Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed December 13, 2024, Anna's Guardian Angel Homecare Agency 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 relicensure survey completed December 13, 2024, Anna's Guardian Angel Homecare Agency Llc was found not to 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:
611.55(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 employee files (EF), and staff employee (EMP) interview, the agency failed to ensure employees met minimum competency requirements for two (3) of seven (7) employee files who care for a consumer using a mechanical lift (EF1, EF2 and EF3).
Findings Include:
During an interview on 12/11/24, at 10:53 a.m. EMP1 the Office Manager confirmed that consumer file CF1 uses a mechanical lift for all transfers that she trained Direct Care Workers EF1, EF2 and EF3 on CF1's mechanical lift (lift to transfer consumer from one surface to another surface) at CF1's residence but did not document the training.
Review of employee files (EF) of Direct Care Workers on 12/11/24, at 12:05 p.m. and 12/12/24, at 8:00 a.m. revealed the following:
EF1, Date of Hire 8/6/23, Start of Service date for CF1 8/23/23, did not contain documentation to show agency provided mechanical lift training to EF1 or evaluated his/her competency to use such lift.
EF2, Date of Hire 6/25/23, Start of Service date for CF1 12/1/24, did not contain documentation to show agency provided mechanical lift training to EF2 or evaluated his/her competency to use such lift.
EF3, Date of Hire 12/18/20, Start of Service date for CF1 11/4/24, did not contain documentation to show agency provided mechanical lift training to EF3 or evaluated his/her competency to use such lift.
During an interview on 12/13/24, at 12:14 p.m. EMP1 the Office Manager confirmed the above findings.
Plan of Correction:We have created a form of training completion on the Hoyer lift. Must be signed by trainer and trainee indicated that the employee has been trained.
We will audit and Retrain staff that works with Hoyer Lift and have both trainer and trainee sign the training form. Audit and retraining will be completed by 01-13-2025
To prevent this from occurring again administration we conduct a annual review of training. Employee must be trained annually or if equipment has changed.
EF1,EF2,EF3 will be retrained by 01-13-2025. Training will be conduct by Office Manager.
01-13-2025
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 review of employee files (EF), and staff employee (EMP) interview, it was determined that the agency failed to show documentation of annual competency reviews for a Direct Care Worker that uses a mechanical lift for one (1) of seven (7) employee files reviewed (EF1).
Findings Include:
During an interview on 12/11/24, at 10:53 a.m. EMP1 the Office Manager confirmed that consumer file (CF) CF1 uses a hoyer lift for all transfers, that she trained Direct Care Worker EF1 on CF1's mechanical lift (lift to transfer consumer from one surface to another surface), but did not document the training.
Review of employee files (EF) of Direct Care Workers on 12/11/24, at 12:05 p.m. and 12/12/24, at 8:00 a.m. revealed the following:
EF1, Date of Hire 8/6/23, Start of Service date for CF1 8/23/23, did not contain documentation to show agency provided an annual competency review of mechanical lift training to EF1 or evaluated his/her competency to use such lift.
During an interview on 12/13/24, at 12:14 p.m. EMP1 the Office Manager confirmed the above findings.
Plan of Correction:We have created a form of training completion on the Hoyer lift. Must be signed by trainer and trainee indicated that the employee has been trained.
We will Retrain staff that works with Hoyer Lift and have both trainer and trainee sign the training form.
Administration we conduct a annual review of training. Employee must be trained annually of when equipment has changed.
EF1, EF2, EF2, will be retrained by 01-13-2025.
Completion Date 01-13-2025
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 review of employee files (EF) and staff employee (EMP) interview, the agency failed to ensure that each employee with direct consumer contact was screened for mycobacterium tuberculosis (TB) in accordance with CDC guidelines for six (6) of seven (7) direct care worker files reviewed (EF1, EF2, EF4, EF5, EF6 and EF7).
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) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis...HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease....A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST within the previous 12 months, a single TST can be administered in the new setting. CDC Guidelines for preventing the 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).
Review of employee files (EF) of Direct Care Workers on 12/11/24, at 12:05 p.m. and 12/12/24, at 8:00 a.m. revealed the following:
EF1, Date of Hire 8/6/23, The file did not contain an individual TB risk assessment.
EF2, Date of Hire 6/25/23, The file did not contain an individual TB risk assessment.
EF4, Date of Hire 10/15/22, The file did not contain an individual TB risk assessment.
EF5, Date of Hire 2/27/24, The file did not contain an individual TB risk assessment.
EF6, Date of Hire 7/7/24, The file did not contain an individual TB risk assessment.
EF7, Date of Hire 10/26/23, The file did not contain an individual TB risk assessment.
During an interview on 12/13/24, at 12:14 p.m. EMP1 the Office Manager confirmed the above findings.
Plan of Correction:Will create a TB risk assessment/questioner that all employees must complete annually and before hire. Will also include a educational document soured form CDC.com informing employees of tuberculosis.
Administers will conduct an review prior to revisit of all employees assuring that all employees TB test or up to date including training and risk assessment. Ef1,Ef2,Ef3,Ef4,Ef5,Ef6,Ef7 will individually complete the TB assessment by 01/13/2025.
will be completed by 01/13/2025
611.56(b) LICENSURE Health Screening Name - Component - 00 (b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.
Observations:
Based on review of employee files (EF), Centers for Disease Control (CDC) Guidelines, and staff employee (EMP) interview, it was determined the agency failed to ensure all workers with direct consumer contact received annual mycobacterium tuberculosis (TB) education for five (5) of seven (7) direct care worker (DCW) employee files reviewed (EF1, EF2, EF3, EF4 and EF7)
Findings include:
The CDC guidelines state...."Serial screening and testing not routinely recommended. Annual TB education is recommended." Retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6819-H.pdf
Review of employee files (EF) of Direct Care Workers on 12/11/24, at 12:05 p.m. and 12/12/24, at 8:00 a.m. revealed the following:
EF1, Date of Hire 8/6/23, There was no documented evidence of an annual tuberculosis education completed in 2024.
EF2, Date of Hire 6/25/23, There was no documented evidence of an annual tuberculosis education completed in 2024.
EF3, Date of Hire 12/18/20, There was no documented evidence of an annual tuberculosis education completed in 2022, 2023 and 2024.
EF4, Date of Hire 10/15/22, There was no documented evidence of an annual tuberculosis education completed in 2023 and 2024.
EF7, Date of Hire 10/26/23, There was no documented evidence of an annual tuberculosis education completed in 2024.
During an interview on 12/13/24, at 12:14 p.m. EMP1 the Office Manager confirmed the above findings.
Plan of Correction:Will create a TB risk assessment/questioner that all employees must complete annually and before hire. we will review all employee to ensure all have completed questioner and are educated on tuberculosis before 01/13/2025.
Will also include a educational document soured form CDC.com informing employees of tuberculosis.
Administers will conduct an annual review of all employees assuring that all employees TB test or up to date including training and risk assessment.
EF1, EF2, EF3, EF4, EF7 will have annual TB training complete by 01-13-2025.
01/13/2025 will be the completion date
611.57(a) LICENSURE Consumer Rights Name - Component - 00 (a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.
Observations:
Based on review of consumer files and staff employee (EMP) interview, the agency failed to ensure consumers were involved in the service planning process for one (1) of seven (7) consumers files reviewed (CF1).
Findings include:
During an interview on 12/11/24, at 10:53 a.m. EMP1 the Office Manager confirmed that consumer file CF1 uses a mechanical lift for all transfers.
During a review of consumers files for CF1 on 12/11/24, at 11:06 a.m. the Service Agreement was signed on 3/26/23, and her care plan was signed by CF1 but was not dated and did not include care planning for their mechanical lift.
During an interview on 12/13/24, at 12:14 p.m. EMP1 the Office Manager confirmed that CF1 did not have documentation of mechanical lift care planning.
Plan of Correction:CarePlan's will be updated to include the use of Hoyer Lift and other equipment needed to provide care.
Will conduct a review of all CarePlan's annually or upon request to add or remove any actions or equipment needed to provide care to consumer. All updates will be finished by 01/13/2025
CF1 care plan has been updated to include that consumer needs Hoyer lift.
Office Manager will contact all consumers to ensure if consumers are currently using Hoyer lists. If so staff will be trained. Training will be completed by 1/13/2025.
Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed December 13, 2024, Anna's Guardian Angel Homecare Agency Llc was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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