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 unannounced state re-licensure survey conducted on June 2, 2021, Amada Senior Care, 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 state re-licensure survey conducted on June 2, 2021, Amada Senior Care, 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(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 a review of personnel files (PF) and an interview with the administrator, the agency failed to provide documentation of a face to face interview for ten (10) of ten (10) PF's reviewed, (PF # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) and the agency failed to obtain at least two satisfactory and verifiable references for ten (10) of ten (10) PF's reviewed, (PF # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10).

Findings include:

A review of PF's was conducted on June 2, 2021 from approximately 10:10 am to 10:45 am.

PF #1 Date of Hire: 4/6/2021, did not contain any documentation of a face to face interview and did not contain any documentation of two satisfactory and verifiable references.

PF #2 Date of Hire: 12/21/19, did not contain any documentation of a face to face interview and did not contain any documentation of two satisfactory and verifiable references.

PF #3 Date of Hire: 8/5/2020, did not contain any documentation of a face to face interview and did not contain any documentation of two satisfactory and verifiable references.

PF #4 Date of Hire: 1/29/2021, did not contain any documentation of a face to face interview and contained documentation of only one satisfactory and verifiable reference.

PF #5 Date of Hire: 1/26/2021, did not contain any documentation of a face to face interview and did not contain any documentation of two satisfactory and verifiable references.

PF #6 Date of Hire: 2/12/2020, did not contain any documentation of a face to face interview and did not contain any documentation of two satisfactory and verifiable references.

PF #7 Date of Hire: 3/19/2020, did not contain any documentation of a face to face interview and did not contain any documentation of two satisfactory and verifiable references.

PF #8 Date of Hire: 3/5/2021, did not contain any documentation of a face to face interview and did not contain any documentation of two satisfactory and verifiable references.

PF #9 Date of Hire: 5/26/2021, did not contain any documentation of a face to face interview and did not contain any documentation of two satisfactory and verifiable references.

PF #10 Date of Hire: 6/24/16, did not contain any documentation of a face to face interview and did not contain any documentation of two satisfactory and verifiable references.


An interview with the administrator on June 2, 2021 at approximately 11:00 am confirmed the above findings.








Plan of Correction:

The Head of HR will provide a sign-in sheet for each interviewee when he or she arrives at an Amada Senior Care office for an interview. This sign-in sheet includes printed name, signature and date of interview. The Head of HR takes a photograph of each prospective employee for documentation and generating a photo-ID.


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 a review of personnel files (PF) and an interview with the administrator, the agency failed to provide documentation of a Pennsylvania State Police Criminal Background Check at the time of application or within 1 year immediately preceding the date of application for one (1) of ten (10) PF's reviewed, (PF # 3).

Findings include:

A review of PF's was conducted on June 2, 2021 from approximately 10:10 am to 10:45 am.

PF #3 Date of Hire: 8/5/2020 had no documentation of a Pennsylvania State Police Criminal Background Check on file.

An interview with the administrator on June 2, 2021 at approximately 11:00 am confirmed the above findings.







Plan of Correction:

The Head of HR is responsible for generating a PATCHES Pennsylvania state police criminal background checks for each interviewee. A background check, completed on the day of the interviews, will be provided. The results of this background check will be scanned and provided as evidence.


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, the agency failed to provide documentation of an annual competency evaluation for four (4) of ten (10) PF's reviewed, (PF # 2, 6, 7, and 10).

Findings include:

A review of PF's was conducted on June 2, 2021 from approximately 10:10 am to 10:45 am.

PF #2 Date of Hire: 12/21/19, did not contain any documentation of an annual competency evaluation for 2020.
PF #6 Date of Hire: 2/12/2020, did not contain any documentation of an annual competency evaluation for 2021.
PF #7 Date of Hire: 3/19/2020, did not contain any documentation of an annual competency evaluation for 2021.
PF #10 Date of Hire: 6/24/16, did not contain any documentation of an annual competency evaluations for 2020.
An interview with the administrator on June 2, 2021 at approximately 11:00 am confirmed the above findings.







Plan of Correction:

The Head of HR assures annual competency evaluations and will provide documentation for PF numbers 2, 6, 7 and 10 will be provided via scanned documents.


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), Centers for Disease Control (CDC) Guidelines, and an interview with the administrator, the agency failed to provide documentation that the individual has received baseline tuberculosis screening upon hire for nine (9 ) of ten (10) PF's reviewed, (PF #1, 2, 3, 4, 5, 6, 7, 8, and 9).

Findings include:

In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: 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. 2. Completion of a tuberculosis symptom questionnaire. 3. Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCWs should receive TB education 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;(5-16-19)



A review of PF's was conducted on June 2, 2021from approximately 10:10 am to 10:45 am.

PF #1 Date of Hire: 4/6/2021, did not contain any documentation that the individual had received baseline tuberculosis screening upon hire.

PF #2 Date of Hire: 12/21/19, did not contain any documentation that the individual had received baseline tuberculosis screening upon hire.

PF #3 Date of Hire: 8/5/2020, did not contain any documentation that the individual had received baseline tuberculosis screening upon hire.

PF #4 Date of Hire: 1/29/2021, contained documentation of a completed chest x-ray dated 9/10/19, but did not contain any documentation of tuberculosis symptom screening questionnaire or risk assessment.

PF #5 Date of Hire: 1/26/2021, did not contain any documentation that the individual had received baseline tuberculosis screening upon hire.

PF #6 Date of Hire: 2/12/2020, contained documentation of baseline tuberculosis screening of only a one-step tuberculin skin test (TST) upon hire. There was no documentation of a tuberculosis symptom questionnaire or risk assessment.

PF #7 Date of Hire: 3/19/2020, contained documentation of baseline tuberculosis screening of only a one-step tuberculin skin test (TST) upon hire. There was no documentation of a tuberculosis symptom questionnaire or risk assessment.

PF #8 Date of Hire: 3/5/2021, did not contain any documentation that the individual had received baseline tuberculosis screening upon hire.

PF #9 Date of Hire: 5/26/2021, contained documentation of baseline tuberculosis screening of only a one-step tuberculin skin test (TST) upon hire. There was no documentation of a tuberculosis symptom questionnaire or risk assessment.

An interview with the administrator on June 2, 2021 at approximately 11:00 am confirmed the above findings.











Plan of Correction:

The Head of HR will provide scanned copies of results of TB PPD skin tests for HC workers in question. The Head of HR will provide scanned, signed and dated copies of risk assessment (symptoms questionnaire) for HC workers in question.


611.57(a) LICENSURE
Consumer Rights

Name - Component - 00
(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

Observations:

Based on a review of consumer files (CF) and an interview with the administrator, the agency failed to provide documentation that the consumer received information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services for four (4) of ten (10) CF's reviewed, (CF #2, 3, 6, and 9).

Findings include:

A review of CF's was conducted on June 2, 2021 from approximately 9:20 am to 10:05 am.

CF #2 Start of Care: 1/11/2021, did not contain any documentation stating the consumer received information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services.

CF #3 Start of Care: 1/22/2021, did not contain any documentation stating the consumer received information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services.

CF #6 Start of Care: 2/9/2020, did not contain any documentation stating the consumer received information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services.

CF #9 Start of Care: 9/17/2020, did not contain any documentation stating the consumer received information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services.

An interview with the administrator on June 2, 2021 at approximately 11:00 am confirmed the above findings.








Plan of Correction:

The owner of Amada Senior Care, Philadelphia will provide scanned, signed and dated documentation that all consumers in question are aware that he or she will receive a 10 day notice of planned withdrawal of services should Amada plan to no longer provide services.


611.57(b) LICENSURE
Prohibitions

Name - Component - 00
(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

Observations:

Based on a review of consumer files (CF) and an interview with the administrator, the agency failed to provide documentation that the consumer received information stating that no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency for four (4) of ten (10) CF's reviewed, (CF #2, 3, 6, and 9).

Findings include:

A review of CF's was conducted on June 2, 2021 from approximately 9:20 am to 10:05 am.

CF #2 Start of Care: 1/11/2021, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.

CF #3 Start of Care: 1/22/2021, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.

CF #6 Start of Care: 2/9/2020, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.

CF #9 Start of Care: 9/17/2020, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.


An interview with the administrator on June 2, 2021 at approximately 11:00 am confirmed the above findings.






Plan of Correction:

The owner of Amada Senior Care, Philadelphia will provide signed, dated and scanned documents for consumers in question such that he or she is aware that no Amada employee shall assume POA or guardianship over a consumer utilizing Senior Care services from Amada.


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 a review of consumer files (CF) and an interview with the administrator, the agency failed to provide documentation that the consumer received information stating who to contact at the Department (717) 783-1379 for information about licensure requirements for the agency for ten (10) of ten (10) CF ' s reviewed, (CF #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10); and the agency failed to provide documentation of 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 for two (2) of ten (10) CF's reviewed, (CF #2 and 6).


Findings include:

A review of CF's was conducted on June 2, 2021 from approximately 9:20 am to 10:05 am.

CF # 1 Start of Care: 5/16/2021, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency.

CF #2 Start of Care: 1/11/2021, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency, and did not contain any documentation of a direct care worker disclosure.

CF #3 Start of Care: 1/22/2021, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency.

CF #4 Start of Care: 12/6/19, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency.

CF #5 Start of Care: 10/9/2020, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency.

CF #6 Start of Care: 2/9/2020, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency, and did not contain any documentation of a direct care worker disclosure.

CF #7 Start of Care: 9/16/19, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency.

CF #8 Start of Care: 12/9/2020, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency.

CF #9 Start of Care: 9/17/2020, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency.

CF #10 Start of Care: 10/3/19, did not contain any documentation that the agency provided information stating who to contact at the Department for information about licensure requirements for the agency.


An interview with the administrator on June 2, 2021 at approximately 11:00 am confirmed the above findings.







Plan of Correction:

The owner of Amada Senior Care Philadelphia will provide scanned, dated and signed documents for all consumers in question which explains the contact number 717-783-1379 can be used to learn about the requirements for becoming a Home Care company in Pennsylvania. The consumer may also learn about the status any specific HC company has currently with the PA Department of Health.


Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted on June 2, 2021, Amada Senior Care, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: