QA Investigation Results

Pennsylvania Department of Health
AMEN CONCIERGE SERVICE, LLC
Health Inspection Results
AMEN CONCIERGE SERVICE, LLC
Health Inspection Results For:


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Initial Comments:


Based on the findings of an unannounced on-site state re-licensure survey conducted on April 30, 2024, Amen Concierge Service, 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 unannounced on-site state re-licensure survey conducted on April 30, 2024, Amen Concierge Service, LLC was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Subpart H, Chapter 611, 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 agency personnel files (PF) and staff (EMP) interview, it was determined the agency failed to obtain not less than two satisfactory references for two (2) of five (5) PF reviewed (PF3 & 5).


Findings included:

Review of PF completed on April 30, 2024, between approximately 10:00am and 11:00am revealed:

PF3, date of hire (DOH) 4/11/22, start of service (SOS) 4/17/22. PF failed to contain evidence of 2 satisfactory references.
PF5, DOH 1/13/23, SOS 1/24/23. PF failed to contain evidence of 2 satisfactory references.

Exit interview with owner on April 30, 2024 at approximately 1:00pm confirmed findings.









Plan of Correction:

Company Hiring Policy will be created to include applicant will provide 2 verifiable references at time of application.
Satisfactory results will be obtained prior to hiring.

Management is responsible for conducting this process prior to hiring.
This documentation will become part of the applicant's permanent file prior to hiring.
Management will complete an audit prior to hiring to ensure all mandatory requirements are fulfilled.





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 agency personnel files (PF) and staff (EMP) interview, it was determined the agency failed to ensure a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record was obtained for four (4) of five (5) PF reviewed void of evidence the applicant had been a resident of the commonwealth for 2 years preceding hire (PF1 & 3-5).

Findings included:

Review of PF completed on April 30, 2024, between approximately 10:00am and 11:00am revealed:

PF1, date of hire (DOH) 12/17/23, start of service (SOS) 1/2/24. PF, void of proof of residency in the commonwealth for 2 years preceding hire, failed to contain a federal criminal history record and a letter of determination from the Department of Aging.

PF3, DOH 4/11/22, SOS 4/17/22. PF, void of proof of residency in the commonwealth for 2 years preceding hire, failed to contain a federal criminal history record and a letter of determination from the Department of Aging.

PF5, DOH 1/13/23, SOS 1/24/23.
PF, void of proof of residency in the commonwealth for 2 years preceding hire, failed to contain a federal criminal history record and a letter of determination from the Department of Aging.

Exit interview with owner on April 30, 2024, at approximately 1:00pm confirmed findings.










Plan of Correction:

Policy being created for Managing personnel to conduct the following steps before hiring.
The management will perform pre-hiring audit to ensure continued client safety. The following items have been added to the hiring packet to achieve this goal:

1. Document 2-year proof of residency at in-person interview. With proper identification, before hiring.

2. A Federal Criminal History Report will be received if no proof of 2-year residency cannot be provided.

3. A letter of Determination from the Dept. of Aging will be obtained and become part of permanent file.

All present employees are in the process of obtaining Federal Criminal History Clearances for permanent files. Followed by a letter from the department of Aging.

Monthly managerial audits will be conducted to maintain compliancy.




611.55(a) LICENSURE
Competency Requirements

Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.

Observations:


Based on a review of agency personnel files (PF) and staff (EMP) interview, it was determined the agency failed to ensure that prior to assigning a direct care worker to provide services to a consumer, the direct care worker passed the competency exam developed by the agency for two (2) of five (5) PF reviewed (PF2 &4).

Findings included:

Review of PF completed on April 30, 2024, between approximately 10:00am and 11:00am revealed:

PF2, date of hire (DOH) 6/8/21, start of service (SOS) 6/20/21. PF failed to contain evidence that direct care worker passed the competency exam developed by the agency.

PF4, DOH 4/2/24, SOS 4/4/24. PF contained competency exam developed by the agency dated 4/26/24, 20 days after consumer contact.

Exit interview with owner on April 30, 2024, at approximately 1:00pm confirmed findings.










Plan of Correction:

An auditing document has been created to Document a graded Competency Survey, Competency Demonstration test, and a TB Competency test are requirements for hiring.
This information has been added to the employee manual under policy & procedures.
These tests will be completed, graded, signed & dated pre-hire and repeated annually to ensure client safety and competency of employees.

The tests must be passed with a grade of 90%, signed & dated before client contact. Tests results remain in the employee file.
An internal audit will be performed monthly to ensure competency of direct care worker & client safety.



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 agency personnel files (PF), CDC (Centers for Disease Control) guidance, and staff (EMP) interview, it was determined the agency failed to ensure that each direct care worker, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis for four (4) of five (5) PF reviewed (PF1 & 3-5).

Findings included:


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...HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease....A second TST 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 TST within the previous 12 months, a single TST can be administered in the new setting. 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.

Review of PF completed on April 30, 2024, between approximately 10:00am and 11:00am revealed:

PF1, date of hire (DOH) 12/17/23, start of service (SOS) 1/2/24. PF contained QuantiFERON Gold result dated 1/26/24, 24 days after consumer contact.

PF3, DOH 4/11/22, SOS 4/17/22. PF failed to contain evidence of negative TB screen within 1 year prior to hire or upon hire. PF contained negative 1-step TB screen dated 1/9/2020, greater than 2 years prior to hire.

PF4, DOH 4/2/24, SOS 4/4/24. PF contained negative TB screening dated 4/24/24, 20 days after consumer contact.

PF5, DOH 1/13/23, SOS 1/24/23. PF failed to contain documentation of TB screening.

Exit interview with owner on April 30, 2024, at approximately 1:00pm confirmed findings.














Plan of Correction:

New Tuberculosis policy developed & implemented.
Policy states:
Obtain TB screening at time of in- person interview, prior to hiring.

T.b. information packet (current CDC) and competency completed prior to hiring.
A negative 2-step T.B. test is required prior to client contact.

Annual competency re-assessment will occur at time of annual testing.
Obtain documented Negative results of 2 step T,B. test, Gold blood test, or Chest film on an annual basis.

Monthly internal audit performed by management to ensure compliance.


611.56(b) LICENSURE
Health Screening

Name - Component - 00
(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.

Observations:


Based on a review of agency personnel files (PF), CDC (Centers for Disease Control) guidance and staff (EMP) interview, it was determined the agency failed to ensure Tuberculosis (TB) education provided annually for four (4) of four (4) PF files reviewed with at least 12 months of employment (PF1-3 & 5).

Findings included:

The CDC guidelines state that 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).

Review of PF completed on April 30, 2024, between approximately 10:00am and 11:00am revealed:

PF1, date of hire (DOH) 12/17/23, start of service (SOS) 1/2/24. PF failed to contain evidence of annual TB education.

PF2, DOH 6/8/21, SOS 6/20/21. PF failed to contain evidence of annual TB education.

PF3, DOH 4/11/22, SOS 4/17/22. PF failed to contain evidence of annual TB education.

PF5, DOH 1/13/23, SOS 1/24/23. PF failed to contain evidence of annual TB education.

Exit interview with owner on April 30, 2024, at approximately 1:00pm confirmed findings.












Plan of Correction:

The annual T.B. requirements policy has been created & implemented.

Initiate an annual T.B. education and competency test in compliance with CDC.

The Tuberculosis competency test will be repeated annually.
A graded, signed & dated annual competency will be in employee file.

All Tuberculosis information will be monitored monthly by manager.


611.57(b) LICENSURE
Prohibitions

Name - Component - 00
(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

Observations:


Based on a review of agency consumer files (CF) and staff (EMP) interview, it was determined the agency failed to provide the consumer or legal guardian a document informing that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. Or that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency for four (4) of four (4) CF reviewed (CF1-4).


Findings included:

Review of CF completed on April 30, 2024, between approximately 11:00pm and 12:30pm revealed:

CF1, start of service (SOS) 9/17/23. Service Agreement in CF failed to inform that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. Or that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency.

CF2, SOS 12/23/23. Service Agreement in CF failed to inform that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. Or that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency.

CF3, SOS 12/1/23. Service Agreement in CF failed to inform that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. Or that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency.

CF4, SOS 12/19/23. Service Agreement in CF failed to inform that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. Or that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency.

Exit interview with owner on April 30, 2024, at approximately 1:00pm confirmed findings.










Plan of Correction:

Updated Service Agreement now included in section B.SERVICES
information in accordance with Title 28.
No individual associated with Amen Concierge Service will assume power of attorney or guardianship over a consumer utilizing our services. No financial transactions are to be performed by staff of Amen Concierge Service. No checks are to be endorsed for Amen Concierge Service by employees.

This will be reviewed with client at time of signing by management.
All clients will be reviewing and signing new agreement by 06/01/2024

Management will monitor with client on an in-person monthly review.



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 agency consumer files (CF) and staff (EMP) interview, it was determined the agency the agency failed to provide to the consumer or the consumer's legal representative or responsible family member an information packet containing the hours when services would be provided and 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 for four (4) of four (4) CF reviewed (CF1-4).

Findings included:

Review of CF completed on April 30, 2024, between approximately 11:00pm and 12:30pm revealed:

CF1, start of service (SOS) 9/17/23. Service Agreement in CF failed to indicate the hours that services would be provided to consumer. CF also failed to include 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.

CF2, SOS 12/23/23. Service Agreement in CF failed to indicate the hours that services would be provided to consumer. CF also failed to include 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.

CF3, SOS 12/1/23. Service Agreement in CF failed to indicate the hours that services would be provided to consumer. CF also failed to include 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.

CF4, SOS 12/19/23. Service Agreement in CF failed to indicate the hours that services would be provided to consumer. CF also failed to include 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.

Exit interview with owner on April 30, 2024, at approximately 1:00pm confirmed findings.










Plan of Correction:

Client agreement will be amended to include hours and PRN/as needed status per client request, with advanced notice and staffing availability.
The original agreement has a #11. CONSUMER NOTICE OF DIRECT CARE WORKER STATUS included. An additional PA form containing this information will be presented to client at time of agreement signing or signature & date.
Client will be given a copy of agreement signed by client or POA.
Management will do monthly audits of all client agreements and amendments to ensure compliance.


611.57(d) LICENSURE
Documentation

Name - Component - 00
(d) The home care agency or home care registry shall maintain documentation on file at the agency or registry of compliance with the requirements of this section which shall be available for Department inspection.

Observations:


Based on a review of agency consumer files (CF) and staff (EMP) interview, it was determined the agency failed to maintain documentation on file at the agency or registry of compliance with the requirements of this section which shall be available for Department inspection for three (3) of four (4) CF reviewed (CF1, 2, & 4).

Findings included:

Review of CF completed on April 30, 2024, between approximately 11:00pm and 12:30pm revealed:

CF1, start of service (SOS) 9/17/23. CF failed to include documentation of services provided. Owner unable to produce records of days, time, and services provided to consumer upon request.

CF2, SOS 12/23/23. CF failed to include documentation of services provided. Owner unable to produce records of days, time, and services provided to consumer upon request.

CF4, SOS 12/19/23. CF failed to include documentation of services provided. Owner unable to produce records of days, time, and services provided to consumer upon request.


Exit interview with owner on April 30, 2024, at approximately 1:00pm confirmed findings.










Plan of Correction:

Client files will be retained on site.

Service records will be on file bi- monthly.

Management will audit all up-dated service records.


Initial Comments:


Based on the findings of an unannounced on-site state re-licensure survey conducted on April 30, 2024, Amen Concierge Service, LLC was found to be in compliance with the requirements of 35 P.S. 448.809 (b).










Plan of Correction: