Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on May 30, 2024, Angelic Hero's Homecare, 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 May 30, 2024, Angelic Hero's Homecare, 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:
611.52(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 direct care worker personnel files (PF) and an interview with the agency administrator, the agency failed to document proof of residency for the two years immediately preceding the date of hire for four (4) of seven (7) PF reviewed. (PF # 1, 4, 5, and 6).
Findings include:
Review of PF's on May 30, 2024, from approximately 2:15 P.M. to 2:45 P.M. revealed the following:
PF #1, date of hire May 26, 2023, contained a Pennsylvania driver's license issued January 24, 2023. There was no documentation that the applicant resided in Pennsylvania for the two (2) years immediately preceding the date of hire.
PF #4, date of hire March 30, 2024, contained a Pennsylvania driver's license issued December 28, 2023. There was no documentation that the applicant resided in Pennsylvania for the two (2) years immediately preceding the date of hire.
PF #5, date of hire March 1, 2024, contained a Pennsylvania identification card issued May 24, 2023. There was no documentation that the applicant resided in Pennsylvania for the two (2) years immediately preceding the date of hire.
PF #6, date of hire March 27, 2024, contained a Pennsylvania driver's license issued March 22, 2024. There was no documentation that the applicant resided in Pennsylvania for the two (2) years immediately preceding the date of hire.
An interview with the agency administrator on May 30, 2024, at approximately 2:45 P.M. confirmed the above findings.
Plan of Correction:To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files including and specifically Personnel file #'s (1, 4, 5 and 6), as directed by Citation 0330.
The review showed the Agency does obtain proof of Pennsylvania (PA) residency for employees, but did not provide documentation for employees' personnel #'s (1, 4, 5 and 6) as required by 611.51(a).
To correct this error as of June 12, 2024; the Admin has obtained the required documentation for employees' personnel files #'s(1, 4, 5 and 6).
To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP"). This Policy will ensure all new hiring requirements of 11.51(a), have been met before a new employee can provide service consumers.
EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation.
As of June 12, 2024; with the EPIP implementation, all employee Personnel File's including file #'s (1, 4, 5 and 6), have all required documents as directed by 611.51(a). All deficiencies under Citation 0330 have been addressed.
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 direct care worker personnel files (PF) and an interview with the agency administrator, the agency failed to document that annual competency reviews were conducted for two (2) of two (2) PF of caregivers employed more than one (1) year. (PF # 3 and 7).
Findings include:
A review of PF's conducted on May 30, 2024, from approximately 2:15 P.M. to 2:45 P.M. revealed the following:
PF #3, date of hire June 18, 2022, contained no documentation of an annual competency review in 2023.
PF #7, date of hire October 12, 2022, contained no documentation of annual competency review in 2023.
An interview with the agency administrator on May 30, 2024, at approximately 2:45 P.M. confirmed the above findings.
Plan of Correction:To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files including and specifically Personnel File #'s (3 and 7) as directed by Citation 0621.
The review showed the Agency does provide employees with annual competency training and test, but did not provide documentation for employees' Personnel # (3 and 7) as required by 611.51(a).
To correct this error as of June 12, 2024; the Admin has obtained the required documentation for the annual competency review for employees' personnel # (3 and 7).
To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP"). This Policy will ensure all new hiring requirements of 11.51(a), have been met before a new employee can provide service consumers.
EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation.
As of June 12, 2024; with the EPIP implementation, all employee Personnel file's including file # (1), have all required documents as directed by 611.51(a). All deficiencies under Citation 0621 have been addressed.
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 upon review of personnel files (PF) and an interview with the agency administrator, the agency failed to ensure baseline testing, and/or a symptom screen questionnaire, and/or an individual TB risk assessment, and/or annual TB education was conducted for seven (7) of seven (7) PF reviewed. (PF# 1, 2, 3, 4, 5, 6, and 7).
Findings Include:
The CDC (Centers for Disease and Control and Prevention) guidelines state baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or tuberculin skin test (TST), shall include a symptom screen questionnaire and an individual tuberculosis (TB) risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
A review of PF's conducted on May 30, 2024, from approximately 2:15 P.M. to 2:45 P.M. revealed the following:
PF #1, date of hire May 26, 2023, contained documentation of a single TST completed on April 27, 2023. There was no documentation of a second-step TST. There no documentation that a symptom screen questionnaire and an individual TB risk assessment was completed upon hire. There was no documentation of annual TB education completed.
PF #2, date of hire January 23, 2023, contained no documentation of annual TB education completed.
PF #3, date of hire June 18, 2022, contained documentation of a single TST completed on October 5, 2021. There was no documentation that a symptom screen questionnaire and an individual TB risk assessment was completed upon hire. There was no documentation of annual TB education completed.
PF #4, date of hire April 30, 2024, contained no documentation that a symptom screen questionnaire was completed upon hire.
PF #5, date of hire March 1, 2024, contained documentation of a single TST completed on February 21, 2024. There was no documentation of a second-step TST. There was no documentation that a symptom screen questionnaire was completed upon hire.
PF #6, date of hire March 27, 2024, contained no documentation that a symptom screen questionnaire was completed upon hire.
PF #7, date of hire October 12, 2022, contained no documentation that a symptom screen questionnaire or an individual TB risk assessment was completed upon hire. There was no documentation of annual TB education completed.
An interview with the agency administrator on May 30, 2024, at approximately 2:45 P.M. confirmed the above findings.
Plan of Correction:To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files including and specifically Personnel File #'s (1, 2, 3, 4, 5, 6, and 7) as directed by Citation 0700.
The review showed the Agency does require employees to provide test results for mycobacterium tuberculosis, symptom screen questionnaire, and individual TB risk assessment, including employee annual TB education according to the Center for Disease Control (CDC) guidelines, but did not provide documentation for employees' personnel #'s (1, 2, 3, 4, 5, 6, and 7) as required by 611.51(a).
To correct this error as of May 31, 2024; the Admin has contacted ALL Agency employees' specifically employee's #(1, 2, 3, 4, 5, 6, and 7) and requested mycobacterium tuberculosis testing be completed immediately and for them to provide the negative required testing documentation for its personnel files including ensuring ALL employees have baseline testing, a symptom screen questionnaire, an individual TB risk assessment and annual TB education documentation in their PF's.
To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP"). This Policy will ensure all new hiring requirements of 11.51(a), have been met before a new employee can provide service consumers.
EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation. As of July 1, 2024; with the EPIP implementation, all employee Personnel File's including (1, 2, 3, 4, 5, 6, and 7), will have all required documents as directed by 611.51(a). All deficiencies under Citation 0700 have been addressed.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on May 30, 2024, Angelic Hero's Homecare, LLC was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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