Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on April 24, 2025, Angels On Call 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 state re-licensure survey conducted on April 24, 2025, Angels On Call 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:
611.55(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 a review of personnel files (PF) and an interview with the Office Manager the agency failed to ensure that an annual competency was performed for two (2) of seven (7) PF's reviewed: (PF# 5 and 7).
Findings include:
A review of PF's was conducted on April 24, 2025 at approximately 11:45 am.
PF#5 - Date of Hire: 1/28/2022. PF did not contain documentation that the agency provided the direct care worker with an annual competency for 2023.
PF#7 - Date of Hire: 1/20/2020. PF did not contain documentation that the agency provided the direct care worker with annual competencies for 2021, 2022 and 2023.
An interview with the Director of Quality and Compliance on April 24, 2025 at approximately 1:00 pm confirmed the above findings.
Plan of Correction:Agency has a policy which is consistent with the regulation to ensure Annual Competency documents are completed. Agency will retrain office staff on above mentioned policy that is consistent with regulation to ensure the Annual Competency documents are completed and contained within the staff's personnel file.
Moving forward, HR Staff will be responsible for all Annual Evaluation and documents, including the Annual Competency training, and ensuring all training documents are contained within the employees personnel file.
Annual Competencies will be completed for PF#5, PF#7.
HR staff will review staff files, running reports for Date of Hire to see who is due for their Annual Competency and required documents.
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 a review of personnel files (PF), Centers for Disease Control Guidelines, and an interview with the Director of Quality and Compliance, the agency failed to 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 and provide documentation of an initial Symptom Screening questionnaire and Tuberculosis Risk Assessment upon hire for one (1) of seven (7) PF's, (PF#6).
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, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. 2. Completion of a tuberculosis symptom questionnaire. 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)
Findings include:
A review of PF's was conducted on April 24, 2025 at approximately 11:45 am.
PF#6 - Date of Hire: 9/5/2019. PF contained documentation that the direct care worker received baseline tuberculosis screening upon hire.
An interview with the Director of Quality and Compliance on April 24, 2025 at approximately 1:00 pm confirmed the above findings.
Plan of Correction:Health Screening:
Agency has a policy which is consistent with the regulation to ensure new staff are free from active mycobacterium tuberculosis.
Office staff will be retrained on above mentioned policy, that is consistent with regulations, to ensure either placements of a 2 step PPD are completed, or Bloodwork. If either are positive a Chest X-ray will be completed as well, in addition to a TB Risk Assessment Questionnaire prior to Date of Hire.
New staff members who choose to complete the 2 step PPD testing will be tracked by the HR Department to ensure the 2nd step placement is completed within the date range outlined in the CDC guidelines.
PF#6 will be sent for PPD testing.
611.56(b) LICENSURE
Health Screening
Name - Component - 00
(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 Director of Quality and Compliance, the agency failed to ensure each direct care worker were provided with annual mycobacterium tuberculosis education for seven (2) of seven (7) PF's reviewed, (PF#5 and 7).
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)
Findings include:
A review of PF's was conducted on April 24, 2025 at approximately 11:45 am.
PF#5- Date of Hire: 1/28/2022. PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2023,
PF#7 - Date of Hire: 1/20/2020. PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2021, 2022 and 2023.
An interview with the Director of Quality and Compliance on April 24, 2025 at approximately 1:00 pm confirmed the above findings.
Plan of Correction:Annual TB Screening Questionnaire and Education
Agency has a policy which is consistent with the regulation to ensure Annual TB Education and Screening documents are completed and contained within the staff's personnel file. Agency will retrain office staff on above mentioned policy that is consistent with regulation to ensure Annual TB Education and Screening documents are completed Annually.
Moving forward, the HR Department will be responsible for reviewing and ensuring all Annual Evaluation and documents, including the Annual TB Education and Screening are completed. The documents will be part of the employee's personnel file.
The HR Department will ensure the Annual TB Education and Screening are completed for PF#5 and PF#7.
Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey conducted on April 24, 2025, Angels On Call on, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
|