Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on August 1, 2024, Affectionate Reliable 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 onsite unannounced state re-licensure survey conducted on August 1, 2024, Affectionate Reliable Care, was not found 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 Personal files (PF) and an interview with the administrator, the agency failed to ensure that 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 for seven (7) of the seven (7) PF's, (PF#1,2,3,4,5,6 and 7).
Findings include:
A review of PF's was conducted on August 1, 2024 at approximately 12:00 pm.
PF#1 Date of Hire 8/8/2019. PF did not contain two satisfactory and verifiable references.
PF#2 Date of Hire 9/01/2023. PF did not contain any documentation of a face to face interview and did not contain (2) two satisfactory and verifiable references.
PF#3 Date of Hire 3/05/2024. PF did not contain any documentation of a face to face interview and did not contain (2) two satisfactory and verifiable references.
PF#4 Date of Hire 5/04/2024. PF did not contain any documentation of a face to face interview and did not contain (2) two satisfactory and verifiable references.
PF#5 Date of Hire 2/23/2024. PF did not contain any documentation of a face to face interview and did not contain (2) two satisfactory and verifiable references.
PF # 6 Date of Hire 3/10/2023. PF did not contain any documentation of a face to face interview and did not contain (2) two satisfactory and verifiable references.
PF # 7 Date of Hire 11/01/2019. PF did not contain (2) two satisfactory and verifiable references.
An interview with the administrator on August 1, 2024 at approximately 1:15 pm confirmed the above findings.
Plan of Correction:Affectionate Reliable Care fully intends to comply with the laws set forth by the Department of Health section 611.51a
Face to Face interviews will be uploaded to Employee Profile
Reference Check Form will be added and uploaded to Employee Profile.
We will monitor and amend internal documentation to ensure information has been saved in the proper sections between our payroll and the Talent Acquistion platforms. We will audit employee profiles on the Good Hire platform which digital documentation is kept for each employee hire. We will review quarterly.
611.52(b) LICENSURE
State Police Criminal History Record
Name - Component - 00
If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.
Observations:
Based on review of personnel files (PF), and interview with the administrator, it was determined that a personnel file did not include documentation of a State Police Criminal History report on hire for two (2) of seven (7) personnel files reviewed. (PF#1 and 7)
Findings Include:
Review of personnel files (PF), was conducted on August 1, 2024 at approximately 12:00 PM determined:
PF#1: Date of Hire: 8/8/2019 - PF contained a Pennsylvania Access To Criminal History report (PATCH) dated for 4/26/2023.
PF#7 Date of Hire: 11/01/2019 - File did not contain documentation that a PATCH was obtain prior to hire.
Interview with administrator on August 1, 2024 at approximately 1:15 PM confirmed the above findings.
Plan of Correction:Affectionate Reliable Care will comply with section 611.52b.
1)Criminal Background Checks will be uploaded to Employee Profile.
2)As Affectionate Reliable Care moved to an online platform for employee files, we will ensure that the transfer of old records have been restored completely to the employee profiles by doing an internal audit to be complete by September 15th, 2024.
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 personnel files (PF) and an interview with the administrator determined that the agency failed to document proof of Pennsylvania (PA) residency preceding date of hire 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 two (2) of seven (7) PF's reviewed, (PF#1 and 2).
Findings include:
A review of PF's was conducted on August 1, 2024 from approximately 12:00 PM - 12:50 PM
PF#1 Date of Hire 8/8/2019. PF did not contain documentation that proof of residency was obtained prior to hire.
PF#2 Date of Hire 09/21/2023. PF did not contain documentation that proof of residency was obtained prior to hire.
An interview conducted with the administrator on August 1, 2024 at approximately 1:15 PM confirmed the above findings.
Plan of Correction:Affectionate Reliable Care will comply with section 611.52d.
1)Proof of Residency will be recorded in the online profile.
When the hiring process occurs through our online talent acquisition platform, it is mandatory to upload proof of residency in compliance with I-9 forms. We will continue to review each hire to be sure documentation uploaded is current. Anyone new to PA, will comply with regulations set forth by the State of Pennsylvania and Department of Health. Proof of e-verify is done on each employee, and saved in their profile. we will review each employee as they are hired to ensure information is accurate and shared between platforms.
We will conduct monthly audit of new hires. We will conduct quarterly audits of employee profiles to ensure our auto alerts to update Id's as they become expired or a change of address form /residency certification form is updated.
611.55(a) LICENSURE
Competency 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 personnel files (PF), and an interview with the agency administrator, it was determined the agency failed to demonstrate, prior to assigning or referring a direct care worker to provide services to a consumer, competency by passing an initial competency examination for five (5) of seven (7) PF reviewed. (PF#2,3,4, 5 and 6)
Findings include:
A review of PF conducted on August 1, 2024 at appropriately 12:00 pm revealed the following:
PF#2 Date of Hire 9/01/2023PF did not contain a score indicating a passing score for the initial competency examination prior to hire.
PF #3, Date of Hire 3/5/2024. PF did not contain a score indicating a passing score for the initial competency examination prior to hire.
PF#4 Date of Hire 5/4/2024. PF did not contain a score indicating a passing score for the initial competency examination prior to hire.
PF#5 Date of Hire 2/23/2024. PF did not contain a score indicating a passing score for the initial competency examination prior to hire.
PF#6 Date of Hire 3/10/2023. PF did not contain an initial competency examination prior to hire.
An interview conducted with the agency administrator on August 1, 2024 at approximately 1:15 PM confirmed the above findings.
Plan of Correction:Affectionate Reliable Care will comply with section 611.55a.
Competency test scores will be recorded and uploaded to employee profiles.
Yearly training certificates will be uploaded to the employee profile.
We are working with our online platform to ensure the test results are saved in the proper section. We will review before each hire and every training.
611.55(e) LICENSURE
Competency Requirements
Name - Component - 00
The competency review must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction.
Observations:
Based on a review of personnel files (PF) and an interview with the President/ CEO, the agency failed to ensure that an annual competency was performed for three (3) of seven (7) PF's reviewed: (PF #1,6 and 7).
Findings include:
A review of personnel files (PF) was conducted on August 1, 2024 starting at 12:00 PM.
PF#1 Date of hire 8/8/2019. File did not contain an annual competency for 2021, 2022 and 2023.
PF#6 Date of hire 3/10/2023. File did not contain an annual comptency for 2024.
PF#7 Date of hire 11/01/2019. File did not contain an annual competency for 2021 and 2023.
An interview with the administrator on August 1, 2024 starting at 1:15 PM, confirmed the above findings.
Plan of Correction:Affectionate Reliable Care will comply with section 611.55c.
Affectionate Reliable Care requires yearly training. We utilize an online platform for training. A certificate is issued upon completion.
When there is a disciplinary action such as a verbal warning or suspension, due to quality-of-care infraction a retraining is required.
We will continue to audit monthly and quarterly to ensure documentation is recorded between platforms.
611.56(a) LICENSURE
Health Screening
Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.
Observations:
Based on a review of personnel files (PF), Centers for Disease Control Guidelines, and an interview with the administrator, the agency failed to provide documentation that the individual has received baseline tuberculosis screening upon hire and symptom screening/risk assessment initially and TB education annually for four (4) of seven (7) PF's, (PF#1, 2, 6 and 7).
Findings include:
In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: receive baseline tuberculosis screening upon hire by using: a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB), or a negative chest x-ray to test for infection with tuberculosis. 2. Completion of a tuberculosis symptom questionnaire. And 3. Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCWs should receive TB education annually. HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(5-16-19)
A review of PF's was conducted on August 1, 2024 from approximately 12:00 pm.
PF #1, Date of Hire: 8/8/2019. PF did not contain documentation that the agency conduct a tuberculosis symptom screening upon hire.
PF #2, Date of Hire: 9/01/2023. PF did not contain documentation that a two (2) step tuberculin skin test (TST) was performed upon hire.
PF #6, Date of Hire: 3/10/2023. PF did not contain documentation that a two (2) step tuberculin skin test (TST) was performed upon hire. PF did not contain documentation that an initial symptom screening / risk assessment was upon hire.
PF#7, Date of Hire: 11/01/2019. Agency failed to conduct a tuberculosis symptom screening/ risk assessment upon hire and annual TB education for 2021, 2022 and 2023.
An interview with the administrator on August 1, 2024 at approximately 1:15 pm confirmed the above findings.
Plan of Correction:Affectionate Reliable Care will fully comply with section 611.56a.
Health Screening:
(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.
An internal audit of all employee office records will be complete by September 15th, 2024 to ensure all information is linked between online platforms. We will continue to enforce this mandated requirement upon each hire.
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 a review of consumer files (CF) and an interview with the administrator, 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. (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 for five (5) of the five (5) CF's reviewed. (CF#1,2,3,4 and 5)
Findings include:
A review of CF's were conducted on August 1, 2024 starting at approximately 11:00 AM indicated the following with the Start of Care (SOC) indicated below:
CF#1 Start of Care 3/28/2023. File did not contain the identity of the direct care worker, hours when services will be provided. No phone number was listed as to 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. The telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) was not listed for all counties served. No information was listed regarding the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. 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 was incomplete.
CF#2 Start of Care 1/23/2024. File did not contain the hours when services will be provided. No phone number was listed as to 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. The telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) was not listed for all counties served. No information was listed regarding the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. 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 was incomplete.
CF#3 Start of Care 5/04/2023. File did not contain the identity of the direct care worker, hours when services will be provided. No phone number was listed as to 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. The telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) was not listed for all counties served. No information was listed regarding the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. 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 was incomplete.
CF#4 Start of Care 1/6/2024. File did not contain the hours when services will be provided. No phone number was listed as to 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. The telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) was not listed for all counties served. No information was listed regarding the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. 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 was incomplete.
CF#5 Start of Care 1/16/2023. File did not contain hours when services will be provided. No phone number was listed as to 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. The telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) was not listed for all counties served. No information was listed regarding the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. 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 was incomplete.
An interview conducted with the administrator on August 1, 2024 starting at 1:15 PM confirmed the above findings.
`
Plan of Correction:0820:
c.Affectionate Reliable Care has corrected the language in the Welcome Packet.
The consumer will complete the welcome packet in full. We will review each new client to ensure proper completion of the documents and attach a schedule when they become active/approved.
1.We will ensure the list of home care services is complete and the name of the caregiver is filled in.
2.We will fill in the preferred schedule of their hours. We will also reference HHA for their approved schedules.
3.A list of fees with be provided if/when applicable.
4.The Pennsylvania Department of Health Licensure contact phone number has been listed in the correct field.
5.The AAA's list has expanded to surround areas of Philadelphia County and is now listed in the correct field.
6.The hiring and competency requirements are outlined.
7.The disclosure format includes the possible responsibility and repective tax/insurance responsibilities to the consumer.
We will continue to amend the service agreements and consumer disclosure to address the program and needs of said consumer. We will continue semi-annual on-going education to stay up to date on changes and implement within 30 days.
We will audit all our consumer files by 10/01/2024 to reflect the said changes. We will review and approve each new consumer agreement. Monthly reviews of new consumers will be conducted by a secondary auditor. Quartey audits will be done ongoing.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on August 1, 2024, Affectionate Reliable Care, was not found 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
Law amended July 11, 2022 Act 79 2022 HB 2604
(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.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.
(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) All other titles shall be determined by the
department. 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 a review of personnel files (PF) and an interview with the administrator, the agency did not provide photo identification badges in accordance with regulation for seven (7) of seven (7) PFs. (PF# 1, 2, 3,4,5,6, and 7).
Findings include:
A review of personnel files (PF) was conducted on August 1, 2024 at 12:00 PM. The date of hire (DOH) is indicated below:
PF#1 DOH 8/8/2019 did not contain a photo identification badge.
PF#2 DOH 9/01/2023 did not contain a photo identification badge.
PF#3 DOH 3/5/2024 did not contain a photo identification badge.
PF#4 DOH 5/04/2024 did not contain a photo identification badge.
PF#5 DOH 2/23/2024 did not contain a photo identification badge.
PF#6 DOH 3/10/2023 did not contained a photo identification badge.
PF#7 DOH 11/01/2019 did not contain a photo identification badge.
An interview with the administrator on August 1, 2024 at 1:15 PM confirmed that none of the employees were provided with a photo identification badge.
Plan of Correction:Affectionate Reliable Care will comply with.
35 P. S. § 448.809b LICENSURE
Photo Id Reg:
Law amended July 11, 2022 Act 79 2022 HB 2604
Every employee will be issued an ID badge upon hiring. We will upload Id badge to the employee profile for record keeping. A review of each employee and the recording of their badges will be complete by September 15th, 2024.
|