QA Investigation Results

Pennsylvania Department of Health
CASHMERE HOME CARE AGENCY, LLC
Health Inspection Results
CASHMERE HOME CARE AGENCY, LLC
Health Inspection Results For:

This is the only survey for this facility

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 offsite state re-licensure survey conducted on March 26, 2024, Cashmere Home 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 offsite home care agency state re-licensure survey conducted on March 26, 2024, Cashmere Home 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:




611.4(c) LICENSURE
Requirements for HCA and HCR

Name - Component - 00
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), an interview with the administrator, the City of Philadelphia Memorandum: Emergency Regulation Governing The Control and Prevention of COVID-19 Mandating Vaccines for Healthcare Workers and In Higher Education, Healthcare, and Related Settings ( " Vaccine Mandate Regulation " ) dated August 16, 2021; an Update to Mandatory Healthcare Vaccination from the City of Philadelphia, dated October 12, 2021; and a third update from the City of Philadelphia, Division of Disease Control dated October 5, 2022 pertaining to updates to vaccination and masking requirements for health care workers, the home care agency failed to provide evidence of direct care worker vaccination status or direct care worker exemption. The requirement was not evident in three (3) of four (4) PF's reviewed: (PF# 2, 3 and 4).

Findings include:

The City of Philadelphia Memorandum - Emergency Regulation Governing the Control and Prevention of COVID-19 Mandating Vaccines for Healthcare Workers and In Higher Education, Healthcare and Related Settings ( " Vaccine Mandate Regulation " ), dated August 16, 2021, and reviewed October 6, 2022 at approximately 1:30 PM provides the following definitions: 1. "Covered Healthcare Personnel - an individual who falls into one or more of the following categories - a) an employee, contract workers, student or volunteer affiliated with a Healthcare Institution who performs duties in a builing where patients, clients or their visitors are present; b) a Healthcare Worker;" 2. "Healthcare Institution - any person or entity that employs, coordinates, or otherwise engages the services of Covered Healthcare Personnel in the City;' 3. "Healthcare Worker - an individual who provides Healthcare Related Services in person to patients or clients.." The regulation further states, "Effective October 15, 2021, no Healthcare Worker may work at a Healthcare Institution or provide Healthcare Related Services to a patient or client in Philadelphia unless such Healthcare Worker (i) has been Fully Vaccinated; or (ii) has been granted an exemption under paragraph 3 of this Regulation from any applicable Healthcare Institution for whom such individual works and documents ongoing compliance with one or more accommodation(s) set forth in paragraph 4 of this regulation. Paragraph 3 - Exemptions: For the purposes of this Regulation only, a Healthcare Institution subject to this Regulation shall grant a Covered Individual an exemption from the vaccination requirements of this Regulation if such individual qualified for one or both of the exemptions and agrees in writing to abide by the accommodation required by the Healthcare Institution. Medical Exemption - for the purpose of this Regulation only, an exemption shall be granted if the Healthcare Institution determines that the administration of any COVID-19 vaccine is contraindicated because the administration would be detrimental to the health of the Covered Individual (CI). A CI shall request an exemption by submitting a certification from a licensed healthcare provider to the Healthcare Institution certifying that the exemption applies and stating the specific reason that the vaccine is contraindicated for the CI. Such certification must be signed by both the healthcare providers and the CI...... Religions Exemption - For the purpose of this Regulation only, an exemption shall be granted if the CI certifies in writing that such individual has a sincerely held religious belief that precludes such individual from receiving the COVID-19 vaccination. Such certification must be signed the CI. Accommodations: Routine Testing - For Healthcare Institutions and Healthcare Workers - Requiring exempt Covered Healthcare Personnel to submit to either a PCR or antigen test at least twice per week, timed appropriately under the circumstances."

The City of Philadelphia Updates to Mandatory Healthcare Vaccination, dated October 12, 2021 and reviewed October 6, 2022 at approximately 1:30 PM, provided timeline updates for three groups......"Group Two: Group Two includes those designated as healthcare worker or healthcare institution worker that are NOT working in a hospital or LTCF. Employers of workers in all 3 groups must complete a written policy detailing how the employer will verify compliance with extended deadlines." The Update also provided the following definitions: 1. "Direct Care Worker: a) the individual employed by a home care agency or referred by a home care registry to provide home care services to a consumer; or b) a person employed for compensation by a provider or participant who provides personal assistance services or respite services. 2. Healthcare Workers: any individual involved in providing any of the following healthcare regulated services in-person to patients or clients or any individual working in a Healthcare Institution....3. Personal Care, which may include services provided in a personal care home or at the home of a patient or client....." The Update further clarified the following: 1. " Who is Covered Under the Mandate: Healthcare Institution Workers.....includes Direct Care Workers; 2. Limited Vaccination Deadline Extensions..... All other Healthcare Workers and Healthcare Institution Workers are required to receive at least one dose of vaccine in a two-dose vaccination series or the single dose in a one-dose series by October 22, 2021 and comply with all Interim Precautions. The second dose of a two-dose vaccine must be received by November 22, 2021. All workers hired after the vaccination deadline must receive at least one shot in a two-dose series or a single dose in a one-dose series before beginning in-person shifts. Final doses must be received within one month of hire. 3. Limited Home-Based Services Enforcement Exception - The Department will not enforce the Healthcare Worker Vaccine Mandate against certain individuals providing care for a Relative as defined below UNTIL the end of calendar year 2021 or until federal mandates require vaccinations for these individuals, whichever occurs first. Such individuals should be treated as employee who have received a valid religious or medical exemption. 4. Full Summary: The Emergency Regulation Governing the Control and Prevention of COVID-19 Mandating Vaccines for Healthcare Workers and In Higher Education, Healthcare and Related Settings ("Vaccine Mandate Regulation"), effective August 16, 2021, will not be enforced against a Direct Care Workers employed by a Pennsylvania licensed Home Care Agency or Home Care Registry or Participant or a Direct Support/Service Professional employed by a Provider or Participant to provide Personal Assistance Services (Instrumental Activities of Daily Living or Activities of Daily Living) or Respite Services to a Relative in such Relative's home until December 31, 2021 or until such time as the Centers for Medical and Medicaid Services (CMS) issue federal directives on the application of mandatory vaccines to such individuals, whichever occurs first. The term "Direct Care Worker" may have the definition provided in 28 PA. Code 611.5 or 55 PA. Code 52.3, depending upon employing entity and services provided. 5. Exemptions - An individual may not simply opt out of vaccination. The must submit a medical or religions exemption to the Healthcare Institution where such individual works according to policies set by the Institution. Healthcare Institutions and organizations that are granting exemptions must create appropriate exemption policies to implement this regulation. Healthcare Institutions are required to keep records of vaccination status of all vaccinated individuals, exemptions requested and granted, and participation in accommodations granted."

The City of Philadelphia Updates to Vaccination and Masking Requirements for Healthcare Workers dated October 5, 2022 states that healthcare institutions are no longer required to perform asymptomatic screening testing of exempt individuals.

A review of PF's was conducted on March 26, 2024 at approximatley 9:30 am.

PF# 2 Date of Hire: 6/30/2023 did not contain evidence that COVID-19 vaccination had been received, nor was there evidence of a religious exemption being granted by the agency, nor a medical exemption being granted by a medical provider. Direct care worker providing services in Philadelphia County.

PF# 3 Date of Hire: 5/1/2021 did not contain evidence that COVID-19 vaccination had been received, nor was there evidence of a religious exemption being granted by the agency, nor a medical exemption being granted by a medical provider. Direct care worker providing services in Philadelphia County.

PF# 4 Date of Hire: 2/28/2021 only contained evidence that one Pfizer COVID-19 vaccination had been received, nor was there evidence of a religious exemption being granted by the agency, nor a medical exemption being granted by a medical provider. Direct care worker providing services in Philadelphia County.

An interview conducted with the administrator on February 26, 2024 at 1:30 pm confirmed the above findings.














Plan of Correction:

The corrective action plan for PF#2 with DOH 6/30/2023 will correct this deficiency through the direct care worker providing a religious exemption to the agency that will be placed in their file. Moving forward Covid-19 vaccinations, religious exemption or medical exemption will be required at time of hire for all employees providing services in Philadelphia County. The agency will also keep abreast of any new changes or updates to Covid-19 compliance requirements for healthcare workers. This will be corrected by 04/30/2024.

The corrective action plan for PF#3 with DOH 05/01/2021 will correct this deficiency through the direct care worker providing a religious exemption to the agency that will be placed in their file. Moving forward Covid-19 vaccinations, religious exemption or medical exemption will be required at time of hire for all employees providing services in Philadelphia County. The agency will also keep abreast of any new changes or updates to Covid-19 compliance requirements for healthcare workers. This will be corrected by 04/30/2024.

The corrective action plan for PF#4 with DOH 02/28/2021 will correct this deficiency through the direct care worker providing proof of a second Pfizer or similar vaccination has been received or a religious / medical exemption has been granted direct care worker. This proof will then be placed in their file. Moving forward Covid-19 vaccinations, religious exemption or medical exemption will be required at time of hire for all employees providing services in Philadelphia County. The agency will also keep abreast of any new changes or updates to Covid-19 compliance requirements for healthcare workers. This will be corrected by 04/30/2024.



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 on a review of personnel files (PF) and an interview with the administrator, the agency failed to provide documentation of conducting a face to face interview for four (4) of four (4) PF's, (PF # 1, 2, 3 and 4). The agency failed to provide documentation of obtaining two satisfactory and verifiable references for four (4) of the four (4) PF's, (PF # 1, 2, 3 and 4).

Findings include:

A review of PF was conducted on March 26, 2024 from approximately 10:45 am.

PF #1 Date of Hire: 1/18/2023, did not contain any documentation of a completed face to face interview. Also only contained documentation of one completed satisfactory and verifiable references.

PF #2 Date of Hire: 6/30/2023, did not contain any documentation of a completed face to face interview. Also did not contain any documentation of two completed satisfactory and verifiable references.

PF #3 Date of Hire: 5/1/2021 did not contain any documentation of a completed face to face interview. Also did not contain any documentation of two completed satisfactory and verifiable references.

PF #4 Date of Hire: 2/28/2021,did not contain any documentation of a completed face to face interview. Also only contain documentation of one completed satisfactory and verifiable references.

An interview with the administrator on March 26, 2024 at approximately 1:20 pm confirmed the above findings.
















Plan of Correction:

The corrective action plan for PF#1 with DOH 01/18/2023 will correct this deficiency through providing prior documentation of a completed face to face interview form was signed act time of hire. A second satisfactory and verifiable reference will be collected and submitted to correct and satisfy the two references requirement.

The corrective action plan for PF#2 with DOH 06/30/2023 will correct this deficiency through providing prior documentation of a completed face to face interview form was signed act time of hire. Two satisfactory and verifiable reference will be collected and submitted to correct and satisfy the two references requirement.


The corrective action plan for PF#3 with DOH 05/01/2021 will correct this deficiency through providing prior documentation of a completed face to face interview form was signed act time of hire. Two satisfactory and verifiable reference will be collected and submitted to correct and satisfy the two references requirement.

The corrective action plan for PF#4 with DOH 02/28/2021 will correct this deficiency through providing prior documentation of a completed face to face interview form was signed act time of hire. A second satisfactory and verifiable reference will be collected and submitted to correct and satisfy the two references requirement.




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 administrator, the agency failed to provide documentation of an annual competency evaluation for three (3) of four (4) PF's, (PF # 1, 3 and 4).

Findings include:

A review of PF's was conducted on March 26, 2024 from approximately 12:18 pm.

PF # 1, Date of Hire: 1/18/2023, did not contain any documentation of an annual competency evaluation for 2024.

PF # 3, Date of Hire: 5/1/2021, did not contain any documentation of an annual competency evaluation for 2022 and 2023.

PF # 4, Date of Hire: 2/28/2021, did not contain any documentation of an annual competency evaluation for 2022, 2023 and 2024.

An interview with the administrator on March 26, 2024 at 1:18 pm confirmed the above findings.







Plan of Correction:

The corrective action plan for PF#1 with DOH 01/18/2023 will correct this deficiency through providing prior documentation of a completed annual competency evaluation for 2024.

The corrective action plan for PF#3 with DOH 05/01/2021 will correct this deficiency through providing prior documentation of a completed annual competency evaluation for 2022 and 2023.


The corrective action plan for PF#4 with DOH 02/28/2021 will correct this deficiency through providing prior documentation annual competency evaluation for 2022, 2023 and 2024.



611.56(a) LICENSURE
Health Screening

Name - Component - 00
The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.

Observations:

Based on a review of personnel files (PF), recommendations from the Centers for Disease Control (CDC), an interview with the administrator the agency did not contain documentation using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis for two (2) of four (4) PF's, (PF # 2 and 3 ). Also the agency did not contain documentation that the individual had completed annual TB education for three (3) of four (4) PF's, (PF # 1, 3 and 4).

Findings include:

The CDC guidelines state that all Health Care Workers (HCW) should received 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 screen 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;(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 March 26, 2024 at approximately 12:50 pm.

PF# 1, Date of Hire: 1/18/2023, did not contain any documentation of a completed annual TB education for 2024.

PF # 2, Date of Hire: 6/30/2023, did not contain documentation using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis.

PF # 3 Date of Hire: 5/1/2021, did not contain documentation using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. Also did not contain any documentation of a completed annual TB education for 2022 and 2023.

PF # 4 Date of Hire: 2/28/2021, did not contain any documentation of a completed annual TB education for 2022, 2023 and 2024.

An interview conducted with the administrator on March 26, 2024 starting at 1:22 pm confirmed the above findings.

















Plan of Correction:

The corrective action plan for PF#1 with DOH 01/18/2023 will correct this deficiency through providing prior documentation of a completed annual TB education for 2024.

The corrective action plan for PF#2 with DOH 06/30/2023 will correct this deficiency through providing proof of a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis.

The corrective action plan for PF#3 with DOH 05/01/2021 will correct this deficiency through providing proof of a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis.We will also provide prior documentation of completed annual TB education for 2022 and 2023.

The corrective action plan for PF#4 with DOH 02/28/2021 will correct this deficiency through providing prior documentation annual TB education for 2022, 2023 and 2024.



Initial Comments:


Based on the findings of an offsite home care agency state re-licensure survey conducted on March 26, 2024, Cashmere Home Care 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

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 an interview with the administrator, it was determined that the Agency failed to provide evidence of photo identification tags that would include the employee's name, title, picture and name of the Agency.

Findings include:

During discussion with the administrator on March 26, 2024 at approximately 1:15 p.m., the administrator was asked if the Agency is using photo identification tags for employees. The administrator stated she needs to start doing the photo identification tags again: the direct care workers did not have identification tags.

In an interview conducted with the administrator on March 26, 2024 at approximately 1:15 p.m., the above findings were confirmed.










Plan of Correction:

The agency will construct work id's for all current employees and future employees. The work id's will consist of the employees picture, first and last of the employee and the name of the agency.