Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on October 25, 2023, Joyfull Care Home Care, 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 home care agency state re-licensure survey conducted on October 23, 2023, Joyfull Care Home Care, Llc 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:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
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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 personnel files (PF), and interview with agency staff the agency failed to ensure direct care worker files contained not less than two (2) satisfactory references for one (1) of seven (7) files reviewed. PF #2.
Findings include:
Review of PF on 10/25/2023 between approximately 11:00am-1:00pm revealed:
PF#2, date of hire 8/7/23 : contained no documentation of two (2) satisfactory references being completed.
Interview with agency staff completed 10/25/2023 at approximately 1:30PM confirmed the above findings.
Plan of Correction:1. Obtain 2 complete satisfactory references for PF#2 and move forward for all new hires before starting services.
2. To oversee a review of new employee files to avoid a repeat of the deficient practice.
3. Follow the agency checklist of all new hires that will be used to confirm that the deficient practice does not recur.
4. To assign an administrative assistant to monitor new employee files every six months to ensure that deficient practice will not occur.
611.52(a) LICENSURE
Criminal Background Checks
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The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.
Observations:
Based on a review of personnel files (PF), and an interview with the agency administrators, the agency failed to provide documentation of a Pennsylvania State Police Criminal Background Check at the time of application or within 1 year immediately preceding the date of application for six (6) of seven (7) PF reviewed. (PF #1, PF #2, PF#3, PF#4, PF#5 and PF#6)
Findings include:
Personnel file review was conducted on October 25, 2023 from approximately 11:00 AM 1:00 PM revealed the following:
PF #1, Date of Hire (DOH) 11/18/2021: Pennsylvania State Police Criminal Background Check on file dated 1/09/2023, which is after the hire date.
PF #2, Date of Hire (DOH) 08/07/2023: Pennsylvania State Police Criminal Background Check on file dated 08/15/2023, which is after the hire date.
PF #3, Date of Hire (DOH) 10/02/2023: Pennsylvania State Police Criminal Background Check on file dated 10/19/2023, which is after the hire date.
PF #4, Date of Hire (DOH) 12/02/2023: Pennsylvania State Police Criminal Background Check on file dated 04/22/2021, which is after the hire date.
PF #5, Date of Hire (DOH) 05/19/2023: Pennsylvania State Police Criminal Background Check on file dated 05/23/2023, which is after the hire date.
PF #6, Date of Hire (DOH) 12/16/2022: Pennsylvania State Police Criminal Background Check on file dated 03/30/2023, which is after there hire date.
Interview with agency staff completed 10/25/2023 at approximately 1:30PM confirmed the above findings.
Plan of Correction:For PF#1, PF#2, PF#3, PF#4, PF#5, PF#6 the POC is as follows.
1. To ensure the Pennsylvania state police criminal background is completed and dated before the hire date.
To update files to display the date of hire as the first-day employees have been sent for assignment and not the date the application was filled as shown in the checklist.
2. To oversee a review of new employee files to avoid a repeat of the deficient practice.
3. Follow the agency checklist of all new hires that will be used to confirm that the deficient practice does not recur.
4. To assign an administrative assistant to monitor new employee files every six months to ensure that deficient practice will not occur.
611.55(a) LICENSURE
Competency Requirements
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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 three (3) of seven (7) PF reviewed. (PF #1, PF #4 and PF #6)
Findings include:
A review of PF conducted on October 25, 2023 between approximately 11:00 AM and 1:00 PM revealed the following:
PF #1, Date of Hire (DOH) 11/18/2023; no documentation showing an initial competency completed prior to assigning or referring a direct care worker to provide services to a consumer.
PF #4, DOH 12/02/2019; no documentation showing an initial competency completed prior to assigning or referring a direct care worker to provide services to a consumer.
PF #6, DOH 12/16/2022; 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 the agency administrator completed on October 25,2023 at approximately 1:30 pm confirmed the above findings.
Plan of Correction:The POC for PF#1, PF4, and PF6 is as follows.
1. Employees hired before 2023 had completed an initial competency test that, upon previous surveys and reviews, was revealed to be outdated by the state officer representative. After the previous POCs, the agency updated a new competency test, which was completed by PF#1, PF#4, and PF#6.
- The agency will ensure that all new hires complete an initial competency test before being assigned as a direct care worker to a consumer. (Please reference previous POCs in regard to the competency test.)
2. To oversee a review of new employee files to avoid a repeat of the deficient practice.
3. Follow the agency checklist of all new hires that will be used to confirm that the deficient practice does not recur.
4. To assign an administrative assistant to monitor new employee files before assignment as a direct care worker to a consumer to ensure that deficient practice will not occur.
611.56(a) LICENSURE
Health Screening
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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 on review of personnel files (PF) and staff interview it was determined the facility failed to ensure direct care workers were screened for and were free from active mycobacterium tuberculoses prior to assignment with clients that five (5) out of seven (7) direct care workers were not screened for mycobacterium tuberculosis per CDC guidelines. (PF#1, PF#2, PF#3, PF4 and PF#5)
Findings include:
PF#1 date of hire DOH is 11/18/2021. The QuantiFERON (QFT) result dated 5/10/2022 was after the hire date.
PF#2 DOH is 8/7/2023. The QFT result dated 8/9/2023 was after the hire date.
PF#3 DOH is 10/02/2023. The #1 Tuberculin skin test (TST) result dated 10/05/2023 with a negative reading was after the hire date. There was no documentation in the PF to show a second TST was completed.
PF#4 DOH is 12/02/2019. The QFT result dated 03/30/2023 was after the hire date.
PF#5 DOH is 05/19/2023. The #1 TST result dated 05/03/2023 with a negative reading. There was no documentation in the PF to show a second TST was completed.
An interview conducted with the agency administrator completed on October 25,2023 at approximately 1:30 pm confirmed the above findings
The CDC guidelines state that all Health Care Workers (HCW) should received baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screen 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;(RR-17)
http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.
Plan of Correction:0701
1.To review and correct all current employee file to reflect correct TB testing as per CDC guidelines.
-To ensure new hires get the second TST and have complete TSTs. The agency will also verify all TB tests and results reading are done before the hiring date.
-To rectify the checklists, show the hire date as the first work date and not the date of application signed as previously shown. This is to ensure the agency has all the complete documentation before assignments.
2. To oversee a review of new employee files to avoid a repeat of the deficient practice.
3. Follow the agency checklist of all new hires that will be used to confirm that the deficient practice does not recur.
4. Establish a compliance monitoring system to ensure new hires and current employees complete TB tests in the required time and to avoid deficient practices from recurring.
611.56(b) LICENSURE
Health Screening
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(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 personnel files (PF) and staff interview, it was determined that the agency failed to ensure all workers with direct consumer contact had an updated screening for tuberculosis completed at least every 12 months for one (1) of the seven (7) direct care workers hired prior to December 12, 2009. (PF6)
Findings include:
Review of personnel files on October 25,2023 at approximately 11:00am-1:00pm.
PF#6 date of hire is 12/16/2022, and the most recent PPD (purified protein derivative) test was completed on 5/22/2022. No documentation of an annual screening completed in 2023.
An interview conducted with the agency administrator completed on October 25,2023 at approximately 1:30 pm confirmed the above findings
Plan of Correction:0710.
1. For PF#6, the annual screening material was completed on 07/08/2023 and is in the file.
611.57(c) LICENSURE
Information to be Provided
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(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 facility information packet, clinical files (CF), service agreement and interview conducted on October 25, 20023, it was determined the agency failed to provide consumers with the hours services will be provided for one (1) out of the five (5) files reviewed.
CF#1.
Findings include:
CF#1 reviewed 10/25/2023 at approximately 10:301 AM ,start of care date 07/08/2023. The schedule for the service agreement was blank. No other documentation to show the consumer was notified of the service hours.
Interview with agency staff completed 10/25/2023 at approximately 1:30PM confirmed the above findings.
Plan of Correction:0820.
1. CF#1 The services were requested for one day, which was not included on the schedule in the file but was on HHA. Moving forward, we will ensure this information is in CF#1 and other consumer files.
2. To oversee new consumers enrollments files, have this information completed in their files.
3. To establish a monitoring system to ensure this issue does not happen and to prevent deficient practice from recurring.
4. Put the administrative assistant in control of ensuring all the information is duly entered into all the new participant files to ensure no recurrence of the actions
5. To perform a yearly audit of active consumer files to ensure deficient practice does not recur.
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