Initial Comments:
Based on the findings of an onsite unannounced home care agency complaint survey conducted on February 7, 2024, Quality Life Healthcare, LLC., was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries
Plan of Correction:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
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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 personnel files (PF) and an interview with the administrator, the agency failed to provide documentation that an interview was conducted for two (2) of eleven (11) PF's reviewed, (PF #1 and 10); and to provide documentation that at least two satisfactory and verifiable references were obtained for one (1) of eleven (11) PF's reviewed, (PF #10).
Findings include:
A review of PF's conducted on February 7, 2024 from approximately 9:30 am to 11:00 am revealed the following:
PF #1, Date of Hire: 9/5/2022. File did not contain any documentation that an interview was conducted.
PF #10, Date of Hire: 8/27/2023. File did not contain any documentation that an interview was conducted and did not contain any documentation of at least two (2) verifiable and satisfactory reference checks.
An interview with the administrator on February 7, 2024, at approximately 11:00 am confirmed the above findings.
Plan of Correction:-The Administrator will review with staff the agency's policy and procedure manual on hiring of new staff.
-For the two (2) PFs without documentation, the office manager will contact each individual and obtain this documentation promptly.
-To identify other individuals lacking this information, the Employee Compliance Coordinator will review agency case files and request any employee missing references provide this information within the next fourteen (14) days and schedule face to face interviews during this period.
-Moving forward, The Recruiting and Onboard Coordinator will ensure face to face interviews are conducted at orientation with prospective candidates who meet the qualifications for employment with the agency.
-At orientation, the Recruiting and Onboard Coordinator will require applicants to provide two (2) references from previous employers or persons not related who can attest to the candidate's ability to perform direct care services.
-The Recruiting and Onboard Coordinator will follow up on references by verbal or written correspondence to past employers to verify candidates' information.
-Documentation of face-to-face interviews and references will be scanned and placed in the applicant's file.
-Candidates will be informed employment is contingent upon all required documentation being submitted prior to hiring.
-The Operations Manager will continue to provide ongoing monitoring by conducting an audit of all candidate records to ensure all candidates have provided this information. Audits will commence prior to hiring and annually thereafter.
Completion date April 4, 2024
611.55(a) LICENSURE
Competency Requirements
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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 agency failed to document that prior to assigning a direct care worker to provide services to a consumer, the home care agency ensured that the direct care worker completed an initial competency for two (2) of eleven (11) PF's reviewed, (PF #1 and 10).
Findings include:
A review of PF's conducted on February 7, 2024, from approximately 9:30 am to 11:00 am.
PF #1, Date of Hire: 9/5/2022, did not contain any documentation of an initial competency completed prior to assigning a direct care worker to provide services to a consumer.
PF #10, Date of Hire: 8/27/2023, did not contain any documentation of an initial competency completed prior to assigning a direct care worker to provide services to a consumer.
An interview with the administrator on February 7, 2024, at approximately 11:00 am confirmed the above findings.
Plan of Correction:The Administrator will review staff policy concerning compliance with Competency Requirements.
- To identify other individuals missing this information, the Employee Compliance Coordinator will review agency case files, documents and schedule any individual missing a competency test.
- Moving forward, as part of the agency's orientation process, the Recruiting and Onboard Coordinator will ensure all candidates take a written competency test to determine if the applicant is suitable for employment with the agency.
-The Recruiting and Onboard Coordinator will score each applicant test and ensure individuals who fail to pass the competency requirement with a score of 70 or above are not hired until competency requirements are met.
-The Recruiting and Onboard Coordinator will refer to the agency's orientation checklist to verify each individual competency's test is in the case files prior to hire.
-For the two (2) Pf's reviewed that did not have this information, the Recruiting and Onboard coordinator will begin immediately to schedule the competency test to be given to these individuals.
- The Operations Manager will continue to provide ongoing monitoring by conducting an audit of all candidate records to ensure all candidates have provided this information. Audits will commence prior to hiring and annually thereafter.
Completion date March 29,2024
611.55(e) LICENSURE
Competency Requirements
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The competency review must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction.
Observations:
Based on a review of personnel files (PF) and an interview with the administrator, the agency failed to provide documentation of an annual competency evaluation for one (1) of eleven (11) PF's reviewed, (PF #4).
Findings include:
A review of PF's conducted on February 7, 2024, from approximately 9:30 am to 11:00 am revealed the following:
PF #4, Date of Hire: 3/31/2020, did not contain any documentation of an annual competency evaluation for 2021 or 2022.
An interview with the administrator on February 7, 2024, at approximately 11:00 am confirmed the above findings.
Plan of Correction:The Administrator will review staff policy concerning compliance with Annual Competency Evaluation Requirements.
- To identify individuals missing this information, the Employee Compliance Coordinator will review agency case files, notify employees and schedule any individual missing a competency test.
- Moving forward, the Employee Compliance Coordinator will establish a tickler system to keep track of annual competency examination due dates for all direct care workers.
-The Employee Compliance Coordinator will ensure individuals meet the Annual Competency requirements by sending reminders of testing dates by letter to employees 60 days before renewal.
- For the one (1) PF reviewed that did not have this information, the Recruiting and Onboard coordinator will begin immediately to schedule the competency test to be given to this individual.
-The Operations Manager will continue to provide ongoing monitoring by conducting an audit of all candidate records to ensure all candidates have provided this information. Audits will commence prior to hiring and annually thereafter.
Completion date March 29,2024
611.56(b) LICENSURE
Health Screening
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(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 personnel files (PFs), the Centers for Disease Control guidelines, and interview with the administrator, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, were provided with annual mycobacterium tuberculosis education for one (1) of eleven (11) PF's reviewed, (PF #4).
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 conducted on February 7, 2024 from approximately 9:30 am to 11:00 am revealed the following:
PF #4, Date of Hire: 3/31/2020, did not contain any documentation of annual tuberculosis education provided for 2021 or 2022.
An interview with the administrator conducted on February 7, 2024 at approximately 11:00 am confirmed the above findings.
Plan of Correction:he Administrator will review all staff policy concerning compliance with CDC guidelines for annual mycobacterium tuberculosis testing and provide documentation for the one (1) of eleven PF's reviewed.
-To identify other individual lacking this information, the Employee Compliance Coordinator will review agency case files, documents and schedule any individual missing this information.
-To ensure ongoing compliance, the Recruiting and Onboard Coordinator will provide upon hire baseline tuberculosis screening, completion of a tuberculosis symptom questionnaire and completion of a tuberculosis risk assessment.
-After baseline testing, the Recruiting Onboard Coordinator will provide tuberculosis education annually.
-The Employee Compliance Coordinator will establish a tickler system to record tuberculosis requirements completed and date of renewal for all direct care workers.
-The Employee Compliance Coordinator will ensure individual's obtain tuberculosis testing annually by sending reminders through email or letter to employees 60 days (about 2 months) from renewal of tuberculosis testing.
-The Employee Compliance Coordinator will continue to provide ongoing monitoring by auditing files quarterly to ensure each employee meets the CDC Guidelines concerning tuberculosis testing and this information is in each case file.
Completion date April 5,2024
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