Initial Comments:
Based on the findings of an onsite unannounced State re-licensure survey conducted November 13-14, 2019, Love Dove Personal Care Agency was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilites, Subpart A, Chapter 51.
Plan of Correction:
51.3 (a) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification
(a) A health care facility shall
notify the Department in writing at
least 60 days prior to the intended
commencement of a health care service
which has not been previously provided
at that facility.
Observations:
Per 35 P.S. 448.813, "...Authorization.--For the purpose of determining the suitability of the applicants and of the premises or for determining the adequacy of the care and treatment provided or the continuing conformity of the licensees to this act and to applicable local, State and Federal regulations, any authorized agent of the department may enter, visit and inspect the building, grounds, equipment and supplies of any health care facility licensed or requiring a license under this act and shall have full and free access to the records of the facility and to the patients and employees therein and their records, and shall have full opportunity to interview, inspect, and examine such patients and employees..."
Based on review of Department records, surveyor observation, and staff (EMP) interview, the agency failed to maintain standards required by State authorities, specifically, the agency failed to be subject to an unannounced inspection by authorized representatives of the Department during agency set office hours.
Findings included:
A review of Department records on November 12, 2019 at approximately 10:00 a.m. in preparation for an unannounced State re-licensure survey to be conducted on November 13, 2019, found agency office operating hours to be Monday and Wednesday 9 a.m. to 5 p.m., and Saturday 9 a.m. to 3 p.m. Upon arrival to residence location at approximately 9:15 a.m. on Wednesday, November 13, 2019, Suveyor knocked on front door multiple times with no answer. A phone call was made to agency phone number listed in Department records at approximately 9:30 a.m. while standing at front door with no answer and inability to leave a message as phone rang and rang with no answering machine. Surveyor left card in door and left premises at approximately 10:00 a.m.
An onsite survey was conducted November 14, 2019. EMP7 confirmed the findings during agency telephone conversation on November 13, 2019, at approximately 11:40 a.m. in preparation for a second attempt to survey agency on the same day, November 13, 2019. EMP7 responded, "9 to 5 but you need to call (EMP6)" when surveyor asked for office hours "today" and office hours for "tomorrow." Surveyor also questioned as to staff currently onsite at facility and EMP7 responded with "you need to call (EMP6)." On November 14, 2019 at approximately 12:30 p.m. EMP6 revealed, "I need to update my hours."
Plan of Correction:Love Dove Personal Care Agency will update and revise the Office Hours of Operation with the Pennsylvania Department of Health, Direct Care Workers, Consumers/Participants and any contracted Providers with Love Dove Personal Care Agency by December 15th, 2019. The hours of operation will be revised from Monday-Friday 9a-5p, to Tuesday and Thursday 10:00am-3:00pm.
Love Dove Personal Care Agency will create a "Agency Hours of Operation" policy, mandating at least 1 person must remain in the agency at all times during business hours. The policy will stress the importance of complying with the hours of operation for the purpose of:
.Surveys
.Customer/Participant Visits
.Audits
Love Dove Personal Care Agency will update the contact phone number for the agency. The phone number of 412.788.7729 will be eliminated and the sole contact phone number for the agency will be 412.628.5448. Love Dove Personal Care Agency will update this number with the Pennsylvania Department of Health, Consumers/Participants, Direct Care Workers and all Contracted Providers
Love Dove Personal Care Agency will require an Administrative staff person to be available during the mandated office hours and required to answer the agency phone number.
Love Dove Personal Care Agency Administrative Staff will be required to answer the phone for all calls. The agency will also update the voicemail service to allow callers to leave messages for Agency staff. Agency staff are mandated to return calls within 24 hours.
Love Dove Personal Care Agency will require the premises to the agency to be available to any agent of the Pennsylvania State Department to inspect at will.
Initial Comments:
Based on the findings of an onsite unannounced State re-licensure survey conducted November 13-14, 2019, Love Dove Personal Care Agency was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.
Plan of Correction:
611.4(c) LICENSURE
Requirements for HCA and HCR
Name - Component - 00
Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.
Observations:
Per 35 P.S. 448.813, "...Authorization.--For the purpose of determining the suitability of the applicants and of the premises or for determining the adequacy of the care and treatment provided or the continuing conformity of the licensees to this act and to applicable local, State and Federal regulations, any authorized agent of the department may enter, visit and inspect the building, grounds, equipment and supplies of any health care facility licensed or requiring a license under this act and shall have full and free access to the records of the facility and to the patients and employees therein and their records, and shall have full opportunity to interview, inspect, and examine such patients and employees..."
Based on review of Department records and staff (EMP) interview, the agency failed to maintain standards required by State authorities, specifically, the agency failed to be subject to an unannounced inspection by authorized representatives of the Department during agency office hours.
Findings included:
A review of Department records on November 12, 2019 at approximately 10:00 a.m. in preparation for an unannounced State re-licensure survey to be conducted on November 13, 2019, found agency office operating hours to be Monday and Wednesday 9 a.m. to 5 p.m., and Saturday 9 a.m. to 3 p.m. Upon arrival to residence location at approximately 9:15 a.m. on November 13, 2019, Suveyor knocked on front door with no answer. A phone call was made to agency phone number listed in Department records at approximately 9:30 a.m. while standing at front door with no answer and inability to leave a message as phone rang and rang with no answering machine. Surveyor left card in door and left premises at approximately 10:00 a.m.
An onsite survey was conducted November 14, 2019. EMP7 confirmed the findings during agency telephone conversation on November 13, 2019, at approximately 11:40 a.m. in preparation for a second attempt to survey agency on the same day, November 13, 2019. EMP7 responded, "9 to 5 but you need to call (EMP6)" when surveyor asked for office hours "today" and office hours for "tomorrow." Surveyor also questioned as to staff currently onsite at facility and EMP7 responded with "you need to call (EMP6)." On November 14, 2019 at approximately 12:30 p.m. EMP7 revealed, "I need to update my hours."
Plan of Correction:Love Dove Personal Care Agency will update and revise the Office Hours of Operation with the Pennsylvania Department of Health, Direct Care Workers, Consumers/Participants and any contracted Providers with Love Dove Personal Care Agency by December 15th, 2019. The hours of operation will be revised from Monday-Friday 9a-5p, to Tuesday and Thursday 10:00am-3:00pm.
Love Dove Personal Care Agency will create a "Agency Hours of Operation" policy, mandating at least 1 person must remain in the agency at all times during business hours. The policy will stress the importance of complying with the hours of operation for the purpose of:
.Surveys
.Customer/Participant Visits
.Audits
Love Dove Personal Care Agency will update the contact phone number for the agency. The phone number of 412.788.7729 will be eliminated and the sole contact phone number for the agency will be 412.628.5448. Love Dove Personal Care Agency will update this number with the Pennsylvania Department of Health, Consumers/Participants, Direct Care Workers and all Contracted Providers
Love Dove Personal Care Agency will require an Administrative staff person to be available during the mandated office hours and required to answer the agency phone number.
Love Dove Personal Care Agency Administrative Staff will be required to answer the phone for all calls. The agency will also update the voicemail service to allow callers to leave messages for Agency staff. Agency staff are mandated to return calls within 24 hours.
Love Dove Personal Care Agency will require the premises to the agency to be available to any agent of the Pennsylvania State Department to inspect at will.
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 review occurred at least once per year after initial competency was established for two (2) of five (5) PF reviewed who had more than 12 months of employment. (PF3, PF5)
Findings Included:
Review of PF completed on 11/15/2019 between approximately 10:30 a.m. and 11:00 a.m. revealed:
PF3, date of hire (DOH) 05/21/18, PF contained documentation of initial competency completed 6/11/2018. The PF did not contain evidence of annual competency completed for 2019.
PF5, DOH 4/13/18, PF contained documentation of initial competency completed 5/12/2018. The PF did not contain evidence of annual competency completed for 2019.
Interview completed on 11/15/19 at approximately 12:30 p.m. with EMP6 confirmed the findings. EMP6 stated "we do quarterly training, they might not all be in there."
Plan of Correction:Competency and performance evaluation will be measured on an annual basis through a variety of methods including but not limited to:
- Annual competency and
performance reviews
- Consumer feedback
- Direct observation
- Training and testing
All documentation is subject to validation, e.g. through the licensing or certification agent, or the provider of the training/testing. Originals are preferred.
If the applicant becomes an employee, copies of the documentation will be maintained in the direct care worker's file.
All documentation of the direct care worker's successful completion of training, testing, annual reviews will be maintained in the worker's file and updated within 30 days of initial employment. If certificates of completion are awarded, the worker will receive the original and, at the worker's request a copy may be maintained in the worker's file.
Any documentation related to prior competency testing that is provided by an applicant must include:
- Dates
- Name of training program or
training entity
- Training content or evidence
of the above subject areas
- Evidence of successful
completion
The agency will hold Quarterly and Annual Training with all hired Direct Care Workers and all Direct Care Workers will be required to complete the Competency Test Annually. The training will be completed by the agency Administrator
The completion date for the implementation and completion of mandated initial and annual competency/training for employees will be completed by 11/23/2019
The Administrator, will be responsible for monitoring employee's files and scheduling initial and annual competency ongoing.
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 Centers for Disease Control (CDC) guidelines, agency Personnel files (PF), and staff (EMP) interviews, the agency failed to ensure direct care workers had annual education for tuberculosis (TB) completed every 12 months for one (1) of five (5) PF who were employed greater than 12 months.
Findings Included:
A review of updated CDC Guidelines "...recommendations for tuberculosis (TB) screening and testing of U.S. health care personnel (HCP)" revealed "Serial screening and testing for HCP without LTBI...2019 recommendation...Not routinely recommended (new); can consider for selected HCP groups (unchanged); recommend annual TB education for all HCP (unchanged); including information about TB exposure risks for all HCP (new emphasis)."
Review of PF completed on November 15, 2019 between approximately 10:30 a.m. and 11:30 a.m. revealed:
PF5, date of hire (DOH) 4/13/18, PF contained a two step TB test upon hire revealing series completion date of 3/28/2018. PF did not contain evidence of TB education as recommended by the 2019 update of CDC guidelines, nor did the file contain documented evidence of serial TB testing recommended by prior (2005) CDC guidelines.
Interview completed on November 15, 2019 at approximately 12:30 p.m. with EMP6 confirmed the findings, "Yeah, I'm not exactly sure what the updated guidelines are, I think I have an education and screening form."
Plan of Correction:The agency will require all employees/office staff or contractors who have direct consumer contact must update their screening documentation not less than every 12 months; for purposes of the Department of Health licensing review, "screening" can be a series of questions to determine if the employee has had an exposure to active TB or their level of risk has changed or it can be an annual TST. The 12 month period shall run from the date of the last TB evaluation.
In compliance with Center for Disease Control (CDC) "Every health-care setting should conduct initial and ongoing
evaluations of the risk for transmission of M. tuberculosis,
regardless of whether or not patients with suspected or confirmed
TB disease are expected to be encountered in the setting.
The TB risk assessment determines the types of
administrative, environmental, and respiratory-protection
controls needed for a setting and serves as an ongoing evaluation
tool of the quality of TB infection control and for the
identification of needed improvements in infection-control
measures."
Direct Care Workers will receive Training on the risks of TB Exposure. The Annual TB Screening will be a "refresher" on TB Risks and Exposure, along with a TB Questionnaire.
The Education will highlight the risks of TB Exposure with a Annual Education Online Training by the CDC titled TB: 101 for Health Care Workers. The online training is found on site https://www.cdc.gov/tb/education/ce/tb101.htm.
The Annual training will be required by all staff to complete and the completion of this training will be completed by all staff by 11/23/2019. Agency Administrator will oversee this training guideline.
The CDC TB Continuing Education training covers the following topics; Tuberculosis,
Basic TB Facts
Personal Stories
Testing & Diagnosis
Treatment
Drug-Resistant TB
Research
Health Care Settings,
TB in Specific Populations
Laboratory Information
Data & Statistics
Professional Resources & Tools
Love Dove Personal Care Agency will require all hired and working Direct Care Workers to complete Step 1 and 2 TB Testing prior to their effective start date of working. All current workers will be required to sign and date a TB Test Screening Review Annually in addition to completing the CDC Online TB Continuing Education
The TB Annual Screening will ask Direct Care Workers the following questions to be answered.
1. Direct Care Workers Name
2. Position
3. Date of Last Chest x-ray
4. Signature
5. History of TB Exposure
6. Symptoms (Yes or No)
7.Signature and Date of Direct Care Worker
8. Signature and Date of Interviewer
The TB Annual Screening Review will be signed dated and placed in the Direct Care Workers file and completed yearly. The Annual TB Screening and education/Online CDC training will be filed in the Direct Care Workers file and reviewed monthly by the agency Administrator. All files will be monitored monthly to assure compliance
All Direct Care Workers file will be updated with initial and Annual TB Evaluations by November 23, 2019.
Agency Administrator is responsible for monitoring TB annual education guidelines to avoid future Plan of Correction occurrences by the Pennsylvania Department of Health.
Initial Comments:
Based on the findings of an onsite unannounced State re-licensure survey completed on November 15, 2019, Love Dove Personal Care Agency was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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