Initial Comments:
Based on the findings of a State relicensure survey initiated onsite February 16, 2024 and completed offsite February 23, 2024, Serenityathomecare, Llc was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of a State relicensure survey initiated onsite February 16, 2024 and completed offsite February 23, 2024, Serenityathomecare, 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:
611.52(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 interview with agency staff (EMP), the agency failed to verify proof of residency in Pennsylvania for 2 years prior to date of hire for two (2)of seven (7) direct care worker personnel files reviewed (PF3, PF4).
Findings include:
Personnel file (PF) reviews conducted on 2/16/24 between approximately 11:15 a.m. and 1:00 p.m. revealed:
PF3, date of hire 10/17/22. Start of care 10/23/22. No documented evidence to verify proof of PA residency for the two years immediately preceding the date of hire. PF contained PA driver's license issued 5/26/23.
PF4, date of hire 12/4/23. Start of care 12/10/23. No documented evidence to verify proof of PA residency for the two years immediately preceding the date of hire. PF contained PA identification card issued 11/18/22.
The above findings were reviewed with the agency owner (EMP1) and agency office manager (EMP2) on 2/16/24 at approximately 2:45 p.m.
Plan of Correction:We have taken proactive steps to address the proof of residency issue for our direct care workers.
Firstly, we conducted a thorough review of all employee files to identify direct care workers who required alternative documents as proof of residency. We reached out to these individuals and requested them to provide the necessary documentation, such as utility bills or rental agreements.
For those workers who were unable to provide the required documentation, we initiated the fingerprinting process as an alternative method to establish their identity and residency.
To oversee this process and ensure compliance, we assigned the responsibility to our dedicated office Administrator. Office Admin will be responsible for obtaining and verifying all proof of residency documents before hiring any new direct care workers. And will require fingerprints if no documentation is available. Office Admin will also maintain records for monitoring and compliance.
611.56(a) LICENSURE
Health Screening
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(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 personnel files (PF), interview with agency staff (EMP) and review of CDC Guidelines, the agency failed to ensure each direct care worker, prior to consumer contact, was screened for and free from active mycobacterium tuberculosis for four (4) of seven (7) direct care worker (DCW) personnel files reviewed (PF3, PF4, PF5, PF7).
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. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease (CDC Guidelines for Preventing Transmission of Mycobacterium Tuberculosis in Health Care Settings, 2005. Morbidity and Mortality World Report 2005, RR-17) (http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf).
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
Personnel file (PF) reviews conducted on 2/16/24 between approximately 11:15 a.m. and 1:00 p.m. revealed:
PF3, date of hire 10/17/22. Start of care 10/23/22. No documented evidence of a tuberculosis screening completed. No documented evidence that PF3 completed an individual risk assessment and symptom evaluation prior to hire.
PF4, date of hire 12/4/23. Start of care 12/10/23. No documented evidence of a tuberculosis screening completed. No documented evidence that PF4 completed an individual risk assessment and symptom evaluation prior to hire
PF5, Date of hire 2/1/24. Start of care 2/10/24. No documented evidence of a tuberculosis screening completed. No documented evidence that PF5 completed an individual risk assessment and symptom evaluation prior to hire.
PF7, date of hire 10/28/23. Start of care 10/30/23. No documented evidence of a tuberculosis screening completed. No documented evidence that PF7 completed an individual risk assessment and symptom evaluation prior to hire.
The above findings were reviewed with the agency owner (EMP1) and agency office manager (EMP2) on 2/16/24 at approximately 2:45 p.m.
Plan of Correction:Regarding the Tuberculosis (TB) test results for our direct care workers, we acknowledge that four direct care workers did not have the report during the survey. They had undergone the TB test prior to their hiring through a different company and they are currently in the process of obtaining the test reports from their respective clinics, and we expect to have these reports by 4/1/2024.
We also thoroughly reviewed the files of all other direct care workers and confirmed that they have undergone TB testing.
To prevent such occurrences in the future, the office admin will ensure that all direct care workers undergo a two-step TB test prior to commencing their employment and provide us the report. Our office administrator will closely monitor this process to guarantee that the results are obtained before assigning workers to any members.
Initial Comments:
Based on the findings of a State relicensure survey initiated onsite February 16, 2024 and completed offsite February 23, 2024, Serenityathomecare, Llc 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
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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 review of agency documentation and interview with agency administrator, it was determined that the agency failed to ensure staff were provided a photo identification (ID) badge that contained 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 in accordance with regulatory guidelines for agency staff including agency administrator (EMP1) and agency office manager (EMP2) and for seven (7) of seven (7) direct care worker (DCW) personnel files reviewed. (PF1-PF7).
Findings include:
While conducting the survey and interview with agency administrator (EMP1) on 2/16/24 at approximately 9:35 a.m. surveyor asked to see an agency photo identification (ID) badge that is provided to employees. EMP1 stated "Did not know we needed that."
Plan of Correction:We have taken immediate action to rectify the situation. We have ordered photo identification badges for all our direct care workers and administrators. These badges will contain a recent photograph of the employee, their first name, their title, and the name of our health care facility.
Moving forward, our office administrator will take the responsibility of ensuring that all direct care workers receive their ID badges before they are placed with the consumer.
There will be a checklist that includes a task of issuing ID badges and office admin will review regularly to ensure all direct care workers have received their badges.
We are committed to ensuring compliance with all regulatory guidelines and providing a safe and secure environment for our staff and clients.
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