QA Investigation Results

Pennsylvania Department of Health
ALWAYS BEST CARE
Health Inspection Results
ALWAYS BEST CARE
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced state relicensure survey completed May 28, 2024 Always Best Care 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 an onsite unannounced state relicensure survey completed May 28, 2024 Always Best Care was found not to be in compliance with the following 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(a) LICENSURE
Criminal Background Checks

Name - Component - 00
The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.

Observations:

Based on review of personnel files (PF) and interview with agency staff (EMP), the agency failed to finalize or obtain criminal background checks at the time of application or within one year immediately preceding the date of application for three (3) of seven (7) direct care worker (DCW) personnel files reviewed (PF3, PF6 and PF7).

Findings include:

Personnel file (PF) reviews conducted on 5/28/24, at 11:44 a.m. revealed the following:

PF3, Date of Hire 3/13/24, Start of Care 4/26/24, review of the State PATCH revealed a request date of 5/27/24, (period of 1 month after start of service), and did not a contain a dissemination date (proof of finalization of patch).

PF6, Date of Hire 1/10/23, Start of Care 1/11/23, There was no documented evidence of a criminal background (State PATCH) being conducted at the time of hire.

PF7, Date of Hire 3/19/23, Start of Care 3/19/23, There was no documented evidence of a criminal background (State PATCH) being conducted at the time of hire.

During an interview on 5/28/24, at 2:08 p.m. EMP9 the office administrator confirmed the above findings.




Plan of Correction:

In response to review of PF3 (employee name: Jayden Powell) findings: agency reprinted background check from PATCH on June 11, 2024 that includes dissemination date.

In response to review of PF6 (employee name: Matthew Snyder) findings: agency completed background check through BATCH system on June 11, 2024, and placed hard copy in employee file.

In response to review of PF7 (employee name: Patricia Neelan) agency completed background check through BATCH system on June 11, 2024, and placed hard copy in employee file.

background checks will be completed for all employee prior to date of hire



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 workers personnel files (PF), and staff (EMP) interview, the agency failed to ensure five (5 ) of seven (7) personnel files contained proof of residency (PF2, PF3, PF4, PF5 and PF6).

Findings include:

Personnel file (PF) reviews conducted on 5/28/24, at 11:44 a.m. revealed the following:

PF2, Date of Hire 3/13/24, file contained a PA driver's license issued 5/23/23, (not 2 years preceding the date of hire). PF2 contained no other documentation to show the requirement was met.

PF3, Date of Hire 3/13/24, file contained a PA driver's license issued 2/21/23, (not 2 years preceding the date of hire). PF3 contained no other documentation to show the requirement was met.

PF4, Date of Hire 2/1/24, file contained a PA driver's license issued 11/16/23, (not 2 years preceding the date of hire). PF4 contained no other documentation to show the requirement was met.

PF5, Date of Hire 2/27/24, contained no documentation to show the requirement was met (2 years preceding the date of hire).

PF6, Date of Hire 1/10/23, contained no documentation to show the requirement was met (2 years preceding the date of hire).

During an interview on 5/28/24, at 2:08 p.m. EMP9 the office administrator confirmed the above findings.





Plan of Correction:

In response to review PF2 employee findings: agency will obtain a second form of ID that is older than two years prior to hire date by August 1st.

In response to review PF3 employee name findings: agency obtained an additional ID that is expired to prove PA residency of more than two years on June 3rd.

In response to review PF4 employee findings: agency obtained a second form of ID that is older than two years prior to hire date. This was obtained June 14th.

In response to review PF5 employee findings: agency obtained a second form of ID that is older than two years prior to hire date. This was obtained June 7th.

In response to review PF6 employee findings: agency must obtain an old rental agreement to verify residency of PA for more than the last two years by August 1st.


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 personnel files (PF), Centers for Disease Control (CDC) Guidelines, and staff (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 five (5) of seven (7) direct care worker (DCW) personnel files reviewed (PF1, PF2, PF3, PF4, PF6 and PF7).

Findings included:

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).

Findings include:

Personnel file (PF) reviews conducted on 5/28/24, at 11:44 a.m. revealed the following:

PF1, Date of Hire 9/23/23, did not contain completion of baseline tuberculosis (TB) test, or symptom screen questionnaire and an individual TB risk assessment upon hire.

PF2, Date of Hire 3/13/24, did not contain completion of baseline tuberculosis (TB) test upon hire.

PF3, Date of Hire 3/13/24, did not contain completion of baseline tuberculosis (TB) test, or symptom screen questionnaire and an individual TB risk assessment upon hire.

PF4, Date of Hire 2/1/24, did not contain completion of baseline tuberculosis (TB) test, or symptom screen questionnaire and an individual TB risk assessment upon hire.

PF6, Date of Hire 1/10/23, did not contain completion of baseline tuberculosis (TB) test.

PF7, Date of Hire 3/23/23, did not contain completion of baseline tuberculosis (TB) test.

During an interview on 5/28/24, at 2:08 p.m. EMP9 the office administrator confirmed the above findings.




Plan of Correction:

In response to review PF1 findings: agency requested a copy of his blood test. He completed his TB screening questionnaire in office on June 10, 2024. He will send his blood test results back to us by August 15, 2024

In response to review PF2 findings: agency requested a copy of employee blood test - she will send her blood test results back to us by August 15, 2024

In response to review PF3 findings: agency requested a two step TB test - she is getting that sent back to the office by August 15, 2024; employee completed her TB screening questionnaire in office on June 6, 2024.

In response to review PF4 findings: agency obtained a two step TB test from the employee, and she completed her TB screening questionnaire in office on June 17, 2024.

In response to review PF6 findings: agency found employee's two step TB test on June 11, 2024 it was located within a different section of the employee folder.

In response to review PF7 findings: agency requested another copy of her employee's two step TB test, which shall be provided by August 15, 2024.

For now on we are making sure all employees get their TB test before start of care and will have Office Admin track he TB testings. She will then notify the scheduler when those are completed.


Initial Comments:

Based on the findings of an onsite unannounced state relicensure survey completed May 28, 2024 Always Best Care 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 staff (EMP) interview, the agency failed to include a photograph on an agency provided identification badge for one (1) of one (1) observations (EMP 8 Care Coordinator).

Findings include:

During an observation on 5/28/24, at 12:14 p.m. EMP 8 the Care Coordinator's agency identification badge, did not include a photograph.

During an interview on 5/28/24, at 12:15 p.m. EMP 8 the Care Coordinator confirmed the above observation, and that the agency is not including photographs on their agency identification badges





Plan of Correction:

In response to the Identification badge, we have added a photograph of the caregiver on their badge and have scheduled caregivers to come into the office to distribute them. Deadline to come into the office is August 1st.