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 on site unannounced state relicensure survey completed February 7, 2020, Caresense Home Care was found to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health facilities, Subpart A, Chapter 51.





Plan of Correction:




Initial Comments:


Based on the findings of an onsite unannounced state relicensure survey completed February 7, 2020, Caresense Home Care 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:




611.52(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 direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to obtain proof of residency for three (3) of eight (8) personnel files reviewed (PF1- PF8).

Findings included:

Review of personnel files was conducted on February 7, 2020, between 11:35 a.m. and 12:30 p.m. revealed:

PF1 was hired on 11/1/2018. PF1 contained a Pennsylvania driver's license issued 11/29/2017 (not issued 2 years prior to date of hire).

PF5 was hired on 11/16/2018. PF5 contained a Pennsylvania driver's license issued 10/2/2017.

PF8 was hired on 10/18/2018. PF8 contained a Pennsylvania driver's license issued 8/18/2018.

Findings were confirmed with EMP1 on February 7, 2020 at 1:50 p.m.









Plan of Correction:

For EF#1, EF#5, EF#8
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 using a spreadsheet.

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 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.


611.55(b) LICENSURE
Competency Requirements

Name - Component - 00
A competency examination or training program developed by an agency or registry for a direct care worker shall address, at a minimum, the following subject areas: 1. Confidentiality; 2. Consumer control and the independent living philosophy; 3. Instrumental activities of daily living; 4. Recoginizing changes in the consumer that need to be addressed; 5. Basic infection control; 6. Universal precautions; 7. Handling of emergencies; 8. Documentation; 9. Recognizing and reporting abuse or neglect; and 10. Dealing with difficult behaviors.

Observations:


Based on review of agency personnel files (PF) and staff (EMP) interview, it was determined that the agency failed to implement a competency examination that addressed, at a minimum, the following subject areas: universal precautions and dealing with difficult behaviors for eight (8) of eight (8) PF reviewed. (PF1 - PF8)

Findings Included:

Review of agency competency test completed on 2/7/2020 at approximately 11:25 a.m. revealed the competency test failed to include universal precautions and dealing with difficult behaviors.

Review of personnel files was conducted on February 7, 2020, between 11:35 a.m. and 12:30 p.m. revealed:

PF1, date of hire (DOH) 11/1/18, PF1 did not contain evidence of competency testing in universal precautions and dealing with difficult behaviors.

PF2, DOH 5/24/2017, PF2 did not contain evidence of competency testing in universal precautions and dealing with difficult behaviors.

PF3, DOH 6/20/19, PF3 did not contain evidence of competency testing in universal precautions and dealing with difficult behaviors.

PF4, DOH 9/24/2018, PF4 did not contain evidence of competency testing in universal precautions and dealing with difficult behaviors.

PF5, DOH 11/16/2018, PF5 did not contain evidence of competency testing in universal precautions and dealing with difficult behaviors.

PF6, DOH 12/18/2019, PF6 did not contain evidence of competency testing in universal precautions and dealing with difficult behaviors.

PF7, date of hire (DOH) 12/23/2019, PF7 did not contain evidence of competency testing in universal precautions and dealing with difficult behaviors.

PF8, date of hire (DOH) 10/18/2018, PF8 did not contain evidence of competency testing in universal precautions and dealing with difficult behaviors.

Findings were confirmed with EMP1 on 2/7/2020 at 1:50 p.m.










Plan of Correction:

For EF#1-8 Caresense will
have employees take competency training on all universal precautions and dealing with difficult behaviors.

Caresense will revise
competency test with all
elements required.

Agency will have all employees take training on dealing with difficult behaviors and infection control.

Agency will conduct an audit
of all other files using a spreadsheet.

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.


611.55(c) LICENSURE
Competency Requirements

Name - Component - 00
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: 1. Bathing, shaving, grooming and dressing; 2. Hair, skin and mouth care; 3. Assistance with ambulation and transferring; 4. Meal preparation and feeding; 5. Toileting; 6. Assistance with self-administered medications.

Observations:


Based on a review of agency personnel files (PF), agency competency test and staff (EMP) interview, the agency failed to ensure direct care workers (DCW) met competency requirements including bathing, shaving, grooming, and dressing, hair and assistance with transfer prior to consumer contact for eight (8) of eight (8) PF reviewed. (PF1 - PF8)

Findings included:

Review of agency competency test completed on 2/7/2020 at approximately 11:25 a.m. revealed the competency test failed to include bathing, shaving, grooming, and dressing, hair and assistance with transfer.

Review of personnel files was conducted on February 7, 2020, between 11:35 a.m. and 12:30 p.m. revealed:

PF1, date of hire (DOH) 11/1/18, PF1 did not contain evidence of competency testing in bathing, shaving, grooming, and dressing, hair and assistance with transfer.

PF2, DOH 5/24/2017, PF2 did not contain evidence of competency testing in bathing, shaving, grooming, and dressing, hair and assistance with transfer.

PF3, DOH 6/20/19, PF3 did not contain evidence of competency testing in bathing, shaving, grooming, and dressing, hair and assistance with transfer.

PF4, DOH 9/24/2018, PF4 did not contain evidence of competency testing in bathing, shaving, grooming, and dressing, hair and assistance with transfer.

PF5, DOH 11/16/2018, PF5 did not contain evidence of competency testing in bathing, shaving, grooming, and dressing, hair and assistance with transfer.

PF6, DOH 12/18/2019, PF6 did not contain evidence of competency testing in bathing, shaving, grooming, and dressing, hair and assistance with transfer.

PF7, date of hire (DOH) 12/23/2019, PF7 did not contain evidence of competency testing in bathing, shaving, grooming, and dressing, hair and assistance with transfer.

PF8, date of hire (DOH) 10/18/2018, PF8 did not contain evidence of competency testing in bathing, shaving, grooming, and dressing, hair and assistance with transfer.

Findings were confirmed with EMP1 on 2/7/2020 at 1:50 p.m.









Plan of Correction:

For (EF#1-#8) Caresense will
have employees take
competency training on shaving, grooming, and dressing, hair, bathing and assistance with transfer.

Caresense will revise
competency exam with all
elements required.

Agency will have all
employees take competency
training on shaving, grooming, bathing, and dressing, hair and assistance with transfer.

Agency will conduct an audit
of all other files using a spreadsheet 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 on review of direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to ensure a direct care worker was screened and free from mycobacterium tuberculosis (TB) prior to consumer contact for three (3) of eight (8) active direct care worker personnel files reviewed (PF1- PF8)

Findings included:

Review of personnel files was conducted on February 7, 2020, between 11:35 a.m. and 12:30 p.m. revealed:

PF2 was hired on 5/24/2017 and started on 5/24/2017. PF2 contained an illegible TB screen, could not verify prior to consumer contact.

PF4 was hired on 9/24/2018 and started on 9/24/2018. PF4 did not contain any TB screening upon hire or prior to consumer contact.

PF5 was hired on 11/16/2018 and started on 11/16/2018. PF5 contained negative TB screening from 12/8/2017 and 12/18/2017, but there was no screening completed upon hire, prior to consumer contact.

Findings were confirmed with EMP1 on 2/7/2020 at 1:50 p.m.









Plan of Correction:

For EF#2, EF#4, and EF#5 caresense will have employees complete a two step skin testing for TB.

A two step skin testing for TB will be completed for newly hired employees and the employee will only have consumer contact after the first step is determined to be negative for TB.

Agency will conduct an audit of all other files to ensure compliance. If the employee does not have a 2 step skin testing in file, agency will suspend employee(s) until skin screening is complete.

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
The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.

Observations:


Based on review of the Centers for Disease Control and Prevention Guidelines (CDC), direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to ensure screenings for mycobacterium tuberculosis (TB) were conducted in accordance with CDC Guidelines for two (2) of eight (8) direct care worker personnel files reviewed (PF1- PF8)

Findings included:

According to the "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005," "Baseline testing for M. Tuberculosis infection is recommended for all newly hired HCWs [health care workers] ... If TST [tuberculin skin testing] is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative ... If the first-step TST result is negative, the second-step TST should be administered 1--3 weeks after the first TST result was read."

Review of personnel files was conducted on February 7, 2020, between 11:35 a.m. and 12:30 p.m. revealed:

PF2 was hired on 5/24/2017 and started on 5/24/2017. PF2 contained an illegible TB screen, could not verify TB skin test was completed per CDC guidelines.

PF3 was hired on 6/20/2019 and started on 6/20/2019. PF3 contained a negative TB screening from 6/14/2019, but there was no evidence that a second TB skin test was completed per CDC guidelines.

Findings were confirmed with EMP1 on 2/7/2020 at 1:50 p.m.

















Plan of Correction:

For (PF#1 and PF#8)screenings for mycobacterium tuberculosis (TB) accordance with CDC Guidelines.

HR will obtain documentation of screenings for mycobacterium tuberculosis (TB) accordance with CDC Guidelines upon hire.

Agency will conduct an audit of all other files. Agency will obtain documentation of screenings for mycobacterium tuberculosis (TB) accordance with CDC Guidelines on
any individuals that do not have
one.

A checklist will be in
individual employee files to
assure this task has been completed.

HR is responsible
for implementation and
continued compliance


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 agency employee handbook, the Centers for Disease Control and Prevention Guidelines (CDC), direct care worker personnel files (PF) and staff (EMP)interview, the agency failed to ensure all workers with direct consumer contact had an updated screening for tuberculosis completed at least every 12 months for two (2) of five (5) direct care worker personnel files reviewed (PF1-2, PF4-5, PF8).

Findings included:

The CDC guidelines state.... After baseline testing for infection with tuberculosis, HCWs should receive TB screen annually. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(RR-17) .

Review of personnel files was conducted on February 7, 2020, between 11:35 a.m. and 12:30 p.m. revealed:

PF2 was hired on 5/24/2017 and started on 5/24/2017. PF2 contained an illegible TB screen, could not verify dates TB skin test was completed. There was a negative TB screen completed 10/15/2018. There was no legible TB screen for 2019.

PF4 was hired on 9/24/2018 and started on 9/24/2018. PF4 did not contain any TB screening according to CDC guidelines.

Findings were confirmed with EMP1 on 2/7/2020 at 1:50 p.m.

















Plan of Correction:

For EF#1. EF#4 Caresense will obtain a TB screening according to CDC guidelines.

HR will obtain TB screening according to CDC guidelines upon hire.

Agency will ensure all workers with direct consumer contact have an updated screening for tuberculosis completed at least every 12 months.

Agency will conduct an audit of all other files to ensure compliance. If the employee is not in compliance, agency will suspend employee(s) until they are complying.

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



Initial Comments:



Based on the findings of an onsite unannounced state relicensure survey 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: