Initial Comments:
Based on the findings of a home care agency state re-licensure survey conducted on February 25, 2022, Alma's 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 a home care agency state re-licensure survey conducted on February 25, 2022, Alma's 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
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 personnel files (PF) and an interview with the agency administrator, it was determined the agency failed to ensure documentation of two satisfactory reference checks for seven (7) out of seven (7) PF's reviewed (PF#1-PF#7).
Findings include:
A review of PF#1-PF#7 was conducted on February 25, 2022 from approximately 9:00 AM-10:30 AM, revealing the following:
PF#1 (Date of Hire (DOH): 10/9/2021): No documentation of two satisfactory reference checks.
PF#2 (DOH: 4/08/2020): No documentation of two satisfactory reference checks.
PF#3 (DOH: 11/13/2020): No documentation of two satisfactory reference checks.
PF#4 (DOH: 4/04/2020): No documentation of two satisfactory reference checks.
PF#5 (DOH: 12/07/2019): No documentation of two satisfactory reference checks.
PF#6 (DOH: 6/14/2019): No documentation of two satisfactory reference checks.
PF#7 (DOH: 4/01/2019): No documentation of two satisfactory reference checks.
An interview with the agency administrator on 2/25/2022 at approximately 2:00 PM confirmed the above findings.
Plan of Correction:Chapter 611 51(a)
The administrator will audit each employee file to make sure a copy of a face to face interview was conducted and signed by the employee and proof that two reference checks were contain. The administrator will be responsible to conduct yearly audit to make sure all documentation is in their file.
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 ensure documentation of a satisfactory competency for six (6) out of seven (7) PF's reviewed (PF#1-PF#4, PF#6, PF#7).
Findings include:
A review of PF#1-PF#7 was conducted on February 25, 2022 from approximately 9:00 AM-10:30 AM, revealing the following:
PF#1 (Date of Hire (DOH): 10/9/2021): No documentation of a competency.
PF#2 (DOH: 4/08/2020): No documentation of a competency.
PF#3 (DOH: 11/13/2020): No documentation of a competency.
PF#4 (DOH: 4/04/2020): No documentation of a competency.
PF#6 (DOH: 6/14/2019): No documentation of a competency.
PF#7 (DOH: 4/01/2019): No documentation of a competency.
An interview with the agency administrator on 2/25/2022 at approximately 2:00 PM confirmed the above findings.
Plan of Correction:Chapter 611 56(a)
The administrator will be responsible to audit all employee's files in regards to baseline tuberculosis screening upon hire, using a two-step tuberculin skin test. TB testing for all employees will be conducted in a timely matter completed by the administrator . The administrator will also conduct a yearly audit to make sure all documentation is up to date and not expired.
611.55(e) LICENSURE
Competency Requirements
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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 review of personnel files (PF) and an interview with the agency administrator, it was determined the agency failed to ensure documentation of an annual competency review for 2020 for three (3) out of seven (7) PF's reviewed (PF#5-PF#7) and failed to ensure documentation of an annual competency review for 2021 for six (6) out of seven (7) PF's reviewed (PF#2-PF#7).
Findings include:
A review of PF#1-PF#7 was conducted on February 25, 2022 from approximately 9:00 AM-10:30 AM, revealing the following:
PF#2 (Date of Hire (DOH): 4/08/2020): No documentation an annual competency review for 2021.
PF#3 (DOH: 11/13/2020): No documentation an annual competency review for 2021.
PF#4 (DOH: 4/04/2020): No documentation an annual competency review for 2021.
PF#5 (DOH: 12/07/2019): No documentation an annual competency review for 2020 and 2021.
PF#6 (DOH: 6/14/2019): No documentation an annual competency review for 2020 and 2021.
PF#7 (DOH: 4/01/2019): No documentation an annual competency review for 2020 and 2021.
An interview with the agency administrator on 2/25/2022 at approximately 2:00 PM confirmed the above findings.
Plan of Correction:Chapter 611 55(a)
The administrator will audit and ensure all staff completes competency training. The administrator will also conduct a yearly audit to make sure all documentation is up to date.
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) and review Centers for Disease Control (CDC) guidelines, it was determined the agency failed to ensure that each direct care worker, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis for seven (7) out of seven (7) PF's reviewed (PF#1-PF#7).
Findings include:
The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. ........ HCWs with a baseline positive or newly 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.)
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
A review of PF#1-PF#7 was conducted on February 25, 2022 from approximately 9:00 AM-10:30 AM, revealing the following:
PF#1 (Date of Hire (DOH): 10/9/2021): No documentation of a symptom screen questionnaire and an individual TB risk assessment.
PF#2 (DOH: 4/08/2020): No documentation of a symptom screen questionnaire and an individual TB risk assessment.
PF#3 (DOH: 11/13/2020): No documentation of a symptom screen questionnaire and an individual TB risk assessment.
PF#4 (DOH: 4/04/2020): No documentation of a symptom screen questionnaire and an individual TB risk assessment.
PF#5 (DOH: 12/07/2019): No documentation of a symptom screen questionnaire and an individual TB risk assessment.
PF#6 (DOH: 6/14/2019): No documentation of a symptom screen questionnaire and an individual TB risk assessment.
PF#7 (DOH: 4/01/2019): No documentation of a symptom screen questionnaire and an individual TB risk assessment.
An interview with the agency administrator on 2/25/2022 at approximately 2:00 PM confirmed the above findings.
Plan of Correction:Chapter 611 55(e)
The administrator will audit and conduct a yearly competency review to make sure staff is providing the best quality of care.
Initial Comments:
Based on the findings of a home care agency state re-licensure survey conducted on February 25, 2022, Alma's Care, LLC, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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