QA Investigation Results

Pennsylvania Department of Health
COMPANIONS WHO CARE AGENCY, LLC
Health Inspection Results
COMPANIONS WHO CARE AGENCY, LLC
Health Inspection Results For:


There are  3 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an onsite unannounced state re-licensure survey conducted on December 14, 2022, Companions Who Care 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 state re-licensure survey conducted on December 14, 2022, Companions Who Care 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:




611.51(a) LICENSURE
Hiring or Rostering Prerequisites

Name - Component - 00
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 administrator of the agency, the agency failed to provide documentation of two positive references for three (3) of seven (7) PFs. (PF#'s 2, 3, & 5).

Findings include:

Review of PFs conducted on 12/14/22 at approximately 10:30 AM revealed the following:

PF# 2, Date of Hire: 3/26/22. Contained no documentation of two positive reference obtained.

PF# 3, Date of Hire: 2/8/22. Contained no documentation of two positive reference obtained.

PF# 5, Date of Hire: 6/24/22. Contained no documentation of two positive reference obtained.



An interview with the agency's administrator conducted on 12/14/22 at approximately 12:30 PM confirmed the above findings.


















Plan of Correction:

Prior to hiring any individual care giver, I will conduct and document no less than 2 positive references for potential employee. I will create a new form where I will document who was spoken to, what was said and what questions are asked for each reference


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), the Centers for Disease Control (CDC) guidelines and an interview with the administrator, the agency did not conduct screening for mycobacterium tuberculosis according to guidelines prior to hire for six (6) of seven (7) (PF# 1, 2, 3, 4, 5, & 6)

Findings include:

In May 2019, the Centers for Disease Control (CDC) updated its recommendation for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should receive 1) 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, and 3) Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's 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 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).

A review of PF's was conducted on 12/14/22 starting at approximately 10:30 AM. The date of hire (DOH) is indicated below.

PF#1 DOH: 2/20/22 did not contain documentation of a baseline tuberculosis (TB) symptom screen questionnaire and an individual TB risk assessment upon hire..

PF#2 DOH: 3/26/22 did not contain documentation of a baseline tuberculosis (TB) symptom screen questionnaire and an individual TB risk assessment upon hire.

PF#3 DOH: 2/8/22 did not contain documentation of a baseline tuberculosis (TB) symptom screen questionnaire and an individual TB risk assessment upon hire. File contained documentation of TST completed on 2/7/22 but did not contain the second step of the initial two-step tuberculin skin test.

PF#4 DOH: 4/3/22 did not contain documentation of a baseline tuberculosis (TB) symptom screen questionnaire and an individual TB risk assessment upon hire.

PF#5 DOH: 6/24/22 did not contain documentation of a baseline tuberculosis (TB) symptom screen questionnaire and an individual TB risk assessment upon hire. File contained documentation of TST completed on 4/30/22 but did not contain the second step of the initial two-step tuberculin skin test.


PF#6 DOH: 3/5/22 did not contain documentation of a baseline tuberculosis (TB) symptom screen questionnaire and an individual TB risk assessment upon hire.



An interview with the administrator conducted on 12/14/22 at approximatley 12:30 PM confirmed the above findings.










Plan of Correction:

Currently I do not have the baseline screening required by the CDC. Beginning 01/06/2023 any new hires will need to complete a baseline screen for TB symptoms and risk assessment per CDC guidelines and include this questionnaire in their file. I will also make sure all potential employees have a 2 step tb skin test completed upon hire. I will conduct monthly file audits on each newly hired employee to ensure the proper paperwork is there. I will also stay current on the requirements per Dept of Health.


Initial Comments:


Based on the findings of an onsite state re-licensure survey conducted on December 14, 2022, Companions Who Care Agency, LLC., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: