QA Investigation Results

Pennsylvania Department of Health
ARCADIA HOME CARE & STAFFING
Health Inspection Results
ARCADIA HOME CARE & STAFFING
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite unannounced state re-licensure survey conducted on February 14, 2020, Westmoreland County Homemakers was found not to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.








Plan of Correction:




51.6 (a)(2) LICENSURE
IDENTIFICATION OF PERSONNEL

Name - Component - 00
51.6. Identification of personnel

(a) When working in a health care
facility and when clinically feasible,
the following individuals shall wear
an identification tag which displays
that person's name and professional
designation:
(2) Health care providers employed
by health care facilities.

Observations:


Based on observation and staff (EMP) interview, the agency failed to ensure that two (2) of two (2) staff members observed were issued a photo identification badges which display their name and professional designation/job title when providing services to consumers in the consumers' homes. (EMP2, EMP3)

Findings included:

Observation of EMP2 and EMP3 on February 14, 2020 at approximately 9:30 a.m. revealed neither employee was wearing a photo identification badge.
An interview with EMP2 and EMP3 on February 14, 2020 at approximately 12:15 p.m. revealed that both employees do cover shifts in patient homes and neither had been provided a photo identification badge. EMP 2 states, " I carry a business card and give it to the consumer, so they know who I am. "









Plan of Correction:

Office staff has been re-educated regarding Personnel Policy 108: Dress Code, which states: "A temporary Name Tag will be issued to all employees during their orientation. An official County HomeMakers, Inc. Name Tag will be provided to you within 30 days from your date of hire, and will state the Company's Name, employee's full name, photo and their job title. Your Name Tag must be worn at all time during working hours." The Director of Human Resources will audit all employee files to identify any files that need identification (ID) tags. ID tags will be provided to any employee that is missing one in his/ her file (to include Employees #2 and #3.) and the date provided will be entered into the employee's electronic file. The extra ID tags will be kept in the employee's personnel file. The electronic report showing who has been issued a nametag will be run, printed and e-mailed to the Director of Training and Compliance weekly.


Initial Comments:


Based on the findings of an onsite unannounced state re-licensure survey conducted on February 14, 2020, Westmoreland County Homemakers 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(c) LICENSURE
Federal Criminal History Record

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If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code § 15.144(b) (relating to procedure).

Observations:




Based on review of personnel files (PF), and staff (EMP) interview, it was determined that the agency failed to obtain a federal criminal history report and a letter of determination from the Department of Aging for three (3) of three (3) PFs reviewed who did not have evidence of residence of the Commonwealth within the preceding two years of hire. (PF2,4,8)


Findings included:

PF's reviewed on February 14, 2020 between 12:20 p.m. and 2:00 p.m. revealed:


PF2, date of hire (DOH) 6/25/19, PF failed to contain evidence of residency of the Commonwealth within the preceding two years of hire and failed to contain evidence of a Federal criminal history report.

PF4, DOH 11/9/18, PF failed to contain evidence of residency of the Commonwealth within the preceding two years of hire and failed to contain evidence of a Federal criminal history report.

PF8, DOH 7/1/19, PF failed to contain evidence of residency of the Commonwealth within the preceding two years of hire and failed to contain evidence of a Federal criminal history report.


Exit interview conducted with EMP1, 2, and 3, on February 14, 2020 at approximately 3:00 p.m. confirmed findings.



















Plan of Correction:

Office staff was re-educated on Personnel Policy #109: Clearances & Provisional Employment regarding 2 –year proof of residency. Our policy states: "Employees must provide County HomeMakers, Inc. with proof they have been a resident of the State of Pennsylvania for two years prior to their date of hire. If the employee cannot provide proof, or was not a resident for at least two years prior to their date of hire, the employee must obtain a Federal Criminal History Clearance for 2 Year Proof within 90 days of hire. The employee must provide proof or documentation they submitted for the Federal Criminal History Clearance for 2 Year Proof prior to their hire date. This proof must in their personnel file before they are able to work in a consumer's home. During this 90-day period, employees will be provisionally monitored. If the Federal Criminal History Clearance for 2 Year Proof is not received within 90 days from the date of hire, the employee will be suspended pending receipt of the Federal Clearance. The Federal Criminal History Clearance for 2 Year Proof is in addition to the Pennsylvania State Police Criminal Record Check, Federal Criminal History Check for Child Services and Pennsylvania Child Abuse Clearance. Employees will be responsible to obtain and pay for the Federal Criminal History Clearance for 2 Year Proof ($23.85, as of 1/1/2019). The office must have the original clearance in each employee's personnel file. When applying for the Federal Criminal History Clearance for 2 Year Proof, the employee should use Service Code: 1KG8RJ. County HomeMakers, Inc. is not permitted to accept a volunteer Federal Criminal History Clearance for employment purposes. Acceptable proof of residency documents include: motor vehicle records (specifically driver's license or state-issued identification), housing records (specifically mortgage or rent receipts), public utilities (such as an electric bill, water/sewage bill, garbage, gas/heating bills, etc.), local tax records (must be three years prior to the hire date), completed and signed federal, state or local tax returns with employee's name and address pre-printed (must be three years prior to the hire date), and employment records (including records of unemployment compensation). " All employee files have been audited by the Director of Human Resources to ensure that each file has a valid 2-year proof of residency or an FBI Clearance for the 2 year proof of residency. All new employee files will be monitored by the Assistant Director of Training and Compliance to ensure that either a two-year proof of residency or the FBI for two-year proof of PA residency has been submitted prior to hire date.




611.56(a) LICENSURE
Health Screening

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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 a review of Centers for Disease Control (CDC) guidelines, agency personnel files (PF) and staff (EMP) interview, it was determined the agency failed to ensure direct care workers, prior to consumer contact, ensured the individual had been screened for and was free from active mycobacterium tuberculosis (TB) for three (3) of ten (10) PF reviewed. (PF1,3,& 4)

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...A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST result within the previous 12 months, a single TST can be administered in the new setting...This additional TST represents the second stage of the two-step testing..."


PF's reviewed on February 14, 2020 between 12:20 p.m. and 2:00 p.m. revealed:


PF1, date of hire (DOH) 8/23/19, PF contained TB placed 8/20/19 and read 8/23/19. PF failed to contain evidence of second step TB test.

PF3, DOH 9/24/19, PF contained TB placed 9/16/19 and read 9/18/19. PF failed to contain evidence of second step TB test.


PF4, DOH 11/9/18, PF contained TB placed 10/31/18 and read 11/2/18. PF failed to contain evidence of second step TB test.


Exit interview conducted with EMP1, 2, and 3 , on February 14, 2020 at approximately 3:00 p.m. confirmed findings.







Plan of Correction:

Office staff has been re-educated on Personnel Policy # 112 regarding TB testing, which states: A Two-Step Tuberculin (TB) Skin Test is required of all employees who provide care to consumers (or come into consistent contact with consumers) prior to consumer contact in accordance with CDC Guidelines and the employee will be screened annually thereafter. If the Tuberculin (TB) test reads positive, a clear chest x-ray must be obtained at the cost of the employee not employer. The employee must have their first step administered and read prior to their hire date. They may not begin work until the office receives documentation the first step was read and the employee's test results were negative. The second step must be administered within 21 days of the date the first step was read. If the employee fails to provide a second step within 21 days, they will receive a verbal/written warning for direct rule violation, and provided 10 days to obtain a second step Tuberculin (TB). If the employee fails to comply with their 10-day warning, the employee will be suspended pending receipt of the second step Tuberculin (TB) test. All employee files will be audited by the Director of Human Resources to ensure TB tests are documented correctly in the employees'' personnel files and to identify anyone who is in need of a 2nd step TB test. Any employees identified as needing a second step will obtain one. The Assistant Supervisor of Care will run a weekly 2-step TB report and monitor the report to ensure that all employees are adhering to the 2-step TB policy. For the next 6 weeks, this report will be sent to the Assistant Director of Training and Compliance for her review. After the 6 week period, the Assistant Director of Training and Compliance will run this report monthly to ensure that the office staff continues to monitor the TB test requirements are being met.


611.57(c) LICENSURE
Information to be Provided

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(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 agency admission packet,consumer files (CF), and staff (EMP) interviews it was determined the agency failed to ensure the consumer or the consumer's legal representative was informed of the identity of the direct care worker who would provide the services and the hours when those services would be provided for seven (7) of ten (10) CF's reviewed. (CF1-3,5,6,8,9)

Findings Included:


Interview with EMP1 on February 14, 2020 revealed, " (Consumers) receive and sign the patient profile/care items form that lists the hours, services, and caregiver name upon starting services and quarterly."



CF's reviewed on February 14, 2020 between 9:45 a.m. and 12:10 p.m. revealed:


CF1, start of service (SOS) 11/4/19, CF failed to contain evidence of the identity of the direct care worker who would provide the services and the hours when those services would be provided. CF contained patient profile/care items form void of caregiver identity and not signed by consumer.

CF2, SOS 1/27/18, CF failed to contain evidence of the identity of the direct care worker who would provide the services and the hours when those services would be provided. CF contained patient profile/care items form and not signed by consumer.

CF3, SOS 6/1/19, CF failed to contain evidence of the identity of the direct care worker who would provide the services and the hours when those services would be provided. CF contained patient profile/care items form and not signed by consumer.

CF5, SOS 7/8/19, CF failed to contain evidence of the identity of the direct care worker who would provide the services and the hours when those services would be provided. CF contained patient profile/care items form void of caregiver identity and not signed by consumer.

CF6, SOS 8/14/19, Interview February 14, 2020 at approximately 11:30 a.m. with EMP1 revealed chart unable to be located. No evidence consumer provided with the identity of the direct care worker who would provide the services and the hours when those services would be provided.

CF8, SOS 7/1/19, Interview February 14, 2020 at approximately 11:30 a.m. with EMP1 revealed chart unable to be located. No evidence consumer provided with the identity of the direct care worker who would provide the services and the hours when those services would be provided.

CF9, SOS 9/17/18, CF failed to contain evidence of the identity of the direct care worker who would provide the services and the hours when those services would be provided. CF contained patient profile/care items form and not signed by consumer.



Exit interview conducted with EMP1, 2, and 3, on February 14, 2020 at approximately 3:00 p.m. confirmed findings.








Plan of Correction:

All Consumer Patient Care Item (PCI) sheets have been updated to include the initial Personal Care Aide (PCA) and the Consumer's schedule. All existing Consumers have been mailed an updated PCI. A copy of the PCI (with the date it was mailed documented) is being maintained in the Consumer's file. Office staff is aware that the identity of the initial PCA and the Consumer's schedule must be included on all PCIs going forward and that the PCI is part of the new Consumer packet that each Consumer receives at their Meet and Greet, prior to start of services. The Zone Coordinator will monitor that Consumers are given completed PCIs going forward when she reviews all new files during her monthly consumer file audits.


611.57(d) LICENSURE
Documentation

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(d) The home care agency or home care registry shall maintain documentation on file at the agency or registry of compliance with the requirements of this section which shall be available for Department inspection.

Observations:


Based on review of consumer files (CF) and staff (EMP) interviews it was determined the agency failed to maintain documentation on file at the agency for compliance with the requirements of this section for two (2) of ten (10) CF requested. (CF6 & 8.)



Findings Included:

CF's reviewed on February 14, 2020 between 9:45 a.m. and 12:10 p.m. revealed:


CF6, SOS 8/14/19, Interview February 14, 2020 at approximately 11:30 a.m. with EMP1 revealed chart unable to be located.

CF8, SOS 7/1/19, Interview February 14, 2020 at approximately 11:30 a.m. with EMP1 revealed chart unable to be located.



Exit interview conducted with EMP1, 2, and 3, on February 14, 2020 at approximately 3:00 p.m. confirmed findings.









Plan of Correction:

The Director of Human Resources has audited the Consumer files and compared them to a list of active Consumers to ensure that the office has maintained compliant documentation on file at the agency for each Consumer. Office staff will meet with Consumer #8 (and any other Consumer, if any are discovered during our internal audit) and provide him with the required compliant documentation, which is included in our Welcome Packet. A signed copy of the Welcome Packet is being maintained in the Consumers' files in the office. Consumer #6 is no longer receiving services through our agency and is not interested in receiving any documentation regarding her services; therefore, her file will not be recovered. The Zone Coordinator will run a Consumer list monthly and will include all new consumer files as part of her monthly audits to ensure that office maintains a Consumer file on site for each Consumer.


Initial Comments:




Based on the findings of an onsite unannounced state re-licensure survey conducted on February 14, 2020, Westmoreland County Homemakers was found not to be in compliance with the requirements of 35 P.S. 448.809 (b).















Plan of Correction:




35 P. S. § 448.809b LICENSURE
Photo Id Reg

Name - Component - 00
(1) The photo identification tag shall include a recent photograph of the employee, the employee's FIRST name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.



Observations:


Based on observation and staff (EMP) interview, the agency failed to ensure that two (2) of two (2) staff members observed were issued a photo identification badges which display their name and professional designation/job title when providing services to consumers in the consumers' homes. (EMP2, EMP3)

Findings included:

Observation of EMP2 and EMP3 on February 14, 2020 at approximately 9:30 a.m. revealed neither employee was wearing a photo identification badge.
An interview with EMP2 and EMP3 on February 14, 2020 at approximately 12:15 p.m. revealed that both employees do cover shifts in patient homes and neither had been provided a photo identification badge. EMP 2 states, " I carry a business card and give it to the consumer, so they know who I am. "





Plan of Correction:

Office staff has been re-educated regarding Personnel Policy 108: Dress Code, which states: "A temporary Name Tag will be issued to all employees during their orientation. An official County HomeMakers, Inc. Name Tag will be provided to you within 30 days from your date of hire, and will state the Company's Name, employee's full name, photo and their job title. Your Name Tag must be worn at all time during working hours." Office staff now understands they are to wear their ID tags during times of consumer contact. Employee #2 and Employee #3 have been issued a photo ID tag that meets the Photo ID regulations as described in 35 P.S. 448.809b. The Executive Assistant Director will monitor that name tags are completed for all Administrative Staff during her initial audit of the new employee file.