QA Investigation Results

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

This is the only survey for this facility

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an onsite state re-licensure survey conducted on 05/09/2024, Ashe Homecare 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 on-site state relicensure survey completed 05/09/2024, Ashe Homecare LLC, was found to not be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, 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 on review of personnel files (PF), and interview with the administrator, it was determined that personnel files did not include documentation of a State Police Criminal History report on hire for two (2) of seven (7) personnel files reviewed. (PF3 and PF4)

Findings Include:

Review of personnel files (PF), was conducted on 05/09/2024 from approximately 10:30AM until approximately 11:30AM revealed:

PF3: Date of Hire 05/27/2023, file did not contain a Pennsylvania Access To Criminal History report (PATCH) on hire or thereafter.

PF4:Date of Hire 06/14/2023, file did not contain a Pennsylvania Access To Criminal History report (PATCH) on hire or thereafter.

Interview with administrator on 05/09/2024 at approximately 12:00 PM confirmed the above findings.










Plan of Correction:

Administration from Ashe Home Care will audit files from PF3 and PF4 and apply for Criminal History report (PATCH) in order to update file and keep in compliance.

Ashe Home Care manager will ensure during application onboarding process that new employee will fill out criminal background form so that issue does not reoccur. Additionally, Ashe Home Care manager will use onboarding checklist to make sure all documents from employee are secured and filled out. Ashe Home Care manager will do yearly audits to make sure paperwork is up to date.


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 on review of direct care worker personnel files (PF) and an interview with the Administrator, the agency failed to document proof of Pennsylvania (PA) 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 for five (5) of seven (7) PF reviewed. (PF # 2, 3, 5, 6, and 7).

Findings include:

A review of PF on 05/09/2024, from approximately 10:30 am to approximately 11:30 am revealed the following:

PF2: Date of Hire 02/21/2024, contained a Pennsylvania driver's license issued 09/23/23. There was no verifiable documentation of Pennsylvania residency for the two (2) years preceding the date of hire.

PF3: Date of Hire 05/27/2023, contained no Pennsylvania driver's license. There was no verifiable documentation of Pennsylvania residency for the two (2) years preceding the date of hire.

PF5: Date of Hire 11/27/2023 , contained a Pennsylvania driver's license issued 02/21/2022. There was no verifiable documentation of Pennsylvania residency for the two (2) years preceding the date of hire.

PF6: Date of Hire 11/27/2023, contained no Pennsylvania driver's license. There was no verifiable documentation of Pennsylvania residency for the two (2) years preceding the date of hire.

PF7: Date of Hire 04/04/2024, contained a Pennsylvania driver's license issued 12/12/2023. There was no verifiable documentation of Pennsylvania residency for the two (2) years preceding the date of hire.


An interview with the Administrator on 05/09/2024, at approximately 12:00 pm confirmed the above findings.










































































Plan of Correction:

Ashe Home Care administration will audit files for PF2, PF3, PF5, PF6 and PF7 and will update files with verifiable documentation (listed in the observations) showing that each hire has been a resident of PA for over 2 years.

Ashe Home Care manager will ensure during application onboarding process that new employee's state ID is dated 2 years or more; and if not, supplemental records validating residency will be obtained so that issue does not reoccur. In order to do this Ashe Home Care manager will use onboarding checklist to make sure all documents from employee are secured. Ashe Home Care manager will do yearly audits to make sure paperwork 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), the Centers for Disease Control (CDC) guidelines and an interview with the administrator, the agency did not provide documentation that a direct care worker completed 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 for three (3) of seven (7) PF's: PF# 2, 5, and 6, or a baseline tuberculosis symptom screen questionnaire and individual tuberculosis risk assessment upon hire for seven (7) of seven (7) PF's: PF# 1, 2, 3, 4, 5, 6, and 7.

Findings include:

In May 2019, the Centers for Disease Control (CDC) updated its recommendation for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should receive 1) 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; 2) Completion of a tuberculosis symptom questionnaire, and 3) Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's 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 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's was conducted on 05/09/2024 starting at approximately 10:30 am until approximately 11:30 am revealed:

PF1: Date of Hire 09/15/2021, PF did not contain completion of a baseline TB symptom screen questionnaire and an individual TB risk assessment upon hire.

PF2:, Date of Hire 02/21/2024, contained a TST baseline dated 05/08/2023 and did not contain completion of second step of TST baseline TB screening upon hire; PF did not contain completion of a baseline TB symptom screen questionnaire and an individual TB risk assessment upon hire.

PF3: Date of Hire 05/27/2023, did not contain completion of a baseline TB symptom screen questionnaire and an individual TB risk assessment upon hire.

PF4: Date of Hire 06/14/2023, did not contain completion of a baseline TB symptom screen questionnaire and an individual TB risk assessment upon hire.

PF5: Date of Hire 11/27/2023, contained a TST baseline dated 12/15/2023 and did not contain completion of a second step of TST baseline screening upon hire; PF did not contain completion of a baseline TB symptom screen questionnaire and an individual TB risk assessment upon hire.

PF6: Date of Hire 11/27/2023, contained a TST baseline dated 11/19/2023 and did not contain completion of second step of TST baseline TB screening upon hire; PF did not contain completion of a baseline TB symptom screen questionnaire and an individual TB risk assessment upon hire.

PF7: Date of Hire 04/042024, did not contain completion of a baseline TB symptom screen questionnaire and an individual TB risk assessment upon hire.

An interview conducted with the administrator on 05/09/2024 at approximately 12:00 PM confirmed the above findings.










Plan of Correction:

Ashe Home Care administration will audit files to make PF#'s 2,5 and 6 compliant with having either a single blood assay for TB or a two step tuberculin test added to their file.

Ashe Home Care administration will also audit files to make sure PF#'s 1-7 are in compliance and have a baseline TB symptom screen questionnaire as well as a TB Risk Assessment added to their file.

Ashe Home Care manager will ensure during application onboarding process that new employee's have an understanding of the appropriate TB tests that may be accepted so that the issue does not reoccur. Additionally, Ashe Home Care manager will use onboarding checklist to make sure all TB forms from employee have been approved prior to patient contact. Ashe Home Care manager will do yearly audits to make sure paperwork is up to date.




Initial Comments:


Based on the findings of an onsite relicensure survey completed 05/09/2024, Ashe Homecare LLC, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).







Plan of Correction: