Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on February 15, 2024, Care and Help Home Care, LLC., was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on February 15, 2024, Care and Help Home Care, LLC., was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries.
Plan of Correction:
611.55(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 personnel files (PF) and an interview with the administrator, the home care agency failed to ensure that the direct care worker (DCW) demonstrated competency by passing a competency examination developed by the home care agency. Four (4) of seven(7) PF's did not meet the requirement: PF#2, 3, 4, &7
Findings include:
A review of personnel files was conducted on February 15, 2024 starting at approximately 12:00 PM. The date of hire (DOH) is indicated below.
PF#2 DOH 8/26/23 contained a competency examination that was developed by the home care agency and completed by the DCW on 8/22/23, but the competency examination was not scored and therefore, the outcome as to whether the DCW passed the examination was unable to be determined.
PF#3 DOH 12/1/21 contained a competency examination that was developed by the home care agency and completed by the DCW on 12/1/21, but the competency examination was not scored and therefore, the outcome as to whether the DCW passed the examination was unable to be determined.
PF#4 DOH 8/3/23 contained a competency examination that was developed by the home care agency and completed by the DCW on 8/3/23, but the competency examination was not scored and therefore, the outcome as to whether the DCW passed the examination was unable to be determined.
PF#7 DOH 7/5/23 contained a competency examination that was developed by the home care agency and completed by the DCW on 7/5/23, but the competency examination was not scored and therefore, the outcome as to whether the DCW passed the examination was unable to be determined.
An interview with the administrator on February 15, 2024 starting at 2:30PM confirmed the above findings.
Plan of Correction:On-Site PA DHS Licensure visit - Huntingdon Valley Office
Feb 15, 2024
Corrective Action Plan DUE within 10 calendar days of report
4 of 7 records reviewed were missing scoring of the competency examination demonstrating organization review. Feedback from surveyors was to ensure the competency examination was able to demonstrate immediately that the results were scored by someone, the date and the score of the examination was documented and that the threshold of a passing score for the organization was referenced. Below are details of the plan for correction.
Core Elements for POC
What corrective action will be accomplished for those individuals and /or practices identified in the deficiency statement(s)?
Competency tests for the four (4) files identified have been reviewed and scored for completion. Copies of these scored tests are now filed and available within personnel records for the four employees. Completed by the Manager of Human Resources on 2/29/2024.
How will you identify other individuals having the potential to be affected by the same deficient practice?
New hires for January 2024 through date of new competency form implementation will be reviewed for documentation of the competency examination scoring status. This retrospective review and update to the documents will be completed by the Managers of Recruitment by March 31, 2024. The results of this audit will be collated by the Manager of Compliance and presented to the SVP of Operations.
What measures (actions/forms/system changes, etc.) will be put in place to ensure that the deficient practice does not recur?
Prior to the on-site survey, on 2/2/2024, the competency examination was requested to be reviewed by the VP of Clinical (a Nurse Practitioner). On 2/6/2024 a draft was completed for review including a crosswalk to the appropriate regulations in PA Title 28 Chapter 611 and § 611.55. On 2/9/2024 the draft was approved by the SVP of Operations and other operational leaders within the organization. On 2/16/2024 the proposed new competency examination was compared to the feedback of the on-site survey team. Edits were made to the new competency examination including the following documentation fields: Number of Questions Correct, the Passing benchmark of 24 of 30 questions (80%), Pass/Fail status, Agency Reviewer Name, Reviewer Signature, and Date. Final review of this form was completed on 2/27/2024 by the SVP of Operations, VP of Operations, Manager of Human Resources, Manager of Compliance, and VP of Clinical and will be implemented for all new hires on 2/29/2024.
How will the corrective action be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance programs will be established/followed?
Position - The Manager of Compliance will audit 100% of new hire competency examinations for documentation of scoring.
Tools - An audit tool collating the full list of new applicants as the sample size will include the presence of a competency test as well as the presence of all fields noted on the revised competency examination; Number of Questions Correct, Pass/Fail Status, Agency Reviewer Name, Agency Reviewer Signature, and Date.
Frequency - Compliance reviews will happen in real time as part of the onboarding process. Weekly results will be reported to the Managers of Recruitment and the Director of Recruitment. Bi-weekly or monthly results will be reported by the Manager of Compliance at the Operations Management meeting.
Measures - The compliance % for each of the presence of a competency test as well as the five (5) review items will be scored separately with a goal of 100% compliance.
Date of when corrective action will be completed. All corrective actions will be implemented by March 31, 2024.
Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on February 15, 2024, Care and Help Home Care, LLC., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
|