Initial Comments:
Based on the findings of an onsite State relicensure survey initiated March 15, 2023 and completed offsite March 20, 2023, Jo's Home Health Care was found not to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
51.3 (f) LICENSURE
NOTIFICATION
Name - Component - 00
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 registry submissions to the Department of Health (Department) online event reporting system (ERS), registry complaint process and interview with registry owner(EMP), it was determined the registry was not aware of requirements of ERS and failed to notify the Department of one (1) incident that could have seriously compromised patient safety and failed to report one (1) staff member positive COVID -19 since change of ownership 3/1/21.
Findings include:
Review of the registry's submissions to the Department's online event reporting system on 3/8/23, at approximately 3:15 p.m. as part of pre-survey preparation revealed that the registry had not reported any events in this system.
Surveyor requested registry's complaint log. Registry owner EMP1 stated "Never kept track of that. I don't have a log. I don't get a lot of complaints. I get mostly scheduling calls." " I am not aware of the reporting system. I had one incident of inappropriate behavior of a direct care worker and a client. The direct care worker was taking the client to bars and drinking with him. I considered it abuse of older people and I called the Area Agency on Aging and reported it. I didn't know I needed to report to the Department of Health." " An employee tested positive for COVID-19 on 10/5/21 but didn't know I needed to report that either."
Plan of Correction:The registry owner will notify current consumers and DCW of the requirement of reporting the state of the below events by sending a letter to them.
The registry owner will maintain a record of complaints from consumers in the registry office.
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.
The registry owner will be responsible for collecting and maintaining records of complaints in the registry office and report all required events which seriously compromise quality assurance or patient safety include, but are not limited to, the following Deaths due to injuries, suicide or unusual circumstance. Deaths due to malnutrition, dehydration or sepsis. Deaths or serious injuries due to a medication error. Elopements. Transfers to a hospital because of injuries or accidents. Complaints of patient abuse, whether or not confirmed by the facility. Rape. Surgery performed on the wrong patient or on the wrong body part. Hemolytic transfusion reaction. Infant abduction or infant discharged to the wrong family. Significant disruption of services due to disaster such as fire, storm, flood, or another occurrence. Notification of termination of any services vital to the continued safe operation of the facility or the health and safety of its patients and personnel, including, but not limited to, the anticipated or actual termination of electric, gas, steam heat, water, sewer and local exchange telephone service. Unlicensed practice of a regulated profession. Receipt of a strike notice.
The registry owner will advise consumers and DCW to contact registry owner to report any of the above mentioned events as soon as possible after they occur and registry owner will notify dept of health.
Initial Comments:
Based on the findings of an onsite State relicensure survey initiated March 15, 2023 and completed offsite March 20, 2023, Jo's Home Health Care was found not to be in compliance with the requirements of 28 PA Code, Part IV, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.
Plan of Correction:
611.52(a) LICENSURE
Criminal Background Checks
Name - Component - 00
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 review of registry personnel files (PF) and staff (EMP) interview it was determined the registry failed to obtain criminal history records at time of application or a report obtained within 1 year immediately preceding date of application for four (4) of eight (8) direct care worker personnel files reviewed. (PF3, PF4, PF6, PF7).
Findings include:
Personnel file (PF) review was conducted on 3/15/23 between approximately 10:50 a.m. and 12:10 p.m. revealed:
PF3, date of hire 6/19/21. Start of care 6/21/21. No documented evidence of a Pennsylvania State Police Criminal Record Check being conducted at the time of hire.
PF4, date of hire 3/23/22. Start of care 4/25/22. No documented evidence of a Pennsylvania State Police Criminal Record Check being conducted at the time of hire.
PF6, date of hire 12/2/21. Start of care 12/17/21.No documented evidence of a Pennsylvania State Police Criminal Record Check being conducted at the time of hire.
PF7, date of hire 2/2/22. Start of care 2/8/22. No documented evidence of a Pennsylvania State Police Criminal Record Check being conducted at the time of hire.
An exit conference was conducted via phone on 3/20/23 at approximately 3:00 p.m. with EMP1 (registry owner). Above findings were reviewed.
Plan of Correction:All required current criminal background checks for DCW have been completed and placed in DCW files.
The following DCW are no longer with Jo's Home Health Care PF3, PF6, PF7
Registry owner will require perspective applicant to submit information to give permission to complete a criminal history background check in accordance with requirements of PA Criminal Background Check Policy.
Registry owner will be responsible to monitor the continued implementation of the plan of correction
To monitor the following requirements for each DCW a chart shall be maintained by the registry to update and monitor the following.
Criminal background check, health screening, competency/training, name badge. The DCW chart will be reviewed every 6 months. The documentation will be maintained in the registry office.
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 a review of direct care workers (DCW) files and an interview with registry owner (EMP), it was determined that the registry failed to show proof of residency through submission of any one of the following documents: motor vehicle records, such as a valid driver's license or a state-issued identification; housing records, such as mortgage records or rent receipts; public utility records and receipts, such as electric bills; local tax records; a completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it; employment records, including records of unemployment compensation for three (3) of eight (8) DCW personnel files reviewed (PF3, PF4, PF5).
Findings include:
Personnel file (PF) review was conducted on 3/15/23 between approximately 10:50 a.m. and 12:10 p.m. revealed:
PF3, date of hire 6/19/21. Start of care 6/21/21. No documented evidence to verify proof of PA residency for the two years immediately preceding the date of hire. PF3 file contained PA driver's license issued 4/7/21.
PF4, date of hire 3/23/22. Start of care 4/25/22. No documented evidence to verify proof of PA residency for the two years immediately preceding the date of hire. PF4 file contained PA driver's license issued 8/11/21.
PF5, date of hire 9/28/22. No start date as of date of survey. No documented evidence to verify proof of PA residency for the two years immediately preceding the date of hire. PF5 file contained an insurance card dated 7/7/21 and an electric bill dated 3/13/23.
An exit conference was conducted via phone on 3/20/23 at approximately 3:00 p.m. with EMP1 (registry owner). Above findings were reviewed.
Plan of Correction:A letter will be mailed to current DCW requesting proof of residency through submission of motor vehicle records, such as valid drivers license or valid state issued ID. Housing records such as mortgage records or rent receipts, public utility records and receipts such as electric, gas, water bills. Employment records.
One of the previous required documents for residency will needs to be dated 2
years prior from the date of hire to verify DCW has lived in State of Pennsylvania. If DCW has not lived in State of Pennsylvania for the last 2 years they with be required to complete a FBI background check.
Per your Personnel File Review PF3 is no longer working with Jo's Home Health Care.
Registry owner will request a perspective applicant to furnish proof of PA residence through submission of two of the following
Valid PA drivers' license or valid PA state issued ID.
Housing records, such as mortgage records or rent receipts.
Public utility records and receipt such as electric bill
Local tax records
Registry owner will verify and retain completed documentation of PA residency in DCW confidential file.
Registry owner will be responsible for monitoring the continued implementation of plan of correction.
To monitor the following requirements for each DCW a chart shall be maintained by the registry to update and monitor the following.
Criminal background check, health screening, competency/training, name badge. The DCW chart will be reviewed every 6 months. The documentation will be maintained in the registry office.
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 (PF) and interview with registry owner (EMP), the registry failed to ensure direct care workers (DCW) met minimum competency requirements prior to assigning DCWs to provide services to a consumer for one (1) of eight (8) direct care worker personnel files reviewed (PF3).
Findings include:
Personnel file (PF) review was conducted on 3/15/23 between approximately 10:50 a.m. and 12:10 p.m. revealed:
PF3, date of hire 6/19/21. Start of care 6/21/21. There was no documented evidence of competency being conducted at the time of hire.
An exit conference was conducted via phone on 3/20/23 at approximately 3:00 p.m. with EMP1 (registry owner). Above findings were reviewed.
Plan of Correction:Per your review of PF3, this DCW is no longer working for Jo's Home Health Care.
The registry owner will require all potential DCW to provide evidence of one of the following.
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: Obtained a valid nurse's license in this Commonwealth. Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsections (b) and (c). Successfully completed one of the following: A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsections (b) and (c). A home health aide training program meeting the requirements of 42 CFR 484.36 (relating to the conditions of participation; home health aide services).
A training program meeting the training standards imposed on the agency or registry by virtue of the agencies 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. Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department's web site. A competency examination or training program developed by an agency or registry for a direct care worker must address, at a minimum, the following subject areas: Confidentiality. Consumer control and the independent living philosophy. Instrumental activities of daily living. Recognizing changes in the consumer that need to be addressed. Basic infection control. Universal precautions. Handling of emergencies. Documentation. Recognizing and reporting abuse or neglect. Dealing with difficult behaviors.
A competency examination or training program developed by an agency or registry for a direct care worker who will provide personal care must address the following additional subject areas: Bathing, shaving, grooming, and dressing. Hair, skin, and mouth care. Assistance with ambulation and transferring. Meal preparation and feeding. Toileting. Assistance with self-administered medications.
The home care agency or home care registry shall include documentation of the direct care worker's satisfactory completion of competency requirements in the direct care worker's file. If the direct care worker has a nurse's license or other licensure or certification as a health professional, the individual's file shall include a copy of the current license or certification. Documentation of satisfactory completion of competency requirements is transferable from one home care agency or registry to another home care agency or registry, provided the break in the individual's employment or roster status does not exceed 12 months.
The home care agency or home care registry also shall include documentation in the direct care worker's file that the agency or registry has reviewed the individual's competency to perform assigned duties through direct observation, testing, training, consumer feedback or other method approved by the Department or through a combination of methods. 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.
Obtained a valid nurse's license in this Commonwealth. Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsections (b) and (c). Successfully completed one of the following: A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsections (b) and (c). A home health aide training program meeting the requirements of 42 CFR 484.36 (relating to the conditions of participation; home health aide services).
The registry owner has been advised that PA Dept of Education Training for DCW www.pde.state.pa.us is no longer available for the public to use. On the website PHA Learning Center 2.0 (pahomecare.org) the potential DCW will register on the website and complete the follow video courses Required courses. When the DCW completes the below course they need to email, text or mail a copy of the certificate to the registry owner
Understanding HIPAA and Confidentiality (5min 54sec) (B1)
Consumer Choice and Independent Living Philosophy (15min 35sec) (B2)
Understanding Instrumental Activities of Daily Living (7min 13sec) (B3)
Recognizing Common Behavioral Health Issues & Available Resources (12min 41sec) (B4)
Depression: Recognizing the Signs and Symptoms (17min 38sec) (B4)
Physical Changes of Aging (5min 51sec) (B4)
Effects of Aging on Emotions and the Five Senses (9min 59sec) (B4)
How to Protect Against Infection ((10min 43sec) (B5-6)
Proper Hand Washing (8min 24sec) (B5-6)
Recognizing Common Infections (14min 28sec) (B5-6)
Handling Emergencies (17min 14sec) (B7)
Incident Reporting (11min 50sec) (B8)
Elder Abuse and Neglect (7min 19sec) (B9)
Preventing Fraud and Financial Abuse of Seniors (13min 41sec) (B9)
Caring for an Aggressive Person (4min 7sec) (B10)
The Effects of Dementia on the Brain (5min 30sec) (B10)
How Attitudes and the Environment Affect Agitation and Aggression (6min 29sec) (B10)
Identifying and Assessing Aggression (5min 47sec) (B10)
Providing Care for Someone with Dementia (7min 15sec) (B10)
Understanding Dementia and Alzheimer's Disease (8min 14sec) (B10)
Understanding the Physical Causes of Agitation and Aggression (6min 2sec) (B10)
Understanding Activities of Daily Living (9min 1sec) (C1-6)
The Importance of Protecting a Senior's Skin (17min 40sec) (C1-2)
Bathing and Showering Someone with Dementia (8mins 7secs) (C1)
Dental and Oral Care (11min 52sec) (C2)
Proper Skin Care and Bathing (19min 58sec) (C2)
Back Anatomy and Body Mechanics (9min 51sec) (C3)
How Direct Care Workers Can Help Consumers Improve Mobility (16min 22sec) (C3)
Tools to Help Lift and Transfer Consumers Safely (16min 22sec) (C3)
Transferring People, the Right Way (5min 52sec) (C3)
New Course Easy and Healthy Meal Tips for Caregivers (15min 32sec) (C4)
Importance of Nutrition and Diet for Good Health (12min 20sec) (C4)
Bathroom Blues (11min 7sec) (C5)
Direct Care Workers and Medication Assistance (8min 3sec) (C6)
The following course are optional.
Maintaining Boundaries with a Consumer (17min 24sec)
Professionalism (21min 34sec)
Improving Cultural Competency in Home-Based Care (9min 57sec)
Understanding Pennsylvania's Homecare Agency and Registry Licensure (15min 11sec)
Ethical Behaviors - What's Right and Wrong (12min 56sec)
To monitor the following requirements for each DCW a chart shall be maintained by the registry to update and monitor the following.
Criminal background check, health screening, competency/training, name badge. The DCW chart will be reviewed every 6 months. The documentation will be maintained in the registry office.
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 personnel files (PF), and interview with registry owner (EMP), the registry failed to review the direct care worker's competency at least once per year for four (4) of eight (8) personnel files of direct care workers (DCW) who have been employed at agency for more than one year (PF2, PF6, PF7, PF8).
Findings include:
Personnel file (PF) review was conducted on 3/15/23 between approximately 10:50 a.m. and 12:10 p.m. revealed:
PF2, date of hire 9/29/18. Start of care 10/10/18. There was no documented evidence of an annual competency review completed in 2021, 2022.
PF6, date of hire 12/2/21. Start of care 12/17/21. There was no documented evidence of an annual competency review completed in 2022.
PF7, date of hire 2/2/22. Start of care 2/8/22. There was no documented evidence of an annual competency review completed in 2023.
PF8, date of hire 4/10/18. Start of care 4/16/18. There was no documented evidence of an annual competency review completed in 2021, 2022.
An exit conference was conducted via phone on 3/20/23 at approximately 3:00 p.m. with EMP1 (registry owner). Above findings were reviewed.
Plan of Correction:Per this survey PF6, PF7 & PF8 are no longer with Jo's Home Health Care
PF2 is still with Jo's Home Health Care.
The registry owner will inform potential and current DCW of the State of PA's requirement for annual competency training.
The registry owner will inform current caregiver about the deficiency with the competency requirement and provide them with the requirements outline below so that the registry will be in compliance.
The registry owner will be responsible to monitor the continued implementation of the plan of correction.
The home care agency or home care registry also shall include documentation in the direct care worker's file that the agency or registry has reviewed the individual's competency to perform assigned duties through direct observation, testing, training, consumer feedback or other method approved by the Department or through a combination of methods. 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.
Obtained a valid nurse's license in this Commonwealth. Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsections (b) and (c). Successfully completed one of the following: A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsections (b) and (c). A home health aide training program meeting the requirements of 42 CFR 484.36 (relating to the conditions of participation; home health aide services).
The registry owner has been advised that PA Dept of Education Training for DCW www.pde.state.pa.us is no longer available for the public to use. On the website PHA Learning Center 2.0 (pahomecare.org) the potential DCW will register on the website and complete the follow video courses Required courses. When the DCW completes the below course, they need to email, text or mail a copy of the certificate to the registry owner
Understanding HIPAA and Confidentiality (5min 54sec) (B1)
Consumer Choice and Independent Living Philosophy (15min 35sec) (B2)
Understanding Instrumental Activities of Daily Living (7min 13sec) (B3)
Recognizing Common Behavioral Health Issues & Available Resources (12min 41sec) (B4)
Depression: Recognizing the Signs and Symptoms (17min 38sec) (B4)
Physical Changes of Aging (5min 51sec) (B4)
Effects of Aging on Emotions and the Five Senses (9min 59sec) (B4)
How to Protect Against Infection ((10min 43sec) (B5-6)
Proper Hand Washing (8min 24sec) (B5-6)
Recognizing Common Infections (14min 28sec) (B5-6)
Handling Emergencies (17min 14sec) (B7)
Incident Reporting (11min 50sec) (B8)
Elder Abuse and Neglect (7min 19sec) (B9)
Preventing Fraud and Financial Abuse of Seniors (13min 41sec) (B9)
Caring for an Aggressive Person (4min 7sec) (B10)
The Effects of Dementia on the Brain (5min 30sec) (B10)
How Attitudes and the Environment Affect Agitation and Aggression (6min 29sec) (B10)
Identifying and Assessing Aggression (5min 47sec) (B10)
Providing Care for Someone with Dementia (7min 15sec) (B10)
Understanding Dementia and Alzheimer's Disease (8min 14sec) (B10)
Understanding the Physical Causes of Agitation and Aggression (6min 2sec) (B10)
Understanding Activities of Daily Living (9min 1sec) (C1-6)
The Importance of Protecting a Senior's Skin (17min 40sec) (C1-2)
Bathing and Showering Someone with Dementia (8mins 7secs) (C1)
Dental and Oral Care (11min 52sec) (C2)
Proper Skin Care and Bathing (19min 58sec) (C2)
Back Anatomy and Body Mechanics (9min 51sec) (C3)
How Direct Care Workers Can Help Consumers Improve Mobility (16min 22sec) (C3)
Tools to Help Lift and Transfer Consumers Safely (16min 22sec) (C3)
Transferring People, the Right Way (5min 52sec) (C3)
New Course Easy and Healthy Meal Tips for Caregivers (15min 32sec) (C4)
Importance of Nutrition and Diet for Good Health (12min 20sec) (C4)
Bathroom Blues (11min 7sec) (C5)
Direct Care Workers and Medication Assistance (8min 3sec) (C6)
The following course are optional.
Maintaining Boundaries with a Consumer (17min 24sec)
Professionalism (21min 34sec)
Improving Cultural Competency in Home-Based Care (9min 57sec)
Understanding Pennsylvania's Homecare Agency and Registry Licensure (15min 11sec)
Ethical Behaviors - What's Right and Wrong (12min 56sec)
The registry owner will continue to monitor the following requirements for each DCW a chart shall be maintained by the registry to update and monitor the following.
Criminal background check, health screening, competency/training, name badge. The DCW chart will be reviewed every 6 months. The documentation will be maintained in the registry office.
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) and interview with registry staff (EMP), review of CDC Guidelines, and the PA Department of Health Guidance for Home Care Agencies During COVID-19 Pandemic, the agency failed to ensure each direct care worker, prior to consumer contact, was screened for active mycobacterium tuberculosis for five (5) of eight (8) direct care worker (DCW) personnel files reviewed (PF3, PF4, PF5, PF6, PF7).
Findings include:
The CDC guidelines state that all Health Care Workers (HCW) should received 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...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.
PA Department of Health..."...Guidance for Home Care Agencies, Home Health Care Agencies and Hospices During COVID-19 Pandemic...May 20, 2020...Pre-employment Health Screening...The requirement for an initial baseline 2 step Mantoux skin test for tuberculin skin testing is temporarily suspended. All applicants must complete an individual risk assessment and symptom evaluation prior to hire...Any new employee who does not provide evidence of a Mantoux skin test within the previous 12 months must, as a condition of employment, receive the tuberculin skin test as soon as possible following termination of the Governor's COVID-19 Disaster Declaration...."
Personnel file (PF) review was conducted on 3/15/23 between approximately 10:50 a.m. and 12:10 p.m. revealed:
PF3, date of hire 6/19/21. Start of care 6/21/21. PF contained documentation of a step 1 TST planted 6/23/21, read 6/25/21. Step 2 TST planted 7/7/21, read 7/9/21 which was not prior to consumer contact.
PF4, date of hire 3/23/22. Start of care 4/25/22. No documented evidence of a tuberculosis screening completed. No documented evidence that PF completed an individual risk assessment and symptom evaluation prior to hire
PF5, date of hire9/28/22. No start date as of date of survey. PF contained documentation of a step 1 TST planted 10/3/22, read 10/5/22. Step 2 TST planted 10/12/22, read 10/12/22.(second read date not per CDC guidelines).
PF6, date of hire 12/2/21. Start of care 12/17/21. No documented evidence of a tuberculosis screening completed. No documented evidence that PF completed an individual risk assessment and symptom evaluation prior to hire.
PF7, date of hire 2/2/22. Start of care 2/8/22. No documented evidence of a tuberculosis screening completed. No documented evidence that PF completed an individual risk assessment and symptom evaluation prior to hire.
An exit conference was conducted via phone on 3/20/23 at approximately 3:00 p.m. with EMP1 (registry owner). Above findings were reviewed.
Plan of Correction:Per your Personnel File Survey 3/13/2023 the follow DCW are no longer with Jo's Home Health Care PF3, PF6, PF7.
PF4 and PF5 files have been updated to included 2-step TB testing.
Registry owner will ensure that all DCW, office staff shall provide documentation that the individual has completed a 2-step screening for and is free from active mycobacterium tuberculosis, prior to consumer contact. The screening shall be conducted in accordance with the CDC guidelines. The documentation will indicate the date of the screening which may not be more than one year prior to the individuals start date.
The registry owner will require each DCW to have annual TB education, at least every 12 months, the 12 months must run from the date of the last evaluation.
Registry owner will be responsible to monitor then continued implementation of the plan of correction.
To monitor the following requirements for each DCW a chart shall be maintained by the registry to update and monitor the following.
Criminal background check, health screening, annual TB education, competency/training, name badge. The DCW chart will be reviewed every 6 months. The documentation will be maintained in the registry office.
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 personnel files (PFs) and interview with registry owner (EMP), it was determined that the registry failed to ensure each direct care worker with direct consumer contact, were provided with annual mycobacterium tuberculosis education for six (6) of eight (8) PFs reviewed. (PF1, PF2, PF3, PF6, PF7, PF8).
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. 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).
Personnel file (PF) review was conducted on 3/15/23 between approximately 10:50 a.m. and 12:10 p.m. revealed:
PF1, date of hire 7/22/17. Start of care 8/2017. No documented evidence of annual TB education for 2021, 2022.
PF2, date of hire 9/29/18. Start of care 10/10/18. No documented evidence of annual TB education for 2021, 2022.
PF3, date of hire 6/19/21. Start of care 6/21/21. No documented evidence of annual TB education for 2022.
PF6, date of hire 12/2/21. Start of care 12/17/21. No documented evidence of annual TB education for 2022.
PF7, date of hire 2/2/22. Start of care 2/8/22. No documented evidence of annual TB education for 2023.
PF8, date of hire 4/10/18. Start of care 4/16/18. No documented evidence of annual TB education for 2021, 2022.
An exit conference was conducted via phone on 3/20/23 at approximately 3:00 p.m. with EMP1 (registry owner). Above findings were reviewed.
Plan of Correction:Registry owner will provide a handout about Mycobacterium Tuberculosis to DCW to read at least every 12 months and provide documentation to the 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.
Registry owner will be responsible to monitor the continued implementation of the plan of correction
To monitor the following requirements for each DCW a chart shall be maintained by the registry to update and monitor the following.
Criminal background check, health screening, competency/training, name badge. The DCW chart will be reviewed every 6 months. The documentation will be maintained in the registry office.
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 (CFs), consumer information packet and interview with registry owner (EMP), the registry failed to provide, prior to the commencement of services, the following information in a form that was easily read and understood in the consumer information packet: (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 for five (5) of five (5) consumer files reviewed (CF1-CF5).
Findings include:
Consumer file (CF) reviews conducted on 3/15/23 between approximately 12:15 p.m. and 12:48 p.m. revealed:
CF1, start of service 11/1/2020, Contained no documented evidence of (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.
CF2, start of service 11/5/2020, Contained no documented evidence of (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.
CF3, start of service 10/19/18, Contained no documented evidence of (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.
CF4, start of service 6/12/2020, Contained no documented evidence of (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.
CF5, start of service 4/20/18, Contained no documented evidence of (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.
An exit conference was conducted via phone on 3/20/23 at approximately 3:00 p.m. with EMP1 (registry owner). Above findings were reviewed.
Plan of Correction:The Registry owner has updated the consumer information packets to include "Who time contact at the Department of Health 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.
Per your review CF3, CF4 & CF5 are no longer consumers of Jo's Home Health Care.
The Registry will mail the updated forms, including the updated required information, to the remaining two consumers.
The Registry owner will be responsible to monitor the continued implementation of the plan of correction
To ensure that all consumer files are in compliance with the state of Pa's department of Health requirements. The registry owner will maintain a list of information to be provided for each consumer and initial each required form as it is put into the consumer's file. The list of required documents are The list of available homecare services that will be provided to the consumer by the DCW, the identity of the DCW who will provide the services. The hours when those services will be provided. Fees and total costs for those services on an hourly or weekly basis. Who to contact at the Department for information about licensure requirements for a HHA or HCR and for compliance information about a particular HHA or HCR. 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. (412-350-6905). The hiring and competency requirements applicable to DCW employed by the HCR or HCR or referred by the HCR. 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 DCW providing services to the consumer and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the HCA or HCR.
The consumer files will be review every 6 months. The required documents will be maintained in registry office.
Initial Comments:
Based on the findings of an onsite State relicensure survey initiated March 15, 2023 and completed offsite March 20, 2023, Jo's Home Health Care was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
|