QA Investigation Results

Pennsylvania Department of Health
ELITE LIVING HOME CARE, LLC
Health Inspection Results
ELITE LIVING HOME CARE, 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 state re-licensure survey conducted on March 4, 2020, Elite Living Home Care, 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 state re-licensure survey conducted on March 4, 2020, Elite Living Home Care, 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 agency policies, direct care worker personnel files (PF), and an interview with the agency CEO and the administrator, the agency failed to document that a face-to-face interview was conducted and/or two (2) satisfactory references were obtained before the first day of employment, for ten (10) of ten (10) personnel files reviewed. (PF #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10).

Findings Include:

Review of agency "Welcome Package and Patient Notices" on March 4, 2020, at approximately 1:45 P.M. states, "Hiring or Rostering of Direct Care Worker Requirements: (a) Hiring or rostering prerequisites. 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 at least 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..."

Review of PF conducted on March 4, 2020, from approximately 12:30 P.M. to 1:45 P.M. revealed the following:

PF #1, date of hire November 4, 2019, contained no documentation of a face-to-face interview or documentation of two (2) satisfactory references.

PF #2, date of hire September 10, 2019, contained no documentation of a face-to-face interview or documentation of two (2) satisfactory references.

PF #3, date of hire July 3, 2019, contained no documentation of a face-to-face interview or documentation of two (2) satisfactory references.

PF #4, date of hire September 16, 2019, contained no documentation of a face-to-face interview or documentation of two (2) satisfactory references.

PF #5, date of hire November 27, 2019, contained no documentation of a face-to-face interview or documentation of two (2) satisfactory references.

PF #6, date of hire April 15, 2019, contained no documentation of a face-to-face interview or documentation of two (2) satisfactory references.

PF #7, date of hire May 31, 2019, contained no doucmentation of a face-to-face interview or documentation of two (2) satisfactory references.

PF #8, date of hire July 9, 2019, contained no documentation of a face-to-face interview or documentation of two (2) satisfactory references.

PF #9, date of hire November 25, 2019, contained no documentation of a face-to-face interview or documentation of two (2) satisfactory references.

PF #10, date of hire September 23, 2018, contained no documentation of a face-to-face interview or documentation of two (2) satisfactory references.

An interview with the agency CEO and the administrator on February 4, 2020, at approximately 2:00 P.M. confirmed the above findings.











































Plan of Correction:

Hiring or Rostering Prequisites:

The corrective action plan accomplished for the individuals identified in the deficiency statement(s) (PF# 1,2,3,4,5,6,7,8,9 and 10) shall ensure (1) A face to face interview is conducted with each individual direct care worker, which will be dated and documented. (2) At least two satisfactory references are obtained for each individual direct care worker, prior to hiring or rostering a direct care worker, which will be dated and documented.
Elite Living Home Care, LLC shall conduct an audit of all current active PF to identify all PF that require (1) A face to face interview (2) Two satisfactory references to become compliant and require those PF to obtain (1) A face to face interview (2) Two satisfactory references.
To ensure that this deficiency in practice does not recur, Elite Living Home Care, LLC shall develop a new hire checklist, and conduct weekly audits until documentation is provided in regards to (1) A face to face interview (2) Two satisfactory references, suspension or termination if documentation is not provided.
Elite Living Home Care, LLC shall conduct quarterly file audits regarding (1) A face to face interview (2) Two satisfactory references to ensure sustained compliance.
The CEO is responsible for monitoring the implementation of the corrective action plan in regards to (1) A face to face interview (2) Two satisfactory references. The corrective action plan shall be completed 5/3/2020.




611.52(a) LICENSURE
Criminal Background Checks

Name - Component - 00
The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.

Observations:


Based on review of agency policy, direct care worker personnel files (PF) and an interview with the agency CEO and the administrator, it was determined that the agency failed to ensure criminal background checks were obtained at the time of application for employment and/or have the potential employee submit documentation of a criminal background check that was obtained within one year preceding the application date for eight (8) of ten (10) PF reviewed. (PF# 1, 2, 4, 5, 6, 7, 9, and 10)

Findings include:

A review of "Employee Handbook and Company Guidelines" on March 4, 2020, at approximately 1:45 P.M. states, "Mandatory Criminal Background Checks: ELHC requires all employees prior to any offer of employment; all employees must successfully pass a state mandatory criminal background check..."

Review of PF conducted on March 4, 2020, from approximately 12:30 P.M. to 1:45 P.M. revealed the following:

PF #1, date of hire November 14, 2019, contained a Pennsylvania State Police criminal background check completed on February 11, 2020.

PF #2, date of hire September 10, 2019, contained a Pennsylvania State Police background check completed on November 6, 2019.

PF #4, date of hire September 16, 2019, contained a Pennsylvania State Police criminal background check completed on November 6, 2019.

PF #5, date of hire November 27, 2019, contained no documentation of a Pennsylvania State Police criminal background check.

PF #6, date of hire April 15, 2019, contained a Pennsylvania State Police criminal background check completed on June 25, 2019.

PF #7, date of hire May 31, 2019, contained a Pennsylvania State Police criminal background check dated June 25, 2019.

PF #9, date of hire November 25, 2019, contained a Pennsylvania State Police criminal background check dated February 11, 2020.

PF #10, date of hire September 23, 2018, contained a Pennsylvania State Police criminal background check dated June 25, 2019.

An interview with the agency CEO and the administrator on March 4, 2020, at approximately 2:00 P.M. confirmed the above findings.












































Plan of Correction:

The corrective action plan accomplished for the individuals identified in the deficiency statement(s) (PF# 1,2,4,5,6,7,9, and 10) shall ensure criminal background checks are obtained at the time of application for employment for each direct care worker, which will be dated and documented.
Elite Living Home Care, LLC shall conduct an audit of all current active PF that require a criminal background check to become compliant and require those PF to obtain a criminal background check.
To ensure that this deficiency in practice does not recur, Elite Living Home Care, LLC shall develop a new hire checklist, and conduct weekly audits until documentation is provided regarding that a criminal background check has been obtained.
Elite Living Home Care, LLC shall conduct quarterly file audits regarding criminal background checks, to ensure sustained compliance.
The CEO is responsible for monitoring the implementation of the corrective action plan regarding criminal background checks. The corrective action plan shall be completed 5/3/2020.


611.52(c) LICENSURE
Federal Criminal History Record

Name - Component - 00
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 a review of agency policy, direct care worker personnel files (PF), and an interview with the agency CEO and the administrator, the agency failed to provide documentation of obtaining Federal criminal history report for one (1) of ten (10) PF. (PF #9).

Findings include:

A review of agency "Employee Handbook and Company Guidelines", conducted on March 4, 2020, at approximately 1:45 P.M. states, "Mandatory Background/Criminal Check: (c) Federal criminal history record. If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall obtain a Federal criminal history record and letter of determination from the Department of Aging , based on the individual's Federal criminal history record..."

A review of PF's conducted on March 4, 2020, from approximately 12:30 P.M. to 1:45 P.M. revealed:

1. PF #9, date of hire November 25, 2019, contained a Delaware driver's license issued on January 21, 2016. There was no documentation in the PF pertaining to length of residency in Pennsylvania. There was no documentation of a Federal criminal history report.

An interview conducted with the agency CEO and the administrator on March 4, 2020, at approximately 2:00 P.M. confirmed the above findings.
























Plan of Correction:

Federal Criminal History Record:

The corrective action plan accomplished for the individual identified in the deficiency statement(s) (PF# 9) shall ensure that at the time of application for employment, if the individual has not been a resident of this Commonwealth for two years preceding the date of the request for a criminal background history report, the individual shall obtain a Federal criminal history record check and letter of determination from the Department of Aging, based on the individual's Federal criminal history record, which will be dated and documented.
Elite Living Home Care, LLC will conduct an audit of all current active PF to identify all PF that require Federal criminal history record checks to become compliant and require those PF to obtain a Federal criminal record check.
To ensure that this deficiency in practice does not recur, Elite Living Home Care, LLC shall develop a new hire checklist, and conduct weekly audits until documentation is provided regarding that a Federal criminal history check is obtained or submitted at the time of application for employment, if the individual has not been a resident of this Commonwealth for two years preceding the date of the request for a criminal history report, the individual shall obtain a Federal criminal history record check.
Elite Living Home Care, LLC shall conduct quarterly file audits regarding Federal criminal history record checks to ensure sustained compliance.
The CEO is responsible for monitoring the implementation of the corrective action plan regarding Federal criminal history record checks. The corrective action shall be completed 5/3/2020.


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 agency policy, direct care worker personnel files (PF), and an interview with the agency CEO and the administrator, the agency failed to document proof of Pennsylvania (PA) 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 for ten (10) of ten (10) PF reviewed. (PF # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10).

Findings include:

A review of "Employee Handbook and Company Guidelines" on March 4, 2020, at approximately 1:45 P.M. states, "Mandatory Background/Criminal Checks: (d) Proof of residency. 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..."

A review of PF conducted on March 4, 2020, from approximately 12:30 P.M. through 1:45 P.M. revealed the following:

PF #1, date of hire November 4, 2019. The agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application.

PF #2, date of hire September 19, 2019, contained a PA driver ' s license issued January 11, 2019. The agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application.

PF #3, date of hire July 3, 2019, contained a PA driver ' s license issued September 6, 2017. The agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application.

PF #4, date of hire September 16, 2019, contained a PA Identification (ID) card issued July 26, 2019. The agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application.

PF #5, date of hire November 27, 2019, contained a PA driver ' s license issued April 6, 2019. The agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application.

PF #6, date of hire April 15, 2019, contained a PA driver ' s license issued May 30, 2017. The agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application.

PF #7, date of hire May 31, 2019, contained a PA driver ' s license issued March 29, 2018. The agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application.

PF #8, date of hire July 9, 2019, contained a PA driver ' s license issued April 13, 2018. The agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application.

PF #9, date of hire November 25, 2019. The agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. No documentation of a federal criminal background check.
PF #10, date of hire September 23, 2018, contained a PA ID issued March 29, 2018. The agency failed to provide proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application.

An interview with the agency CEO and the administrator on March 4, 2020, at approximately 2:00 P.M. confirmed the above findings.







































Plan of Correction:

Proof of Residency:

The corrective action plan accomplished
for the individual's identified in the deficiency statement(s) (PF# 1,2,3,4,5,6,7,8,9, and 10) shall ensure direct care workers provide proof of Pennsylvania(PA) 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 for ten(10) of ten(10) PF reviewed. This information shall be documented and dated.
Elite Living Home Care, LLC shall conduct an audit of all current active PF to identify all PF that require proof of residency to become compliant and require those PF to furnish proof of residency.
To ensure this deficiency in practice does not recur, Elite Living Home Care, LLC shall develop a new hire checklist, and conduct weekly audits until documentation is provided regarding proof of residency has been obtained, suspension or termination if documentation is not provided.
Elite Living Home Care, LLC shall conduct quarterly file audits regarding proof of residency to ensure sustained compliance.
The CEO is responsible for monitoring the implementation of the corrective action plan regarding proof of residency. The corrective action plan shall be completed 5/3/2020.




611.55(a) LICENSURE
Compentency Requirements

Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.

Observations:


Based on review of agency policy, direct care worker personnel files (PF), and an interview with the agency CEO and the administrator, the agency failed to document verification of competency or certification of an accepted training program approved by the Department prior to assigning or referring direct care workers to provide service to a consumer for ten (10) of ten (10) PF reviewed. (PF# 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10).

A review of "Employee Handbook and Company Guidelines" on March 4, 2020, at approximately 1:45 P.M., states, "Job Description: Companion/Caregiver. ...Competency Requirements. (a) Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure the direct care worker has done one of the following... 3. Successfully completed one of the following; A competency examination or training program developed by the agency or registry for a direct care worker ..."

A review of PF conducted on March 4, 2020, from approximately 12:30 P.M. 1:45 P.M. revealed the following:

PF #1, date of hire November 4, 2019, contained no documentation of competency prior to assigning or referring direct care workers to provide service to a consumer.

PF #2, date of hire September 10, 2019, contained no documentation of competency prior to assigning or referring direct care workers to provide service to a consumer.

PF #3, date of hire July 3, 2019, contained no documentation of competency prior to assigning or referring direct care workers to provide service to a consumer.

PF #4, date of hire September 16, 2019, contained no documentation of competency prior to assigning or referring direct care workers to provide service to a consumer.

PF #5, date of hire November 27, 2019, contained no documentation of competency prior to assigning or referring direct care workers to provide service to a consumer.

PF #6, date of hire April 15, 2019, contained no documentation of competency prior to assigning or referring direct care workers to provide service to a consumer.

PF #7, date of hire May 31, 2019, contained no documentation of competency prior to assigning or referring direct care workers to provide service to a consumer.

PF #8, date of hire July 9, 2019, contained no documentation of competency prior to assigning or referring direct care workers to provide service to a consumer.

PF #9, date of hire November 25, 2019, contained no documentation of competency prior to assigning or referring direct care workers to provide service to a consumer.

PF #10, date of hire September 23, 2018, contained no documentation of competency prior to assigning or referring direct care workers to provide service to a consumer.

An interview with the agency CEO and the administrator on March 4, 2020, at approximately 2:00 P.M. confirmed the above findings.
















































Plan of Correction:

Competency Requirements:

(a) The corrective action plan accomplished for the individuals identified in the deficiency statement(s) (PF# 1,2,3,4,5,6,7,8,9, and 10) shall ensure prior to assigning or referring a direct care worker to provide services to a consumer, the direct worker has done one of the following 3... Obtain a valid nurse's license in the Commonwealth of Pennsylvania; Successfully completed a competency examination or training program developed by Elite Living Home Care, LLC or the Department of Health, which will be dated and documented.
Elite Living Home Care, LLC shall conduct an audit of all current active PF to identify all PF that require competency examinations to become compliant and require those PF to obtain a competency examination.
To ensure that this deficiency in practice does not recur, Elite Living Home Care, LLC shall develop a new hire checklist, and conduct weekly audits until documentation is provided regarding competency requirements, suspension or termination if documentation is not provided.
Elite Living Home Care, LLC shall conduct quarterly file audits regarding Competency Requirements to ensure sustained compliance.
The CEO is responsible for monitoring the implementation of the corrective action regarding competency requirements. The corrective action shall be completed 5/3/2020.








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 review of agency policy, direct care worker personnel files (PF) and an interview with the agency CEO and the administrator, the agency failed to ensure an annual competency review was conducted for one (1) of ten (10) PF reviewed. (PF # 10).

Findings include:

A review of "Employee Handbook and Company Guidelines" on March 4, 2020, at approximately 1:45 P.M. revealed no guidelines on annual competency testing.

A review of the PF conducted on March 4, 2020, from approximately 12:30 P.M to 1:45 P.M. revealed the following:

PF #10, date of hire September 23, 2018, did not contain documentation of an annual competency review in 2019.

A interview with the agency CEO and the administrator on March 4, 2020, at approximately 2:00 P.M. confirmed that the above findings.











































Plan of Correction:

Competency Requirements:

(b) The corrective action plan accomplished for the individual identified in the deficiency statement(s) (PF# 10) shall ensure direct care workers employed by Elite Living Home Care, LLC complete an annual competency review 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, which will be dated and documented.
Elite Living Home Care, LLC shall conduct an audit of all current active PF to identify all PF that require a competency review to become compliant and require those PF to obtain a competency review.
To ensure that this deficiency in practice does not recur, Elite Living Home Care, LLC shall develop a monthly competency review checklist, and conduct weekly audits until documentation is obtained regarding competency reviews, suspension or termination if documentation is not provided.
Elite Living Home Care, LLC shall conduct quarterly file audits regarding competency reviews to ensure sustained compliance.
The CEO is responsible for monitoring the implementation of the corrective action plan regarding competency reviews. The corrective action shall be completed 5/3/2020.


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 agency policy, direct care worker personnel files (PF) and an interview with the agency CEO and the administrator, the agency did not conduct testing for mycobacterium tuberculosis according to the Center for Disease Control guidelines prior to hire for seven (7) of ten (10) PF reviewed. (PF #1, 3, 4, 5, 6, 7, and 9).

Findings include:

The CDC guidelines state that all Health Care Workers (HCW) should receive 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 screening annually. HCWs with a baseline positive or newly 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 "Employee Handbook and Company Guidelines" on March 4, 2020, at approximately 1:45 P.M. states, "Tuberculosis Screening Policy: ELHC established and maintains a policy to comply with regulations pertaining to Tuberculosis (TB) screening. All ELHC employees who have direct Patient contact (direct care workers) will be tested for active tuberculosis utilizing a two-step process in accordance with CDC guidelines prior to Patient contact and screened annually thereafter to prevent the potential infection and spread of TB... "

A review of PF conducted on March 4, 2020, from approximately 12:30 P.M. through 1:45 P.M. revealed the following:

PF #1, date of hire November 4, 2019, contained documentation of a single TST completed on April 19, 2019. There was no documentation of a second-step TST being completed.
PF #3, date of hire July 1, 2019, contained documentation of a single TST completed on July 1, 2019. There was no documentation of a second-step TST being completed.
PF #4, date of hire September 16, 2019, contained documentation of a single TST completed on September 9, 2019. There was no documentation of a second-step TST being completed.
PF #5, date of hire November 27, 2019, contained documentation of a single TST completed on November 24, 2019. There was no documentation of a second-step TST being completed.
PF #6, date of hire April 15, 2019, contained documentation of a single TST completed on July 23, 2019. There was no documentation of a second-step TST being completed.
PF #7, date of hire May 31, 2019, contained documentation of a single TST completed on December 31, 2018. There was no documentation of a second-step TST being completed.
PF #9, date of hire November 25, 2019, contained documentation of a single TST completed on January 31, 2018. There was no documentation of a two-step TST being completed.
Interview with the agency CEO and the administrator on March 4, 2020, at approximately 2:00 P.M. confirmed the above findings.






























































Plan of Correction:

Health Screening:

The corrective action plan accomplished for the individuals identified in the deficiency statement(s) (PF# 1,3,4,5,6,7, and 9) shall ensure that each direct care worker and other staff or contractors with direct consumer contact, provide documentation that the individual has been screened for and free from active mycobacterium tuberculosis. A two-step tuberculin skin test shall be obtained for individuals employed by Elite Living Home Care, LLC at the time of application for employment, anyone that has a baseline positive or newly positive test for tuberculosis infections will receive one chest radiograph result to exclude tuberculosis disease, which will be dated and documented.
Elite Living Home Care, LLC shall conduct an audit of all current active PF to identify all PF that require a two-step tuberculosis screening to become compliant and require those PF to obtain a two-step tuberculosis screening.
To ensure that this deficiency does not recur, Elite Living Home Care, LLC shall develop a new hire checklist, and conduct weekly audits until documentation is provided in regards that a two-step tuberculosis screening has been obtained, suspension or termination if documentation is not provided.
Elite Living Home Care, LLC shall conduct quarterly file audits regarding two-step tuberculosis screenings to ensure sustained compliance.
The CEO is responsible for monitoring the implementation of the corrective action regarding Health Screenings (two-step tuberculosis screenings). The corrective action shall be completed 5/3/2020.


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 agency policy, direct care worker personnel files (PF) and an interview with the agency CEO and the administrator, the agency did not conduct testing for mycobacterium tuberculosis according to the Center for Disease Control guidelines annually for one (1) of ten (10) PF reviewed. (PF #10).

Findings include:

The CDC guidelines state that all Health Care Workers (HCW) should receive 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 screening annually. HCWs with a baseline positive or newly 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 "Employee Handbook and Company Guidelines" on March 4, 2020, at approximately 1:45 P.M. states, "Tuberculosis Screening Policy: ELHC established and maintains a policy to comply with regulations pertaining to Tuberculosis (TB) screening. All ELHC employees who have direct Patient contact (direct care workers) will be tested for active tuberculosis utilizing a two-step process in accordance with CDC guidelines prior to Patient contact and screened annually thereafter to prevent the potential infection and spread of TB... "

A review of PF conducted on March 4, 2020, from approximately 12:30 P.M. to 1:45 P.M. revealed the following:

PF #10, date of hire September 23, 2019, contained documentation of an initial two-step Tuberculin skin test (TST) completed on May 21, 2018, and June 1, 2018. There was no documentation of an annual screening for tuberculosis conducted in 2019.

An interview with the agency CEO and the administrator, on March 4, 2020, at approximately 2:00 P.M. confirmed the above findings.










































Plan of Correction:

Health Screening:

(b) The corrective action plan accomplished for the individual(s)identified in the deficiency statement(s) (PF# 10) shall ensure that each direct care worker, and other office or contractors with direct consumer contact, complete a TB symptom questionnaire, and training regarding the risks and symptoms of TB at least every 12 months, which will be dated and documented. The 12 months will run from the date of the last TB evaluation.




Elite Living Home Care, LLC will date and document tuberculosis evaluations for Health Care Workers, and will be kept in the individuals file.
Elite Living Home Care, LLC shall conduct an audit of all current active PF to identify all PF that require an annual tuberculosis examination to become compliant and require those PF to obtain an annual TB examination.
To ensure that this deficiency does not recur, Elite Living Home Care, LLC shall develop a monthly TB examination checklist, and conduct weekly audits until documentation is provided in regards to annually tuberculosis examination screenings from the date of the last tuberculosis examination screening, suspension or termination if documentation is not provided.
Elite Living Home Care, LLC shall conduct quarterly file audits regarding annually tuberculosis examination screenings (The 12 months will run from the date of the last tuberculosis evaluation) to ensure sustained compliance.
The CEO is responsible for monitoring the implementation of the corrective action regarding annually tuberculosis examination screenings. The corrective action shall be completed 5/3/2020.




611.57(a) LICENSURE
Consumer Rights

Name - Component - 00
(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

Observations:

Based on review of the consumer packet, consumer records (CR) and interview with the agency CEO and the administrator, the agency failed to provide documentation that the consumer had received information regarding the right to receive at least ten (10) calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than ten (10) days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk for ten (10) of ten (10) CR reviewed. (CR#'s 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10)

Findings include:

Review of CR conducted on March 4, 2020, from approximately 10:45 A.M. to 12:00 P.M. revealed the following:

CR# 1, start of care October 24, 2019, did not contain documentation that the consumer had received information regarding the right to receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

CR# 2, start of care September 11, 2019, did not contain documentation that the consumer had received information regarding the right to receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

CR# 3, start of care July 15, 2019, did not contain documentation that the consumer had received information regarding the right to receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

CR# 4, start of care September 15, 2019, did not contain documentation that the consumer had received information regarding the right to receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.


CR# 5, start of care November 25, 2019, did not contain documentation that the consumer had received information regarding the right to receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

CR# 6, start of care April 15, 2019, did not contain documentation that the consumer had received information regarding the right to receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

CR# 7, start of care May 29, 2019, did not contain documentation that the consumer had received information regarding the right to receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

CR# 8, start of care July 8, 2019, did not contain documentation that the consumer had received information regarding the right to receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

CR# 9, start of care December 9, 2019, did not contain documentation that the consumer had received information regarding the right to receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

CR# 10, start of care September 26, 2018, did not contain documentation that the consumer had received information regarding the right to receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

An interview with the agency CEO and the administrator on March 4, 2019, at approximately 2:00 P.M. confirmed the above findings.










Plan of Correction:

Consumer Rights:

The corrective action plan accomplished for the individuals identified in the deficiency statement(s) (CR#'s 1,2,3,4,5,6,7,8,9, and 10) shall ensure that each consumer receive a consumer information packet regarding the right to receive at least 10 calender days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk. This information shall be dated, documented, and inserted in the consumer's file.
Elite Living Home Care, LLC shall conduct an audit of all current active CR to identify all CR that require a consumer information+ packet to become compliant and require those CR to obtain a consumer information packet, which will be dated, documented, and inserted in the consumer's file.
To ensure that this deficiency does not recur, Elite Living Home Care, LLC shall develop a new consumer checklist, and conduct weekly audits until documentation is provided regarding consumer information packets.
Elite Living Home Care, LLC shall conduct quarterly file audits regarding consumer packets, to ensure sustained compliance.
The Administrator is responsible for monitoring the implementation of the corrective action regarding consumer packets.
The corrective action shall be completed 5/3/2020.








611.57(c) LICENSURE
Information to be Provided

Name - Component - 00
(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 review of the consumer packet, consumer records (CR) and interview with the agency CEO and the administrator, the agency failed to provide documentation prior to the commencement of services, the home care agency or home care registry provided 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. (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) for ten (10) of ten (10) CR reviewed. (CR# 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10)

Findings include:

Review of CR conducted on March 4, 2020, from approximately 10:45 A.M. through 12:00 P.M. revealed the following:

CR# 1, start of care October 24, 2019, did not contain documentation that the consumer received the following information prior to the start of services: (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. (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).

CR# 2, start of care September 11, 2019, did not contain documentation that the consumer received the following information prior to the start of services: (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. (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).

CR# 3, start of care July 15, 2019, did not contain documentation that the consumer received the following information prior to the start of services: (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. (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).

CR# 4, start of care September 15, 2019, did not contain documentation that the consumer received the following information prior to the start of services: (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. (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).

CR# 5, start of care November 25, 2019, did not contain documentation that the consumer received the following information prior to the start of services: (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. (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).

CR# 6, start of care April 1, 2019, did not contain documentation that the consumer received the following information prior to the start of services: (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. (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).

CR# 7, start of care May 29, 2019, did not contain documentation that the consumer received the following information prior to the start of services: (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. (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).

CR# 8, start of care July 8, 2019, did not contain documentation that the consumer received the following information prior to the start of services: (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. (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).


CR# 9, start of care December 9, 2019, did not contain documentation that the consumer received the following information prior to the start of services: (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. (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).

CR# 10, start of care September 26, 2018, did not contain documentation that the consumer received the following information prior to the start of services: (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. (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).

An interview with the agency CEO and the administrator on March 4, 2019, at approximately 2:00 P.M. confirmed the above findings.











Plan of Correction:

Information to be Provided:

The corrective action plan accomplished for the individuals identified in the deficiency statement(s) (CR#'s 1,2,3,4,5,6,7,8,9, and 10) shall ensure that documentation is provided prior to the commencement of services per 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)The Department of Health's complaint Hot Line (1800-254-5164) and the telephone number of the Obudsman Program located with the local Area Agency on Aging (AAA).

Elite Living Home Care, LLC shall conduct an audit of all current active CR to identify all CR that require the information that shall be provided into the consumer packet to become compliant and require those CR to obtain this information that shall be provided in the consumer packet.
To ensure that this deficiency does not recur, Elite Living Home Care, LLC shall develop a new consumer checklist, and conduct weekly audits until documentation is provided in regards to the information being added to the consumer packet.
Elite Living Home Care, LLC shall conduct quarterly file audits in regards that this information has been added to the consumer packet to ensure sustained compliance.
The Administrator is responsible for monitoring the implementation of the corrective action in regards to the information being added to the consumer packet.
The corrective action shall be completed 5/3/2020.



Initial Comments:


Based on the findings of an onsite unannounced state re-licensure survey conducted on March 4, 2020, Elite Living Home Care, LLC 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 an interview with the agency CEO and the administrator and observation of the office staff, the agency failed to ensure that all staff were issued a photo identification badge.

Findings Include:

On March 4, 2020, at approximately 11:00 A.M., the agency CEO and the administrator were observed not wearing the required photo identification badge.

An interview with the agency CEO and the administrator, at approximately 2:00 P.M. confirmed that the staff were not issued photo identification badges.











































Plan of Correction:

Photo ID Regulation:

The corrective action plan accomplished for the individuals identified in the deficiency statement(s) (Entire Staff) shall ensure that all staff are issued a photo identification badge. The photo identification badge shall include a recent photograph of the employee, the employee's title and the name of our health care facility.
Elite Living Home Care, LLC shall conduct an audit of all current active staff required to obtain a photo identification badge.
To ensure that this deficiency does not recur, Elite Living Home Care, LLC shall develop a new hire checklist, and conduct weekly audits until photo identification badges are provided to all staff.
Elite Living Home Care, LLC shall conduct quarterly file audits regarding photo identification badges to ensure sustained compliance.
The Administrator is responsible for monitoring the implementation of the corrective action regarding photo identification badges.
The corrective action shall be completed 5/3/2020.