QA Investigation Results

Pennsylvania Department of Health
CARECRUIZ HOMECARE AGENCY, LLC
Health Inspection Results
CARECRUIZ HOMECARE 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 onsite unannounced state license survey completed February 24, 2020, Carecruiz Homecare Agency, Llc, was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.



Plan of Correction:




Initial Comments:

Based on the findings of an onsite unannounced state license survey completed February 24, 2020, Carecruiz Homecare Agency, Llc was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, 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 on review of direct care worker files (PF) and staff (EMP) interview, the agency failed to ensure, prior to hiring the direct care worker, that face-to-face interviews, reference checks and criminal history reports were completed for seven (7) of eight (8) personnel files reviewed (PF2-PF9).

Findings included:

Review of personnel files conducted on February 24, 2020, from 9:30 a.m. to 12 p.m.

PF2 was hired on 3/28/2019. PF2's criminal history report was not initiated until 6/13/2019 (late & not prior to hire), and contained no references.

PF3 was hired on 1/22/2020. PF3's criminal history report was not initiated until 1/31/2020, and only contained one reference dated 2/4/2020 (late & not prior to hire).

PF4 was hired on 11/9/2019. PF4's criminal history report was not initiated until 11/12/2019, contained an undated face-to-face interview form, and two undated reference checks.

PF5 was hired on 11/25/2019. PF5's criminal history report was not initiated until 11/26/2019, contained an undated face-to-face interview form and had no reference checks completed. A hand written note on one of the documents in PF5 showed, "No number listed or place of employment so we couldn't contact [references]. Made a decision based on judgement of character at the time of initial interview."

PF6 was hired on 1/22/2020. PF6's criminal history report was not initiated until 1/24/2020, and only contained one reference dated after hire on 2/4/2020.

PF7 was hired on 9/15/2019. PF7's criminal history report was not initiated until 9/16/2019, and contained two undated reference checks.

PF8 was hired on 2/4/2020. PF8 contained only 1 reference dated after hire on 2/4/2020.

PF9 was hired on 1/16/2020. PF9's criminal history report was not initiated until 1/28/2020, contained an undated face-to-face interview form and no reference checks.

Interview with EMP1 on February 24, 2020, between 12:58 p.m. and 2 p.m. confirmed above findings.











Plan of Correction:

611.51
The administrator had a meeting with the HR manager on 2/27/20 reviewed the agency policy on direct care worker hiring process. The administrator instructed the HR manager that per agency policy all direct care worker must have: 1- a face to face interview prior being hired to the agency. 2- the direct care worker must provide 2 references of which a former employer or another person not related to the individual. The administrator instructed the HR manager that the references must be verified either verbal or written, that references must give a satisfactory positive reference of the direct care worker. If the reference is not from an employer (from a person not related to the individual) the person must affirm the individual ability to provide home care services. 3- The administrator instructed the HR manager that all direct care worker must have a criminal history report (relating to criminal background checks) prior being hired to the agency.
The HR manager will review 100% of active direct care worker by 3/6/20 to verify that all active direct care worker files have a face to face interview, face to face interview are dated, have 2 references that are checked and references are dated and have a criminal history report.
The HR manager will contact any direct care worker who does not have 2 references documented in their file to provide references of former employer or another person not related to them. The direct care worker must provide the reference information no later than 3/8/20. The HR manager will contact the references and have documentation of the references on the direct care worker file. If by 3/8/20 the direct care worker did not provide the information requested by the HR manager, the HR manager will notify the administrator. The administrator will contact the direct care worker regarding the information. Any employee who fails to provide the reference by 3/8/20 will have disciplinary action and or termination.
To maintain compliance the HR manager will have a checklist on all direct care worker files. The HR manager will review direct care worker file 1 week after being hired and update the checklist, any missing information must be completed prior the employee first shift. Any direct care worker file who is not complete or missing document won't be scheduled until all required documents are in the direct care worker file. Any direct care worker unable to obtain a criminal history report and unable to provide 2 references of an employer or another person not related to them won't be hired to the agency.








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 review of direct care worker personnel files (PF), Centers for Disease Control and Prevention (CDC) Guidelines, and staff (EMP) interview, the agency failed to ensure direct care workers were screened from mycobacterium tuberculosis (TB) in accordance with CDC guidelines for five (5) of seven (7) personnel files who had a TB skin test (PF3, PF4, PF6, PF7, & PF9).

Findings included:

According to the "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005," "Baseline testing for M. Tuberculosis infection is recommended for all newly hired HCWs [health care workers] ... If TST [tuberculin skin testing] is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative ... If the first-step TST result is negative, the second-step TST should be administered 1--3 weeks after the first TST result was read."

Review of personnel files conducted on February 24, 2020, from 9:30 a.m. to 12 p.m.

PF3 was hired on 1/22/2020. PF3 had a negative one-step TB skin test on 1/31/2020, but no second-step TB test completed.

PF4 was hired on 11/9/2019. PF4 had a negative one-step TB test on 11/7/2019, but no second-step TB test completed

PF6 was hired on 1/22/2020. PF6 had a negative one-step TB test on 1/24/2020, but no second-step TB test completed

PF7 was hired on 9/15/2019. PF7 had a negative one-step TB test on 1/20/2019, but no second-step TB test completed

PF9 was hired on 1/16/2020. PF9 had a negative one-step TB test on 1/23/2020, but no second-step TB test completed

Interview with EMP1 on February 24, 2020, between 12:58 p.m. and 2 p.m. confirmed above findings.







Plan of Correction:

611.56

The administrator had a meeting with the HR manager on 2/27/20 reviewing the agency policy screening for Mycobacterium tuberculosis upon hire. The administrator instructed the HR manager that all newly hired direct care worker must be screened for Mycobacterium tuberculosis. If TST (tuberculin skin test) is used for baseline testing, two-step testing is recommended for health care worker whose initial TST results are negative. If the first step TST is negative. The second step TST should be administered 1-3 weeks after the first TST result was read.
The HR manager will review 100% of all active direct care worker file by 3/6/20 focusing on result of Mycobacterium tuberculosis testing upon hire. The HR manager will contact any/all employee missing second-step TB by 3/6/20 to have the test performed. Any employee missing second-step TB should have a test result to the office no later than 3/13/20. The HR manager will notify the administrator of any employee fails to submit TB test result by 3/13/20 and the employee will be removed from the schedule until TB testing result documentation is provided, the employee may have disciplinary action and or termination.
To maintain compliance the HR manager will have a tuberculosis screening tracking sheet to monitor all new hire tuberculosis result. The HR manager will review the tracking sheet 1 weeks after an employee being hired then 3 weeks after to make sure any employee needed of a second step provided the second step TB test result. The HR manager will notify the administrator of any health care worker unable to provide a second step TB by the 4th week of being employed by the agency. Any employee unable to provide TB test result will have disciplinary action and or termination.



Initial Comments:

Based on the findings of an onsite unannounced state license survey completed February 24, 2020, Carecruiz Home Care Agency, Llc was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: