Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on April 12, 2022, Interim Healthcare, Inc., 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 state re-licensure survey conducted on April 12, 2022, Interim Healthcare, Inc., 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 a review of personnel files (PF) and an interview with the administrator, there was no documentation that the agency conducted an interview with the potential hire for six (6) of seven (7) PFs, ( PF# 1, 2, 3, 4, 5 & 7) and the files did not contain two satisfactory references for six (6) of seven (7) PFs ( PF# 1, 2, 3, 4, 5 & 7)
Findings include:
A review of PFs was conducted on 4/12/22 at 11:00 AM and revealed the following:
PF#1 Date of Hire (DOH) 9/27/21, did not contain documentation of an interview and did not contain any satisfactory references for employment.
PF#2 Date of Hire (DOH) 9/5/21, did not contain documentation of an interview and did not contain any satisfactory references for employment.
PF#3 Date of Hire (DOH) 9/25/21, did not contain documentation of an interview and did not contain any satisfactory references for employment.
PF#4 Date of Hire (DOH) 2/2/22, did not contain documentation of an interview and did not contain any satisfactory references for employment.
PF#5 Date of Hire (DOH) 6/1/20, did not contain documentation of an interview and did not contain any satisfactory references for employment.
PF#7 Date of Hire (DOH) 6/5/19, did not contain documentation of an interview and did not contain any satisfactory references for employment.
An interview with the administrator on 4/12/22 at 12:00 PM confirmed the above findings.
Plan of Correction:1. All appropriate documentation will be completed and placed in each of the deficient employee files.
2. Every employee file will be reviewed to ensure that all appropriate information is in the files.
3. All agency staff will be inserviced on the necessary information required when hiring an employee.
4. All new employee files will be reviewed by the agency administrator monthly to ensure compliance.
5. This will be completed by June 8, 2022.
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 on a review of personnel files (PF) and an interview with agency's manager, 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 four (4) of seven (7) PF's reviewed, (PF # 1, 3, 4, & 5).
Findings include:
A review of PF's was conducted on 4/12/22 at approximately 11:00 AM which revealed:
PF #1 Date of Hire: 9/27/21, no documentation of a Pennsylvania State Police Criminal Background Check completed.
PF #3 Date of Hire: 9/25/21, no documentation of a Pennsylvania State Police Criminal Background Check completed.
PF #4 Date of Hire: 2/2/22, no documentation of a Pennsylvania State Police Criminal Background Check completed.
PF #5 Date of Hire: 6/1/20, no documentation of a Pennsylvania State Police Criminal Background Check completed.
An interview with the administator on 4/12/22 at approximately 12:00 PM confirmed the above findings.
Plan of Correction:1. All missing Pa State Police Criminal Background checks will be completed immediately.
2. All employee files will be reviewed to ensure the proper criminal background check has been completed.
3. All agency staff will be inserviced on the conducting of criminal background checks for all new employees.
4. All new employee files will be reviewed by the agency administrator to ensure compliance with the criminal background checks.
5. The corrective action will be completed by June 8, 2022.
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 on a review of personnel files (PF) and an interview with the agency's administrator, the agency did not obtain a federal criminal history report for an employee who has not been a resident of Pennsylvania for 2 years immediately preceding the date of the request for a criminal history report for one (1) of seven (7) PFs. (PF #5).
Findings include:
Pennsylvania Act 169 of 1996 as amended by Act 13 of 1997 requires an applicant/ employee who has not been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application for employment or currently lives out-of-state, in addition to the Pennsylvania State Police Criminal History Check, the applicant/employee will also need to obtain an FBI Criminal History Check within ninety (90) days of employment. An employee is defined as any applicant or new employee hired after July 1, 1998. The definition of employee includes contract employees who have direct contact with residents or unsupervised access to their personal living quarters.
Findings:
A review of PFs was conducted on 4/12/22 at approximately 11:00 A.M. which revealed:
PF#5: Date of Hire 6/1/20, Direct care worker's file revealed Florida Identification Card issued on 3/4/19. The file contained no federal criminal history report.
An interview with the agency's administrator on 4/12/22 at approximately 12:00 P.M. confirmed the above findings.
Plan of Correction:1. All missing Pa State Police Criminal Background checks will be completed immediately.
2. All employee files for those that do not have 2 years of residency in the state of Pennsylvania will be reviewed to ensure the proper criminal background check has been completed.
3. All agency staff will be inserviced on the conducting of federal criminal background checks for all new employees.
4. All new employee files for those that do not have 2 years of residency in the state of Pennsylvania will be reviewed by the agency administrator to ensure compliance with the federal criminal background checks.
5. The corrective action will be completed by June 8, 2022.
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 a review of the agency's personnel files (PF), and an interview with the agency's administator, it was determined the agency failed to ensure competency of the direct care worker prior to assigning the direct care worker to provide services to the consumer for five (5) of seven (7) PFs reviewed. (PF#'s 1, 3, 4, 5, & 7).
Findings Included:
Review of PFs completed on 4/12/22, at approximately 11:00 AM revealed:
PF#1, Date of Hire: 9/27/21, Contained no documentation that initial competency was completed.
PF#3, Date of Hire: 9/25/21, Contained no documentation that initial competency was completed.
PF#4, Date of Hire: 2/2/22, Contained no documentation that initial competency was completed.
PF#5, Date of Hire: 6/1/20, Contained no documentation that initial competency was completed.
PF#7, Date of Hire: 6/5/19, Contained no documentation that initial competency was completed.
Interview completed on 4/12/22 at approximately 12:00 P.M. with the administrator who confirmed the above findings.
Plan of Correction:1. All appropriate competency documentation will be completed and placed in each of the deficient employee files.
2. Every employee file will be reviewed to ensure that all appropriate competency information is in the files.
3. All agency staff will be inserviced on the necessary competency information required when hiring an employee.
4. All new employee files will be reviewed by the agency administrator monthly to ensure competency compliance.
5. This will be completed by June 8, 2022.
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 (PFs) and an interview with the administrator, the agency failed to ensure an annual competency review was conducted for three (3) of seven (7) personnel files reviewed. (PFs #'s 5, 6 & 7).
Findings include:
A review of the personnel files was conducted on 4/12/22 at approximately 11:00 AM which revealed the following:
PF#5, Date of hire: 6/1/20, did not have documentation of the review of the individual's annual competency for 2021.
PF#6, Date of hire: 4/26/18, did not have documentation of the review of the individual's annual competency for 2021.
PF#7, Date of hire: 6/5/19, did not have documentation of the review of the individual's annual competency for 2018, 2019 and 2021.
An interview with the administator on 4/12/22 at approximately 12:00 PM confirmed the above findings.
Plan of Correction:1. All appropriate annual competency review will be completed and placed in each of the deficient employee files.
2. Every employee file will be reviewed to ensure that all appropriate competency reviews have been completed.
3. All agency staff will be inserviced on the annual competency information required for all employees.
4. All new employee files will be reviewed by the agency administrator monthly to ensure compliance.
5. This will be completed by June 8, 2022.
611.57(b) LICENSURE
Prohibitions
Name - Component - 00
(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.
Observations:
Based on review of the agency's consumer information packet, consumer records (CR) and interview with the agency's administrator, the agency failed to provide documentation that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry and that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry for five (5) of five (5) CR reviewed. (CR#'s 1-5)
Findings include:
Review of CR conducted on 4/12/22, at approximately 10:00 A.M. revealed the following:
CR# 1, start of care: 6/3/20, did not contain documentation that the consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry and that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.
CR# 2, start of care: 1/19/22, did not contain documentation that the consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry and that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.
CR# 3, start of care: 12/28/21, did not contain documentation that the consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry and that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.
CR# 4, start of care: 9/25/21, did not contain documentation that the consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry and that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.
CR# 5, start of care: 10/22/20, did not contain documentation that the consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry and that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.
Interview with the administrator on 4/12/22, at approximately 12:00 P.M. confirmed the above findings.
Plan of Correction:1. All deficient consumer files that do not include the information that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry and that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care will be updated with a copy going to the consumer via email or regular mail and a copy will be placed in each of the deficient consumer files.
2. Every consumer file will be reviewed to ensure that all appropriate information is in the files.
3. All agency staff will be inserviced on the necessary consumer information required when signing on a new consumer.
4. All new consumer files will be reviewed by the agency administrator monthly to ensure compliance.
5. This will be completed by June 8, 2022.
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 on review of the consumer records (CRs) and interview with administrator, the agency failed to 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 prior to the commencement of services: 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 for three (3) of five (5) CRs reviewed (CR #'s 1, 2, 3, 4 & 5).
Findings include:
Review of CRs conducted on 4/12/22, at approximately 10:00 A.M. revealed the following:
CR# 1, Start of Care (SOC): 6/3/20, did not contain 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, 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.
CR# 2, (SOC): 1/19/22, did not contain 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, 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.
CR# 3, (SOC): 12/28/21, did not contain 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, 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.
Interview with the administator on 4/12/22, at approximately 12:00 P.M. confirmed the above findings.
Plan of Correction:1. The appropriate information packet containing prior to services 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 will be completed and placed in each of the deficient consumer files with copies sent out via email or regular mail to be reviewed by the consumer.
2. Every consumer file will be reviewed to ensure that all appropriate information is in the files.
3. All agency staff will be inserviced on the necessary consumer information required when signing on a new consumer.
4. All new consumer files will be reviewed by the agency administrator monthly to ensure compliance.
5. This will be completed by June 8, 2022.
Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on April 12, 2022, Interim Healthcare, Inc., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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