QA Investigation Results

Pennsylvania Department of Health
AMADA SENIOR CARE, PHILADELPHIA - WEST SUBURBS
Health Inspection Results
AMADA SENIOR CARE, PHILADELPHIA - WEST SUBURBS
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite state re-licensure survey conducted on 05/21/2024, Amada Senior Care Philadelpihia - West Suburbs 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 State Re-Licensure Survey conducted on 05/21/2024, Amada Senior Care Philadelphia - West Suburbs 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(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 personnel files (PF), and an interview with the agency administrator and staff, it was determined the agency failed to obtain proof of residency for one (1) of seven (7) PF's reviewed, (PF # 4).

Findings include:

A review of PF's conducted on 05/21/2024 at approximately 12:45 pm and revealed the following:

PF #4, Date of Hire: 12/16/2021, did not contain any documentation showing proof of PA residency for the two years preceding the date of hire.

An interview with the agency administrator and staff on 05/21/2024 at approximately 1:30 pm confirmed the above findings.





Plan of Correction:

Amada will correct the deficiency and demonstrate proof of PA residency by conducting an FBI background check and obtain additional proof of residency such as utility records and receipts, or local tax records with the applicant's name preprinted on it, on PF#4. Amada's updated or altered system will assure all existing and new applicants provide proof of PA residency for at least two years by securing said proof in the manner stated above at time of hire. In order to sustain this solution, the Office manager is assigned to check all new hire files monthly and document said review on spreadsheet. This will be completed by June 2, 2024.


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 and staff, the agency did not provide documentation that after an initial competency is established, that a competency review was conducted at least annually for four (4) of seven (7) PFs.. PF# 1, 2, 4, and 6.

Findings include:

A review of PFs was conducted on 05/21/2024 at 12:45pm :

PF# 1 Date of hire: 04/03/2022, did not contain documentation that a competency review was conducted annually for 2023.

PF# 2 Date of hire: 05/21/2019 did not contain documentation that a competency review was conducted annually for 2020, 2021, 2022 or 2023.

PF# 4 Date of hire: 12/16/2021 did not contain documentation that a competency review was conducted annually for 2022 and 2023.

PF# 6 Date of hire: 09/13/2021 did not contain documentation that a competency review was conducted annually for 2022 and 2023.


An interview with the administrator and staff on 05/21/2024 at approximately 1:30 PM confirmed the above findings.













Plan of Correction:

An annual competency exam covering all topics in PA 611.55 competency requirements will be issued to and completed by Caregivers representing PF#1 for 2023,PF#2 for 2020, 2021, 2022 and 2023,PF4 for 2022 and 2023 and PF6 for 2022 and 2023. Amada system will be altered by issuing said competency exam at hire and annually thereafter for all Caregivers. In order to assure this solution is sustained, the Office Manager will monitor adherence to said plan of action monthly via personnel file reviews. This action will be completed by June 2, 2024.


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), the Centers for Disease Control (CDC) guidelines and an interview with the administrator and staff, the agency did not provide documentation that a direct care worker completed 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 for four (4) of seven (7) PF's: PF# 1, 3, 6 and 7. Findings include:

In May 2019, the Centers for Disease Control (CDC) updated its recommendation for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should receive 1) 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, and 3) Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's 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 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).

A review of PF's was conducted on 05/21/2024 at approximately 12:45pm revealed:

PF 1: Date of Hire: 04/03/2022, PF contained a two-step tuberculin skin test (TST) baseline dated 01/21/2022 and did not contain completion of a second step TST baseline TB screening upon hire.

PF 4: Date of Hire: 03/04/2023, PF contained a TST baseline dated 01/31/2022 and did not contain completion of a second step TST baseline TB screening upon hire.

PF 6: Date of Hire: 09/13/2021, PF did not contain completion of a (TST) or a single blood assay for tuberculosis (TB) upon hire.

PF 7: Date of Hire: 11/29/23, PF did not contain completion of a (TST) or a single blood assay for tuberculosis (TB) upon hire.

An interview conducted with the administrator and staff on 05/21/2024 at approximately 1:30 PM confirmed the above findings.












Plan of Correction:

Caregivers representing PF numbers 1,3, 6 and 7 will complete and provide documentation (to be placed in files) they have been screened for and are free from active TB using a two-step TB skin test or a single blood assay for TB. Additionally, said Caregivers will complete a symptom questionnaire and a Risk Assessment. The current Amada system will be altered by requiring existing and new hires to provide documentation of a current negative two-step TB skin test or a single negative blood assay for TB and complete a symptom questionnaire and risk assessment. The Amada Office Manager is assigned to monitor Caregiver files monthly to assure this solution is sustained. This corrective action will be completed on June 2, 2024.


Initial Comments:


Based on the findings of an onsite home care agency state re-licensure survey conducted on 05/21/2024 Amada Senior Care Philadelphia - West Suburbs was found to be in compliance with the requirements of 35 P.S. 448.809 (b).






Plan of Correction: