Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed February 26, 2024, Active Home Care Services, Llc. was found to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed February 26, 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
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 employee files and an interview with the agency Administrator, the agency failed to obtain not less than two satisfactory references, prior to hire, for five (5) out of seven (7) employee files (EF) reviewed (EF#3-EF#7).
Findings include:
A review of EFs was conducted on February 26, 2024 at approximately 10:00 a.m. Employee date of hire (DOH) is listed below.
EF#3 DOH 11/12/23: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable). Documentation provided of one reference being obtained on 11/10/23, by a family member (brother).
EF#4 DOH 06/28/23: Documentation provided of obtaining two references being obtained on 06/26/23, by family members (father, sister).
EF#5 DOH 11/09/23: Documentation provided of obtaining one satisfactory/verifiable reference on 11/06/23. Documentation provided of obtaining one reference on 11/06/23, by a family member (wife).
EF#6 DOH 07/12/23: Documentation provided of obtaining one satisfactory/verifiable reference on 07/10/23. Documentation provided of obtaining one reference on 07/10/23, by a family member (brother).
EF#7 DOH 11/15/23: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable). Documentation provided of obtaining one reference on 11/12/23, by a family member (husband).
An interview conducted with the agency Administrator on February 26, 2024 at approximately 12:00 p.m. confirmed the above findings.
Plan of Correction:To correct this finding:
1. Two satisfactory references for all employees identified in the finding will be obtained and filed.
2. Compliance Manager will conduct an audit of all files of Direct Care Worker to make sure that no other individuals have been affected by the same deficient practice.
3. All Staffs involving in hiring the direct care worker will be educated through the in-service education, group orientation and staff training to make sure that two satisfactory references are obtained. All staffs will be instructed through the same method that no immediate family member can be used as for a satisfactory reference.
4. The compliance Manager will do an audit of all files of the direct care worker in every quarter and the first audit will be done on 03/19/2024.
5. The date the corrective action will be completed will be as soon as possible but no later than 04/25/2024.
611.52(c) LICENSURE
Federal Criminal History Record
Name - Component - 00
If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code § 15.144(b) (relating to procedure).
Observations:
Based on a review of employee files and an interview with the agency Administrator, agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for two (2) out of seven (7) employee files (EF) reviewed (EF#1, EF#2).
Findings include:
A review of EFs was conducted on February 26, 2024 at approximately 10:00 a.m. Employee date of hire (DOH) is listed below.
EF#1, DOH 11/08/23: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Drivers License issued 10/21/22 with an expiration date of 10/26/26. 'Employment Application Form' record was reviewed. 'Employment History' Employer listed with an incomplete address (no state listed). 'Start Date: 05/23/22, 'End Date: 11/01/23. No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 11/08/21-10/21/22.
EF#2, DOH 11/10/23: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Drivers License issued 01/26/23 with an expiration date of 06/30/24. 'Employment History' "Honduras Job" written in this section. No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 11/10/21-01/26/23.
An interview conducted with the agency Administrator on February 26, 2024 at approximately 12:00 p.m. confirmed the above findings.
Plan of Correction:To Correct this findings:
1. Documentation showing that the application was a resident of Pennsylvania (pa) for the two years immediately preceding application for employment will be obtained from all identified in the findings. We will also complete the Department of Aging Check for all employees.
2. All employees files will be reviewed by the compliance manager to make sure that no other individual have been affected by the same deficient practice.
3. Active Home Care Services LLC will do Inservice education, group orientation and staff training to all staffs involved in employee onboarding process to make sure that the proof of PA resident for the 2 years immediately preceding application for an employment is obtained and filed.
4. The Compliance Manager Will be reviewing all employee files in every quarter. The first review will be done on 03/22/2024.
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 employee files and an interview with the agency Administrator, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, was screened for and is free from active mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for seven (7) out of seven (7) employee files (EF) reviewed (EF#1-EF#7).
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) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs 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 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 EFs was conducted on February 26, 2024 at approximately 10:00 a.m. Employee date of hire (DOH) is listed below.
EF#1, DOH 11/08/23: No documentation provided of an individual TB risk assessment nor a TB symptom screen upon hire.
EF#2, DOH 11/10/23: Documentation of a one-step TST being conducted on 07/31/23. No documentation of a second-step TST being conducted. No documentation provided of an individual TB risk assessment nor a TB symptom screen upon hire.
EF#3 DOH 11/12/23: No documentation provided of an individual TB risk assessment nor a TB symptom screen upon hire.
EF#4 DOH 06/28/23: No documentation provided of a TB test being conducted upon hire. No documentation provided of an individual TB risk assessment nor a TB symptom screen upon hire.
EF#5 DOH 11/09/23: No documentation provided of an individual TB risk assessment nor a TB symptom screen upon hire.
EF#6 DOH 07/12/23: No documentation provided of an individual TB risk assessment nor a TB symptom screen upon hire.
EF#7 DOH 11/15/23: No documentation provided of a TB test being conducted upon hire. No documentation provided of an individual TB risk assessment nor a TB symptom screen upon hire.
An interview conducted with the agency Administrator on February 26, 2024 at approximately 12:00 p.m. confirmed the above findings.
Plan of Correction:To correct this findings:
1. TB test for all employees identified in the findings will be obtained prior to consumer contact, was screened for and is free from active mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines and documented in their files. Additionally Employees will be asked to complete the TB symptom screening questionnaire and an individual TB risk assessment will be conducted.
2. Compliance Manager will review all employees files to make sure that no other individual have been affected by the same deficiency.
3. All staffs will be instructed through the group orientation, in-service education and staff training to make sure that the TB test result is documented in files of all employees prior to them starting to provide the services to the participant.
4. Internal Audit of all files will be done quarterly by the compliance manager to make sure that there is the individual has obtained done the TB test and the result is placed in their files.
611.57(c) LICENSURE
Information to be Provided
Name - Component - 00
(c) Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.
Observations:
Based on a review of consumer files, the consumer admission packet, and an interview with the agency Administrator, the agency failed to provide the consumer, prior to the commencement of services, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (717-783-1379), for five (5) out of five (5) consumer files (CF) reviewed (CF#1-CF#5).
Findings include:
A review of CFs was conducted on February 26, 2024 at approximately 11:00 a.m. Consumer start of service (SOS) is listed below.
CF#1 SOS 08/09/23: No documentation provided of the agency providing the consumer who to contact at the Department (717-783-1379) for information about licensure requirements for a home care agency/home care registry.
CF#2 SOS 05/14/23: No documentation provided of the agency providing the consumer who to contact at the Department (717-783-1379) for information about licensure requirements for a home care agency/home care registry.
CF#3 SOS 08/16/23: No documentation provided of the agency providing the consumer who to contact at the Department (717-783-1379) for information about licensure requirements for a home care agency/home care registry.
CF#4 SOS 10/04/23: No documentation provided of the agency providing the consumer who to contact at the Department (717-783-1379) for information about licensure requirements for a home care agency/home care registry.
CF#5 SOS 08/03/23: No documentation provided of the agency providing the consumer who to contact at the Department (717-783-1379) for information about licensure requirements for a home care agency/home care registry.
An interview conducted with the agency Administrator on February 26, 2024 at approximately 12:00 p.m. confirmed the above findings.
Plan of Correction:To correct this findings:
1. All consumers identified in the findings will be given the, who to contact at the Department for information about licensure requirements for a home care agency prior to the commencement of services and have them signed and dated as an acknowledgement of receipt of this information.
2. The Compliance Manager will reach out to all consumers and review their files to make sure that they have received who to contact at the Department for information about licensure requirements for a home care agency and signed and dated by the consumers.
3. All staffs/employees will be educated through the group orientation, Inservice education and staff training to provide the, who to contact at the Department for information about licensure requirements for a home care agency to all consumers that we are intending to provide services prior to the commencement of services and signed and dated by the consumers.
4.Internal audit of all files of the consumers' will be done quarterly by the compliance manager to make sure that the document is in place in the individual's file and the acknowledgement of receipt of the information is signed and dated.
5. The completion date will be on 04/25/2024.
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed February 26, 2024, Active Home Care Services, 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 observation of Identification badges (ID) and an interview with the agency Administrator, agency failed to format/issue ID badges per regulatory requirements for one (1) of one (1) observation (Observation #1).
Findings include:
Observation #1: Observation of employee Identification Badge (ID) on February 26, 2024 at approximately 11:45 a.m. revealed the current ID badge employee title does not occupy the bottom 1/2" of the badge, as large as possible. The employee title is listed as "Caregiver", not the required 'Direct Care Worker', and is approximately 1/8" tall and is located towards the center of the badge.
An interview conducted with the agency Administrator on February 26, 2024 at approximately 12:00 p.m. confirmed the above findings.
Plan of Correction:To correct this findings:
1. Identification Badge (ID) for all employees identified in the findings will be format per regulatory requirements the titled as "Direct Care Worker", and occupy the bottom 1/2" of the badge, as large as possible is issued to all employees.
2. The compliance Manager will make sure that all employees are issued the Identification Badge (ID) and is per the regulatory requirement, the titled as Direct Care Worker, and occupy the bottom 1/2" of the badge, as large as possible.
3. Staffs/ employees responsible for issuing the ID will be trained the staff training and group orientation to format the badge exactly as per the regulatory requirements, the titled as Direct Care Worker, and occupy the bottom 1/2" of the badge, as large as possible is issued to all employees.
4. The Compliance Manager will go through the ID of all employees to make sure that they are formatted per regulatory requirements, the titled as Direct Care Worker, and occupy the bottom 1/2" of the badge, as large as possible is issued to all employees.
5. The POC will be completed as soon as possible but not later than April 25th,2024.
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