QA Investigation Results

Pennsylvania Department of Health
CORABIA HOME HEALTH CARE, LLC
Health Inspection Results
CORABIA HOME HEALTH CARE, LLC
Health Inspection Results For:


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Initial Comments:


An on-site follow-up survey conducted on August 23, 2019, found that Corabia Home Health Care Llc, had not corrected the deficiencies cited under the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries. The deficiencies were cited as a result of a re-licensure survey completed on November 15, 2018 and a follow-up survey completed on May 1, 2019.
As a result of the on-site survey completed on August 23, 2019, new deficiencies have been cited



























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 review of Agency's plan of corrections, personnel files (PF) review and an interview with the agency's Administrator's assistant, it was determined the agency failed to ensure documentation of obtaining two satisfactory references prior to rostering direct care workers for five (5) out of ten (10) PF's reviewed (PF#3, PF# 4, PF# 6, PF# 7, and PF#9).

Findings include:

Review of Agency's plan of correction, approved by the Department on 5/24/2019, on 8/23/19 revealed, "I will make that my assistant checks each employees documents every month to confirm that all documents are in order. I will also do a review every three months to make sure that my assistant is checking that all the folders are complete. This will start to run from May 16 of 2019 and will be something we will do constantly because our main objective has always been to ensure the well-being of our clients so that they maintain an active life in society. On May 16, 2019 I reviewed those three folders and called to confirm the two references of each person. I commit myself to ensure that this kind of thing does not happen again with any other employee..."


Personnel files were reviewed on 8/23/19 from approximately 11:30 AM-1:10 PM, revealing the following:

PF#3 (Date of hire (DOH): 4/22/19): No documentation of two satisfactory reference checks.

PF#4 (DOH: 7/30/18): Documentation of only one reference check being verified.

PF#6 (DOH: 5/17/18): Documentation of only one reference check being verified.

PF#7 (DOH: 11/2/17): Documentation of only one reference check being verified.

PF#9 (DOH: 8/30/18): Documentation of only one reference check being verified.



An interview with the agency's Administrator assistant on 8/23/19 at approximately 1:30 PM confirmed the above findings.




























Plan of Correction:

First I want to apologize for not having been as pending as I promised with the documents in our files.
September first we did a massive review of all the documents of our employees and fixed any errors that we found, I recognize that it can be difficult to keep track of the things that are missing in all those documents, but we promise that it will not happen again.

*September 1st, We went through each of the files of our employees and we called each of them, we asked for information from a second reference and that same day we called to ask for references from that Employee.

Milda Sanchez Also Will Do a Monthly Review of any new employee file just to make sure we keep track on it.

We also have a method on the computer where we keep an eye on when each document that will let us know when the documents are about to expire.

Mary Castillo


611.51(b) LICENSURE
Direct Care Worker Files

Name - Component - 00
Files for direct care workers employed or rostered shall include documentation of the date of the face-to-face interview with the individual and of references obtained. Direct Care Worker files also shall include other information as required by 611.52, 611.53, if applicable, 611.54, 611.55 and 611.56 (relating to criminal background checks, child abuse clearance, provisional hiring, competency requirements; and health evaluations).

Observations:


Based on reviews of Agency's approved plan of corrections, Personnel files (PFs), and an interview with the agency administrator's assistant, it was determined the agency failed to ensure documentation of obtaining two satisfactory references prior to rostering direct care workers for five (5) out of ten (10) PF's reviewed (PF#3, PF# 4, PF# 6, PF# 7, and PF#9); the facility failed to ensure direct care workers were screened for and were free from active mycobacterium tuberculosis (TB) prior to assignment with consumers for one (1) out of ten (10) files reviewed. (PF# 9); the agency failed to ensure that direct care workers had annual PPD screening completed for two (2) of ten (10) personnel files reviewed. (PF# 1 and PF# 5)


Findings include:

Review of Agency's plan of correction, approved by the Department on 5/24/2019, on 8/23/19 revealed, "I will make that my assistant checks each employees documents every month to confirm that all documents are in order. I will also do a review every three months to make sure that my assistant is checking that all the folders are complete. This will start to run from May 16 of 2019 and will be something we will do constantly because our main objective has always been to ensure the well-being of our clients so that they maintain an active life in society. On May 16, 2019 I reviewed those three folders and called to confirm the two references of each person. I commit myself to ensure that this kind of thing does not happen again with any other employee..."


Personnel files were reviewed on 8/23/19 from approximately 11:30 AM-1:10 PM, revealing the following:

PF# 1: Date of hire (DOH): 2/6/18; contained no documentation of annual PPD in year 2019.

PF#3 (Date of hire (DOH): 4/22/19): No documentation of two satisfactory reference checks.

PF#4 (DOH: 7/30/18): Documentation of only one reference check being verified.

PF# 5: Date of hire (DOH): 7/2/18; contained no documentation of annual PPD in year 2019.

PF#6 (DOH: 5/17/18): Documentation of only one reference check being verified.

PF#7 (DOH: 11/2/17): Documentation of only one reference check being verified.

PF#9 (DOH: 8/30/18): Documentation of only one reference check being verified.; contained no documentation of a two-step TST on hire.


An interview with the agency's Administrator assistant on 8/23/19 at approximately 1:30 PM confirmed the above findings.












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Plan of Correction:

First I want to apologize for not having been as pending as I promised with the documents in our files.
September first we did a massive review of all the documents of our employees and fixed any errors that we found, I recognize that it can be difficult to keep track of the things that are missing in all those documents, but we promise that it will not happen again.

I personally commit myself that 2 personal references will be done to each of the new employees and be reviewed the same day the interview is conducted.

*September 1st, We went through each of the files of our employees and we called each of them, we asked for information from a second reference and that same day we called to ask for references from that Employee.

Milda Sanchez Also Will Do a Monthly Review of any new employee file just to make sure we keep track on it.

We also have a method on the computer where we keep an eye on when each document that will let us know when the documents are about to expire.

Mary Castillo


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 CDC recommendations, personnel files (PF) and interview with Agency Adminstrator's assistant, it was determined the facility failed to ensure direct care workers were screened for and were free from active mycobacterium tuberculosis (TB) prior to assignment with consumers for one (1) out of ten (10) files reviewed. (PF# 9)

Findings include:

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.

Review of Personnel files (PF) conducted on 8/23/19 between 11:30 AM-1:10 PM revealed the following:

PF# 9: Date of hire(DOH): 8/30/18; contained no documentation of a two-step TST on hire.



An interview with the Agency's Administrator assistant on 8/23/19 at 1:30 PM confirmed the above findings.












Plan of Correction:

First I want to apologize for not having been as pending as I promised with the documents in our files.
September first we did a massive review of all the documents of our employees and fixed any errors that we found, I recognize that it can be difficult to keep track of the things that are missing in all those documents, but we promise that it will not happen again.

*September 1st, a 2-step TB Test was requested from that person and we already have it on file.

Milda Sanchez Also Will Do a Monthly Review of any new employee file just to make sure we keep track on it.

We also have a method on the computer where we keep an eye on when each document that will let us know when the documents are about to expire.

Mary Castillo


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 personnel files (PF) and an interview with the Agency Adminstrator's assistant, it was determined that the agency failed to ensure that direct care workers had annual PPD screening completed for two (2) of ten (10) personnel files reviewed. (PF# 1 and PF# 5)



Review of Personnel files (PF) conducted on 8/23/19 between 11:30 AM-1:10 PM revealed the following:


PF# 1: Date of hire (DOH): 2/6/18; contained no documentation of annual PPD in year 2019.

PF# 5: Date of hire (DOH): 7/2/18; contained no documentation of annual PPD in year 2019.



An interview with the Agency Administrator's assistant conducted on 8/23/19 at 1:30 PM confirmed the above findings.








Plan of Correction:

First I want to apologize for not having been as pending as I promised with the documents in our files.
September first we did a massive review of all the documents of our employees and fixed any errors that we found, I recognize that it can be difficult to keep track of the things that are missing in all those documents, but we promise that it will not happen again.

*September 1st, we ensure that all documents for the PPD annual Renewal were updated for 2019.

Milda Sanchez Also Will Do a Monthly Review of any new employee file just to make sure we keep track on it.

We also have a method on the computer where we keep an eye on when each document that will let us know when the documents are about to expire.

Mary Castillo