QA Investigation Results

Pennsylvania Department of Health
BLUE MOUNTAIN HOME HEALTH CARE, INC.
Health Inspection Results
BLUE MOUNTAIN HOME HEALTH CARE, INC.
Health Inspection Results For:


There are  5 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:


Based on the findings of an onsite unannounced complaint investigation survey completed /3/2020, Blue Mountain Home Health 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 complaint investigation survey completed 3/3/2020, Blue Mountain Home Health Care, was found to be not 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:




611.52(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 upon review of agency policy, personnel files (PF), and interview with administrator ( EMP #1), agency failed to show evidence a criminal history report from PA state was obtained for one (1) of three (3) files reviewed. ( PF # 1).

Findings included:

Review of agency policy on 3/3/2020, at approximately 12:30 PM-1:00 PM titled " Background Check (Policy: HR.002)" stated " agency conducts background checks on all job candidates post-offer...The background check screening included.. A. Pennsylvania Criminal Background check (upon hire)"


Review of PF on 2/28/2020, between approximatley 10:30 AM-11:45 AM, revealed:

PF # 1, Date of Hire (DOH) 1/10/2020; no evidence PA criminal history report was obtained.

Interview with EMP # 1 on 3/3/2020, at approximately 12:55 PM confirmed above findings.













Plan of Correction:

1. What corrective action will be accomplished for those individuals and/or practices identified in the deficiency statements?

Administrative assistant will review staff files of individuals identified during survey and will conduct state police background check for them.

2. How will you identify other individuals having the potential to be affected by the same deficient practice?

Administrative assistant will review staff files of all current staff and ensure that state police background check are present in the staff files.

3. What measures (actions/forms/system changes, etc. ) will be put in place to ensure that the deficient practice does not reoccur?

The Agency is planning on adopting a new staff checklist, which will include:

-Face to Face interview and review.

-Two satisfactory reference check confirmation.

-Appropriate Background Check confirmation

-2 Year Residency confirmation

This checklist will be part of the application package and all new staff files will have this checklist. The Administrator will check off items during the hiring process.

4. How will the corrective action be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance programs will be established or followed?

Administrator will conduct quarterly review of new staff files and document findings in a quarterly report. The report will be discussed within the office administration in order to ensure compliance.

5. Date of when the corrective action will be completed?

The corrective action will be completed on 4-20-2020.


611.52(c) LICENSURE
Federal Criminal History Record

Name - Component - 00
If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code 15.144(b) (relating to procedure).

Observations:


Based upon review of agency policy, personnel files (PF), and interview with administrator ( EMP #1), agency failed to show evidence FBI fingerprinting was obtained for one (1) of three (3) files reviewed. ( PF # 1).

Findings included:

Review of agency policy on 3/3/2020, at approximately 12:30 PM-1:00 PM titled " Background Check (Policy: HR.002)" stated " agency conducts background checks on all job candidates post-offer...The background check screening included. C. FBI Background Check ( if PA residenct less than 2 years).

Review of PF on 2/28/2020, between approximatley 10:30 AM-11:45 AM, revealed:

PF # 1, Date of Hire (DOH) 1/10/2020; current Maryland (MD) driver's license, no evidence FBI fingerprinting was obtained.

Interview with EMP # 1 on 3/3/2020, at approximately 12:55 PM confirmed above findings.














Plan of Correction:

0320. Federal Background
Check:

1.What corrective action will be accomplished for those individuals and/or practices identified in the deficiency statements?

Administrative assistant will review staff files of individuals identified during survey and will conduct state police background check for staff where a 2 year PA residency can be established. If a 2 year PA residency cannot be established, then the staff will be required to submit to a federal background check.

2.How will you identify other individuals having the potential to be affected by the same deficient practice?

Administrative assistant will review staff files of all current staff and ensure that a state police background check is present in the file in case a 2 year Pennsylvania residency is established. If a 2 year PA residency cannot be established then the staff will be required to submit to a federal background check.

3. What measures (action/forms/system changes,ect.) will be put in place to ensure that the deficient practice does not reoccur?

The agency is planning on adopting a new staff checklist, witch will include:

-Face to Face interview & review

-Two satisfactory reference check confirmation

-Appropriate Background Check confirmation

-2 Year Residency confirmation

This checklist will be part of the application package and all new staff files will have this checklist.The administrator assistant will check off items during the hiring process.

Administration will require staff to submit to a Federal Background Check if the staff member has recently moved to Pennsylvania or is unable to establish a continuous 2 year residency.

4. How will the corrective action be monitored to ensure that the deficient practice will not recur,i.e. what quality assurance programs will be established or followed?

Administrative assistant will conduct quarterly review of new staff files and document findings in a quarterly report. The report will be discussed within the office administration in order to ensure compliance.

5.Date of when the corrective action will be completed?

The corrective actions will be implemented by 4/20/2020.


611.52(d) LICENSURE
Proof of Residency

Name - Component - 00
The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation

Observations:


Based upon review of agency policy, personnel files (PF), and interview with administrator ( EMP #1), agency failed to show evidence employee resided in PA for two consecutive years prior to hire for one (1) of three (3) files reviewed. (PF # 3).

Findings included:

Review of agency policy on 3/3/2020, at approximately 12:30 PM-1:00 PM titled " Background Check (Policy: HR.002)" stated " agency conducts background checks on all job candidates post-offer...The background check screening included. C. FBI Background Check ( if PA resident less than 2 years).

Review of PF on 2/28/2020, between approximatley 10:30 AM-11:45 AM, revealed:

PF # 3, Date of Hire (DOH) 7/22/19; current PA driver's license with issue date of 8/31/18. No documentation of PA residency for 2017.

Interview with EMP # 1 on 3/3/2020, at approximately 12:55 PM confirmed above findings.











Plan of Correction:

0330. Proof of Residency:

1. What corrective action will be accomplished for those individuals and/or practices identified in the deficiency statements?

Administrative assistance will review staff files of individuals identified during survey and will conduct state police background check for staff where a 2 year PA residency can be established. If a 2 year PA residency cannot be established, the the staff will be required to submit to a federal background check.

2. How will you identify other individuals having the potential to be affected by the same deficient practice?

Administrative assistant will review staff files of all current staff and ensure that a state police background check is present in the file in case a 2 year Pennsylvania residency is established. If a 2 year PA residency cannot be established then the staff will be required to submit to a federal background check.

3. What measures (actions/forms/system changes,etc.) will be put in place to ensure that the deficient practice does not reoccur?

The agency is planning on adopting a new staff checklist, which will include:

Face to Face interview & review

-Two satisfactory reference check confirmation

-Appropriate Background Check confirmation

-2 Year Residency confirmation

This checklist will be part of the application package and all new staff files will have this checklist. The Administrator will check off items during the hiring process.

Administration will require staff to submit to a Federal Background Check if the staff member has recent moved to Pennsylvania or is unable to establish a continuous 2 year residency.

The 2 year continuous residency at the time of application will be verified through various sources, some of which are given below:

1. State issued Photo ID's

2. Employment records covering past 2 years

3. Rent/lease agreements

4. Utility Bills

5. Medical Records

If 2 year residency is not established then Federal Background Check will be requested.

4. How will the corrective action be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance programs will be established or followed?

Administrator will conduct quarterly review of new staff files and document findings in a quarterly report. The report will be discussed within the office administration in order to ensure compliance.

5. Date of when the corrective action will be completed?

The corrective actions will be implemented by 4/20/2020


611.55(d) LICENSURE
Competency Requirements

Name - Component - 00
(d) The home care agency or home care registry shall include documentation of the direct care worker's satisfactory completion of competency requirements in the direct care worker's file.

Observations:


Based upon review of agency policy, personnel files (PF), and interview with administrator ( EMP #1), agency failed to include documentation of satisfactory completion of competency for one (1) of three (3) files reviewed. ( PF # 3).

Findings included:

Review of agency policy on 3/3/2020, at approximately 12:30 PM-1:00 PM titled " Home Health Aide: Training/Evaluation/Supervision (Policy: HR.020)" stated " (B.) competency evaluation: (d). " Must achieve a passing score on the written/oral exam of 80 % in all required categories."

Review of PF on 2/28/2020, between approximately 10:30 AM-11:45 AM, revealed:

PF # 3, Date of Hire (DOH) 7/22/19; competency tool was not dated so, no means to determine if test was completed prior to initial consumer contact.

Interview with EMP # 1 on 3/3/2020, at approximately 12:55 PM confirmed above findings.












Plan of Correction:

0610. Competency
Requirements:

1. What corrective action will be accomplished for those individuals and/or practices identified in the deficiency statements?

Administrator will review staff files of individuals identified during survey and will complete the annual competency evaluations for them

2. How will you identify other individuals having the potential to be affected by the same deficient practice?

All existing current staff files will be reviewed and all staff with more then 12 month work history with agency will be required to undertake the Annual Competency Evaluation. The certificate/record of completion of Annual assessment will be kept in the staff file.

3. What measures (actions/forms/system changes,etc.) will be put in place to ensure that the deficient practice does not reoccur?

The Agency is planning on adopting its own internal Competency Evaluation which will comply with Section 611.55 Subsection (b) and (c).

All new staff applications which are received on or after 4/20/2020 will have to go through this Competency Evaluation and an Evaluation Completion Certificate will be added to each new staff file. Competency Assessments will include Bathing,Shaving,Grooming, and Dressing,Hair,Skin and mouth care; Assistance with ambulation and transferring; Meal preparation and feeding; Toileting, and Assistance with self-administered medications.

The Competency Evaluation will be finalized by 4/20/2020 and all new staff files created on or after 4/20/2020 will be in compliance to all above.

Emp#1 and administrative assistant will ensure that the Annual Competency Evaluation is completed for all staff who will be with the Agency for more then 12 months.

4. How will the corrective action be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance programs will be established or followed?

Administrator will conduct quarterly review of new staff files and document findings in a quarterly report. The report will be discussed within the office administration in order to ensure compliance

5. Date of when the corrective action will be completed?

The corrective actions will be implemented by 4/20/2020




611.56(a) LICENSURE
Health Screening

Name - Component - 00
The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.

Observations:


Based upon review of CDC (Center for Disease and Control) guidelines, agency policy, personnel files (PF), and interview with administrator ( EMP #1), agency failed to show documentation of initial Two (2) step TB screening was completed for two (2) of three (3) files reviewed. ( PF # 1-2).

Findings included:

Review of CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in health-Care Settings, 2019, included that all Health Care Workers (HCW) should receive baseline TB screening upon hire, using two-step TST or a single BAMT to test for infection with M. Tuberculosis. The second step TST should be administered 1-3 weeks after the first step was read. In addition, at hire, employee shall complete a symptom screen questionnaire and an individual tuberculosis (TB) risk assessment. Annual TB education is recommended. ( CDC/MMWR/May 17, 2019/Vol.68/No.19).

Review of agency policy on 3/3/2020, at approximately 12:30 PM-1:00 PM titled " Employee Initial TB Testing" stated " perform the Tuberculin Skin Test ( TB)... upon employment and annually... (2.) Test will be read within 48-72 hours."

Review of PF on 2/28/2020, between approximately 10:30 AM-11:45 AM, revealed:

PF # 1, Date of Hire (DOH) 1/20/2020; initial Two step read on 4/10/19. No evidence second step was administered.

PF # 2, DOH 1/30/2020; initial Two step was administered " 4/7 \ and read 4/9 \ with second step administered 4/16 \ and read date 4/19 with EMP # 1 on 3/3/2020, at approximately 12:55 PM confirmed above findings.










Plan of Correction:

0701. Two Step PPD:
1. What corrective action will be accomplished for those individuals and/or practices identified in the deficiency statements?
Agency will review staff files of individuals identified during survey and will complete 2-Step PPD for them
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
Agency will review staff files of all current staff and ensure that a 2-Step PPD is present in the files.
3. What measures (actions/forms/system changes, etc.) will be put in place to ensure that the deficient practice does not reoccur?
The agency will ensure that a current 2 Step PPD is available for all new staff members. The agency will also review all active staff file in order to ensure compliance with 2 Step PPD requirement and annual health screening questionnaire.
The agency will also roll out annual educational paper for TB. This paper will be part of the annual health screening questionnaire.
Emp#1 and admin staff will be responsible for implementing this and it will be completed for all new staff files created on or after 4/20/2020
4. How will the corrective action be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance programs will be established or followed?
Agency will conduct quarterly review of new staff files and document findings in a quarterly report. The report will be discussed within the office administration in order to ensure compliance
5. Date of when the corrective action will be completed?
The corrective actions will be implemented by 4/20/2020



611.57(c) LICENSURE
Information to be Provided

Name - Component - 00
(c) Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.

Observations:


Based upon review of agency consumer packet, consumer files (CF), and interview with administrator ( EMP #1), agency failed to give consumer correct contact information for Department of Health (DOH) hotline number for one (1) of three (3) files reviewed. ( PF # 3).

Findings included:

Review of agency consumer packet on 2/28/2020, at approximately 11:30 AM-12:45 PM form titled " Consumer Rights/Prohibitions" stated " (3.) the Department's Complaint Hotline (1-866-254-5164)"

Review of CF on 2/28/2020, between approximately 11:45 AM-12:45 PM and 1:15 PM-2:45 PM revealed:

CF # 3, SOS 12/3/19; consumer signed form on 12/3/19. Incorrect DOH information given for complaints.

Interview with EMP # 1 on 3/3/2020, at approximately 12:55 PM confirmed above findings.






Plan of Correction:

0820. Client In-Take Process:
1. What corrective action will be accomplished for those individuals and/or practices identified in the deficiency statements?
Agency will review client files of individuals identified during survey and will get new client in-take packages signed by the clients.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
Agency will review client files of all current clients and ensure that new client in-take package is signed by the clients and a current copy is placed in client files.
3. What measures (actions/forms/system changes, etc.) will be put in place to ensure that the deficient practice does not reoccur?
The Agency will review its intake process and ensure that the following information is given to the client prior to the start of services
- Identity of Direct Care Worker
- Hours of Service
- Fees & Total Cost of Services (Hourly or Weekly)
- Contact Number for PA Department of Health regarding Agency Licensing Questions
- Contact Number for Department Complaint Hotline
- Contact Number for Local Ombudsman for Area Agency on Aging
- Hiring & Competency requirements applicable to Direct Care Workers
The record will be kept in the patient files.
Emp#1 and admin staff will be responsible for implementing this and it will be completed for all new staff files created on or after 10
4. How will the corrective action be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance programs will be established or followed?
Agency will conduct quarterly review of new client files and document findings in a quarterly report. The report will be discussed within the office administration in order to ensure compliance
5. Date of when the corrective action will be completed?
The corrective actions will be implemented by 4/20/2020



Initial Comments:


Based on the findings of an onsite unannounced complaint investigation survey completed 3/3/2020, Blue Mountain Home Health Care, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).









Plan of Correction: