Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on March 14, 2024, Olar Home Care Services, 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 March 14, 2024, Olar Home Care Services, 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:
611.55(a) LICENSURE
Competency Requirements
Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.
Observations:
Based on reviews of Personnel files (PFs), and an interview with the agency administrator, the agency failed to ensure completed documentation demonstrating each direct care worker had satisfactorily completed an initial competency exam containing ten (10) areas of care and an additional six (6) areas of personal care for ten (10) of ten (10) files reviewed. (PFs #1- #10).
Reviews of personnel files conducted on 3/14/24 between 11:25 AM and 12:50 PM revealed the following:
PF#1, date of hire: 9/8/23, contained an incomplete written competency test containing all sixteen (16) areas required dated 8/3/23. There was no grade or signature of the person that reviewed the test.
PF#2, date of hire: 9/8/23, contained an incomplete written competency test containing all sixteen (16) areas required dated 9/8/23. There was no grade or signature of the person that reviewed the test.
PF#3, date of hire: 4/12/23, contained an incomplete written competency test containing all sixteen (16) areas required with no date of when test was completed. There was no grade or signature of the person that reviewed the test.
PF#4, date of hire: 3/11/21, contained an incomplete written competency test containing all sixteen (16) areas required dated 3/10/21. There was no grade or signature of the person that reviewed the test.
PF#5, date of hire: 4/10/23, contained an incomplete written competency test containing all sixteen (16) areas required dated 4/10/23. There was no grade or signature of the person that reviewed the test.
PF#6, date of hire: 6/10/23, contained an incomplete written competency test containing all sixteen (16) areas required with no date of when the test was completed. There was no grade or signature of the person that reviewed the test.
PF#7, date of hire: 1/12/23, contained an incomplete written competency test containing all sixteen (16) areas required dated 1/10/23. There was no grade or signature of the person that reviewed the test.
PF#8, date of hire 1/11/24, contained an incomplete written competency test containing all sixteen (16) areas required with no date of when the test was completed. There was no grade or signature of the person that reviewed the test.
PF#9, date of hire: 2/2/24, contained an incomplete written competency test containing all sixteen (16) areas required with no date of when the test was completed. There was no grade or signature of the person that reviewed the test.
PF#10, date of hire: 2/14/24, contained an incomplete written competency test containing all sixteen (16) areas required with no date of when the test was completed. There was no grade or signature of the person that reviewed the test.
An interview conducted with the agency administrator on 3/14/24 at approximately 1:00 pm confirmed the above findings.
Plan of Correction:1. For PF 1 through PF 10 will have each PF and future PF complete written competency test containing all 16 areas required. We will ensure that each completed test has a date of when the test was completed, grade of the exam, and the signature of the office worker/ admin that reviewed the test.
2. To ensure that this deficiency does not occur in the future, the agency competency packet will be updated to include a final page containing the name of the caregiver, the exam score, signature of who reviewed the exam and the date the exam was taken and scored.
3. The measures our facility will take to ensure this deficiency does not occur again are as follows: Update competency packet to include final page containing caregiver name, exam score, date and signature. We will add a specific column to our monthly employee audits labeled "competency test and exam score sheet", that will ensure deficient practice does not occur again.
4. The agency administrator will audit 5 random employee charts every quarter to monitor that the deficient practice will not occur again. Agency admin checklist will be utilized.
5. Date of completed corrective action: 3/15/24
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 review of personnel files (PF) and interview with the agency administrator, it was determined the agency failed to ensure direct care workers were screened for and were free from active mycobacterium tuberculosis (TB) prior to assignment with consumers in two (2) of ten (10) files reviewed. (PFs # 8 and # 10)
Findings include:
The CDC guidelines state that all Health Care Workers (HCW) should receive 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)
.
Reviews of personnel files conducted on 3/14/24 between 11:25 AM and 12:50 PM revealed the following:
PF#8, date of hire 1/11/24, contained no documentation of Tuberculosis risk assessment or screening upon hire.
PF#10, date of hire: 2/14/24, contained no documentation of Tuberculosis risk assessment or screening upon hire.
An interview conducted with the agency administrator on 3/14/24 at approximately 1:00 pm confirmed the above findings
Plan of Correction:1. For PF 8 and PF 10, we will obtain documentation of Tuberculosis risk assessment or screening.
2. To prevent this deficiency from occurring again, we have updated our prior to hire checklist to include the TB risk assessment form. This will ensure that the incoming employees have filled out this specific document before they are hired.
3. The measures this facility is taking to ensure the problem does not occur again, is to add a column to our monthly monthly employee chart audit, conducted by the office manager/ assistant, labeled "TB risk assessment" This will ensure no other individuals are effected by this same deficient practice.
4. The agency administrator will audit 5 random employees charts every quarter to to ensure that the deficient practice does not continue. A agency administrator checklist will be utilized to ensure no further issues.
5. Date of completed corrected action: 3/15/24
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on March 14, 2024, Olar Home Care Services, Llc, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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