Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on July 1, 2024, Compassionate Caretakers Home Care Agency, 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 July 1, 2024, Compassionate Caretakers Home Care Agency, was not found 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 Personal files (PF) and an interview with the administrator, the agency failed to ensure that 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) for five (5) of the seven (7) PF's, (PF#1,2,3, 5 and 6).
Findings include:
A review of PF's was conducted on July 1, 2024 at approximately 12:00 pm.
PF #1 Date of Hire 2/19/2019, PF did not contain any documentation of two satisfactory and verifiable references were obtained.
PF#2 Date of Hire 12/31/2022, PF did not contain documentation that a face-to-face interview was conducted prior to hire, no documentation of two satisfactory and verifiable references were obtained. PF did not contain documentation that a Pennsylvania Criminal Background was conducted.
PF#3 Date of Hire 2/15/2024, PF did not contain documentation that a face-to-face interview was conducted prior to hire, no documentation of two satisfactory and verifiable references were obtained. PF did not contain documentation that a Pennsylvania Criminal Background was conducted.
PF#5 Date of Hire 10/20/2023, PF did not contain documentation that a face-to-face interview was conducted prior to hire, no documentation of two satisfactory and verifiable references were obtained.
PF#6 Date of Hire 2/05/2023, PF did not contain documentation that a face-to-face interview was conducted prior to hire, no documentation of two satisfactory and verifiable references were obtained.
An interview with the administrator on July 1, 2024 at approximately 1:15 pm confirmed the above findings.
Plan of Correction:PF #1 Corrective action plan A face to face interview was done on 2/19/19 at compassionate caretakers home care agency. On July 2, 2024 Two satisfactory and verified references for PF #1 was also obtained. In our efforts to maintain compliance we added a face to face interview sheet with reference check sheets attached to our application packet to ensure that this step will be implemented, completed, and not missed during the interview process; this was done on July 2, 2024. In Addition our human resources will conduct monthly audits on each employee file to ensure compliance with face to face interviews and references 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, that were satisfiable, verified and completed to maintain compliance of each employee record.
PF #2 Corrective action plan A face to face interview was done on 2/19/19 at Compassionate Caretakers Home Care Agency. On July 3, 2024 Two satisfactory and verified references for PF #2 was also obtained. In our efforts to maintain compliance we added a face to face interview sheet with reference check sheets attached to our application packet to ensure that this step will be implemented, completed, and not missed during the interview process; this was done on July 2, 2024. In Addition our human resources will conduct monthly audits on each employee file to ensure compliance with face to face interviews and references 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, that were satisfiable, verified and completed to maintain compliance of each employee record. Criminal disclosure for PF #2 was filed on 7/10/24 PATCH control #R31328359. We will also continue to obtain criminal background checks within the agency prior to the start of employment, and conduct monthly audits on each employee file to ensure compliance with the 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 were maintained and documented.
PF #3 Corrective action plan A face to face interview was done on 2/15/2024 at compassionate caretakers home care agency. On July 5, 2024 Two satisfactory and verified references for PF #3 was also obtained and noted in the file. In our efforts to maintain compliance we added a face to face interview sheet with reference check sheets attached to our application packet to ensure that this step will be implemented, completed, and not missed during the interview process; this was done on July 2, 2024. In Addition our human resources will conduct monthly audits on each employee file to ensure compliance with face to face interviews and references 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, that were satisfiable, verified and completed to maintain compliance of each employee record. Criminal disclosure for PF #3 was filed on 7/10/24 PATCH control #R31328360 . We will also continue to obtain criminal background checks within the agency prior to the start of employment, and conduct monthly audits on each employee file to ensure compliance with the 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 were maintained and documented.
PF #5 Corrective action plan A face to face interview was done on 10/23/23 at compassionate caretakers home care agency. On July 8, 2024 Two satisfactory and verified references for PF #5 was also obtained and noted in the file. In our efforts to maintain compliance we added a face to face interview sheet with reference check sheets attached to our application packet to ensure that this step will be implemented, completed, and not missed during the interview process; this was done on July 2, 2024. In Addition our human resources will conduct monthly audits on each employee file to ensure compliance with face to face interviews and references 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, that were satisfiable, verified and completed to maintain compliance of each employee record.
PF #6 Corrective action plan A face to face interview was done on 2/5/2023 at compassionate caretakers home care agency. On July 8, 2024 Two satisfactory and verified references for PF #6 was also obtained and noted in the file. In our efforts to maintain compliance we added a face to face interview sheet with reference check sheets attached to our application packet to ensure that this step will be implemented, completed, and not missed during the interview process; this was done on July 2, 2024. In Addition our human resources will conduct monthly audits on each employee file to ensure compliance with face to face interviews and references 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, that were satisfiable, verified and completed to maintain compliance of each employee record.
611.52(a) LICENSURE
Criminal Background Checks
Name - Component - 00
The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.
Observations:
Based on a review of personnel files (PF) and an interview with the administrator, the agency failed to obtain a Pennsylvania State Police Criminal Background report at the time of application or within one year immediately preceding the date of application for four (4) of seven (7) files reviewed. (PF#1,5,6 and 7.)
Findings include:
A review of PF's was conducted on July 1, 2024 at approximately 12:00
pm.
PF#1 Date of Hire 2/18/2019; contained a Pennsylvania State Police Criminal Background dated for 3/27/2019.
PF#5 Date of Hire 10/20/2023; contained a Pennsylvania State Police Criminal Background dated for 10/26/2023.
PF#6 Date of Hire 2/5/2023; contained a Pennsylvania State Police Criminal Background dated for 7/24/2023.
PF#7 Date of Hire 1/22/2020; contained a Pennsylvania State Police Criminal Background dated for 3/2/2020.
An interview with the administrator on July 1, 2024 at approximately 1:15 PM confirmed the above findings
Plan of Correction:Corrective Action Plan was done on 7/10/2024 by Human Resources Manager at our location 2439 College Ave Philadelphia Pa 19121 for PF #1 criminal disclosure filed on PATCH control # R31328367 To maintain compliance here at Compassionate Caretakers Home Care Agency We will be conducting criminal background checks within the agency prior to the start of employment. Our Human Resources manager will conduct monthly audits on each employee file to ensure compliance that criminal disclosures were completed and will be reprocessed annually to ensure compliance. Quarterly staff in-services will be conducted by the Administrator with Human Resources manager & field nurse to maintain compliance of each employee record.
Corrective Action Plan was done on 7/10/2024 by Human Resources Manager at our location 2439 College Ave Philadelphia Pa 19121 for PF #5 criminal disclosure filed on PATCH control #R31328362 To maintain compliance here at Compassionate Caretakers Home Care Agency We will be conducting criminal background checks within the agency prior to the start of employment. Our Human Resources manager will conduct monthly audits on each employee file to ensure compliance that criminal disclosures were completed and will be reprocessed annually to ensure compliance. Quarterly staff in-services will be conducted by the Administrator with Human Resources manager & field nurse to maintain compliance of each employee record.
Corrective Action Plan was done on 7/10/2024 at by Human Resources Manager at our location 2439 College Ave Philadelphia Pa 19121 for PF #6 criminal disclosure filed on PATCH control # R31328364To maintain compliance here at Compassionate Caretakers Home Care Agency We will be conducting criminal background checks within the agency prior to the start of employment. Our Human Resources manager will conduct monthly audits on each employee file to ensure compliance that criminal disclosures were completed and will be reprocessed annually to ensure compliance. Quarterly staff in-services will be conducted by the Administrator with Human Resources manager & field nurse to maintain compliance of each employee record.
Corrective Action Plan was done on 7/10/24 by Human Resources Manager at our location 2439 College Ave Philadelphia Pa 19121 for PF #7 criminal disclosure filed on PATCH control #R31328363 To maintain compliance here at Compassionate Caretakers Home Care Agency We will be conducting criminal background checks within the agency prior to the start of employment. Our Human Resources manager will conduct monthly audits on each employee file to ensure compliance that criminal disclosures were completed and will be reprocessed annually to ensure compliance. Quarterly staff in-services will be conducted by the Administrator with Human Resources manager & field nurse to maintain compliance of each employee record.
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 employee files and an interview with the agency Administrator, agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for one (1) out of seven (7) Personal Files (PF) reviewed (PF#1).
Findings include:
A review of PFs was conducted on July 1, 2024 at approximately 12:00 pm
PF#3, Date of Hire 2/15/24: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Georgia Drivers License issued 07/22/2022 with an expiration date of 4/17/2030.
An interview conducted with the agency Administrator on July 1, 2024 at approximately 1:15 p.m. confirmed the above findings.
Plan of Correction:PF#3 is no longer a employee as of July 1st at the request of her consumer prior to review, However a federal criminal history record was requested to the former employee along with a letter of determination from GA Department of Aging.
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 personnel files (PF) and an interview with the administrator determined that the agency failed to document proof of Pennsylvania (PA) residency preceding date of hire 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 two (2) of seven (7) PF's reviewed, (PF#2 and 3)
Findings include:
A review of PF's was conducted on July 1, 2024 at approximately 12:00 PM
PF#2 Date of Hire 12/31/2022. File contained a Pennsylvania Driver's license issued on 12/13/2022. There was no proof of Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire.
PF#3 Date of Hire 2/15/2024. File contained a Georiga Driver's license issued on 7/22/2022. There was no proof of Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire.
An interview conducted with the administrator on July 1, 2024 at approximately 1:15 PM confirmed the above findings.
Plan of Correction: On July 9, 2024 we obtained PF#2 a Motor vehicle record which was a valid driver ' s license pa State-issued identification that was issued prior to issued on 12/13/2022 which was issued on 7/17.2020 and placed in her file. Administration here at Compassionate Caretakers Homecare Agency will conduct monthly audits on each employee file to ensure that a federal criminal history record was completed and received and 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 pre printed on it to ensure the employee has been a Pennsylvania residency for the two (2) consecutive years immediately preceding the date of hire. .If an employee 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 employee will be asked to 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 will be collected. Quarterly staff in-services will be conducted by the Administrator with Human Resources to maintain compliance of each employee record.
PF#3 Is no longer an employee last day of employment was 7/1/24 at the request of consumer prior to review, however we still requested former employee to provide Pennsylvania residency for the two (2) consecutive years. haven't received it yet along with a letter of determination from GA Department of Aging. Administration here at Compassionate Caretakers Homecare Agency will conduct monthly audits on each employee file to ensure that a federal criminal history record was completed and received and 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 pre printed on it to ensure the employee has been a Pennsylvania residency for the two (2) consecutive years immediately preceding the date of hire. .If an employee 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 employee will be asked to 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 will be collected. Quarterly staff in-services will be conducted by the Administrator with Human Resources to maintain compliance of each employee record.
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 review of personnel files (PF), and an interview with the agency administrator, it was determined the agency failed to demonstrate, prior to assigning or referring a direct care worker to provide services to a consumer, competency by passing an initial competency examination for one (1) of seven (7) PF reviewed. (PF #3)
Findings include:
A review of PF conducted on July 1, 2024 at appropriately 12:00 pm revealed the following:
PF #3, Date of Hire 2/15/2024: PF did not contain documentation that an initial competency exam was completed prior to providing services to a consumer.
An interview conducted with the agency administrator on July 1, 2024 at approximately 1:15 PM confirmed the above findings.
Plan of Correction:PF #3 initial competency exam was completed on date of hire on 2/15/24 it was filed away in competency binder a copy was placed in her file . In our efforts to remain in compliance Our Human Resources manager will conduct monthly audits on each employee file to ensure compliance that all competency exams are copied in the files before placing them in competency binders. Quarterly staff in-services will be conducted by the Administrator with Human Resources manager & field nurse to maintain compliance of each employee record.
611.56(a) LICENSURE
Health Screening
Name - Component - 00
The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.
Observations:
Based on a review of personnel files (PF), Centers for Disease Control Guidelines, and an interview with the administrator, the agency failed to provide documentation that the individual has received baseline tuberculosis screening upon hire and symptom screening/ risk assessment initally and TB education annually for seven (7) of seven (7) PF's, (PF #1,2,3,4,5,6 and 7).
Findings include:
In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: receive baseline tuberculosis screening upon hire by using: a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB), or a negative chest x-ray 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, HCWs should receive TB education 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;(5-16-19)
A review of PF's was conducted on July 1, 2024 from approximately 12:00 pm.
PF #1, Date of Hire: 2/18/2019. PF did not contain documentation of a two (2) step tuberculin skin test (TST) upon hire. PF did not contain documention of an initial symptom screening/risk assessment for 2019 and no annual TB education for 2020, 2021, 2022, 2023 and 2024.
PF#2 Date of Hire: 12/31/2022. PF did not contain documention of an initial symptom screening/risk assessment for 2022 and no annual TB education for 2023 and 2024.
PF#3 Date of Hire 2/15/2024. PF did not contain documentation of a two (2) step tuberculin skin test (TST) upon hire. PF did not contain documention of an initial symptom screening/risk assessment for 2022 and no annual TB education for 2023 and 2024.
PF#4 Date of Hire 2/23/2022. PF contained documentation of a one (1) step tuberculin skin test (TST) dated for 11/10/2021. No evidence on file that the employee received a two (2) step PPD. PF did not contain documention of an initial symptom screening/risk assessment for 2022 and no annual TB education for 2023 and 2024.
PF#5 Date of Hire 10/20/2023. PF contained documentation of a one (1)step tuberculin skin test (TST) dated for 3/29/2023. No evidence on file that the employee received a two (2) step PPD. PF did not contain documention of an initial symptom screening/risk assessment for 2023.
PF#6 Date of Hire 2/5/2023. PF did not contain documentation of a two-step tuberculin skin test (TST) upon hire. PF did not contain documention of an initial symptom screening/risk assessment for 2023 and no annual TB education for 2024.
PF#7 Date of Hire 1/22/2020. PF contained documentation of a one (1) step tuberculin skin test (TST) dated for 1/21/2020. No evidence on file that the employee received a two (2) step PPD. PF did not contain documention of an initial symptom screening/risk assessment for 2020 and no annual TB education for 2021, 2022, 2023 and 2024.
An interview with the administrator on July 1, 2024 at approximately 1:15 pm confirmed the above findings.
Plan of Correction:PF #1 Documentation of PPD completed on 11/20/2019 Quertofiron gold with negative results found in her original file . An initial symptom screening/risk assessment was completed 3/14/22 and was found in the TB/Health Assessment Binder. A copy was put in employee file and annual TB education for 2022 was completed 3/14/22, 2023 was completed 6/12/23 and 2024 was completed 3/11/24 all training were located in binder copies were made and placed in employee file. Human Resources will conduct monthly audits of all employee files and make copies of all health screenings and tb education in employees files before filing them away in binders. We will also Continue to document that our employees have received baseline tuberculosis screening upon hire and symptom screening/ risk assessment initially and TB education annually. Quarterly staff in-services will be conducted by the Administrator with Human Resources to maintain compliance of each employee record.
PF#2 Documentation of an initial symptom screening/risk assessment was completed 12/21/22 and was found in the TB/Health Assessment Binder. A copy was put in employee file , and annual TB education for 2023 was completed 6/12/23 and 2024 was completed 3/11/24 all training were located in binder copies were made and placed in employee file. Human Resources will conduct monthly audits of all employee files and make copies of all health screenings and TB education in employees files before filing them away in binders. We will also Continue to document that our employees have received baseline tuberculosis screening upon hire and symptom screening/ risk assessment initially and TB education annually. Quarterly staff in-services will be conducted by the Administrator with Human Resources to maintain compliance of each employee record.
PF#3 Documentation of PPD was completed on 2/26/24 quantiferon gold with negative results found in file bin. Documentation of an initial symptom screening/risk assessment was completed 2/14/24 and annual TB education for 2024 was completed 3/11/24 Training documents found in the TB/Health Assessment Binder and a copy was put in employee file. We will also Continue to document that our employees have received baseline tuberculosis screening upon hire and symptom screening/ risk assessment initially and TB education annually. Human Resources will conduct monthly audits of all employee files and make copies of all health screenings and Tb education in employees files before filing them away in binders. Quarterly staff in-services will be conducted by the Administrator with Human Resources to maintain compliance of each employee record.
PF#4 Documentation of a one (1) step tuberculin skin test (TST) dated for 11/10/2021 was in file. Also on July 26, 2024 a negative quantiferon gold result was also in her file. An initial symptom screening/risk assessment for 2022 was completed 2/23/22 and an annual TB education was completed 6/12/23 and 2024 was completed 3/11/24 all training were found in binder copies were made and placed in employee file and TB education for 2024 was completed 3/11/24. Human Resources will conduct monthly audits of all employee files and make copies of all health screenings and TB education in employees files before filing them away in binders. We will also Continue to document that our employees have received baseline tuberculosis screening upon hire and symptom screening/ risk assessment initially and TB education annually. Quarterly staff in-services will be conducted by the Administrator with Human Resources to maintain compliance of each employee record.
PF#5 Documentation of a one (1)step tuberculin skin test (TST) dated for 3/29/2023. An initial symptom screening/risk assessment for 2023 was completed 10/19/23 and was found in the TB/Health Assessment Binder. TB education for 2024 was completed 3/11/24 training found in binder as well and copies were made and placed in the employee file. Human Resources will conduct monthly audits of all employee files and make copies of all health screenings and TB education in employees files before filing them away in binders. We will also Continue to document that our employees have received baseline tuberculosis screening upon hire and symptom screening/ risk assessment initially and TB education annually. Quarterly staff in-services will be conducted by the Administrator with Human Resources to maintain compliance of each employee record.
PF#6 Date of Hire a one step tuberculin skin test (TST) was completed 2/13/23 and was negative was found in the TB/Health Assessment Binder. An initial symptom screening/risk assessment for 2023 was completed 1/27/2023 and annual TB education for 2024 was completed 3/11/2024. Training found in binder as well and copies were made and placed in the employee file. Human Resources will conduct monthly audits of all employee files and make copies of all health screenings and TB education in employees files before filing them away in binders. We will also Continue to document that our employees have received baseline tuberculosis screening upon hire and symptom screening/ risk assessment initially and TB education annually. Quarterly staff in-services will be conducted by the Administrator with Human Resources to maintain compliance of each employee record.
PF#7 Documentation of a one (1) step tuberculin skin test (TST) dated for 1/21/202. An initial symptom screening/risk assessment was completed 2/15/2023 A copy was put in employee file and annual TB education for 2022 was completed 3/14/22, 2023 was completed 6/12/23 and 2024 was completed 3/11/24 all training were located in binder copies were made and placed in employee file. Human Resources will conduct monthly audits of all employee files and make copies of all health screenings and tb education in employees files before filing them away in binders. We will also Continue to document that our employees have received baseline tuberculosis screening upon hire and symptom screening/ risk assessment initially and TB education annually.Quarterly staff in-services will be conducted by the Administrator with Human Resources to maintain compliance of each employee record.
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 a review of consumer files (CF) and an interview with the manager, there was no evidence that the agency provided the consumer with information regarding the prohibitions that 1) no individual as a result of the individual's affiliation with the home care agency may assume power of attorney or guardianship of a consumer using the services of the agency, and 2) the home care agency may not require a consumer to endorse checks over to the home care agency for five (5) of five (5) CF's reviewed: CF#1, CF#2, CF#3, CF#4, CF#5.
Findings include:
The admission packet provided by the agency to the consumer, reviewed on July 1, 2024 found that information pertaining to the prohibitions was not complete in the admission packet.
A review of CF's was conducted on July 1, 2024 at approximately 11:15 am. The start of care (SOC) is indicated below:
CF#1 SOC 2/26/2018, CF contained information regarding power of attorney but did not have language about the agency may not require a consumer to endorse checks over to the agency.
CF#2 SOC 10/04/2021, CF contained information regarding power of attorney but did not have language about the agency may not require a consumer to endorse checks over to the agency.
CF#3 SOC 10/22/2019, CF contained information regarding power of attorney but did not have language about the agency may not require a consumer to endorse checks over to the agency.
CF#4 SOC 10/25/2021, CF contained information regarding power of attorney but did not have language about the agency may not require a consumer to endorse checks over to the agency.
CF#5 SOC 2/3/2020, CF contained information regarding power of attorney but did not have language about the agency may not require a consumer to endorse checks over to the agency.
An interview conducted with the administrator on July 1,2024 starting at 1:15 PM confirmed the above findings.
Plan of Correction:CF#1 The admission packet provided by Compassionate Caretakers Home Care Agency to the consumer was revised on July 2, 2024 with correct language that states, No individual as a result of the individual's affiliation with our home care agency may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency. Also Compassionate Caretakers Home Care Agency may not require a consumer to endorse checks over to the home care agency. A new service agreement was reissued to CF#1 and a signed copy was also placed in the consumer file. In our efforts to maintain compliance all service agreements were revised and reissued to all current consumers. We will ensure that during the initial welcome process that all documents are accurate and updated by the standards of homecare regulations. Administration will also conduct monthly audits of all consumer files to ensure that all files are correct and updated. Quarterly visits are also being conducted to ensure binders at their homes are revised and updated as well.
CF#2 The admission packet provided by Compassionate Caretakers Home Care Agency to the consumer was revised on July 2, 2024 with correct language that states, No individual as a result of the individual's affiliation with our home care agency may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency. Also Compassionate Caretakers Home Care Agency may not require a consumer to endorse checks over to the home care agency. A new service agreement was reissued to CF#2 and a signed copy was also placed in the consumer file. In our efforts to maintain compliance all service agreements were revised and reissued to all current consumers. We will ensure that during the initial welcome process that all documents are accurate and updated by the standards of homecare regulations. Administration will also conduct monthly audits of all consumer files to ensure that all files are correct and updated. Quarterly visits are also being conducted to ensure binders at their homes are revised and updated as well.
CF#3 The admission packet provided by Compassionate Caretakers Home Care Agency to the consumer was revised on July 2, 2024 with correct language that states, No individual as a result of the individual's affiliation with our home care agency may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency. Also Compassionate Caretakers Home Care Agency may not require a consumer to endorse checks over to the home care agency. A new service agreement was reissued to CF#3 and a signed copy was also placed in the consumer file. In our efforts to maintain compliance all service agreements were revised and reissued to all current consumers. We will ensure that during the initial welcome process that all documents are accurate and updated by the standards of homecare regulations. Administration will also conduct monthly audits of all consumer files to ensure that all files are correct and updated. Quarterly visits are also being conducted to ensure binders at their homes are revised and updated as well.
CF#4 The admission packet provided by Compassionate Caretakers Home Care Agency to the consumer was revised on July 2, 2024 with correct language that states, No individual as a result of the individual's affiliation with our home care agency may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency. Also Compassionate Caretakers Home Care Agency may not require a consumer to endorse checks over to the home care agency. A new service agreement was reissued to CF#4 and a signed copy was also placed in the consumer file. In our efforts to maintain compliance all service agreements were revised and reissued to all current consumers. We will ensure that during the initial welcome process that all documents are accurate and updated by the standards of homecare regulations. Administration will also conduct monthly audits of all consumer files to ensure that all files are correct and updated. Quarterly visits are also being conducted to ensure binders at their homes are revised and updated as well.
CF#5 The admission packet provided by Compassionate Caretakers Home Care Agency to the consumer was revised on July 2, 2024 with correct language that states, No individual as a result of the individual's affiliation with our home care agency may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency. Also Compassionate Caretakers Home Care Agency may not require a consumer to endorse checks over to the home care agency. A new service agreement was reissued to CF#5 and a signed copy was also placed in the consumer file. In our efforts to maintain compliance all service agreements were revised and reissued to all current consumers. We will ensure that during the initial welcome process that all documents are accurate and updated by the standards of homecare regulations. Administration will also conduct monthly audits of all consumer files to ensure that all files are correct and updated. Quarterly visits are also being conducted to ensure binders at their homes are revised and updated as well.
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 a review of consumer files (CF) and an interview with the administrator, 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. (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. (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 for five (5) of the five (5) CF's reviewed. (CF#1,2,3,4 and 5)
Findings include:
A review of CF's were conducted on July 1, 2024 starting at approximately 11:15 AM indicated the following with the Start of Care (SOC) indicated below:
CF#1 Start of Care 2/26/2018. File did not contain the identity of the direct care worker, hours when services will be provided, No information was listed regarding the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. 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 was not on file.
CF#2 Start of Care 10/4/2021. File did not contain the identity of the direct care worker, hours when services will be provided, No information was listed regarding the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.
CF#3 Start of Care 10/22/2019. File did not contain the identity of the direct care worker, hours when services will be provided, No information was listed regarding the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.
CF#4 Start of Care 10/25/2021. File did not contain the identity of the direct care worker. No information was listed regarding the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.
CF#5 Start of Care 2/3/2020. File did not contain the identity of the direct care worker, hours when services will be provided, No information was listed regarding the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.
An interview conducted with the administrator on July 1, 2024 starting at 1:15 PM confirmed the above findings.
Plan of Correction:The admission packet provided by Compassionate Caretakers Home Care Agency to the CF #1 service agreement was revised on July 3, 2024 so it contains the identity of the consumer's valid current ID direct care worker, hours when services will be provided, hiring and competency requirements applicable to direct care workers employed by Compassionate Caretakers Home Care Agency.. In our efforts to maintain compliance all service agreements revised and reissued to all current consumers. We will ensure that during the initial start of care welcome process that all documents are accurate and updated by the standards of homecare regulations. Administration will also conduct monthly audits of all consumer files to ensure that all files are correct and updated. Quarterly visits are also being conducted to ensure binders at their homes are revised and updated as well.
The admission packet provided by Compassionate Caretakers Home Care Agency to the CF #2 service agreement was revised on July 3, 2024 so it contains the identity of the consumer's valid current ID direct care worker, hours when services will be provided, hiring and competency requirements applicable to direct care workers employed by Compassionate Caretakers Home Care Agency.. In our efforts to maintain compliance all service agreements revised and reissued to all current consumers. We will ensure that during the initial start of care welcome process that all documents are accurate and updated by the standards of homecare regulations. Administration will also conduct monthly audits of all consumer files to ensure that all files are correct and updated. Quarterly visits are also being conducted to ensure binders at their homes are revised and updated as well.
The admission packet provided by Compassionate Caretakers Home Care Agency to the CF #3 service agreement was revised on July 3, 2024 so it contains the identity of the consumer's valid current ID direct care worker, hours when services will be provided, hiring and competency requirements applicable to direct care workers employed by Compassionate Caretakers Home Care Agency.. In our efforts to maintain compliance all service agreements revised and reissued to all current consumers. We will ensure that during the initial start of care welcome process that all documents are accurate and updated by the standards of homecare regulations. Administration will also conduct monthly audits of all consumer files to ensure that all files are correct and updated. Quarterly visits are also being conducted to ensure binders at their homes are revised and updated as well.
The admission packet provided by Compassionate Caretakers Home Care Agency to the CF #4 service agreement was revised on July 3, 2024 so it contains the identity of the consumer's valid current ID direct care worker, hours when services will be provided, hiring and competency requirements applicable to direct care workers employed by Compassionate Caretakers Home Care Agency.. In our efforts to maintain compliance all service agreements revised and reissued to all current consumers. We will ensure that during the initial start of care welcome process that all documents are accurate and updated by the standards of homecare regulations. Administration will also conduct monthly audits of all consumer files to ensure that all files are correct and updated. Quarterly visits are also being conducted to ensure binders at their homes are revised and updated as well.
The admission packet provided by Compassionate Caretakers Home Care Agency to the CF #5 service agreement was revised on July 3, 2024 so it contains the identity of the consumer's valid current ID direct care worker, hours when services will be provided, hiring and competency requirements applicable to direct care workers employed by Compassionate Caretakers Home Care Agency.. In our efforts to maintain compliance all service agreements revised and reissued to all current consumers. We will ensure that during the initial start of care welcome process that all documents are accurate and updated by the standards of homecare regulations. Administration will also conduct monthly audits of all consumer files to ensure that all files are correct and updated. Quarterly visits are also being conducted to ensure binders at their homes are revised and updated as well.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey, Compassionated Caretakers Home Care Agency on July 1, 2024, was found not to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
35 P. S. § 448.809b LICENSURE
Photo Id Reg
Name - Component - 00
Law amended July 11, 2022 Act 79 2022 HB 2604
(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.
(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.
(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.
(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.
Observations:
Based on a review of personnel files (PF) and an interview with the administrator, the agency did not provide photo identification badges in accordance with regulation. (1) The photo identification tag shall include a recent photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] (2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge for seven (7) of seven (7) PFs. PF# 1, 2, 3,4,5,6,and 7.
Findings include:
A review of personnel files (PF) was conducted on July 1, 2024 at 12:00 PM. The date of hire (DOH) is indicated below:
PF#1 DOH 2/18/2019 Contained a photo identification badge but not according to regulation whereas the photo and name were small and no title was indicated on the badge.
PF#2 DOH 12/31/2022 Contained a photo identification badge but not according to regulation whereas the photo and name were small and no title was indicated on the badge.
PF#3 DOH 2/15/2024 Contained a photo identification badge but not according to regulation whereas the photo and name were small and no title was indicated on the badge.
PF#4 DOH 2/23/2022 Contained a photo identification badge but not according to regulation whereas the photo and name were small and no title was indicated on the badge.
PF#5 DOH 10/20/2023 Contained a photo identification badge but not according to regulation whereas the photo and name were small and no title was indicated on the badge.
PF#6 DOH 2/5/2023 Contained a photo identification badge but not according to regulation whereas the photo and name were small and no title was indicated on the badge.
PF#7 DOH 1/22/2020 Contained a photo identification badge but not according to regulation whereas the photo and name were small and no title was indicated on the badge.
An interview with the administrator on July 1, 2024 at 1:15 PM confirmed that none of the employees were provided with an identification badge according to regulation .
Plan of Correction:PF #1 Corrective action plan was done on July 3, 2024 at compassionate caretakers home care agency new employee ID made with the name and logo of the agency, a current photo of the employee large with title of the employee as large as possible in block type which is one-half inch tall strip close to the bottom edge of the badge. Copy was placed in the employee's file and badge given to the employee. In our efforts to maintain compliance we will ensure that during the hiring process that all IDs are issued and updated yearly with a current photo and employee title. Human Resources will also conduct monthly audits of all employee files to ensure current IDs were obtained and are in good standing. Quarterly staff in-services will be conducted by the Administrator with Human Resources to maintain compliance of each employee record.
PF #2 Corrective action plan was done on July 3, 2024 at compassionate caretakers home care agency new employee ID made with the name and logo of the agency, a current photo of the employee large with title of the employee as large as possible in block type which is one-half inch tall strip close to the bottom edge of the badge. Copy was placed in the employee's file and badge given to the employee. In our efforts to maintain compliance we will ensure that during the hiring process that all IDs are issued and updated yearly with a current photo and employee title. Human Resources will also conduct monthly audits of all employee files to ensure current IDs were obtained and are in good standing. Quarterly staff in-services will be conducted by the Administrator with Human Resources to maintain compliance of each employee record.
PF #3 Corrective action plan was done on July 3, 2024 at compassionate caretakers home care agency new employee ID made with the name and logo of the agency, a current photo of the employee large with title of the employee as large as possible in block type which is one-half inch tall strip close to the bottom edge of the badge. Copy was placed in the employee's file and badge given to the employee. In our efforts to maintain compliance we will ensure that during the hiring process that all IDs are issued and updated yearly with a current photo and employee title. Human Resources will also conduct monthly audits of all employee files to ensure current IDs were obtained and are in good standing. Quarterly staff in-services will be conducted by the Administrator with Human Resources to maintain compliance of each employee record.
PF #4 Corrective action plan was done on July 3, 2024 at compassionate caretakers home care agency new employee ID made with the name and logo of the agency, a current photo of the employee large with title of the employee as large as possible in block type which is one-half inch tall strip close to the bottom edge of the badge. Copy was placed in the employee's file and badge given to the employee. In our efforts to maintain compliance we will ensure that during the hiring process that all IDs are issued and updated yearly with a current photo and employee title. Human Resources will also conduct monthly audits of all employee files to ensure current IDs were obtained and are in good standing. Quarterly staff in-services will be conducted by the Administrator with Human Resources to maintain compliance of each employee record.
PF #5 Corrective action plan was done on July 3, 2024 at compassionate caretakers home care agency new employee ID made with the name and logo of the agency, a current photo of the employee large with title of the employee as large as possible in block type which is one-half inch tall strip close to the bottom edge of the badge. Copy was placed in the employee's file and badge given to the employee. In our efforts to maintain compliance we will ensure that during the hiring process that all IDs are issued and updated yearly with a current photo and employee title. Human Resources will also conduct monthly audits of all employee files to ensure current IDs were obtained and are in good standing. Quarterly staff in-services will be conducted by the Administrator with Human Resources to maintain compliance of each employee record.
PF #6 Corrective action plan was done on July 3, 2024 at compassionate caretakers home care agency new employee ID made with the name and logo of the agency, a current photo of the employee large with title of the employee as large as possible in block type which is one-half inch tall strip close to the bottom edge of the badge. Copy was placed in the employee's file and badge given to the employee. In our efforts to maintain compliance we will ensure that during the hiring process that all IDs are issued and updated yearly with a current photo and employee title. Human Resources will also conduct monthly audits of all employee files to ensure current IDs were obtained and are in good standing. Quarterly staff in-services will be conducted by the Administrator with Human Resources to maintain compliance of each employee record.
PF #7 Corrective action plan was done on July 3, 2024 at compassionate caretakers home care agency new employee ID made with the name and logo of the agency, a current photo of the employee large with title of the employee as large as possible in block type which is one-half inch tall strip close to the bottom edge of the badge. Copy was placed in the employee's file and badge given to the employee. In our efforts to maintain compliance we will ensure that during the hiring process that all IDs are issued and updated yearly with a current photo and employee title. Human Resources will also conduct monthly audits of all employee files to ensure current IDs were obtained and are in good standing. Quarterly staff in-services will be conducted by the Administrator with Human Resources to maintain compliance of each employee record.
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