Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on September 22, 2022, Care With Love Home Health Agency, 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 September 22, 2022, Care With Love Home Health Agency, 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:
611.4(c) LICENSURE
Requirements for HCA and HCR
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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 10/14/2021, and an interview with the administrator, the agency failed to provide documentation employees were either vaccinated against COVID-19 or received testing as required for six (6) of seven (7) PF's, (PF #1, 3, 4, 5, 6, and 7).
Findings include:
Philadelphia Department of Public Health, Division of COVID-19 Containment Health Alert Dated 10/14/2021, states "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 Healthcare Worker or Healthcare Institution Worker who is granted an exemption must strictly follow the applicable accommodation, including documenting their participation in the accommodation process that their employer or institution has agreed upon. Healthcare Institutions are required to keep records of vaccination status of all vaccinated individuals, exemptions requested and granted, and participation in accommodations granted. Records must be made available to PDPH upon request.
Self-employed Healthcare Workers must carefully document the need for exemption and ongoing compliance with routine testing as set forth below under " Accommodations for Exceptions. "
Medical
The Healthcare Worker or Healthcare Institution 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 Healthcare Worker or Healthcare Institution 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.
Accommodations for Exemptions
Healthcare Institutions must instruct exempted workers to comply with, and such workers must comply with, one of the following options for accommodation:
1. Routine Testing: Exempt individuals must be tested by a PCR test or an antigen test for COVID-19 at least twice (2x) per week. The two tests should be spread out appropriately over the week, but there is not a required time interval to account for varying schedules. If the individual ' s test is within 72 hours of their work shifts for the week, one test may suffice.
2. Virtual accommodation: If possible, the Healthcare Institution can create a fully virtual option for the individual."
A review of PF's was conducted on September 22, 2022, from approximately 9:45 am to 10:10 am.
PF #1, Date of Hire: 1/3/2022, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption or documentation of twice weekly testing.
PF #3, Date of Hire: 2/1/2022, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption or documentation of twice weekly testing.
PF #4, Date of Hire: 11/19/19, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption or documentation of twice weekly testing.
PF #5, Date of Hire: 5/18/2021, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption or documentation of twice weekly testing.
PF #6, Date of Hire: 5/4/2022, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption or documentation of twice weekly testing.
PF #7, Date of Hire: 2/3/2022, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption or documentation of twice weekly testing.
An interview with the administrator conducted on September 22, 2022, at approximately 10:45 am confirmed the above findings.
Plan of Correction:I've contacted the employees and some sent me their vaccination card. And for the ones who didn't requested appointments to get their vaccination done. and the employees who can't get the vaccine will get exemption form filled out . I sent the administrator copies of the documents i did receive
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 on a review of personnel files (PF) and an interview with the administrator, the agency failed to provide documentation of an interview for six (6) of seven (7) PF's, (PF # 1, 2, 3, 5, 6, and 7).
Findings include:
A review of PF's was conducted on September 22, 2022 from approximately 9:45 am to 10:10 am.
PF #1, Date of Hire: 1/3/2022, did not contain any documentation that an interview was conducted.
PF #2, Date of Hire: 1/8/2022, did not contain any documentation that an interview was conducted.
PF #3, Date of Hire: 2/1/2022, did not contain any documentation that an interview was conducted.
PF #5, Date of Hire: 5/18/2021, did not contain any documentation that an interview was conducted.
PF #6, Date of Hire: 5/4/2022, did not contain any documentation that an interview was conducted.
PF #7, Date of Hire: 2/3/2022, did not contain any documentation that an interview was conducted.
An interview with the administrator on September 22, 2022 at approximately 10:45 am confirmed the above findings.
Plan of Correction:I created a interview sheet for each employee that did not have one and noted down how the interview went and the names of the references i spoke to. Moving forward i will make sure each new employee will have one in their file.
611.52(c) LICENSURE
Federal Criminal History Record
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If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code § 15.144(b) (relating to procedure).
Observations:
Based on a review of personnel files (PF) and an interview with the administrator, the agency failed to provide documentation of a Federal Bureau of Investigation criminal history report for two (2) of seven (7) PF's reviewed, (PF #1 and 3).
Findings include:
Pennsylvania Act 169 of 1996 as amended by Act 13 of 1997 requires an applicant/ employee who 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 and letter of determination from the Department of Aging within ninety (90) days of employment. An employee is defined as any applicant or new employee hired after July 1, 1998. The definition of employee includes contract employees who have direct contact with residents or unsupervised access to their personal living quarters.
A review of PF's was conducted on September 22, 2022 from approximately 9:45 am to 10:10 am.
PF #1, Date of Hire: 1/3/2022, did not contain any documentation of a Federal Bureau of Investigation criminal history report. File contained a copy of a New Jersey driver's license issued 8/1/19 and states on employment application current address is in New Jersey.
PF #3, Date of Hire: 2/1/2022, did not contain any documentation of a Federal Bureau of Investigation criminal history report. File contained a copy of a Delaware driver's license issued 6/28/2021 and states on employment application current address is in Delaware.
An interview with the administrator on September 22, 2022 at approximately 10:45 am confirmed the above findings.
Plan of Correction:I contacted both employees and referred them IdentoGO to search the nearest location and told them to get a fbi background check. And for any new employees that reside outside of PA i will make sure i have a FBI check completed
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 (PF) and an interview with the administrator, the agency failed to provide documentation of an annual competency evaluation for two (2) of seven (7) PF's reviewed, (PF #4 and 5).
Findings include:
A review of PF's was conducted on September 22, 2022 from approximately 9:45 am to 10:10 am.
PF #4, Date of Hire: 11/19/19, did not contain any documentation of an annual competency evaluation for 2021.
PF #5, Date of Hire: 5/18/2021, did not contain any documentation of an annual competency evaluation for 2022.
An interview with the administrator on September 22, 2022 at approximately 10:45 am confirmed the above findings.
Plan of Correction:The employees that was missing competency paperwork i contacted them and had them compete a new one . i will do 2-3 month file checks and note down any upcoming expired paperwork so i can notify each individual.
Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on September 22, 2022, Care With Love Home Health Agency, LLC., 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
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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 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 September 22, 2022 at approximately 10:30 AM, the administrator was asked if the Agency was using photo identification tags and to provide evidence of the use of photo identification tags. The Administrator stated that the Agency was not using photo identification tags at this time.
In an interview conducted with the Administrator on September 22, 2022 at approximately 10:45 AM, the above findings were confirmed.
Plan of Correction:I will order a id maker machine and provide a id Badge to each current employee and future employee.
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