Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on June 1, 2023, 7248 Home Health Care, Inc., 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 June 1, 2023, 7248 Home Health Care, Inc., 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:
611.4(c) LICENSURE
Requirements for HCA and HCR
Name - Component - 00
Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.
Observations:
Based on a review of personnel files (PF), the Philadelphia Department of Public Health, Division of COVID-19 Containment Health Alert Dated 10/17/2022, and an interview with the administrator, the agency failed to provide documentation employees were either vaccinated against COVID-19 or had documentation of exemption for seven (7) of seven (7) PF's, (PF #1, 2, 3, 4, 5, 6, and 7).
Findings include:
Philadelphia Department of Public Health, Division of COVID-19 Containment Health Alert Dated 10/17/2022, states "The City of Philadelphia issued an Emergency Regulation Governing the Control and Prevention of COVID-19 Mandating Vaccines for Healthcare Workers and In Higher Education, Healthcare, and Related Settings ( " Vaccine Mandate Regulation " ), which mandates vaccine for healthcare workers and in higher education, healthcare and related settings. This mandate became Effective on August 16, 2021. Certain settings and individuals previously required to comply with the Vaccine Mandate Regulation are excluded from the vaccination requirements. Routine screening testing of exempt individuals is no longer required. These requirements are modified according to the Philadelphia Department of Public Health ' s (the Department) recommendations. Any changes will be announced via traditional print and social media, posted on the Department ' s website, and communicated in Health Action Notifications (HAN)...
Covered healthcare workers and individuals will be required to wear at least a surgical mask that fully covers their nose and mouth while providing patient facing care or in patient facing settings...
All symptomatic individuals must continue to test, regardless of vaccination status...
Covered Healthcare Workers
All Covered Healthcare Workers performing duties in the City of Philadelphia: Individuals who are not required to be vaccinated include only who those are not patient-facing either through their direct work or the setting of their work..
1. Individuals who perform their duties completely through telework.
2. Individuals who are employed at a retail establishment that provides only incidental
healthcare related services, such as pharmacies and grocery store
3. Individuals who are employed by an excluded Healthcare Institution;
4. Individuals who do not provide healthcare or healthcare related services to patients or
clients; and do not work in a building where patients or clients receive such services, such as a medical billing specialist or appointment setter...
Covered Healthcare Workers are required to receive at least one dose of vaccine in an initial twovaccination series or a single dose in an initial one-dose series before beginning in-person
work. Second doses must be received within 8 weeks of hire or the first day of in-person work.
Covered Healthcare Workers and Healthcare Institutions must comply with all Interim Precautions
described below.
All other Healthcare Workers are required to receive at least one dose of their initial vaccine series prior to beginning employment...
EXEMPTIONS:
An individual may not simply opt out of vaccination. They must submit a medical or religious exemption to the Healthcare Institution where such individual works according to the policies set by the institution. The Institution will determine if an exemption applies.
Healthcare Institutions and organizations that are granting exemptions must create appropriate exemption policies to implement this regulation. Institutions may establish stricter vaccination policies for their workers, contractors, and volunteers that exceed the requirements of the Vaccine Mandate Regulation, to the extent otherwise permitted by applicable law.
A Covered Healthcare Worker who is granted an exemption must strictly follow the conditions for exemption. Healthcare Institutions are required to keep records of vaccination status of all vaccinated individuals and exemptions requested. Records must be made available to PDPH upon request...
Medical
The Covered Healthcare Worker may request an exemption by submitting a certification from a licensed healthcare provider to the appropriate Healthcare Institution.
Medical exemptions must include a statement signed by a licensed healthcare provider that states the exemption applies to the specific individual submitting the certification because the COVID-19 vaccine is medically contraindicated for the individual. The certification must also be signed by the Healthcare Worker or Healthcare Institution Worker. For the purposes of the Vaccine Mandate Regulation a licensed healthcare provider means a physician, nurse practitioner, or physician assistant licensed by an authorized state licensing board...
Religious
The Covered Healthcare Worker may request an exemption by submitting a signed statement in writing that the individual has a sincerely held religious belief that prevents them from receiving the COVID-19 vaccination. An institution may request the worker explain in the certification why the worker ' s religious belief prevents them receiving the COVID-19 vaccine.
Philosophical or moral exemptions are not permitted...
CONDITIONS
1. Testing: Screening testing is no longer required. Institutions may choose to conduct continued asymptomatic screening testing. Typically testing could be done 1-2 times per week...
2. Masking: All healthcare institutions must continue to enforce masking for all with at least a surgical mask in all patient-facing areas and for all patient-facing services regardless of vaccination status...
RECORD KEEPING
Vaccination Records
The institution must maintain vaccination records and exemption records must be made available to the Department of Public Health upon request.
Vaccination records must include the following information: numbers of fully, partially, unvaccinated and vaccination status unknown staff/contractors; and numbers of staff/contractors with medical or religious exemptions...
Enforcement
Beginning October 16th, 2021, the Department will exercise its inspection authority to review records per Chapter 6-500, Section 501 of the Philadelphia Code. These records must be made available to the Department upon request as dictated by Chapter 6-200, Section 202(4) of the Philadelphia Code and the August 4, 2022 AMENDMENT TO THE EMERGENCY REGULATION GOVERNING THE CONTROL AND PREVENTION OF COVID-19 MANDATING VACCINES FOR HEALTHCARE WORKERS AND IN HIGHER EDUCATION, HEALTHCARE, AND RELATED SETTINGS.
Records may be examined via a future scheduled submission calendar and/or unannounced in-person or electronic compliance audits of records by Department personnel. Method and timeline for unannounced audits will be determined in part by information reported to the (CDC) National Healthcare Safety Network (NHSN) system and may be required in response to complaints received against an institution. Failure to comply may result in remediation planning or immediate penalties..."
A review of PF's was conducted on June 1, 2023, from approximately 1:30 pm to 2:15 pm.
PF #1, Date of Hire: 2/10/2023, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption.
PF #2, Date of Hire: 1/2/2023, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption.
PF #3, Date of Hire: 7/10/2022, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption.
PF #4, Date of Hire: 10/6/2022, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption.
PF #5, Date of Hire: 8/21/2022, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption.
PF #6, Date of Hire: 7/3/2022, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption.
PF #7, Date of Hire: 5/24/2022, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption.
An interview with the administrator conducted on June 1, 2023, at approximately 2:30 pm confirmed the above findings.
Plan of Correction:Administrator will review all current employee files by June 30th for any out of compliance direct care workers. Administrator will contact any employee that is out of compliance by July 1st and require their response within (14) days to provide Covid-19 vaccination card, Covid-19 exception form or a commitment to start Covid-19 vaccination. Any direct care worker who is unable to respond to our office with a valid excuse will have it sent via mail or email and must be returned within (10). Covid-19 vaccination paperwork will be completed by July 15th.
Any direct care worker who is currently having direct contact with consumers who do not complete the Covid-19 vaccination documentation requirement within that (10) business days will be removed from all work sites and labeled inactive until their Covid-19 vaccination documentation has been completed.
Administrators will review all current employee files by July 15th for health screening requirements prior to administering care to prevent the transmission of Covid-19 in health care settings. Administrators will perform yearly reviews for compliance with policies and procedures.
Administrators going forward will sign off on the employee "personal checklist" to ensure that annually the employee has the proper Covid-19 vaccine documentation.
Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on June 1, 2023, 7248 Home Health Care, Inc., 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
Name - Component - 00
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 observation and an interview with the administrator, it was determined that the Agency failed to provide photo identification tags that would include the employee's name, title, picture, and the name of the Agency.
Findings include:
During discussion with the administrator on June 1, 2023 at approximately 1:45 pm, the administrator was asked if the Agency is using photo identification tags and to provide evidence of the use of photo identification tags. The Administrator stated that the Agency is not using photo identification tags at this time.
An interview with the administrator conducted on June 1, 2023 at approximately 2:30 pm confirmed the above findings.
Plan of Correction:Administrator will review all current employee files by June 15th for any out of compliance direct care workers. Administrator will contact any employee that is out of compliance by June 16th and provide within (15) days photo identification tag. Any direct care worker who is unable to respond to our office with a valid excuse will be sent via mail or email and must be returned within (10). All direct care workers will receive a photo identification tag completed by July 1st.
Any direct care worker who is currently having direct contact with consumers who have not received photo identification within that (10) business days will be removed from all work sites and labeled inactive until their photo identification requirement has been fulfilled.
Administrators will review all current employee files by July 30th for photo identification compliance prior to administering care to meet current regulations. Administrators will perform yearly reviews for compliance with policies and procedures.
Administrators going forward will sign off on the employee "personal checklist" to ensure that annually the employee has the proper photo identification requirement.
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