Initial Comments:
An offsite follow up survey completed on June 28, 2024 found that Active Home Care Services, Llc. had not corrected the deficiencies cited under the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries. The deficiencies were cited as a result of a state re-licensure survey completed on February 26, 2024 and a state relicensure follow-up survey completed on June 28, 2024.
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 the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure two satisfactory references for all employees (employee #3-employee #5, employee #7) identified in the finding will be obtained and failed to ensure the Compliance Manager conducted an audit of all files of the Direct Care Workers, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 06/28/2024 at approximately 1:00 p.m., approved by the Department on 06/14/2024, revealed the following:
"To correct this finding:
1. Two satisfactory references for all employees identified in the finding will be obtained and filed. (employees #3-#5, employee #7).
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. ........"
Corrective action date: 06/15/2024.
Documentation review #1: Plan of Correction documentation was requested via email on 06/17/24. No response. Due to no response vial email, arrived at agency on 06/25/24 to conduct an onsite follow up survey. Nobody present at the office. The Administrator was contacted via telephone. Administrator stated there should be someone there and stated "I will call the guy." Administrator called at approx 11:00 a.m. and requested to send the documentation via email. Stated office staff is out on a home visit evaluation. Administrator was directed to send the documentation via email by the end of business day, 06/25/24. Administrator sent documentation on 6/26/24 at approximately 2:50 p.m. The documentation submittal was incomplete. Spoke with Adminstrator via phone on 06/27/24 at approximately 10:29 a.m. to discuss what was needed, in detail, per the POC. Administrator stated understanding would send by the end of the day, 06.27/24. No documentation sent.
No documentation provided of the agency obtaining two satisfactory references for employee #3-employee#5, employee #7) and failed to ensure the Compliance Manager conducted an audit of all files of the Direct Care Workers.
Email correspondence on June 28, 2024 at approximately 1:45 p.m. with the agency Administrator 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. (employees #3-#5, employee #7).
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. The document on two satisfactory references identified in the findings will be emailed no later than 10/01/2024.
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 the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure all employees files were reviewed by the compliance manager, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 06/28/2024 at approximately 1:00 p.m., approved by the Department on 06/14/2024, revealed the following:
To Correct this findings:
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.
Corrective action date: 06/15/2024.
Documentation review #1: Plan of Correction documentation was requested via email on 06/17/24. No response. Due to no response vial email, arrived at agency on 06/25/24 to conduct an onsite follow up survey. Nobody present at the office. The Administrator was contacted via telephone. Administrator stated there should be someone there and stated "I will call the guy." Administrator called at approx 11:00 a.m. and requested to send the documentation via email. Stated office staff is out on a home visit evaluation. Administrator was directed to send the documentation via email by the end of business day, 06/25/24. Administrator sent documentation on 6/26/24 at approximately 2:50 p.m. The documentation submittal was incomplete. Spoke with Adminstrator via phone on 06/27/24 at approximately 10:29 a.m. to discuss what was needed, in detail, per the POC. Administrator stated understanding would send by the end of the day, 06.27/24. No documentation sent.
No documentation provided of the Compliance Manager reviewing all employees files.
Email correspondence on June 28, 2024 at approximately 1:45 p.m. with the agency Administrator confirmed the above findings.
Plan of Correction: To Correct this findings.
1. Agnecy Manager has reviewed files of all employees to make sure that no other individuals have been affected by this deficiency.
2. Proof of review of documents will be emailed no later than 10/01/2024.
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 the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure a TB (tuberculosis) test was conducted for all employees (employee #2, employee #7) identified in the findings, failed to ensure employees (employees #1-employee #5, employee #7) completing a TB symptom screening questionnaire and an individual TB risk assessment, and failed to ensure the Compliance Manager reviewed all employees files, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 06/28/2024 at approximately 1:00 p.m., approved by the Department on 06/14/2024, revealed the following:
"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. ....."
Corrective action date: 06/15/2024.
Documentation review #1: Plan of Correction documentation was requested via email on 06/17/24. No response. Due to no response vial email, arrived at agency on 06/25/24 to conduct an onsite follow up survey. Nobody present at the office. The Administrator was contacted via telephone. Administrator stated there should be someone there and stated "I will call the guy." Administrator called at approx 11:00 a.m. and requested to send the documentation via email. Stated office staff is out on a home visit evaluation. Administrator was directed to send the documentation via email by the end of business day, 06/25/24. Administrator sent documentation on 6/26/24 at approximately 2:50 p.m. The documentation submittal was incomplete. Spoke with Adminstrator via phone on 06/27/24 at approximately 10:29 a.m. to discuss what was needed, in detail, per the POC. Administrator stated understanding would send by the end of the day, 06.27/24. No documentation sent.
No documentation provided of a TB test being conducted for employee #2 and employee #7, failed to ensure employee #1-employee #5, employee #7 completed a TB symptom screening questionnaire and an individual TB risk assessment, and failed to ensure the Compliance Manager reviewed all employees files.
Email correspondence on June 28, 2024 at approximately 1:45 p.m. with the agency Administrator 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. The proof of documents pertaining to this findings will be emailed no later than 10/01/2024.
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 the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure consumers identified in the findings will be given who to contact at the Department for information about licensure requirements, consumer files reviewed, and employees education provided, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 05/22/2024 at approximately 2:00 p.m., approved by the Department on 03/19/2024, revealed the following:
"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.
The completion date will be on 04/25/2024."
Corrective action date: 04/25/2024.
Documentation review #1: Documentation was requested via email on 04/30/24. No response from the agency. Documentation requested a second time via email and phone voicemail message on 05/06/24. No response from agency. Documentation requested a third time via email and phone conversation on 05/14/24. Agency responded to the email request via email on 05/14/24 stating "Hey ......, I'm out of town but i forwarded the email to my office admin. He should be responding today." No response from "Office Admin." Documentation requested a fourth time via email on 05/16/24. Agency emailed documentation on 05/21/24.
No documentation provided of ensuring consumers identified in the findings were given who to contact at the Department for information about licensure requirements, consumer files reviewed, nor employees education provided.
Email correspondence on May 22, 2024 at approximately 2:45 p.m. with the agency Administrator confirmed the above findings.
Plan of Correction:- To Correct this findings.
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.
The completion date will be on 04/25/2024."
10 The proof of documents will be emailed no later than 10/01/2024.
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