Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on September 6, 2024, Anastasia Care Services, 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 September 6, 2024, Anastasia Care Services, LLC, 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 (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) 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 September 6, 2024 at approximately 12:45 pm.
PF #1 Date of Hire 7/10/2020. PF contained two (2) references, however only one reference was verified. PF contained a PATCH (Pennsylvania State Policey Criminal Background check) that was dated for 8/13/2020.
PF#2 Date of Hire 6/17/2024 , PF did not contain documentation that a face to face interview was conducted and no documentation that two satisfactory and verifiable references were obtained. PF contained a PATCH that was dated for 9/02/2024.
PF#3 Date of Hire 8/04/2022 PF did not contain documentation that a face-to-face interview was conducted prior to hire, no documentation of two satisfactory and verifiable references were obtained. PF contained a PATCH that was dated for 11/18/2022.
PF#4 Date of Hire 10/27/2020. PF contained a PATCH that was dated for 5/06/2021.
PF#5 Date of Hire 6/17/2022, PF did not contain documentation of two satisfactory and verifiable references were obtained. PF contained a PATCH that was dated for 11/18/2022.
PF#6 Date of Hire 8/15/2024 , PF did not contain documentation of two satisfactory and verifiable references were obtained. PF did not contain documentation that a PATCH was obtained prior to date of hire.
PF#7 Date of Hire 11/17/2021. PF contained a PATCH that was dated for 10/21/2021, however, PATCH resulted in Under Review and no results were obtained by the agency.
An interview with the administrator on September 6, 2024 at approximately 2:30 pm confirmed the above findings.
Plan of Correction:PF#1
We will verify the other reference.
We will ensure that in the future the criminal background check is done prior to employment.
PF#2
We will conduct a post- employment face to face interview and file it accordingly.
We will ensure that in the future the criminal background check is done prior to employment.
PF#3
We will conduct a post- employment face to face interview and file it accordingly.
We will obtain and verify two references and file them accordingly.
We will ensure that in the future the criminal background check is done prior to employment.
PF#4
We will ensure that in the future the criminal background check is done prior to employment.
PF#5
We will obtain and verify two references and file them accordingly.
We will ensure that in the future the criminal background check is done prior to employment.
PF#6
We will obtain and verify two references and file them accordingly.
We will ensure that in the future the criminal background check is done prior to employment.
PF#7
We will conduct another PATCH and also ensure that in the future the criminal background check is done prior to employment.
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 3).
Findings include:
A review of PF's was conducted on September 6, 2024 at approximately 12:45 PM.
PF#1 Date of Hire 7/10/2020. PF did not contain documentation that proof of residency was obtained prior to hire.
PF#3 Date of Hire 8/04/2022. PF did not contain documentation that proof of residency was obtained prior to hire.
An interview conducted with the administrator on September 6, 2024 at approximately 2:30 PM confirmed the above findings.
Plan of Correction:PF#1
We will obtain evidence of prior residency such as an old ID, old Rent receipts or old utility bills, or old tax returns that prove residency and file in PF#1 personal file.
PF#3
We will obtain evidence of prior residency such as an old ID, old Rent receipts or old utility bills, or old tax returns that prove residency and file in PF#3 personal file.
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, and a review of agency exam, which indicated a passing score of 85% score required for each applicant, prior to assigning or referring a direct care worker to provide services to a consumer, for two (2) of seven (7) PF reviewed. (PF#1 and 7)
Findings include:
A review of PF conducted on September 6, 2024 at appropriately 12:45 pm revealed the following:
PF #1, Date of Hire 7/10/2020. PF contained an initial competency exam dated for 7/21/2020. Exam did not contain a score.
PF#7, Date of Hire 11/17/2021. PF contained an initial competency exam dated for 10/22/2021. Exam contained a score of 78%.
An interview conducted with the agency administrator on September 6, 2024 at approximately 2:30 PM confirmed the above findings.
Plan of Correction:PF#1
We will grade the initial competency test and if found deficit will make the PF#1 do another test. A passing result will be filed in the personal file. F necessary we will ensure the PF#1 undergoes another training and orientation.
PF#7
We retest the PF#7will grade the initial competency test and if found deficit will ensure the PF#7 undergoes another training and orientation.
We will make PF#7 do another test. A passing result will be filed in the personal file.
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 administrator, the agency failed to ensure that an annual competency was performed for four (4) of seven (7) PF's reviewed: (PF#1,4,5 and 7).
Findings include:
A review of personnel files (PF) was conducted on September 6, 2024 starting at 12:45 PM.
PF#1, Date of Hire 7/10/2020. PF did not contain annual competency for 2021, 2022 and 2024.
PF#4 Date of Hire 10/27/2020. File did not contain an annual competency for 2021, 2022 and 2023.
PF#5 Date of Hire 6/17/2022. File did not contain an annual comptency for 2024.
PF#7 Date of Hire 11/17/2021. File did not contain an annual competency for 2023.
An interview with the administrator on September 6, 2024 starting at 2:30 PM, confirmed the above findings.
Plan of Correction:Plan of Correction:
PF#1 Will be made to undergo a competency test in addition to the existing annual training and this will subsequently be incorporated annually and filed
PF#4 Will be made to undergo a competency test in addition to the existing annual training and this will subsequently be incorporated annually and filed
PF#5 Will be made to undergo a competency test in addition to the existing annual training and this will subsequently be incorporated annually and filed.
PF#7 Will be made to undergo a competency test in addition to the existing annual training and this will subsequently be incorporated annually and filed.
In addition to the above stated individual plans of correction:
1. We will designate one of our staff members as a compliance officer going forward, to oversee every area of these corrected plans and generally oversee our compliance with all the requirements of the PA Code 28 Chapter 611. Home Care Agencies and Home Care Registries.
2. To protect patients in similar situations, We will review the operating policies affecting all the plans for correction to update each one of them to encompass the omissions that necessitated a plan of correction. This is to ensure that the problems do not recur.
3. Indicate how it plans to monitor its performance to make sure that solutions are sustained; and
4. All dates when corrective action will be completed have been included.
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 seven (7) of seven (7) PF's, (PF#1, 2,3,4,5, 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 September 6, 2024 from approximately 12:45 pm.
PF #1, Date of Hire: 7/10/2020. PF contain documentation of a one (1) step PPD that was conducted on 2/11/2020. No documentation that a two (2) step PPD was obtained upon hire. PF did not contain documentation that the agency conduct a tuberculosis symptom screening/ risk assessment upon hire. File did not contain documentation that annual TB education was conducted for 2021, 2022, 2023 and 2024.
PF #2, Date of Hire: 6/17/2024. PF contain documentation of a one (1) step PPD that was conducted on 6/26/2024. No documentation that a two (2) step PPD was obtained upon hire.
PF #3, Date of Hire: 8/04/2022. PF did not contain documentation that annual TB education was conducted for 2023 and 2024.
PF#4, Date of Hire: 10/27/2020. PF did not contain documentation that a two (2) step PPD was obtain upon hire. PF did not contain documentation that the agency conduct a tuberculosis symptom screening/ risk assessment upon hire. File did not contain documentation that annual TB education was conducted for 2022 and 2023.
PF#5, Date of Hire: 6/17/2022. PF did not contain documentation that the agency conduct a tuberculosis symptom screening/ risk assessment upon hire. File did not contain documentation that annual TB education was conducted for 2023 and 2024.
PF#6, Date of Hire: 8/15/2024. PF contain documentation of a one (1) step PPD that was conducted on 3/26/2024. No documentation that a two (2) step PPD was obtained upon hire. PF did not contain documentation that the agency conduct a tuberculosis symptom screening/ risk assessment upon hire.
PF#7, Date of Hire: 11/17/2021 PF did not contain documentation that annual TB education was conducted for 2022 and 2023.
An interview with the administrator on September 6, 2024 at approximately 2:30 pm confirmed the above findings.
Plan of Correction:PF #1 Will be made to undergo another Quantiferon Test and if negative the results will be entered in PF#1's file. If positive, this will be reported to the local health care authorities and PF#1 prevented from work until cleared to do so.
Annual TB Education will be conducted for PF#1 and this will be incorporated for ALL HCWs moving forward.
PF #2 Will be made to undergo another Quantiferon Test and if negative the results will be entered in PF#2's file. If positive, this will be reported to the local health care authorities and PF#1 prevented from work until cleared to do so.
PF#3 Will be made to undergo another Quantiferon Test and if negative the results will be entered in PF#3's file. If positive, this will be reported to the local health care authorities and PF#3 prevented from work until cleared to do so.
Annual TB Education will be conducted for PF#3 and this will be incorporated for ALL HCW moving forward.
PF#4 Will be made to undergo a Quantiferon Test and if negative the results will be entered in PF#4's file. If positive, this will be reported to the local health care authorities and PF#4 prevented from work until cleared to do so.
Annual TB Education will be conducted for PF#4 and this will be incorporated for ALL HCWs going forward.
PF#5 Will be made to undergo a Quantiferon Test and if negative the results will be entered in PF#5's file. If positive, this will be reported to the local health care authorities and PF#5 prevented from work until cleared to do so.
Annual TB Education will be conducted for PF#5 and this will be incorporated for ALL HCWs going forward.
PF#6 Will be made to undergo a Quantiferon Test and if negative the results will be entered in PF#6's file. If positive, this will be reported to the local health care authorities and PF#6 prevented from work until cleared to do so.
Annual TB Education will be conducted for PF#6 and this will be incorporated for ALL HCW moving forward.
PF#7 Will be made to undergo a Quantiferon Test and if negative the results will be entered in PF#7's file. If positive, this will be reported to the local health care authorities and PF#7 prevented from work until cleared to do so.
Annual TB Education will be conducted for PF#7 and this will be incorporated for ALL HCW moving forward.
In addition to the above stated individual plans of correction:
1. We will designate one of our staff members as a compliance officer going forward, to oversee every area of these corrected plans and generally oversee our compliance with all the requirements of the PA Code 28 Chapter 611. Home Care Agencies and Home Care Registries.
2. To protect patients in similar situations, We will review the operating policies affecting all the plans for correction to update each one of them to encompass the omissions that necessitated a plan of correction. This is to ensure that the problems do not recur.
3. Indicate how it plans to monitor its performance to make sure that solutions are sustained; and
4. All dates when corrective action will be completed have been included.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey, Anastasia Care Services, LLC., on September 6, 2024, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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