Initial Comments:
An off-site follow-up survey conducted on August 26, 2019, found that Mother's Love Home Health Care Assistance Inc., had corrected the deficiencies cited under the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
The deficiencies were cited as a result of a re-licensure survey completed on April 25, 2019.
Plan of Correction:
Initial Comments:
An off-site follow-up survey conducted on August 26, 2019, found that Mother's Love Home Health Care Assistance Inc., had not corrected the deficiencies cited under the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries. The deficiencies were cited as a result of a state re-licensure survey conducted on April 25, 2019.
Plan of Correction:
611.51(b) LICENSURE
Direct Care Worker Files
Name - Component - 00
Files for direct care workers employed or rostered shall include documentation of the date of the face-to-face interview with the individual and of references obtained. Direct Care Worker files also shall include other information as required by § 611.52, § 611.53, if applicable, § 611.54, § 611.55 and § 611.56 (relating to criminal background checks, child abuse clearance, provisional hiring, competency requirements; and health evaluations).
Observations:
Based on review of agency's plan of corrections, personnel file review(PF) and an interview with the agency's administrator, it was determined the agency failed to ensure documentation of obtaining two satisfactory references prior to rostering direct care workers for one (1) out of five (5) PF's reviewed (PF# 5); failed to demonstrate documentation that a federal criminal history was obtained for personnel not residing in the this Commonwealth for the two years immediately preceding the date of the request for a criminal history report in one (1) out of five (5) personnel files reviewed. (PF# 3); failed to provide proof of residency in one (1) out of five (5) personnel files reviewed. (PF# 5); failed to ensure direct care workers were screened for and were free from active mycobacterium tuberculosis (TB) prior to assignment with consumers two (2) out of five (5) files reviewed. (PF# 2 and PF#5 ).
Review of Agency's plan of correction, approved by the Department on 5/16/19, on 8/26/2019 at approximately 8:45 AM revealed, "1. Going forward, all face-to-face interviews will be documented and properly dated. Current files will be updated to include the required documentation. 2. Two satisfactory references will also be obtained prior to rostering direct care workers. Current file will also be updated. 3. Current files will be updated to include criminal history report on all files. 4. The file concerned will be updated to reflect proof of residency. 5. All files will be updated to included documentation confirming that direct care workers were screened and are free from active TB. This will include two-step TST..' " A checklist will be developed to prevent incomplete files going forward. An internal audit will be done every 3 months to ensure compliance and sustainability. Executive Director will monitor and ensure all corrective actions are completed in a timely manner. Executive Director will ensure continued compliance.."
Findings include:
Personnel files #1-#5 were reviewed on 8/26/2019 from approximately 09:00 AM-9:30 AM, revealing the following:
PF#2 (DOH: 11/29/18): Contained no updated documentation of a two-step TST on hire.
PF#3 (DOH: 11/20/18): Contained no updated documentation of PA ID being issued with no other proof of PA residency being verified prior to the start date. file contained documentation of a Florida state driver's license being issued 3/2018, with no Federal criminal history record documented.
PF#5 (DOH: 3/26/19): contained documentation of only one (1) reference being verified; contained no documentation of PA ID being issued with no other proof of PA residency being verified prior to the start date. file contained documentation of a New York ID being issued 10/11/18.; contained no documentation of a two-step TST on hire.
An interview with the agency executive director on August 26, 2019 at approximately 9:30 AM confirmed the above findings.
Plan of Correction:Aide referred to as PF # 5 was given until 9/10/19 to provide a copy of all required documents. She has been advised that her services will be terminated if documents are not presented by the specified date. In the meantime, The CEO, Grace Minto will constantly monitor this Aide to protect the patient. (a new Aide with all required documents was already assigned). Documents were sent off on 9/16/19. To prevent any further infractions, an Administrative Assistant was hired to monitor all documentations and to ensure compliance using the checklist that was created. This will be one of her major functions.
PF #3 - In reviewing this file it was determined that the documents were already on file. They probably had gotten lost in the fax transmission to the auditor. This was re-sent to her on 9/12/19.
PF # 2 - In reviewing this file it was determined that the document was already on file. It had probably gotten lost in the fax transmission to the auditor. This was re-sent to her on 9/12/19.
Initial Comments:
An off-site follow-up survey conducted on August 26, 2019, found that Mother's Love Home Health Care Assistance Inc., had corrected the deficiencies cited under the requirements of 35 P.S. 448.809 (b).The deficiencies were cited as a result of a re-licensure survey completed on April 25, 2019.
Plan of Correction:
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