QA Investigation Results

Pennsylvania Department of Health
AVALON AT HOME, LLC
Health Inspection Results
AVALON AT HOME, LLC
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted on May 11, 2021, Avalon At Home, 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 unannounced state re-licensure survey conducted on May 11, 2021, Avalon At Home, 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 interview with the administrator, the agency failed to obtain not less than two satisfactory references for the individual that is a positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual for eight (8) of ten (10) PFs. PF# 1, 2, 3, 5, 6, 7, 8, and 9.
Findings include:
A review of personnel files was conducted on May 11, 2021 at 11:03 AM.
PF #1 Date of hire 1/03/2020 did not contain two satisfactory references for the individual that is positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
PF #2 Date of hire 6/12/2018 did not contain two satisfactory references for the individual that is positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
PF #3 Date of hire 3/19/2019 did not contain two satisfactory references for the individual that is positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
PF #5 Date of hire 7/30/2019 did not contain two satisfactory references for the individual that is positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
PF #6 Date of hire 5/01/2018 did not contain two satisfactory references for the individual that is positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
PF #7 Date of hire 12/12/2019 did not contain two satisfactory references for the individual that is positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
PF #8 Date of hire 8/04/2019 did not contain two satisfactory references for the individual that is positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
PF #9 Date of hire 4/26/2019 did not contain two satisfactory references for the individual that is positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
An interview with the administrator on May 11, 2021 at 12/45 PM confirmed the above findings







Plan of Correction:

Avalon at Home will obtain two satisfactory references prior to hiring, positive and verifiable references either verbal (if verbal name of non-related individual or former employer, title and date will be recorded and included in the employee's file) or a written reference from a non-related individual or former employer affirming the applicant's ability to provide home health care. Avalon at Home staff member will be re-trained by the Compliance Manager given guidance of what are satisfactory references to avoid the error from recurring. The Quality Assurance Office will continue to interview clients ensuring (within 30 days when a new caregiver is assigned and quarterly overall) that their needs are being met and the assigned caregiver is providing satisfactory care. At any time, if the caregiver does not meet the needs of the client the caregiver will be removed immediately and replaced.
The Compliance Manager will perform internal audits within the next 60 days, monitoring files and procedures, ensuring that the Plan of Correction is being implemented. 611.52 Criminal History and Background Checks & 611.53 Child Abuse Clearance Criminal history checks reported in accordance with the requirements of 611.52 and childline verification 611.53 will be completed prior to hiring and verified by dates completed.
Intermediate Term Plan of Corrections: The Compliance Manager will perform internal audits within the next 60 days to ensure that the Plan of Correction is being implemented guaranteeing two satisfactory references are obtained, criminal history checks and childline verifications are completed prior to hiring. Long Term Plan of Corrections: Satisfactory references will be obtained and included in all employees' files. The practice obtaining criminal history checks and childline verifications will continue to be completed prior to hiring.




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 (PF) and an interview with the administrator, the agency did not perform a competency review at least once per year after initial competency is established for seven (7) of ten (10) PFs. PF#2, 3, 5, 6, 7, 8, and 9.

Findings include:

A review of PFs was conducted on May 11, 2021 at 11:03-12:00 PM.

PF#2 Date of hire 6/12/2018 did not contain an annual competency review for 2019 and 2020.

PF#3 Date of hire 3/19/2019 did not contain an annual competency review for 2020 and 2021.

PF#4 Date of hire 6/26/2020 did not contain an annual competency review for 2021.

PF#5 Date of hire 7/30/2019 did not contain an annual competency review for 2020.

PF#6 Date of hire 5/01/2018 did not contain an annual competency review for 2019, 2020 and 2021.

PF#7 Date of hire 12/12/2019 did not contain an annual competency review for 2020.

PF#8 Date of hire 8/04/2019 did not contain an annual competency review for 2020.

PF#9 Date of hire 4/26/2019 did not contain an annual competency review for 2020.

An interview with the billing administrator on May 11, 2020 at 12:45 PM confirmed the above findings.







Plan of Correction:

Avalon at Home will perform a competency review at least once a year after initial competency is established for all Avalon at Home Home Health Aides.
Avalon at Home will require within
the next 60 days all home
health aids who worked more than
year to complete annual competency exam. They will be required
to show competency in all
areas, including universal
precautions, recognizing and
reporting abuse or neglect,
shaving, dressing, hair care and
feeding.
Long Term Plan of Correction:
Avalon at Home will continue to
perform competency review at least once a year.


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), recommendations from the Centers for Disease Control, and an interview with the administrator, the agency did not ensure that each direct care worker with direct consumer contact have documentation that the individuals have been screened for and is free from active mycobacterium tuberculosis using an annual questionnaire for seven (7) of ten (10) PFs. PF# 2, 3, 5, 6, 7, 8 and 9.
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) 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 screening annually. 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) .

A review of PFs was conducted on May 11, 2021 at 11:03 - 12:45 PM
PF #2 Date of hire 6/12/2018 did not contain an annual TB screening for 2019 and 2020
PF #3 Date of hire 3/19/2019 did not contain an annual TB screening for 2020
PF #5 Date of hire 7/30/2019 did not contain an annual TB screening for 2020
PF #6 Date of hire 5/1/2018 did not contain an annual TB screening for 2019, 2020 and 2021
PF #7 Date of hire 12/12/2019 did not contain an annual TB screening for 2020
PF #8 Date of hire 8/4/2019 did not contain an annual TB screening for 2020
PF #9 Date of hire 4/26/2019 did not contain an annual TB screening for2020
An interview with the administrator on May 11, 2021 at 12:45 PM confirmed the above findings.






Plan of Correction:


Short Term Plan of Corrections:
Avalon at Home will implement recommendations from the Centers for Disease Control which is to ensure that each direct care worker with direct consumer contact have documentation that the individuals have been screened for and is free from active mycobacterium tuberculosis using an annual questionnaire. The Compliance Manager will conduct an audit of all health screens (TB test) within the next 60 days ensuring the Plan of Corrections is being implemented; using an annual questionnaire.

Long Term Plan of Corrections:
Avalon at Home Compliance Manager will continue to conduct annual calendar audits ensuring the Plan of Correction is being implemented; and will follow CDC guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings.


Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted on May 11, 2021, Avalon At Home, LLC, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).






Plan of Correction: