Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on January 12, 2024, Active 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 January 12, 2024, Active 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:
611.51(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 review of personnel files (PF) and interview with office managers, it was determined the agency failed to ensure that two (2) verifiable references were obtained prior to hiring each direct care worker for ten (10) of ten (10) files reviewed. (PF# 1-10); the agency failed to show proof that a face-to-face interview was conducted for three (3) of ten (10) files reviewed (PF # 1, # 8 and #9).
Review of personnel files (PF) conducted on 1/12/24 from 11:00 AM-12:15 PM revealed the following:
PF # 1, Date of hire (DOH): 8/8/23; had no documentation of references being verified; contained no documentation that a face-to-face interview was conducted.
PF # 2, Date of hire (DOH): 7/2/23; had no documentation of references being verified.
PF # 3, Date of hire (DOH): 4/23/23; had no documentation of references being verified.
PF # 4, Date of hire (DOH): 6/23/23; had no documentation of references being verified.
PF # 5, Date of hire (DOH): 3/20/23; had no documentation of references being verified.
PF # 6, Date of hire (DOH): 7/4/23; had no documentation of references being verified.
PF # 7, Date of hire (DOH): 6/24/23; had no documentation of references being verified.
PF # 8, Date of hire (DOH): 4/12/23; had no documentation of references being verified; contained documentation of face-to-face interview questions but no date to indicate when interview was conducted.
PF # 9, Date of hire (DOH): 4/15/23; had no documentation of references being verified; contained documentation of face-to-face interview questions but no date to indicate when interview was conducted.
PF # 10, Date of hire (DOH): 11/6/23; had no documentation of references being verified.
An interview with the office managers conducted on January 12, 2024 at approximately 12:40 PM confirmed the above findings.
Plan of Correction:For (PF# 1-10) We will conduct and audit entire of their files. We will verify at least two professional references for them. In addition, we will also go through all of our employee files and verify two references if needed.
For (PF #1, #8 and #9), We will conduct face to face interviews and also go through all of our DCW files for review and add it to their files.
We will also indicate the date when the interview was conducted and update to their files.
611.52(d) LICENSURE
Proof of Residency
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The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation
Observations:
Based upon review of personnel files (PF), and interview with agency office managers, the agency failed to show proof of Pennsylvania (PA) residency for two (2) of ten (10) files reviewed (PF # 4 and #10).
Findings included:
Review of personnel files (PF) conducted on 1/12/24 from 11:00 AM-12:15 PM revealed the following:
PF # 4, DOH 6/23/23; had PA driver's license with issue date of 9/13/22 but no evidence produced to show residency for 2020 and 2021 and no federal criminal background conducted.
PF # 10, DOH 11/6/23; had PA driver's license with issue date of 4/4/23 but no evidence produced to show residency for 2021 and 2022 and no federal criminal background conducted.
An interview with the office managers conducted on January 12, 2024, at approximately 12:40 PM confirmed the above findings.
Plan of Correction:For (PF #4 and #10), We have already obtained proof of residency from both employees that they have lived in PA for 2 years, one being their old local tax return and we got the other one fingerprinted and was eligible.
We will use a checklist for employee files to make sure all needed documents are in place.
We also plan on doing quarterly audits.
611.56(a) LICENSURE
Health Screening
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(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 office managers, 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 nine (9) of ten (10) files reviewed. (PFs # 1-#3, and # 5- # 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)
.
Review of personnel files (PF) conducted on 1/12/24 from 11:00 AM-12:15 PM revealed the following:
PF # 1, Date of hire (DOH): 8/8/23; had no documentation of tuberculosis screening upon hire.
PF # 2, Date of hire (DOH): 7/2/23; had no documentation of tuberculosis screening upon hire.
PF # 3, Date of hire (DOH): 4/23/23; had no documentation of tuberculosis screening upon hire.
PF # 5, Date of hire (DOH): 3/20/23; had no documentation of tuberculosis screening or testing upon hire.
PF # 6, Date of hire (DOH): 7/4/23; had no documentation of tuberculosis screening upon hire.
PF # 7, Date of hire (DOH): 6/24/23; had no documentation of tuberculosis screening or two-step testing upon hire. File contained documentation of a one-step test completed on 5/5/23.
PF # 8, Date of hire (DOH): 4/12/23; had no documentation of tuberculosis screening upon hire.
PF # 9, Date of hire (DOH): 4/15/23; had no documentation of tuberculosis screening upon hire.
PF # 10, Date of hire (DOH): 11/6/23; had no documentation of tuberculosis screening upon hire.
An interview with the office managers conducted on January 12, 2024, at approximately 12:40 PM confirmed the above findings.
Plan of Correction:For (PF #1-10) The agency will obtain tuberculosis results or X-ray reports that shown negative results for all the employees and put in chart.
As per my understanding, everyone was screened negative for TB but we had lost access to our online TB result portal.
As of today, we will make sure all employees get tested before and only with proper result documentation, we will hire them.
As part of improvement, we also integrated annual TB questionnaires package to make sure both employee and participant are in a safe and health environment.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on January 12, 2024, Active 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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