Initial Comments:
Based on the findings of an onsite unannounced relicensure survey completed June 17, 2021, Map It Out Home Care Services, was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed June 17, 2021, Map It Out Home Care Services, was found NOT to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, 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 employee files, and interview with the office manager, it was determined that the agency failed to conduct a face-to-face interview with the individual, and to obtain two verifiable references that affirms the ability of a Direct Care Worker, (DCW) to provide home care services for three, (3), of four, (4), employee files reviewed. (DCW #2, 3, and 4).
Findings include:
1. Review of personnel files on June 17, 2021, at approximately 12:15 p.m. revealed that DCW #2 was hired on July 15, 2020. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.
2. Review of personnel files on June 17, 2021, at approximately 12:30 p.m. revealed that DCW #3 was hired on July 1, 2019. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.
3. Review of personnel files on June 17, 2021, at approximately 12:45 p.m. revealed that DCW #4 was hired on February 28, 2021. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.
In an interview with the Office Manager on June 17, 2021 at approximately 1:30 p.m., it was confirmed that the agency failed to conduct a face-to-face interview, and to obtain two verifiable references for each DCW employed at the agency.
Plan of Correction:Even though face to face interviews, as well as reference checks was performed on current employees, it was not properly documented. Therefore, in the future, the Operations Manager (1st interview) as well as the Owner (2nd interview) will document all employees face to face interviews and reference checks. Upon completion documentation will be placed in employee's file.
611.52(a) LICENSURE
Criminal Background Checks
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The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.
Observations:
Based on review of facility policy, personnel files, and interview with the office manager, it was determined that the agency failed to provide a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application for two (2) of four (4), Direct Care Worker, (DCW) files reviewed. (DCW #2 and #4).
Findings include:
1. Review of personnel files on June 17, 2021, at approximately 12:15 p.m. revealed that DCW #2 was hired on July 15, 2020. There was no evidence that a Pennsylvania State Police Criminal Background Check had been conducted.
3. Review of personnel files on June 17, 2021, at approximately 12:45 p.m. revealed that DCW #4 was hired on February 28, 2021. There was no evidence that a Pennsylvania State Police Criminal Background Check had been conducted.
In an interview with the Office Manager on June 17, 2021 at approximately 1:30 p.m., it was confirmed that a Pennsylvania State Police Criminal Background Check had not been conducted.
Plan of Correction:All employees was notified immediately that they have 30 days to submitted up to date criminal background checks. Moving forward, in the future, all potential employees must provide a up to date criminal background check before starting the first day of employment. Also, the office manager will perform a check on all employee's files to guarantee that all needed documentations is up to date.
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 employee files, Center for Disease Control, (CDC) guidelines, and office manager interview, it was determined the facility failed to ensure Direct Care Workers, (DCW) were screened and free from active mycobacterium tuberculosis (TB), (an infectious bacterial disease characterized by the growth of nodules (tubercles) in the tissues, especially the lungs), prior to assignment to clients for two, (2), of four, (4), DCW's reviewed. (DCW #3, and #4).
Findings include:
A review of the Center for Disease Control guidelines, Titled, "TB Screening and Testing of Health Care Personnel," Updated March 8, 2021, revealed, under subtitle, "Baseline TB Screening and Testing:
All U.S. health care personnel should be screened for TB upon hire (i.e., preplacement). TB screening is a process that includes:
baseline individual TB risk assessmentpdf icon,
symptom evaluation,
TB test (e.g., TB blood test or a TB skin test), and
evaluation for TB disease as needed.
Information from the baseline individual TB risk assessmentpdf icon should be used to interpret the results of a TB blood test or TB skin test given upon hire (i.e., preplacement). Health care personnel with a positive TB test result should receive a symptom evaluation and a chest x-ray to rule out TB disease. Additional workup may be needed based on those results......All health care personnel should receive TB education annually. TB education should include information on TB risk factors, the signs and symptoms of TB disease, and TB infection control policies and procedures."
1. Review of personnel files on June 17, 2021, at approximately 12:30 p.m. revealed that DCW #3 was hired on July 1, 2019, (pre-COVID-19). Step-1, of a TST was administered on August 21, 2019. There was no evidence or documentation that Step-2, of the TST had occurred.
2. Review of personnel files on June 17, 2021, at approximately 12:45 p.m. revealed that DCW #4 was hired on February 28, 2021. There was no evidence that DCW #4 had been questioned or screened for TB.
In an interview with the Office Manager on June 17, 2021 at approximately 1:30 p.m., it was confirmed that the agency failed to screen DCW's for TB, upon hire, (pre-COVID-19). The office manager stated that she, "Did not know that the TB skin test was done twice."
Plan of Correction:Employees was notified immediately that up to date TB screening and testing, with the 2-step process must be done as soon as possible or within 30 days. In the future, all new-hire employees will be required to initially obtain the 2-step TB screening and testing. If this requirement is NOT followed, then the employee will NOT be permitted to work with clients. Furthermore, annual educational classes will be given to all employees on TB risk factors, signs and symptoms, infection control, polices and procedures. Also, monthly checks will be conducted on all employee's files, by the operations manager and then signed off by the owner, to guarantee that all documentation is up to date.
Initial Comments:
Based on the findings of an onsite unannounced relicensure survey completed June 17, 2021, Map It Out Care Services, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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