QA Investigation Results

Pennsylvania Department of Health
CARING ANGELS HOME CARE, LLC
Health Inspection Results
CARING ANGELS HOME CARE, LLC
Health Inspection Results For:


There are  3 surveys for this facility. Please select a date to view the survey results.

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 unannounced, on-site state re-licensure survey conducted on May 11, 2021, Caring Angels Home Care, 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 unannounced, on-site state re-licensure survey conducted on May 11, 2021, Caring Angels Home Care, 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:




611.4(c) LICENSURE
Requirements for HCA and HCR

Name - Component - 00
Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.

Observations:


Based observations and an interview with the agency Director (EMP# 1), it was determined the agency failed to ensure visual alerts were posted at the office entrance providing instructions about wearing a well-fitting form of source control... for one (1) of one (1) observations (Observation #1) and the agency failed to ensure that everyone entering the health care facility is screened and triaged for COVID-19 for one (1) of one (1) observations. (Observation #2)

Findings Include:

Pennsylvania Department of Health 'Health Alert Network' dated April 9, 2021 'Subject' 'UPDATE: Interim Infection Prevention and Control
Recommendations for Healthcare Settings during the COVID-19
Pandemic' (B) 'Screen and Triage Everyone Entering a Healthcare Facility for signs and symptoms of COVID-19':....symptom screening remains an important strategy to identify those who could have COVID-19... Post visual alerts (e.g., signs, ;posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about wearing a well-fitting form of source control and how and when to perform hand hygiene...". "Screen everyone (patients, healthcare personnel, visitors) entering the facility for symptoms consistent with COVID-19 .....". "Actively take their temperature and document absence of symptoms consistent with COVID-19".

Observation #1: No posters or signage observed posted on the agency office door entrance.

Observation #2: No screening process noted upon entry to the office building. On May 11, 2021 at approximately 9:57 a.m. the state surveyor began the onsite survey. The state surveyor was not screened in any manner for COVID-19.
An interview conducted with EMP# 1 on May 11, 2021 at approximately 3:15 p.m. confirmed the above findings.







Plan of Correction:

Plan of Action for Observation #1:
Agency EMP#1 will create and implement a poster or signage in accordance with PA Department of health Alert Dated April 9, 2021. Base on the above Alert, EMP #1 will implement a system were everyone entering the office building will be screen for signs and symptoms of Covid-19 to identify those who have Covid-19 and those who are also symptom free. EMP #1 will also develop a visual alerts signs and posters at the office entrance, waiting areas, and inside the office showing detail Alert instructions in various appropriate languages, on how to wear masks, and when to perform hand hygiene. EMP# 1 will also create a spread sheet were all patients, care workers, and visitors entering the office building will be screen with temperature check for symptoms consistent with Covid-19 and will consistently document the absence of Covid-19 these screening are going to be done upon arrival at the facility. EMP# 1 will also implement an electronic monitoring system in which, prior to arrival at the facility, people will report absence of fever and symptoms of COVID-19, absence of a diagnosis of SARS-CoV-2 infection in the prior 10 days, and confirm they have not been exposed to others with SARS CoV-2 infection during the prior 14 days.
visitor will be ask if they have been advised to self-quarantine because of exposure before entering the building. EMP# 1 will encourage visitors to put on their own well-fitting form of source control before entering the facility and will Instruct patients to call ahead and discuss the need to reschedule their appointment if:
▪ They have symptoms of COVID-19 within 10 days prior to their appointment.
▪ If they have been diagnosed with SARS-CoV-2 infection within the 10 days prior to their appointment.
▪ If they have had close contact with someone with suspected or confirmed SARSCoV-2 infection within 14 days prior to their scheduled appointment. Also, individual will be screen upon arrival, visitors will be also asked to report absence of fever and symptoms of COVID-19, absence of a diagnosis of SARS-CoV-2 infection in the prior 10 days, and confirm they have not been exposed to others with SARS CoV-2 infection during the prior 14 days. In other to adhere to the above deficiencies EMP #1 will continue to monitor the number of visitor entering the facility in making sure they are properly screen in accordance with Corvid 19 Department of health standards and to make sure the above deficient practice does not occur again.



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 review of employee files (EFs) and interview with agency Director (EMP #1), it was determined agency failed to maintain documentation of a face-to-face interview for six (6) of six (6) EFs reviewed (EF# 1-6); and failed to maintain documentation of two satisfactory references prior to hiring or rostering direct care workers for three (3) of six (6) EFs reviewed. (EF# 2, EF# 4 and EF# 6)
Findings include:
Review of EFs conducted on May 11, 2021 between approximately 9:45 a.m. and 10:30 a.m. revealed the following:
EF# 1, Date of Hire (DOH), 6/30/2019: No documentation of face-to-face being conducted prior to hiring or rostering direct care worker.
EF# 2, DOH, 9/20/2019: No documentation of face-to-face being conducted prior to hiring or rostering direct care worker and no documentation of two references being verified prior to hiring or rostering direct care worker. One reference conducted on 7/18/2019.
EF# 3, DOH, 2/10/2021: No documentation of face-to-face being conducted prior to hiring or rostering direct care worker.
EF# 4, DOH, 2/14/2021: No documentation of face-to-face being conducted prior to hiring or rostering direct care worker and no documentation of two references being verified prior to hiring or rostering direct care worker.
EF# 5, DOH, 6/15/2018: No documentation of face-to-face being conducted prior to hiring or rostering direct care worker.
EF# 6, DOH, 11/31/2019: No documentation of face-to-face being conducted prior to hiring or rostering direct care worker and no documentation of two references being verified prior to hiring or rostering direct care worker.
An interview conducted with EMP# 1 on May 11, 2021 at approximately 3:15 p.m. confirmed the above findings.











Plan of Correction:

For EF1: MB/AM/CC/CM/AD/JS # 6-6, EMP#1 will create and implement a face to face interview questionnaire to be use during hiring process, and will make sure all the EF1 6-6 are giving a face to face interview document to be read and signed stating they adhere to the face to face interview questions and it is verify that they met the hiring process. EMP#1 will maintain a documentation of the sign face to face interview in employee's files verifying they met the hiring requirements. In other to avoid the deficiencies from reoccurring, EMP#1 will audit 6-6 EFs files 100% of the charts monthly to monitor that the deficiency practice does not reoccur again.

For EF# 2, EF# 4 and EF# 6 EMP#1 will obtained satisfactory references from the above employee and will verify their employment history with previous employers and will document the respond received in each employee folders. EMP#1 will also developed a computer tracking system and a check list during hiring process in other to make sure all documentation are submitted and reference are being verify before hiring or rostering a direct care worker. In other to avoid the above deficiency, EMP#1 will conduct a quarterly review of 100% of employee charts in verifying if employee reference has been verify and are satisfactory before hiring or rostering, face to face interview is done and documented.



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 review of employee files (EFs) and interview with agency Director (EMP #1), it was determined agency failed to 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) for one (1) of six (6) EFs reviewed. (EF# 1)

Findings include:
Review of EFs conducted on May 11, 2021 between approximately 9:45 a.m. and 10:30 a.m. revealed the following:

EF# 5, Date of Hire (DOH), 6/15/2018: No Federal criminal history record and/or a letter of determination obtained from the Department of Aging.
An interview conducted with EMP# 1 on May 11, 2021 at approximately 3:15 p.m. confirmed the above findings.






Plan of Correction:

For EF#1 1 OF 6 reviewed, EMP#1 will obtained a federal criminal background check upon finding out an individual job application or employment history shows they have not been a PA resident for 2 years. EMP#1 will also add on agency job application a question indicating a federal background check and a letter of determination from the department of aging will be obtained from applicants base on individuals federal criminal records. Base on EF'S reviewed, EMP#1 will create an excel sheet were all job applicants applications and all necessary documents will enter to be reviewed in other to prevent the reoccurrence of the above deficient practice. In other to avoid the reoccurrences of the above deficiency, EMP#1 will conduct a quarterly self audit of 5 charts which is 90% of employee files or will conduct a monthly self audit, to monitor that the deficiency practice will not recur.


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 employee files (EFs) and interview with agency Director (EMP #1), it was determined agency failed to ensure proof of residency for one (1) of six (6) EFs reviewed. (EF# 5)

Findings include:
Review of EFs conducted on May 11, 2021 between approximately 9:45 a.m. and 10:30 a.m. revealed the following:

EF# 5, Date of Hire (DOH), 6/15/2018: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained Pa. Drivers License issued 3/21/2017-3/12/2020
An interview conducted with EMP# 1 on May 11, 2021 at approximately 3:15 p.m. confirmed the above findings.







Plan of Correction:

Based on the EF#5 reviewed, EMP#1 will implement a policy change on employee handbooks and also on job applications stating all applicants are required to submit or obtain a criminal history record to furnish proof of residency through submission of any of the following documents:
1. Local Tax record
2. Employment records, including records of unemployment compensations
3. Motor vehicle records, such as a valid driver's license, or a state issued identification.
4. public utility records and receipts, such as electric bills.
EMP#1 will also implement a new checklist upon interviewing applicants
that will be used to ensure deficient practice does not reoccur.
EMP#1 will also conduct quarterly audits on employees charts by 5 of the 6 charts which is 90% of the charts and will document any findings of incomplete proof of residency.




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 employee files (EFs) and interview with agency Director (EMP #1), it was determined agency failed to demonstrate, prior to assigning or referring a direct care worker to provide services to a consumer, competency by passing a competency examination for four (4) of six (6) EFs reviewed. (EF# 1-4)
Findings include:
Review of EFs conducted on May 11, 2021 between approximately 9:45 a.m. and 10:30 a.m. revealed the following:
EF# 1, Date of Hire (DOH), 6/30/2019: No documentation showing an initial competency completed prior to assigning or referring a direct care worker to provide services to a consumer. Competency certificate dated 8/25/2019, 25 days after initial worked shift on 6/30/2019.
EF# 2, DOH, 9/20/2019: . No documentation showing an initial competency completed prior to assigning or referring a direct care worker to provide services to a consumer.
EF# 3, DOH, 2/10/2021: No documentation showing an initial competency completed prior to assigning or referring a direct care worker to provide services to a consumer. Competency certificate dated 5/10/2021, 89 days after initial worked shift on 2/10/2021.
EF# 4, DOH, 2/14/2021: No documentation showing an initial competency completed prior to assigning or referring a direct care worker to provide services to a consumer.
An interview conducted with EMP# 1 on May 11, 2021 at approximately 3:15 p.m. confirmed the above findings.






Plan of Correction:

Base on review of EF#1-4, EMP#1, will implement a checklist were all new hired initial competency test will be enter successfully upon completion and passing the test before an employee is sent to provide services at any client's house.
EMP#1 will also track employee's competency trainings by auditing each employee's charts 4 out of 6 charts will be audited monthly which is 80% of the charts to make sure staff complete initial competency test are done they have successfully passing the test. EMP#1 will monitor the auditing system and also creating a checklist, practice will help in preventing the deficiency from recurring.
EMP#1 will also develop a system were all hired staff competency test will be keep in their folders with initial competency test date and time it was taking and their hired dates documented to avoid the recurrences of the deficient practice from recurring. EMP# will also make sure EF's initial certificates are file appropriately.



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 employee files (EFs) and interview with agency Director (EMP #1), it was determined agency failed to complete competency review at least once per year after initial competency for three (3) of six (6) EFs reviewed. (EF# 1, EF# 2, and EF# 6)

Findings include:
Review of EFs conducted on May 11, 2021 between approximately 9:45 a.m. and 10:30 a.m. revealed the following:
EF# 1, Date of Hire (DOH), 6/30/2019: No documentation of completed annual competency exam for year 2020.

EF# 2, DOH, 9/20/2019: No documentation of completed annual competency exam for year 2020.

EF# 6, DOH, 11/31/2019: No documentation of completed annual competency exam for year 2020.

An interview conducted with EMP# 1 on May 11, 2021 at approximately 3:15 p.m. confirmed the above findings.









Plan of Correction:

Base on the review for EF# 1, EF# 2,and EF# 6 findings, EMP#1 will obtain an annual competency test from all the employee's at the beginning of each year by creating a computer tracking program in an excel form.
- to help with the dates, times, year, and the due dates as reminders when it is time for EF's to retake the competency test. EMP#1 will also create a checklist to make sure documentations on the completion of the competency test are recorded in a timely manner, prevent deficiencies from reoccurring.
EMP#1 will also conduct a monthly self audit my selecting 5 charts out of 6 which is 90% of the charts quarterly, to monitor that the deficiencies does not reoccur by putting the following additional measures in place:
-Monthly self audit, creating a computer tracking system to enter the dates and time, documentation of completion of annual competency exam for year 2020
--monitoring the agency's an annual competency exams dates it was giving, in other to avoid the deficiencies from reoccurring.



611.56(a) LICENSURE
Health Screening

Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.

Observations:


Based on review of employee files (EFs) and interview with agency Director (EMP #1), it was determined agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, were screened for and free from active mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for six (6) of six (6) EFs reviewed. (EF# 1- 6)
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) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. 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.)
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
Review of EFs conducted on May 11, 2021 between approximately 9:45 a.m. and 10:30 a.m. revealed the following:
EF# 1, Date of Hire (DOH), 6/30/2019: No documentation provided of a completed symptom screen questionaire and an individual TB risk assessment upon hire.
EF# 2, DOH, 9/20/2019: No documentation provided of a completed symptom screen questionaire and an individual TB risk assessment upon hire.
EF# 3, DOH, 2/10/2021: No documentation provided of a completed symptom screen questionaire, an individual TB risk assessment upon hire and no documentation of a baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB). Documentation of one TST on 7/6/2020-7/8/2020.
EF# 4, DOH, 2/14/2021: No documentation provided of a completed symptom screen questionaire, an individual TB risk assessment upon hire and no documentation of a baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB). Documentation of one TST on 2/13/2021-2/15/2021.
EF# 5, DOH, 6/15/2018: No documentation provided of a completed symptom screen questionaire, an individual TB risk assessment upon hire and no documentation of a baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB).
EF# 6, DOH, 11/31/2019: No documentation provided of a completed symptom screen questionaire and an individual TB risk assessment upon hire.
An interview conducted with EMP# 1 on May 11, 2021 at approximately 3:15 p.m. confirmed the above findings.









Plan of Correction:

Base on EFs 1 to 6 review,EMP#1 will obtain a tuberculosis testing two steps testing upon interviewing candidates. The two steps must be completed and candidates must show they are free from tuberculosis by a medical a doctor before offering any employment to that candidates or getting in contact with consumers. EMP#1 will also implement Tuberculosis questionnaires to be completed my staff following their first year of employment with the agency to determine if the staff is not expose to tuberculosis. base on the questions they have answered, EMP#1 will conduct a quarterly audit by selecting 5 charts which is 90% of the charts, this audit will be base on reviewing staff hired dates, when tuberculosis first testing was taking and the due dates for the questionnaires in other to avoid the deficiencies from reoccurring again. Based on the cited EFs files 6 of 6, EMP#1 will provide a a tuberculosis test questionnaire to be completed in accordance with CDC guidelines to determine if they are free from tuberculosis.


611.56(b) LICENSURE
Health Screening

Name - Component - 00
(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.

Observations:


Based on review of employee files (EFs) and interview with agency Director (EMP #1), it was determined agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, were provided with annual mycobacterium tuberculosis education for two (2) of six (6) EFs reviewed. (EF# 1 and EF# 5)

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) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. 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.)
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
Findings include:
Review of EFs conducted on May 11, 2021 between approximately 9:45 a.m. and 10:30 a.m. revealed the following:
EF# 1, Date of Hire (DOH), 6/30/2019: No documentation provided of annual 2020 TB education.
EF# 5, DOH, 6/15/2018: No documentation provided of annual 2019 TB education.

An interview conducted with EMP# 1 on May 11, 2021 at approximately 3:15 p.m. confirmed the above findings.









Plan of Correction:

For EF# 1 and EF# 5, EMP#1 will create/implement a mycobacterium tuberculosis education based on CDC guidelines. EMP#1 will also form questions based on CDC guidelines and will make sure staff are trained annually to avoid deficiencies from reoccurring.
--EMP#1 will audit an entire EFs charts, quarterly and will document the findings to avoid the deficiencies from reoccurring. Base on the deficiencies cited on the review, EMP#1 will educate the employee's that shown deficiencies on CDC guidelines of mycobacterium tuberculosis education questions.



611.57(b) LICENSURE
Prohibitions

Name - Component - 00
(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

Observations:


Based on review of consumer files (CFs) and interview with agency Director (EMP #1), it was determined agency failed to inform the consumer that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry and failed to inform the consumer that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer for three (3) of five (5) CFs reviewed. (CF# 2, CF# 3 and CF# 5).
Findings include:
Review of CFs conducted on May 11, 2021 between approximately 10:32 a.m. and 10:55 a.m. revealed the following:
CF# 2, Date of Hire (DOH), 10/13/20109: No documentation of consumer notification that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer.
CF# 3, DOH, 10/14/2019: No documentation of consumer notification that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer.
CF# 5, DOH, 3/23/2018: No documentation of consumer notification that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer.
An interview conducted with EMP# 1 on May 11, 2021 at approximately 3:15 p.m. confirmed the above findings.









Plan of Correction:

For CFs EMP#1 will implement a change in CFs welcoming package, which is normally completed during an initial contact with CFs before services can begin. In order to avoid the reoccurrence of the deficiencies practices,
EMP#1 WILL:
---implement a change in agency welcoming package informing consumers that the home care agency or home care registry will not endorse checks over to the home care agency or home care registry, and also not assume power of attorney of the consumer to any of the consumers enroll through the agency.
---EMP#1 will also develop a new consumer package, which will reflect a change in agency policies like:

EMP#1 will distribute a new consumer welcoming package to be reviewed and signed indicating they have understood the package.
---EMP#1 will develop a checklist system were EMP#1 will audit 6 out 6 charts monthly to avoid the reoccurrence of the deficiencies.




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 consumer files (CFs) and interview with agency Director (EMP #1), it was determined agency failed to provide, prior to the commencement of services, to the consumer the identity of the direct care worker who will provide the services to five (5) of five (5) CFs reviewed (CF# 1-5); failed to provide the hours when those services will be provided to four (4) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3 and CF# 5); failed to provide the fees and total costs for those services on an hourly or weekly basis to four (4) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3 and CF# 5); failed to provide the contact number of the Pa. Department of Health for licensure requirements or compliance information about a particular home care agency or home care registry to five (5) of five (5) CFs reviewed (CF# 1-5); failed to provide 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) to two (2) of five (5) CFs reviewed (CF# 3 and CF# 5; failed to provide the hiring and competency requirements applicable to direct care workers employed by the home care agency to four (4) of five (5) CFs reviewed (CF# 2, CF# 3, CF# 4 and CF#5); and failed to provide a disclosure, in a format to be published by the Department in the Pennsylvania Bulletin, addressing the employee or independent contractor status of the direct care worker providing services to the consumer to one (1) of five (5) CFs reviewed (CF# 2)
Findings include:
Review of CFs conducted on May 11, 2021 between approximately 10:32 a.m. and 10:55 a.m. revealed the following:
CF# 1, Date of Hire (DOH), 7/30/2017: No documentation of providing the consumer the identity of direct care worker who will provide the services; of providing the hours when those services will be provided; of providing the fees and total costs for those services on an hourly or weekly basis and of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information
CF# 2, DOH, 10/13/2019: No documentation of providing the consumer the identity of direct care worker who will provide the services; of providing the hours when those services will be provided; of providing the fees and total costs for those services on an hourly or weekly basis and of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information; of providing the hiring and competency requirements applicable to direct care workers employed by the home care agency and no documentation provided a disclosure, in a format to be published by the Department in the Pennsylvania Bulletin, addressing the employee or independent contractor status of the direct care worker
CF# 3, DOH, 10/14/2019: No documentation of providing the consumer the identity of direct care worker who will provide the services; of providing the hours when those services will be provided; of providing the fees and total costs for those services on an hourly or weekly basis and of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information; providing 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); and providing the hiring and competency requirements applicable to direct care workers employed by the home care agency
CF# 4, DOH, 2/1/2021: No documentation of providing the consumer the identity of direct care worker who will provide the services; of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information; and providing the hiring and competency requirements applicable to direct care workers employed by the home care agency
CF# 5, DOH, 3/23/2018: No documentation of providing the consumer the identity of direct care worker who will provide the services; of providing the hours when those services will be provided; of providing the fees and total costs for those services on an hourly or weekly basis and of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information; providing 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); and providing the hiring and competency requirements applicable to direct care workers employed by the home care agency
An interview conducted with EMP# 1 on May 11, 2021 at approximately 3:15 p.m. confirmed the above findings.









Plan of Correction:

For CFs 1-5, EMP#1 will implement a change in employee's welcome package, by updating the package to address the deficiencies that were address on the review. Below are the measures the agency will put in place:
---EMP#1 will update client's welcome package by adding a section that will clearly state the direct care workers name that will be sent to consumer homes. Consumer will also signed that the agency has informed them about their direct care worker prior to starting
---EMP#1 will also conduct an internal audit of all consumer files monthly to make sure all appropriate documentations are file including the hours, fee, and cost of the services they are receiving.
In other to avoid deficiencies from reoccurring, EMP#1 will create a check list, were all audited monthly data's will be entered base on the consumer's welcoming package.
---EMP#1 will also update the agency's consumer welcoming package by adding the Department's complaint Hot Line, telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) for each consumer county.
EMP#1 will also conduct an ongoing monitoring on the above deficiencies in other to prevent the
reoccurrence.



Initial Comments:


Based on the findings of an unannounced, on-site state re-licensure survey conducted on May 11, 2021, Caring Angels Home Care, 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 review of ID requirements and interview with agency Director (EMP #1), it was determined agency failed to provide Identification Badges (ID) and format ID badges per requirements to six (6) of six (6) Direct Care Workers (DCW). (DCW#1-6).

Findings included:

Based on viewing Identification badge (ID) on May 11, 2021 at 1:00 p.m., badge revealed title was inch tall instead of required inch tall font. Title was not in block type font and did not occupy the bottom edge of the badge.

An interview conducted with EMP# 1 on May 11, 2021 at approximately 3:15 p.m. confirmed the above findings.






Plan of Correction:

The Agency's director will create and provide all staff of the agency with Identification Badges (ID) that is in compliance with the format ID badge. requirements.

The format of the badge title will be an inch tall font, in block type font at the bottom edge of the badge.