Initial Comments:
Based on the findings of an offsite unannounced complaint investigation survey conducted on March 30, 2020 and March 31, 2020, Charter Home Health, 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 offsite unannounced complaint investigation survey conducted on March 30, 2020 and March 31, 2020, Charter Home Health, 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 upon review of personnel files (PFs) and interview with the owner of the agency, the agency failed to provide documentation of conducting a face to face interview prior to hire and failed to provide documentation of two positive references for two (2) of three (3) PFs. (PF# 2 & 3).
Findings include:
Review of PFs conducted on 3/30/20 between approximately 3:15 PM and 4:00 PM revealed the following:
PF# 2, Date of Hire (DOH): 8/16/19: No documentation of face to face interview or two positive references conducted.
PF# 3, DOH: 12/4/19: No documentation of face to face interview or two positive references conducted.
An interview with the agency's owner conducted on 3/31/20 at approximately 10:00 AM confirmed the above findings.
Plan of Correction:The Agency will carry out reference checks for the audited employees. We will carry out face-to-face interviews and reference checks with all new employees. We will file reports in each employee's file and upload documents on the newly implemented e-system as a backup.
We will carry out a thorough review of documents on each employee's personal file to check on documentation adequacy. The agency will carry out reference checks for all employees with missing documents and put them on file.
The Human Resources Director will oversee and monitor the recruitment process to ensure compliance to procedures including documented face to face interviews and reference checks.
Monitoring Mechanisms
The HR Director will do monthly reviews of all new employee files for that month and sign off to confirm document completeness. We will monitor the e-system daily for document adequacy. The Human Resources Director's performance scorecard will include compliance to recruitment procedures.
Responsible Position – Human Resources Director
Corrective action due Date – 05/25/2020
611.52(b) LICENSURE
State Police Criminal History Record
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If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.
Observations:
Based on review of personnel files (PFs) and interview with the owner, the facility failed to ensure that a criminal background check was completed prior to employment for two (2) of three (3) personnel records (Personnel file # 2 & 3) reviewed.
Findings include:
Act 169 of 1996 as amended by Act 13 of 1997 states: "If the applicant/employee has been a resident of the Commonwealth of Pennsylvania for 2 or more years prior to application for employment, the applicant will need to obtain a clearance from the Pennsylvania State Police. This clearance is obtained by doing the following: Request for Criminal Record Check Form (SP4-164)." "When the applicant/employee has not been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application for employment or currently lives out of state, in addition to the Pennsylvania State Police Criminal History Check, the applicant/employee will also need to obtain an FBI Criminal History Check. Facilities are defined by the act to include: Domiciliary Care Homes, Home Health Care Agency, Nursing Facility (licensed by the Department of Aging), and Personal Care Home (licensed by the Department of Public Welfare). A Home Health Care Agency is further defined to include those agencies licensed by the Department of Health and any public or private organization which provides care to a care-dependent individual in their place of residence." "If entities run into special circumstances where they need to hire an employee before the results of their record checks are returned, there is a provision in CPSL that allows for a provisional hiring period. The period is to not exceed 30 days for in state residents and 90 for out of state residents."
Findings:
A review of the PFs was conducted on March 30, 2020 between approximately 3:15 PM to 4:00 P.M revealed:
PF #2 Date of Hire (DOH): 8/16/19, There was no documentation of a Pennsylvania State Police Criminal Background conducted.
PF #3 DOH: 12/4/19, There was no documentation of a Pennsylvania State Police Criminal Background conducted.
Interview with the agency's owner on March 31, 2020 at approximately 10:00 A.M. confirmed the above findings.
Plan of Correction:The Agency will carry out criminal background checks for the audited employees as a matter of urgency. We will place the reports on the respective employees' files.
We will review each employee personal file and list all those without criminal background checks. The Agency will carry out the required clearances as a priority.
The Human Resources Director will be responsible to ensure there is no missing critical documents on file.
The Human Resources Director will keep an employee record tracker on all active and new employee records to guarantee completeness of documents. The Agency will use the new e-system to enhance document safety and security as a backup.
Position Responsible: Human Resources Director
Due Date: 05/25/2020
611.55(a) LICENSURE
Compentency 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 the agency's personnel files (PF), and an interview with the agency's owner it was determined the agency failed to ensure competency of the direct care worker prior to assigning the direct care worker to provide services to the consumer for two (2) of three (3) PFs reviewed. (PF# 1 & 2).
Findings Included:
Review of PFs completed on 3/30/20 between approximately 3:15 PM. and 4:00 PM. revealed:
PF#1, Date of Hire (DOH): 10/29/18, Contained no documentation that initial competency was completed.
PF#2, DOH: 8/16/19, Contained no documentation that initial competency was completed.
Interview completed on 3/31/20 at approximately 10:00 AM with the agency's owner who confirmed the above findings.
Plan of Correction:The Agency will have the audited employees undergo the missing mandatory training as a matter of urgency.
We will carry out a review of each employee's personal file. All employees with no proof of training on file will be listed as missed training. The Agency will arrange that they undergo training within stipulated time-frames.
Going forward, in a way to avoid recurrence, the Human Resources Director will oversee training and ensure all new employees undergo mandatory training before deployment to consumers.
Monitoring Mechanisms
The HR Director will monitor mandatory training and ensure all employees attend training as required. The Agency will keep a record of all employees who received training including refresher programs annually.
Responsible Position: Human Resources Director
Corrective action due Date: 05/25/2020
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 (PFs) and an interview with the agency's owner, the agency failed to ensure an annual competency review was conducted for one (1) of three (3) personnel files reviewed. (PFs # 1).
Findings include:
A review of the personnel files was conducted on 3/30/20 between approximately 3:15 PM to 4:00 PM:
PF#1, date of hire 10/29/18, did not have documentation of the review of the individual's annual competency in 2019.
An interview with the agency's owner on 3/31/20 at approximately 10:00 AM confirmed that the above personnel files did not have an annual competency review.
Plan of Correction:The Agency will carry out the competency reviews of the audited individuals and place the evaluation report on file.
The Agency will do a detailed check on all employees' personal files. All those with missing reviews will be carried out and filed as required.
To avoid future recurrence, the Agency will put the review dates on the annual calendar and make sure the reviews are done. In addition, the Human Resources Director will take full responsibility of the annual review process.
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 a review of personnel files (PF) and an interview with the agency's owner, the agency did not conduct testing for mycobacterium tuberculosis according to the Center for Disease Control (CDC) guidelines for three (3) of three (3) personnel files reviewed (PFs #'s 1-3)
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) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs 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 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.
A review of PF's conducted on 3/30/20, from approximately 3:15 PM through 4:00 PM revealed the following:
PF#1, Date of Hire (DOH): 10/29/18. File contained no documentation of TB screening completed in 2019.
PF #2, DOH: 8/16/19, File contained no documentation of initial 2-step TST completed.
PF# 3, DOH: 12/4/19 File contained documentation of a TST completed on 7/19/19. There was no documentation of the second step of the initial 2-step TST being completed.
Interview with the agency's owner on 3/31/20 at approximately 10:00 AM confirmed the personnel files lacked screening according to the CDC guidelines.
Plan of Correction:The Agency will prioritize this audit finding and request the audited employees to undergo TB screening and the initial 2-step TST as required
The Agency will go through all employees personal files and review document adequacy around the critical tests. All employees with missing documents will be requested to go for the tests as a matter of urgency, within a given timeline.
The Human Resources Director will keep a tracker on annual testing due dates for each employee and proactively remind them to go for the tests. Furthermore, the Agency will upload all mandatory testing on the e-system. The system will be set to flag the due dates before they expire.
The Human Resources Director will take full responsibility for this critical requirement.
Responsible: Human Resources Director
Due Date: 5/25/2020
Initial Comments:
Based on the findings of an offsite unannounced complaint investigation survey conducted on March 30, 2020 and March 31, 2020, Charter Home Health, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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