QA Investigation Results

Pennsylvania Department of Health
ACTIVE HOME CARE SERVICES, LLC
Health Inspection Results
ACTIVE HOME CARE SERVICES, LLC
Health Inspection Results For:


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Initial Comments:


An offsite follow up survey completed on May 22, 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.






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 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 05/22/2024 at approximately 2:00 p.m., approved by the Department on 03/15/2024, revealed the following:
"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. ........"

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 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 May 22, 2024 at approximately 2:45 p.m. with the agency Administrator confirmed the above findings.


















Plan of Correction:

1. Two satisfactory references for all employees #3, #5 and #7 will be obtained and filed in their files.

2. Compliance Manager will review files of all employees to make sure that two satisfactory references are obtained and filed to make sure that no other individuals have been affected by the same deficiency.

3. All office employee will be instructed to make sure to obtain the two satisfactory references from all perspective employees of Active Home Care Services LLC.

4. Internal audits of all employees' files will be done to make sure that there is two satisfactory references obtained for all of them.

5. References obtained will be obtained by no later than 06/15/2024.



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 05/22/2024 at approximately 2:00 p.m., approved by the Department on 03/19/2024, 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: 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 the Compliance Manager reviewing all employees files.



Email correspondence on May 22, 2024 at approximately 2:45 p.m. with the agency Administrator confirmed the above findings.















Plan of Correction:

1.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.


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 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. 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: 03/06/2024.

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 emauil 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 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 May 22, 2024 at approximately 2:45 p.m. with the agency Administrator confirmed the above findings.













Plan of Correction:

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.


Initial Comments:


An offsite follow up survey completed on May 22, 2024 found that Active Home Care Services, Llc. corrected the deficiency cited under the requirements of 35 P.S. 448.809 (b). The deficiency was cited as a result of a state re-licensure survey completed on February 26, 2024.




Plan of Correction: