Initial Comments:
Based on the findings of an offsite state re-licensure survey conducted on August 1, 2023, We Care For You Home Care, 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 offsite state re-licensure survey conducted on August 1, 2023, We Care For You Home Care, 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:
611.52(a) LICENSURE
Criminal Background Checks
Name - Component - 00
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 a review of personnel files (PF) and an interview with the agency administrator, the agency failed to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application for one (1) of four (4) PFS. PF#3.
Findings include:
The Pennsylvania (Pa.) 'Health and Safety (Title 35)' 'Older Adults protective Services Act' Information relating to prospective facility personnel. (a) General rule, -- A facility shall require all applicants to submit with their applications, ............, who have or may have direct contact with a recipient to submit, there following information obtained within the preceding one-year period: (1) pursuant to 18 Pa.C.S. Ch. 91 (relating to criminal history record information), a report of criminal history record information from the state police or a statement from the State Police that their central repository contains no such information relating to that person".
A review of PFs was conducted on August 1, 2023 at 10:00 AM. The date of hire (DOH) is indicated below.
PF#3 DOH 12/28/2020 the Pa. State Police criminal history report was obtained on 5/5/22. which is after the time of application or within 1 year (365 days) immediately preceding the date of application.
An interview with the administrator on August 1, 2023 at 2:30PM confirmed the above findings.
Plan of Correction:Background Check
Base on the finding that We Care for You Home Care, LLC will correct the deficiency of not having criminal background check done in a timely order moving forward By completing them at the time of hiring. PF(3) will have a new background done so that the file will be completed and in compliance of the company's rules and state regulations. Moving, forward the files will be check every 90 days to make sure that everyone is in compliance which will be done by the Office Manager or the administrator of the company.
611.56(a) LICENSURE
Health Screening
Name - Component - 00
The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.
Observations:
Based upon review of personnel files (PF) and an interview with the administrator, the agency did not ensure a Tuberculosis (TB) symptom screen and an individual Tuberculosis (TB) risk assessment was completed for two (2) of four (4) PFs: PF# 1 and 3; did not contain baseline testing for TB for two (2) of four (4) PFs: PF#2 and 4; and did not contain annual TB education for one (1) of four (4) PF: PF#3.
Findings Include:
According to the "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005," "Baseline testing for M. Tuberculosis infection is recommended for all newly hired HCWs [health care workers]...If TST [tuberculin skin testing] is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative...If the first-step TB result is negative, the second-step TB should be administered 1--3 weeks after the first TB result was read...A second TB is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TB result within the previous 12 months, a single TB can be administered in the new setting...This additional TB represents the second stage of the two-step testing."
The CDC (Centers for Disease Control and Prevention) guidelines state baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or tuberculin skin test (TST), shall include a symptom screen questionnaire and an individual tuberculosis (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 PF's was conducted on August 1, 2023 at 10:05 AM. The date of hire (DOH) is indicated below.
PF#1 DOH 4/29/23 did not contain a TB symptom screen and individual TB risk assessment.
PF#2 DOH 4/13/23 contained a TST dated 6/23/21 that did not include results. The second TST was completed 4/10/23 which is greater than one year from the first TST.
PF#3 DOH 12/28/2020 did not contain a TB symptom screen and individual TB risk assessment and did not contain annual TB education for 2021 and 2022.
PF#4 DOH 2/23/23 did not contain a second TST.
An interview with the administrator on August 1, 2023 at 2:30PM confirmed the above findings.
Plan of Correction:Health Screening,
Based on the finding with the TB testing the applicants shall be required by the agency to have 2 step-TB test that is administered by the doctor's office or the clinic of the applicants choice If the first-step TB result is negative, the second-step TB should be administered 1--3 weeks after the first TB result was read.)Or Chest X-ray or Blood test (Quantiferon). First step will allow the DCW to work on a provisionary base until the second step is, done. If not received or done, the DCW will be taken off the case until received. Moving forward by October 1st these findings shall be corrected
PF#1 DOH 4/29/23 will have a TB symptom screen and individual TB risk assessment done by 10/01/2023
PF#2 DOH 4/13/23 contained a TST dated 6/23/21 that did not include results. The second TST was completed 4/10/23 which is greater than one year from the first TST. Moving forward PF2 will have the TB the TST done to comply with the state regulations.
PF#3 DOH 12/28/2020 will have an a TB symptom screen and individual TB risk assessment done for annual TB education for 2021 and 2022. moving forward all annual TB assessment will be done so that PF's will be in compliance with the company's rules and state regulations
PF#4 DOH 2/23/23 will be informed that a second test is needed.
All new hires will have 2 steps done before working with client and all older Direct care workers will have their annual test done along with TB risk assessment and symptom screen with Annual TB education.
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 (CF) and an interview with the administrator, the agency did not provide the disclosure addressing the employee or independent contractor status of the direct care worker providing services to the consumer and the resultant tax and insurance obligations to the consumer prior to commencement of care for four (4) of six (6) CFs. CF# 2, 3, 4, and 5.
Findings include:
A review of CFs was conducted on August 1, 2023 at 11:30 AM. The start of care (SOC) is indicated below:
CF#2 SOC 6/30/2020 contained an employee or independent contractor disclosure form that was blank.
CF#3 SOC 4/4/23 contained an employee or independent contractor disclosure form that was blank.
CF#4 SOC did not contain an employee or independent contractor disclosure form.
CF#5 SOC contained a employee or independent contractor disclosure form that was blank.
An interview with the administrator on August 1, 2023 at 2:30PM confirmed the above findings.
Plan of Correction:LICENSURE
Based on the review of consumer files (CF), moving forward the agency will provide the disclosure addressing the employee or independent contractor status of the direct care worker providing services to the consumer and the resultant tax and insurance obligations to the consumer prior to commencement of care. Also, Agency will ensure that all new clients have will the disclosure addressing the employee or independent contractor status of the direct care worker providing services to the consumer and the resultant tax and insurance obligations to the consumer prior to commencement of care. The Administrator of the company make sure that it is provided along with making a client for each file and auditing each file every 90 days.
Initial Comments:
Based on the findings of an offsite state re-licensure survey conducted on August 1, 2023, We Care For You Home Care, 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 a review of personnel files (PF) and an interview with the administrator, the agency did not provide photo identification badges in accordance with regulation for four (4) of four (4) PFs. PF# 1, 2, 3, and 4.
Findings include:
A review of personnel files (PF) was conducted on August 1, 2023 at 10:05 AM. The date of hire (DOH) is indicated below:
PF#1 DOH 4/29/23 contained a photo identification badge that did not contain the employee's job title, Direct Care Worker.
PF#2 DOH 4/13/23 contained a photo identification badge that did not contain the employee's job title, Direct Care Worker.
PF#3 DOH 12/28/2020 contained a photo identification badge that did not contain the employee's job title, Direct Care Worker.
PF#4 DOH 2/23/23 contained a photo identification badge that did not contain the employee's job title, Direct Care Worker.
An interview with the administrator on August 1, 2023 at 2:30PM confirmed the above findings.
Plan of Correction:LICENSURE
Based on the review of personnel files (PF) moving forward the agency did not provide photo identification badges in accordance with regulation the title of Direct Care Worker (DCW) moving forward all badges shall have the title of the of the employee and it shall be done by either the Administrator or the Office Manager, all corrections shall be done by October 1,2023.
|