Initial Comments:
Based on the findings of an onsite unannounced state license survey and complaint investigation completed March 19, 2024, Anointed Wings Healthcare Agency, Llc was found to be in compliance with the following 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 license survey and complaint investigation completed March 19, 2024, Anointed Wings Healthcare Agency, Llc 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
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 review of direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to conduct a face-to-face interview prior to hire for five (5) of six (6) direct care worker personnel files (PF1-PF5).
Findings include:
Review of personnel files was conducted on March 19, 2024, at approximately, at 9:30 a.m.
PF1 was hired on 11/21/2024. PF1 contained an undated face-to-face interview.
PF2 was hired on 1/23/2024. PF2 contained an undated face-to-face interview
PF3 was hired on 10/17/2024. PF3 contained an undated face-to-face interview
PF4 was hired on 1/23/2024. PF4 contained an undated face-to-face interview
PF5 was hired on 1/13/2024. PF5 contained no face-to-face interview
Interview with EMP1 on March 19, 2024, at 12 p.m. confirmed above findings.
Plan of Correction:1. Corrective action for the Patients affected by the alleged deficient practice: There were no patients affected by the alleged deficient practice, proper interview was complete for each employee mentioned ( PF1, PF2, PF3, PF4, PF5) but not dated on the face to face interview questions sheet which was meant to be a part of a larger onboarding packet that was dated. Therefore no Patient ever received care from an employee who had not had been interviewed in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.
2. Corrective action taken for those residents having the potential to be affected by the alleged deficient practice: Company office staff has added a date and signature line to face to face interview questions form page for each of the employee files mentioned ( PF1, PF2, PF3, PF4, PF5),there will be no residents that have the potential to be affected by the alleged deficient practice. Office staff found interview for PF5 after
3. Systemic changes put in place to assure the alleged deficient practice does not reoccur: Company office staff has added a date and signature line to interview questions form page to ensure the alleged deficient practice does not reoccur.
4. Corrective actions will be monitored to ensure the alleged deficient practice will not reoccur: Each employee file will be double checked by Office staff and HR department upon hire and before rostering to ensure our new face to face interview forms with date and signature are being used, we will continue the practice of conducting face to face interviews in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.
5. Will be Completed 4/15/2024
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 on a review of CDC (Center for Disease Control and Prevention) guidelines, direct care worker personnel files, and staff (EMP) interview, the agency failed to ensure each direct care worker was screened for mycobacterium tuberculosis (TB) in accordance with CDC (Center for Disease and Control) guidelines prior to consumer contact for five (5) of six (6) active personnel files (PF1-PF5).
Findings included:
According to CDC guidelines "Updated Recommendations ... TB screening is defined as a process that includes a TB risk assessment [and a] symptom evaluation." Retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6819-h.pdf
Review of personnel files was conducted on March 19, 2024, at approximately, at 9:30 a.m.
PF1 was hired on 11/21/2024. PF1 was actively providing services to consumers and contained no TB symptom screen and no TB risk assessment.
PF2 was hired on 1/23/2024. PF2 was actively providing services to consumers and contained no TB symptom screen and no TB risk assessment.
PF3 was hired on 10/17/2024. PF3 was actively providing services to consumers and contained no TB symptom screen and no TB risk assessment.
PF4 was hired on 1/23/2024. PF4 was actively providing services to consumers and contained no TB symptom screen and no TB risk assessment.
PF5 was hired on 1/13/2024. PF5 was actively providing services to consumers and contained no TB symptom screen and no TB risk assessment.
Interview with EMP1 on March 19, 2024, at 12 p.m. confirmed above findings.
Plan of Correction:1. Corrective action for the Patients affected by the alleged deficient practice: There were no Patients affected by the alleged deficient practice, each employee had a TB test completed at Heritage Valley Hospital where they also conducted a TB symptom screen and TB risk assessment. This means no patient was affected by being at risk due to alleged deficient practice. The Company has the TB symptom screen and TB risk assessment on site and have been using it, however was not privy to the updated CDC Guideline changes that suggest they be performed and filed by agency prior to hire as a pose to yearly. Although employee records could not show that TB symptom screen and TB risk assessment had been performed by agency and filed, no patients received care from an employee that had not had a TB test, TB symptom screen and TB risk assessment completed.
2. Corrective action taken for those residents having the potential to be affected by the alleged deficient practice: Each employee mentioned (PF1-PF5) will have a TB symptom screen and TB risk assessment completed before contact with any patients. Company has moved the time that we conduct TB symptom screens and TB risk assessment to be in compliance with CDC guidelines. TB symptom screen and TB risk assessment will now be conducted and added to employee personal files by Office staff at onboarding to ensure each direct care worker was screened for mycobacterium tuberculosis (TB) in accordance with CDC (Center for Disease and Control) guidelines prior to consumer contact.
3. Systemic changes put in place to assure the alleged deficient practice does not reoccur: Company has moved the time that we conduct TB symptom screens and TB risk assessment to be in compliance with CDC guidelines. TB symptom screen and TB risk assessment will now be conducted and added to employee personal files by Office staff at onboarding to ensure each direct care worker was screened for mycobacterium tuberculosis (TB) in accordance with CDC (Center for Disease and Control) guidelines prior to consumer contact.
4. Corrective actions will be monitored to ensure the alleged deficient practice will not reoccur: Each employee file will be double checked by Office staff and HR department upon hire and before employee has contact with a patient to ensure each direct care worker was screened for mycobacterium tuberculosis (TB) in accordance with CDC (Center for Disease and Control) guidelines prior to consumer contact.
5. Will be Completed 4/15/2024
Initial Comments:
Based on the findings of an onsite unannounced state license survey and complaint investigation completed March 19, 2024, Anointed Wings Healthcare Agency, Llc was found to be in compliance with the following requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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