestate re-licensure survey completed
November 30, 2022, Amada Senior care Of Greater Pittsburgh, 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 unannounced onsitestate re-licensure survey completed
November 30, 2022, Amada Senior care Of Greater Pittsburgh, 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:




611.51(b) LICENSURE
Direct Care Worker Files

Name - Component - 00
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 a review of personnel files (PF) and staff (EMP) interviews it was determined the agency failed to ensure personnel records maintained for one (1) of six (6) PF reviewed (PF6).


Findings Included:


Review of PF completed on November 30, 2022, between approximately 11:00 am. and 2:00 pm revealed:

PF6, no date of hire noted. Personnel file contained only evidence of PA state background check. No additional information in file. At time of review, Office manager confirmed employment of individual stated to be a registered nurse who conucts assessments of consumers and TB screenings for the agency. No evidence of interview, nursing license, proof of residency, references, or TB screening for this employee.


Exit interview with Owner, office Manager, and Scheduler on November 30, 2022, at approximately 3:30 pm confirmed findings.

repeat deficiency, previously cited: 5/4/16





Plan of Correction:

Agency owner will have this employee complete all required documents that are applicable and make sure the office manager checks that all new hires have the new hire checklist completed so this does not happen again. We will update the new hire checklist to include interview date, proof of residency docs submitted, references submitted and TB screening results if not already on the list.
These will be reviewed monthly to assure compliance by the office manager.100% of new hires will be audited monthly and our goal is 100% compliance.


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 staff (EMP) interviews it was determined the agency failed to ensure a competency was demonstrated at least once per year after initial competency was established for three (3) of four (4) PF reviewed (PF2, PF4, & PF5) who had more than 12 months of employment.


Findings Included:


Review of PF completed on November 30, 2022, between approximately 11:00 am. and 2:00 pm revealed:

PF2, date of hire 5/25/2021, initial competency dated 5/25/2021. PF contained evidence of failed competency test 5/20/2022. No evidence of passed annual competency.

PF4, date of hire 1/23/2020, initial competency dated 1/21/2020. PF did not contain evidence of annual competency for 2022.

PF5, date of hire 3/13/2020 initial competency dated 3/9/2020. PF did not contain evidence of annual competency for 2021.


Exit interview with Owner, Office Manager, and Scheduler on November 30, 2022, at approximately 3:30 pm confirmed findings.
























Plan of Correction:

Office manager will monitor all caregiver files to ensure that competency tests are completed at least once per year. We will alter the employee checklist to add this and audit it monthly to ensure compliance and that it does not happen again. The office manager will be responsible for oversight of this and 100% of employees who have been with us for 12 months will be audited on their 12 month employment anniversary. Our goal is 100% compliance.


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 Agency Consumer Welcome Packet, Consume Files (CF), and employee (EMP) interview, it was determined that the agency failed to inform the consumer of the hiring and competency requirements applicable to direct care workers employed by the home care agency for five (5) of five (5) CFs reviewed (CF1-5.)


Findings included:


Review of Agency Consumer Welcome Packet on November 30, 2022, at approximately 2:15pm revealed failure of documentation provided to consumers to include the hiring and competency requirements for direct care workers.

Review of CFs on June 30, 2022, btween approximately 2:20pm and 3:30pm revealed:


CF1, start of services (SOS) 2/16/2022, CF failed to contain evidence the consumer was provided with the hiring and competency requirements applicable to direct care workers employed by the home care agency.

CF2, SOS 10/11/2022, CF failed to contain evidence the consumer was provided with the hiring and competency requirements applicable to direct care workers employed by the home care agency.

CF3, SOS 11/25/2022, CF failed to contain evidence the consumer was provided with the hiring and competency requirements applicable to direct care workers employed by the home care agency.

CF4, SOS 6/27/2022, CF failed to contain evidence the consumer was provided with the hiring and competency requirements applicable to direct care workers employed by the home care agency.

CF5, SOS 8/9/2022, CF failed to contain evidence the consumer was provided with the hiring and competency requirements applicable to direct care workers employed by the home care agency.


Exit interview with Owner, Office Manager, and Scheduler on November 30, 2022, at approximately 3:30 pm confirmed findings.

Repeat deficiency, previously cited: 5/4/16, 5/31/19, & 10/1/19




















Plan of Correction:

Welcome packet has been updated to include hiring and competency requirements for caregivers. The office manager will do a monthly audit of all new clients to make sure they receive the updated new client welcome packet. Our goal is 100% compliance with this.


Initial Comments:


Based on the findings of an unannounced onsitestate re-licensure survey completed
November 30, 2022, Amada Senior care Of Greater Pittsburgh, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).






Plan of Correction: