Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on August 8, 2024, 2nd Family, 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 onsite home care agency state re-licensure survey conducted on August 8, 2024, 2nd Family, 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:
611.51(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 personnel files (PF) and an interview with the administrator the agency failed to document verification of at least two satisfactory and verifiable references for seven (7) of seven (7) PF's reviewed, (PF #1, 2, 3, 4, 5, 6, and 7).
Findings include:
A review of PFs was conducted on 8/8/24 from approximately 10:00 AM to 10:50 AM.
PF #1, Date of Hire: 2/17/2023, did not contain any documentation of verification of at least two satisfactory and verifiable references.
PF #2, Date of Hire: 4/19/2023, did not contain any documentation of verification of at least two satisfactory and verifiable references.
PF #3, Date of Hire: 11/9/2022, did not contain any documentation of verification of at least two satisfactory and verifiable references.
PF #4, Date of Hire: 11/13/2020, did not contain any documentation of verification of at least two satisfactory and verifiable references.
PF #5, Date of Hire: 6/18/2024, did not contain any documentation of verification of at least two satisfactory and verifiable references.
PF #6, Date of Hire: 4/12/2023, did not contain any documentation of verification of at least two satisfactory and verifiable references.
PF #7, Date of Hire: 12/22/2021, did not contain any documentation of verification of at least two satisfactory and verifiable references.
An interview with the administrator on August 8, 2024 at approximately 11:00 AM confirmed the above findings.
Plan of Correction:Our plan is to check references included within all new employee's application. We document with date and time of who we have spoken with as a reference check. We will include this documentation for the 5 PF's as required. 2nd Family Main Line has designated Joy Sunit, the Operations Manager, to do a quarterly audit on all CNA records ensuring that their PF files are up to date and complete.
Our Operations Manager will submit a quarterly report to the Director of Operations and Director of Nursing, that includes a checklist of all missing items on the PFs files and a report on who's due for a Performance Appraisal.
611.52(b) LICENSURE
State Police Criminal History Record
Name - Component - 00
If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.
Observations:
Based on a review of personnel files (PF) and an interview with the administrator, the agency failed to provide documentation of a Pennsylvania (PA) State Police Criminal Background Check at the time of application or within 1 year immediately preceding the date of application for five (5) of seven (7) PF's reviewed, (PF #1, 3, 4, 6, and 7).
Findings include:
A review of PF's was conducted on 8/8/24 from approximately 10:00 AM to 10:50 AM.
PF#1, Date of Hire: 2/17/2023, only contained documentation of a PA State Police Criminal Background Check dated 8/5/2024.
PF#3, Date of Hire: 11/9/2022, did not contain any documentation of a PA State Police Criminal Background Check.
PF#4, Date of Hire: 11/13/2020, only contained documentation of a PA State Police Criminal Background Check dated 6/1/2024.
PF#6, Date of Hire: 4/12/2023, only contained documentation of a PA State Police Criminal Background Check dated 8/7/2024.
PF#7, Date of Hire: 12/22/2021, only contained documentation of a PA State Police Criminal Background Check dated 8/6/2024.
An interview with the administrator on August 8, 2024, at approximately 11:00AM confirmed the above findings.
Plan of Correction:Our plan of correction is to include all background checks for the state of PA and save them to the employee's file for future documentation needs. We will send the 5 PF's who need these and have been pulled through the PATCH system.
2nd Family Main Line has designated the Operations Manager, to do a quarterly audit on all CNA records ensuring that their PF files are up to date and complete.
Our Ops Manager will submit a quarterly report to the Director of Operations and Director of Nursing, that includes a checklist of all missing items on the PFs files and a report on who's due for a Performance Appraisal.
611.52(d) LICENSURE
Proof of Residency
Name - Component - 00
The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation
Observations:
Based on review of personnel files (PF) and an interview with the administrator, the agency failed to document proof of Pennsylvania (PA) residency preceding date of hire through submission of any one of the following documents: (1) Motor vehicle records, such as a valid driver's license or a State-issued identification; (2) Housing records, such as mortgage records or rent receipts; (3) Public utility records and receipts, such as electric bills; (4) Local tax records; (5) A completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it; (6) Employment records, including records of unemployment compensation for four (4) of seven (7) PF's reviewed, (PF#3, 4, 6, and 7.)
Findings include:
A review of PF's was conducted on 8/8/24 from approximately 10:00 AM to 10:50 AM.
PF# 3, Date of Hire: 11/9/2022, contained a Pennsylvania Driver's license issued on 3/3/2023. There was no proof of Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire.
PF#4, Date of Hire: 11/13/2020, did not contain any documentation to show proof of Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire.
PF#6, Date of Hire: 4/12/2023, contained a Pennsylvania Driver's license issued on 6/26/2022. There was no proof of Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire.
PF#7, Date of Hire: 12/22/2021, contained a Pennsylvania Driver's license issued on 7/9/2021. There was no proof of Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire.
An interview conducted with the administrator on August 8, 2024 at approximately 11:00 AM confirmed the above findings.
Plan of Correction:The plan of correction for those caregivers hired that do not have a driver's license that was issued 2years+ from their hire date, we will ask for additional documentation. In those we will ask the them to provide one of the following: 1) Motor vehicle records, such as a valid driver's license or a State-issued identification; (2) Housing records, such as mortgage records or rent receipts; (3) Public utility records and receipts, such as electric bills; (4) Local tax records; (5) A completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it.
We will also provide the information for the PF's as required by the audit.
2nd Family Main Line has designated The Operations Manager, to do a quarterly audit on all CNA records ensuring that their PF files are up to date and complete.
Our Operations Manager will submit a quarterly report to the Director of Operations and Director of Nursing, that includes a checklist of all missing items on the PFs files and a report on who's due for a Performance Appraisal.
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 personnel files (PF), the Centers for Disease Control (CDC) guidelines, PA REVISED Guidance for Home Care Agencies, Home Health Care Agencies and Hospices During COVID-19 Pandemic dated May 20, 2020, and an interview with the administrator, the agency did not provide documentation that a direct care worker was screened for and free from active mycobacterium tuberculosis, in accordance with CDC guidelines, for seven (7) of seven (7) PF's reviewed, (PF#1, 2, 3, 4, 5, 6, and 7.)
Findings include:
In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: receive baseline tuberculosis screening upon hire by using: a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB), or a negative chest x-ray to test for infection with tuberculosis. 2. Completion of a tuberculosis symptom questionnaire. And 3. Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCWs should receive TB education annually. HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(5-16-19)
PA REVISED Guidance for Home Care Agencies, Home Health Care Agencies and Hospices During COVID-19 Pandemic dated May 20, 2020, states, "9. Pre-employment Health Screening: The requirement for an initial baseline 2 step Mantoux skin test for tuberculin skin testing is temporarily suspended. All applicants must complete an individual risk assessment and symptom evaluation prior to hire. Any new employee who does not provide evidence of a Mantoux skin test within the previous 12 months must, as a condition of employment, receive the tuberculin skin test as soon as possible following termination of the Governor ' s COVID-19 Disaster Declaration."
A review of PF's was conducted on 8/8/24 from approximately 10:00 AM to 10:50 AM.
PF#1, Date of Hire: 2/17/2023, did not contain any documentation of a completed tuberculosis symptom questionnaire completed at hire.
PF#2, Date of Hire: 4/19/2023, did not contain any documentation of a completed tuberculosis symptom questionnaire at hire.
PF#3, Date of Hire: 11/9/2022, did not contain any documentation of tuberculosis screening within the previous 12 months of hire, did not contain a completed tuberculosis symptom questionnaire at hire, and did not contain any documentation of tuberculosis screening completed since the termination of the Governor ' s COVID-19 Disaster Declaration on May 11, 2023.
PF#4, Date of Hire: 11/13/2020, did not contain any documentation of tuberculosis screening within the previous 12 months of hire and contained documentation of only one (1) negative tuberculosis skin test dated 2/8/2024. File did not contain any documentation of a completed tuberculosis risk assessment completed at the time of hire.
PF#5, Date of Hire: 6/18/2024, did not contain any documentation of tuberculosis screening within the previous 12 months of hire and did not contain a completed tuberculosis symptom questionnaire and risk assessment prior to hire.
PF#6, Date of Hire: 4/12/2023, did not contain any documentation of a completed tuberculosis symptom questionnaire upon hire.
PF#7, Date of Hire: 12/22/2021, did not contain any documentation of a completed tuberculosis symptom questionnaire upon hire.
An interview with the administrator conducted on August 8, 2024 at approximately 11:00 AM confirmed the above findings.
Plan of Correction:Our plan of correction is to make sure we have proof of a clear TB screening for all caregivers prior to their hire date. We will share updated TB screenings for all PF's as required.
2nd Family Main Line has designated The Operations Manager, to do a quarterly audit on all CNA records ensuring that their PF files are up to date and complete.
Our Ops Manager will submit a quarterly report to the Director of Operations and Director of Nursing, that includes a checklist of all missing items on the PFs files and a report on who's due for a Performance Appraisal.
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 review of personnel files (PFs), the Centers for Disease Control guidelines, and interview with the administrator, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, were provided with annual mycobacterium tuberculosis education for six (6) of seven (7) PF's reviewed, (PF# 1, 2, 3, 4, 6, and 7).
Findings include:
In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: receive baseline tuberculosis screening upon hire by using: a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB), or a negative chest x-ray to test for infection with tuberculosis. 2. Completion of a tuberculosis symptom questionnaire. And 3. Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCWs should receive TB education annually. HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(5-16-19)
A review of PF's was conducted on 8/8/24 from approximately 10:00 AM to 10:50 AM.
PF #1, Date of Hire: 2/17/2023, did not contain any documentation of annual tuberculosis education provided for 2024.
PF #2, Date of Hire: 4/19/2023, did not contain any documentation of annual tuberculosis education provided for 2024.
PF #3, Date of Hire: 11/9/2022, did not contain any documentation of annual tuberculosis education provided for 2023.
PF #4, Date of Hire: 11/13/2020, did not contain any documentation of annual tuberculosis education provided for 2021, 2022, or 2023.
PF #6, Date of Hire: 4/12/2023, did not contain any documentation of annual tuberculosis education provided for 2024.
PF #7, Date of Hire: 12/22/2021, did not contain any documentation of annual tuberculosis education provided for 2022, or 2023.
An interview with the administrator conducted on August 8, 2024 at approximately 11:00 AM confirmed the above findings.
Plan of Correction:Our plan of correction is to share the CDC's annual TB fact sheer and have each active caregiver sign that they have reviewed. While saving this to their employee file. We will provide this documentation for the PF's that require this from the audit.
2nd Family Main Line has designated The Operations Manager, to do a quarterly audit on all CNA records ensuring that their PF files are up to date and complete.
Our Ops Manager will submit a quarterly report to the Director of Operations and Director of Nursing, that includes a checklist of all missing items on the PFs files and a report on who's due for a Performance Appraisal.
611.57(a) LICENSURE
Consumer Rights
Name - Component - 00
(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.
Observations:
Based on a review of consumer files (CF) and an interview with the administrator, the agency failed to provide documentation that the consumer received information stating the agency will provide at least ten (10) calendar days advance written notice of the agency's intent to terminate services for five (5) of five (5) CF's, (CF # 1, 2, 3, 4, and 5).
Findings include:
A review of CF's was conducted on August 8, 2024, from approximately 9:45 AM to 10:00 AM.
CF #1, Start of Care: 2/1/2022, did not contain any documentation stating the consumer received information stating the agency will provide at least ten (10) calendar days advance written notice of the agency's intent to terminate services.
CF #2, Start of Care: 5/29/2024, did not contain any documentation stating the consumer received information stating the agency will provide at least ten (10) calendar days advance written notice of the agency's intent to terminate services.
CF #3, Start of Care: 2/14/2024, did not contain any documentation stating the consumer received information stating the agency will provide at least ten (10) calendar days advance written notice of the agency's intent to terminate services.
CF #4, Start of Care: 2/2/2023, did not contain any documentation stating the consumer received information stating the agency will provide at least ten (10) calendar days advance written notice of the agency's intent to terminate services.
CF #5, Start of Care: 6/29/2024, did not contain any documentation stating the consumer received information stating the agency will provide at least ten (10) calendar days advance written notice of the agency's intent to terminate services.
An interview with the administrator conducted on August 8, 2024 at approximately 11:00 AM confirmed the above findings.
Plan of Correction:Our plan of correction is to update our current client agreement to state that 2nd Family will provide 10 days notice prior to ending care for any reason. We will share this updated agreement for each of the CF's reviewed in the audit.
Owner, Director of Operations, will be responsible for making sure each client reviews this updated information. While the update will remain going forward.
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 consumer files (CF) and an interview with the administrator, the agency failed to provide documentation that the consumer received information stating that no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency for five (5) of five (5) CF's, (CF #1, 2, 3, 4, and 5).
Findings include:
A review of CF's was conducted on 8/8/2024 from approximately 9:45 AM to 10:00 AM.
CF #1, Start of Care: 2/1/2022, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.
CF #2, Start of Care: 5/29/2024, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.
CF #3, Start of Care: 2/14/2024, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.
CF #4, Start of Care: 2/2/2023, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.
CF #5, Start of Care: 6/29/2024, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.
An interview with the administrator on August 8, 2024 at approximately 11:00 AM confirmed the above findings.
Plan of Correction:Our plan of correction is to update our client agreement for all future clients to state that no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.
We will notify the CF's in the audit that require this update.
Owner, Director of Operations, will be responsible for making sure each client reviews this updated information. While the update will remain going forward.
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 failed to provide documentation that the consumer received information stating: the Department's complaint Hotline (800-254-5164), the telephone number of the Ombudsman Program located within the local Area Agency on Aging (AAA), and documentation of 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 for five (5) of five (5) CF's, (CF # 1, 2, 3, 4, and 5).
Findings include:
A review of CF's was conducted on 8/8/2024 from approximately 9:45 AM to 10:00 AM.
CF #1, Start of Care: 2/1/2022, did not contain any documentation that the agency provided information stating: the Department's complaint Hotline (800-25405164), the telephone number of the Ombudsman Program located within the local Area Agency on Aging (AAA), and documentation of a direct care worker disclosure.
CF #2, Start of Care: 5/29/2024, did not contain any documentation that the agency provided information stating: the Department's complaint Hotline (800-25405164), the telephone number of the Ombudsman Program located within the local Area Agency on Aging (AAA), and documentation of a direct care worker disclosure.
CF #3, Start of Care: 2/14/2024, did not contain any documentation that the agency provided information stating: the Department's complaint Hotline (800-25405164), the telephone number of the Ombudsman Program located within the local Area Agency on Aging (AAA), and documentation of a direct care worker disclosure.
CF #4, Start of Care: 2/2/2023, did not contain any documentation that the agency provided information stating: the Department's complaint Hotline (800-25405164), the telephone number of the Ombudsman Program located within the local Area Agency on Aging (AAA), and documentation of a direct care worker disclosure.
CF #5, Start of Care: 6/29/2024, did not contain any documentation that the agency provided information stating: the Department's complaint Hotline (800-25405164), the telephone number of the Ombudsman Program located within the local Area Agency on Aging (AAA), and documentation of a direct care worker disclosure.
An interview with the administrator on August 8, 2024, at approximately 11:00 AM confirmed the above findings.
Plan of Correction:Our plan of correction is that our client agreement will include the updated PA Department of Aging HOTLINE phone number: 800-254-5164. We will also send this information to all of the CF's as required from the audit.
Owner, Director of Operations, will be responsible for making sure each client reviews this updated information. While the update will remain going forward.
Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on August 8, 2024, 2nd Family, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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