QA Investigation Results

Pennsylvania Department of Health
DEL COMMUNITY HOME CARE AGENCY, LLC
Health Inspection Results
DEL COMMUNITY HOME CARE AGENCY, LLC
Health Inspection Results For:

This is the only survey for this facility

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:

Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on January 13, 2020, Del Community Home Care Agency, LLC., 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 home care agency state re-licensure survey conducted on January 13, 2020, Del Community Home Care Agency, LLC, 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 two satisfactory references for one (1) of ten (10) PF ' s, PF #10.
Findings:
A review of PF ' s was conducted on January 13, 2020 from approximately 10:10 am to 11:00 am.
PF # 10 Date of Hire: 12/6/19 did not contain documentation of any reference verifications.
An interview with the administrator on January 13, 2020 at approximately 11:00 am confirmed the above findings.







Plan of Correction:

Del Community Home Care Agency LLC has created and implemented policy to review all new staff folders and to ensure that all staff reference verification are completed within the allocated time. Administrator will ensure that all admin staff are properly trained on new hire policy.




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 one year immediately preceding the date of application for one (1) of ten (10) PF ' s, PF #5.
Findings:
A review of PF ' s was conducted on January 13, 2020 from approximately 10:10 am to 11:00 am.
PF #5 Date of Hire: 8/27/19 did not contain any documentation of a Pennsylvania State Police Background Check.
An interview with the administrator on January 13, 2020 at approximately 11:00 am confirmed the above findings.








Plan of Correction:

Del Community Home Care Agency has developed and implemented a process complete all Pennsylvania State Police Criminal Background Check at the time of application at the time application was reviewed. Yearly reviewed will also be conducted to ensure all staff files are within compliance.

The Administrator will ensure that the policy of protective service is implemented and all staff are trained.


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 for one (1) of ten (10) PF ' s, PF #6.
Findings:
A review of PF ' s was conducted on January 13, 2020 from approximately 10:10 am to 11:00 am.
PF #6 Date of Hire: 12/28/18 did not contain any documentation of an annual competency for 2019.
An interview with the administrator on January 13, 2020 at approximately 11:00 am confirmed the above findings





Plan of Correction:

Del Community Home Care Agency LLC has developed and implemented a process to make sure that all staff annual competency are completed PF # 6 annual competency is now completed and in file.










1.Del Community Home Care Agency LLC has developed and implemented a Quality Management policy to ensure that the requirements of 55 PA Code Chapter 52.24


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 Guidelines, and an interview with the administrator, the agency failed to provide documentation of an initial tuberculosis screening for three (3) of ten (10) PF ' s, PF #3, 7, and 10.
Findings:
The CDC guidelines state that all Health Care Workers (HCW) should received baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screen 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;(RR-17)http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.
A review of PF ' s was conducted on January 13, 2020 from approximately 10:10 am to 11:00 am.
PF #3 Date of Hire: 12/1/19 did not contain any documentation of initial tuberculosis screening.
PF #7 Date of Hire: 10/9/19 contained documentation of only a one-step initial tuberculosis skin test dated 5/9/19.
PF #10 Date of Hire: 12/6/19 did not contain any documentation of initial tuberculosis screening.
An interview with the administrator on January 13, 2020 at approximately 11:00 am confirmed the above findings




Plan of Correction:

Del Community Home Care Agency LLC has developed a system to review all documentation of an initial tuberculosis screening for all new hires. PF ' s, PF #3, 7, and 10 were notified and files has been updated.

Quarterly files will be reviewed by administrator before 1st day of work to make sure its in 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 a review of personnel files (PF), The Centers for Disease Control Guidelines, and an interview with the administrator, the agency failed to provide documentation of an annual tuberculosis screening for two (2) of ten (10) PF ' s, PF #4 and 6.
Findings:
The CDC guidelines state that all Health Care Workers (HCW) should received baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screen 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;(RR-17)http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.
A review of PF ' s was conducted on January 13, 2020 from approximately 10:10 am to 11:00 am.
PF #4 Date of Hire: 9/26/19 did not contain any documentation of an annual tuberculosis screening for 2019.
PF #6 Date of Hire: 12/28/18 did not contain any documentation of an annual tuberculosis screening for 2019.
An interview with the administrator on January 13, 2020 at approximately 11:00 am confirmed the above findings.






Plan of Correction:

Del Community Home Care has reviewed all staff files and ensure that all staff will if not yet received all annual tuberculosis screenings to be in compliance

PF #4, & 6 files has been updated. Administrator and admin staff will ensure that system documents are reviewed.


Initial Comments:

Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on January 13, 2020, Del Community Home Care Agency, LLC, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: