QA Investigation Results

Pennsylvania Department of Health
CARESENSE HOME CARE
Health Inspection Results
CARESENSE HOME CARE
Health Inspection Results For:


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Initial Comments:


Based on the findings of an unannounced onsite state re-licensure survey conducted on February 7, 2020, Caresense Home 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 unannounced onsite state re-licensure survey conducted on February 7, 2020, Caresense Home 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:




611.52(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 employee files (EFs) and an interview with the agency Branch Manager, agency failed to ensure proof of residency in Pennsylvania (Pa.) for 2 years immediately preceding date of hire, for three (3) out of ten (10) EFs reviewed (EF#1, EF#6, EF#7).
Findings include:
A review of EFs was conducted on February 7, 2020 at approximately 10:15 a.m. Employee date of hire (DOH) is listed below:
EF#1 DOH 10/21/19: Agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Pa. drivers license issued 06/20/18 with an expiration date of 05/31/21. Employment application was reviewed. Employer listed with a Pa. address 'From': "2015" 'To' "2017". Employer listed with a Pa. address 'From': "2018" 'To' "2019".
No documentation provided for proof of Pa. residency between 10/21/17 - 06/20/18.

EF#6 DOH 03/12/18: Agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Pa. drivers license issued 06/02/17 with an expiration date of 06/07/21. Employment application was reviewed. Employer listed with a Pa. address with 'From' and 'To' left blank. Employer listed with an incomplete address 'From' and 'To' left blank.
No documentation provided for proof of Pa. residency between 03/12/16 - 06/02/17.

EF#7 DOH 05/27/18: Agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Pa. drivers license issued 01/08/18 with an expiration date of 03/07/22. Employment application was reviewed. Employer listed with a Pa. address 'From': "2010" 'To' "2016".
No documentation provided for proof of Pa. residency between 05/27/16 - 01/08/18.
An interview conducted with the agency Branch Manager on February 7, 2020 at approximately 2:00 p.m. confirmed the above findings.











Plan of Correction:

For EF#1, EF#6, EF#7 Caresense will obtain proof of residency in Pennsylvania through submission of any one approved documents.

CareSense will obtain
documentation of proof of Pa.residency for the entire two years (without interruption)immediately preceding the date of application for all new hires.
If documentation cannot be obtained to show proof of residency a federal Department of Aging criminal check will be obtained.

Branch Manager will conduct an
audit of all employee files to
ensure compliance.

Agency will conduct an audit of
all other files. A checklist will
be in individual employee files
to assure this task has been
completed.

Branch Manager will conduct
annual employee file checks
using a spreadsheet, which will
be reviewed by Regional
Manager to ensure compliance.

Branch Manager is responsible
for implementation and
continued compliance for
ensuring proof of residency in
Pennsylvania (Pa.) for 2 years

Regional Manager will have an in-service to ensure the staff responsible for hiring is up to date regarding the requirements of the hiring process.



611.53(a) LICENSURE
Child Abuse Clearances

Name - Component - 00
A home care agency or home care registry that serves persons under 18 years of age shall require each applicant for employment or referral as a direct care worker, each applicant for employment as a member of the agency or registry office staff to request a ChildLine verification regarding whether the applicant is named in the Statewide Central Register as the perpetrator of a founded or indicated report of child abuse as defined at 55 Pa. Code 3490.4 (relating to definitions).

Observations:


Based upon review of employee files (EFs) and an interview with the agency Branch Manager, agency failed to require each applicant for employment or referral as a direct care worker and/or each applicant for employment as a member of the agency or registry office staff to request a ChildLine verification for thirty-one (31) out of thirty-three (33) employee files reviewed (EF#1- EF#3, EF#5 - EF#9, EF#11 - EF#32).
Findings include:
A review of EFs was conducted on February 7, 2020 at approximately 10:15 a.m. Employee date of hire (DOH) is listed below:
EF#1 DOH 10/31/19: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#2 DOH 09/01/19: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#3 DOH 09/01/19: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#5 DOH 07/31/18: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#6 DOH 03/12/18: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#7 DOH 05/27/18: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#8 DOH 09/04/19: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#9 DOH 08/05/19: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#11 DOH 10/16/19: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#12 DOH 10/04/16: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#13 DOH 05/28/16: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#14 DOH 03/29/16: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#15 DOH 07/13/17: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#16 DOH 04/01/19: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#17 DOH 07/18/19: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#18 DOH 08/16/17: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#19 DOH 12/04/15: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#20 DOH 09/17/19: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#21 DOH 08/26/19: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#22 DOH 08/05/15: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#23 DOH 09/10/18: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#24 DOH 09/16/16: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#25 DOH 05/13/19: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#26 DOH 02/15/15: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#27 DOH 10/21/19: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#28 DOH 10/19/19: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#29 DOH 09/14/19: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#30 DOH 10/27/19: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#31 DOH 02/15/18: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#32 DOH 06/09/19: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
EF#33 DOH 06/18/18: Agency failed to provide documentation of a Childline verification being conducted due to the agency providing services to persons less than 18 years of age.
Interviews conducted with the agency Branch Manager on February 7, 2020 at approximately 11:00 a.m. and 2:00 p.m. confirmed the above findings. The Branch Manager was asked if the agency provided care to persons under the age of 18 years of age. The Branch Manager stated "Yes". A consumer (CF#8), who is under the age of 18, first started service with the agency 06/15/2019 and is still listed as an active consumer.














Plan of Correction:

For EF#1- EF#3, EF#5 -EF#9, EF#11 - EF#32.Caresense will obtain Childline
verification.

Agency will conduct an audit of
all other files. If the audit shows no Childline, agency will conduct Childlines. A checklist
will be in individual employee
files to assure this task has been
completed.


Branch Manager will conduct
annual employee file checks
using a spreadsheet, which will
be reviewed by Regional
Manager to ensure compliance.


Branch Manager is responsible
for implementation and
continued compliance for
ensuring each individual has
Childlines.

Regional Manager will have an in-service to ensure the staff responsible for hiring is up to date regarding the requirements of the hiring process.



611.54(a)(1) LICENSURE
Provisional Hiring

Name - Component - 00
The applicant shall have applied for a criminal history report and ChildLine verification, as applicable, and provided the home care agency or home care registry with a copy of the completed request forms.

Observations:


Based upon review of employee files (EFs) and an interview with the agency Branch Manager, agency failed to ensure provisionally hired employees applied for a criminal history report at the time of hire for two (2) out of two (1) provisionally hired EFs reviewed (EF#10, EF#32).
Findings include:
A review of EFs was conducted on February 7, 2020 at approximately 10:15 a.m. Employee date of hire (DOH) is listed below:
EF#10 DOH 06/24/19: No documentation of employee, who provides/provided services to a consumer less than 18 years of age, applying for a federal criminal history report upon hire.

EF#32 DOH 06/09/19: No documentation of employee, who provides/provided services to a consumer less than 18 years of age, applying for a federal criminal history report upon hire.

An interview conducted with the agency Branch Manager on February 7, 2020 at approximately 10:20 a.m. confirmed the above findings. "These employees are/were the direct care workers assigned to CF#8". (Consumer less then 18 years of age).












Plan of Correction:

For EF#10, EF#32.Caresense will obtain federal criminal history report.

Agency will conduct an audit of
all other files. A checklist will
be in individual employee files
to assure this task has been
completed.

Branch Manager will conduct
annual employee file checks
using a spreadsheet, which will
be reviewed by Regional
Manager to ensure compliance.

Branch Manager is responsible
for implementation and
continued compliance.

Regional Manager will have an in-service to ensure the staff responsible for hiring is up to date regarding the requirements of the hiring process.



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 upon review of employee files (EFs) and an interview with the agency Branch Manager, the agency failed to ensure documentation that direct care workers, prior to providing services to consumers, completed/demonstrated an annual competency training covering all required sixteen (16) subject areas for two (2) of ten (10) EFs (EF#6, EF#7).

Findings include:

A review of EFs was conducted on February 7, 2020 at approximately 10:15 a.m. Employee date of hire (DOH) is listed below:

EF#6 DOH 03/12/18: No documentation provided of 2019 annual competency training covering all required sixteen (16) subject areas. Elements required in subsection (c), section (3) and section (6), were not addressed.

EF#7 DOH 05/27/18: No documentation provided of 2019 annual competency training covering all required sixteen (16) subject areas. Elements required in subsection (c), section (3) and section (6), were not addressed.

An interview conducted with the agency Branch Manager on February 7, 2020 at approximately 2:00 p.m. confirmed the above findings.





















Plan of Correction:

Foe EF#6, EF#7 Caresense will
have employees take competency training on all elements required in subsection(c), section (3) and section (6).

Caresense will revise
annual competency with all
elements required in subsection
(c) .

Agency will have all
employees take training on all elements required in subsection (c), section (3) and section (6),

Agency will conduct an audit
of all other files. A checklist
will be in individual employee
files to assure this task has been
completed.

Branch Manager will conduct
annual employee file checks
using a spreadsheet, which will
be reviewed by Regional
Manager to ensure compliance.

HR is responsible for
implementation and continued
compliance.


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 upon review of employee files (EFs) and an interview with the Branch Manager, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, were screened for and are free from active mycobacterium tuberculosis for five (5) of ten (10) employees (EF#1- EF#4, EF#8).


Findings Include:

Baseline (pre-placement) 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 EFs was conducted on February 7, 2020 at approximately 10:15 a.m. Employee date of hire (DOH) is listed below:
EF#1 DOH 10/21/19: No documentation of a symptom screen questionnaire and an individual TB risk assessment upon hire.
EF#2 DOH 09/01/19: No documentation of a symptom screen questionnaire and an individual TB risk assessment upon hire.

EF#3 DOH 09/01/19: No documentation of a symptom screen questionnaire and an individual TB risk assessment upon hire.

EF#4 DOH 10/13/19: No documentation of a symptom screen questionnaire and an individual TB risk assessment upon hire.

EF#8 DOH 09/04/19: No documentation of a symptom screen questionnaire and an individual TB risk assessment upon hire.

An interview conducted with the agency Branch Manager on February 7, 2020 at approximately 2:00 p.m. confirmed the above findings.














Plan of Correction:

For (EF#1- EF#4, EF#8).Caresense
will obtain documentation of a symptom screen questionnaire and an individual TB risk assessment.

Caresense Manager will obtain documentation of a symptom screen
questionnaire and an individual TB
risk assessment upon hire.
Agency will conduct an audit of all other files.

Agency will obtain Tb risk assessments on any individuals that do not have
one. A checklist will be in
individual employee files to
assure this task has been completed.

Branch Manager will conduct annual employee file checks using
a spreadsheet, which will be reviewed by Regional Manager to ensure compliance.

Branch Manager is responsible for
implementation and continued
compliance.


Initial Comments:


Based on the findings of an unannounced onsite state re-licensure survey conducted on February 7, 2020, Caresense Home Care was found to be in compliance with the requirements of 35 P.S. 448.809 (b).






Plan of Correction: