Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on July 25, 2024 and concluded offsite on July 26, 2024, Abacares Services, 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 unannounced state re-licensure survey conducted on July 25, 2024 and concluded offsite on July 26, 2024, Abacares Services, 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 obtain not less than two satisfactory references for the individual that is a positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual for seven (7) of seven (7) PFs prior to hire. PF# 1, 2, 3, 4, 5, 6, & 7.
Findings include:
A review of personnel files was conducted on 7/25/24 at 11:00 AM and revealed the following.
PF#1 Date of hire: 11/28/22, did not contain two satisfactory references for the individual that is a positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
PF#2 Date of hire: 2/3/24, contained two satisfactory reference for the individual however they were documented as obtained on 7/17/24 which is after the date of hire.
PF#3. Date of hire: 6/26/23, contained two satisfactory reference for the individual however they were documented as obtained on 9/7/23 which is after the date of hire.
PF#4. Date of hire: 9/11/23, contained two satisfactory reference for the individual however they were documented as obtained on 10/30/23 which is after the date of hire.
PF#5. Date of hire: 6/5/23, did not contain two satisfactory references for the individual that is a positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
PF#6. Date of hire: 7/9/23, did not contain two satisfactory references for the individual that is a positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
PF#7. Date of hire: 10/22/23, did not contain two satisfactory references for the individual that is a positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
An interview with the administrator on 7/25/24 at 1:30 PM confirmed the above findings.
Plan of Correction:Action Plan:
Policy Revision and Implementation:
Revise Hiring Policy: Update the hiring policy to explicitly require that all references must be obtained and verified before the date of hire. Ensure this policy is clearly communicated to all HR personnel and hiring managers.
Reference Check Form: Create a standardized form for documenting reference checks. This form should include fields for the date of reference check, name and contact information of the referee, and details of the reference provided.
Completion Date: 8/25/24
Training:
Staff Training: Conduct mandatory training sessions for HR staff and hiring managers on the updated hiring policy and procedures for obtaining and documenting references. Include training on the importance of compliance with state regulations. Completion Date: 9/10/24
Annual Refresher Training: Schedule annual refresher training sessions to ensure ongoing compliance and address any updates in regulations or procedures. Completion Date: 9/10/24
Compliance Monitoring:
Pre-Hire Checklist: Implement a pre-hire checklist that includes a section for reference checks. This checklist must be completed and signed off by the hiring manager before extending an offer of employment.Completion Date: 9/10/24
Audits: Conduct quarterly audits of personnel files to ensure compliance with the updated policy. Any discrepancies should be immediately addressed and corrective actions taken. Completion Date: 9/24/24
Documentation and Record-Keeping:
Backup and Recovery: Ensure that all electronic records are backed up regularly and can be easily retrieved in case of an audit or review. Completion Date: 9/24/24
Continuous Improvement:
Feedback Mechanism: Establish a feedback mechanism for HR staff to report any challenges faced during the reference check process. Use this feedback to continuously improve the hiring process.Completion Date: 9/24/24
Policy Review: Review and update the hiring policy annually to ensure it remains compliant with state regulations and addresses any identified gaps.Completion Date: 9/24/24
Responsible Parties:
HR Generalist: Responsible for initiating the reference checks and ensuring documentation is complete before the date of hire.
HR Specialist: Conducts training sessions and audits personnel files quarterly to ensure compliance.
Administrator: Oversees the implementation of the action plan and ensures all HR staff adhere to the updated policies and procedures.
Timeline:
Timeline:
Immediate Action: Revise hiring policy and develop the reference check form by 8/25/24.
Training: Conduct initial training sessions by 9/10/24.
Audits: Begin quarterly audits starting 9/24/24.
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 personnel files (PF) and an interview with the agency's administrator, the agency did not obtain a federal criminal history report for an employee who has not been a resident of Pennsylvania for 2 years immediately preceding the date of the request for a criminal history report for one (1) of seven (7) PFs. (PF #5).
Findings include:
Pennsylvania Act 169 of 1996 as amended by Act 13 of 1997 requires an applicant/ employee who has not been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application for employment or currently lives out-of-state, in addition to the Pennsylvania State Police Criminal History Check, the applicant/employee will also need to obtain an FBI Criminal History Check within ninety (90) days of employment. An employee is defined as any applicant or new employee hired after July 1, 1998. The definition of employee includes contract employees who have direct contact with residents or unsupervised access to their personal living quarters.
Findings:
A review of PFs was conducted on 7/25/24 at approximately 9:45 AM which revealed the following:
PF#5. Date of Hire 6/5/23, Direct care worker's file revealed a Delaware Driver's License that was issued on 11/4/21. The file contained no federal criminal history report.
An interview with the agency's administrator on 7/25/24 at approximately 1:30 P.M. confirmed the above findings.
Plan of Correction:Action Plan:
Policy Revision and Implementation:
Revise Background Check Policy: Update the background check policy to explicitly require federal criminal history reports for applicants and employees who have not been residents of Pennsylvania for the entire two years immediately preceding their application for employment.
Federal Check Requirement: Include a checklist item in the hiring process for HR personnel to verify the applicant's residency status and ensure that federal criminal history checks are obtained within 90 days of employment if required.
Training:
HR Training: Conduct mandatory training sessions for HR staff and hiring managers on the updated background check policy, emphasizing the requirements for federal criminal history reports for non-residents.
Annual Refresher Training: Schedule annual refresher training sessions to ensure ongoing compliance and address any updates in regulations or procedures.
Compliance Monitoring:
Pre-Hire Checklist: Implement a pre-hire checklist that includes a section for verifying residency status and obtaining federal criminal history checks. This checklist must be completed and signed off by the hiring manager before extending an offer of employment.
Audits: Conduct quarterly audits of personnel files to ensure compliance with the updated policy. Any discrepancies should be immediately addressed and corrective actions taken.
Documentation and Record-Keeping:
Electronic Record Management: Utilize an electronic record management system (ERMS) to securely store and manage personnel files, including background check documentation. Ensure all HR staff are trained on how to use the ERMS effectively.
Backup and Recovery: Ensure that all electronic records are backed up regularly and can be easily retrieved in case of an audit or review.
Continuous Improvement:
Feedback Mechanism: Establish a feedback mechanism for HR staff to report any challenges faced during the background check process. Use this feedback to continuously improve the hiring process.
Policy Review: Review and update the background check policy annually to ensure it remains compliant with state regulations and addresses any identified gaps.
Responsible Parties:
HR Generalist: Responsible for initiating and ensuring completion of the background checks, including federal criminal history reports, as per the revised policy.
HR Specialist: Conducts training sessions and audits personnel files quarterly to ensure compliance.
Administrator: Oversees the implementation of the action plan and ensures all HR staff adhere to the updated policies and procedures.
Timeline:
Immediate Action: Revise background check policy and update the pre-hire checklist by 8/25/24.
Training: Conduct initial training sessions by 9/10/24.
Audits: Begin quarterly audits starting by 9/24/24.
611.55(a) LICENSURE
Competency Requirements
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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 the agency's personnel files (PF), and an interview with the agency's administrator, it was determined the agency failed to ensure competency of the direct care worker prior to assigning the direct care worker to provide services to the consumer for seven (7) of seven (7) PFs reviewed. (PF# 1, 2, 3, 4, 5, 6, & 7).
Findings Included:
Review of PFs completed on 7/25/24 at approximately 9:45 AM which revealed:
PF# 1, Date of Hire: 11/28/22, Contained no documentation that initial competency was completed.
PF# 2, Date of Hire: 2/3/24, Contained documentation that initial competency was completed on 3/8/24 which is after the date of hire.
PF# 3, Date of Hire: 6/26/23, Contained documentation that initial competency was completed on 7/27/23 which is after the date of hire.
PF# 4, Date of Hire: 9/11/23, Contained documentation that initial competency was completed on 2/15/24 which is after the date of hire.
PF# 5, Date of Hire: 6/5/23, Contained documentation that initial competency was completed on 7/16/23 which is after the date of hire.
PF# 6, Date of Hire: 7/9/23, Contained documentation that initial competency was completed on 8/13/23 which is after the date of hire.
PF# 7, Date of Hire: 10/22/23, Contained documentation that initial competency was completed on 5/4/24 which is after the date of hire.
Interview completed on 7/25/24, at approximately 1:00 P.M. with the agency's administrator who confirmed the above findings.
Plan of Correction:Action Plan:
Policy Revision and Implementation:
Revise Competency Verification Policy: Update the competency verification policy to ensure that all direct care workers must complete initial competency assessments via the Nevvon platform before their official start date.
Competency Assessment Checklist: Create a standardized checklist for documenting the completion of initial competency assessments. This checklist should include fields for the date of assessment, assessor's name, and competency evaluation results.
Training:
HR and Training Staff Training: Conduct mandatory training sessions for HR staff, hiring managers, and trainers on the updated competency verification policy. Emphasize the importance of completing competency assessments before the start date using the Nevvon platform.
Annual Refresher Training: Schedule annual refresher training sessions to ensure ongoing compliance and address any updates in regulations or procedures.
Competency Assessment Process:
Pre-Hire Competency Assessment: Implement a process where all direct care workers must complete a competency assessment on the Nevvon platform before their official hire date. This can include practical evaluations, written tests, and observations of skills.
Documenting Competency: Ensure that all competency assessments are documented using the standardized checklist and stored in the employee's personnel file.
Compliance Monitoring:
Pre-Hire Checklist: Implement a pre-hire checklist that includes a section for verifying the completion of the competency assessment. This checklist must be completed and signed off by the hiring manager before extending an offer of employment.
Audits: Conduct quarterly audits of personnel files to ensure compliance with the updated policy. Any discrepancies should be immediately addressed and corrective actions taken.
Documentation and Record-Keeping:
Electronic Record Management: Utilize an electronic record management system (ERMS) to securely store and manage personnel files, including competency assessment documentation from the Nevvon platform. Ensure all HR staff are trained on how to use the ERMS effectively.
Backup and Recovery: Ensure that all electronic records are backed up regularly and can be easily retrieved in case of an audit or review.
Continuous Improvement:
Feedback Mechanism: Establish a feedback mechanism for HR staff and trainers to report any challenges faced during the competency assessment process. Use this feedback to continuously improve the hiring process.
Policy Review: Review and update the competency verification policy annually to ensure it remains compliant with state regulations and addresses any identified gaps.
Timeline:
Immediate Action: Revise competency verification policy and update the competency assessment checklist by 8/25/24.
Training: Conduct initial training sessions by 9/10/24.
Audits: Begin quarterly audits starting by 9/24/24.
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 personnel files (PF), the Centers for Disease Control (CDC) guidelines, and an interview with the administrator, the agency did not provide documentation that a direct care worker completed screening for mycobacterium tuberculosis according to guidelines for seven (7) of seven (7) PFs. ( PF# 1, 2, 3, 4, 5, 6 & 7).
Findings include:
In May 2019, the Centers for Disease Control (CDC) updated its recommendation for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should receive 1) 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; 2) Completion of a tuberculosis symptom questionnaire, and 3) Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease (CDC Guidelines for Preventing 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).
*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).
A review of PF's was conducted on 7/25/24 at approximately 9:45 AM. and revealed the following:
PF#1 Start of Hire: 11/28/22 did not contain evidence that an individual TB risk assessment or TB Screening Questionaire was completed upon hire. In addition, there was no documentation of baseline TB testing (2 step TST or blood testing).
PF#2 Start of Hire: 2/3/24 did not contain evidence that an individual TB risk assessment or TB Screening Questionaire was completed upon hire. In addition, there was documentation of a one-step TST completed on 8/15/23 but it was not documented as read in the correct timeframe of 48-72 hours later (it was read 10 minutes after being given). In addition, there was no documentation of the second step of the initial 2-step TST testing completed.
PF#3 Start of Hire: 6/26/23 did not contain evidence that an individual TB risk assessment or TB Screening Questionaire was completed upon hire. In addition, there was documentation of a one-step TST completed after hire on 7/14/23 without any results. In addition, there was no documentation of the second step of the initial 2-step TST testing completed.
PF#4 Start of Hire: 9/11/23 did not contain evidence that an individual TB risk assessment or TB Screening Questionaire was completed upon hire. In addition, there was documentation of a one-step TST completed after hire on 11/11/23 without any results. In addition, there was no documentation of the second step of the initial 2-step TST testing completed.
PF#5 Start of Hire: 6/5/23 did not contain evidence that an individual TB risk assessment or TB Screening Questionaire was completed upon hire. In addition, there was documentation of a one-step TST completed on 5/12/23 however there was no documentation of the second step of the initial 2-step TST testing completed.
PF#6 Start of Hire: 7/9/23 did not contain evidence that an individual TB risk assessment or TB Screening Questionaire was completed upon hire. In addition, there was no documentation of baseline TB testing (2 step TST or blood testing).
PF#7 Start of Hire: 10/22/23 did not contain evidence that an individual TB risk assessment or TB Screening Questionaire was completed upon hire. In addition, there was no documentation of baseline TB testing (2 step TST or blood testing).
An interview conducted with the administrator on 7/25/24 at approximatley 1:00 PM confirmed the above findings.
Plan of Correction:Action Plan:
Policy Revision and Implementation:
Revise TB Screening Policy: Update the TB screening policy to require that all new hires complete the following before starting their duties:
Baseline tuberculosis screening using a two-step tuberculin skin test (TST) or a single blood assay (IGRA) for TB.
Completion of a tuberculosis symptom questionnaire.
Completion of a tuberculosis risk assessment.
Annual TB Screening: Include a requirement for annual TB screening and education for all health care workers.
Training:
HR and Health Staff Training: Conduct mandatory training sessions for HR staff and health personnel on the updated TB screening policy, emphasizing the importance of completing all components of TB screening before the start date.
Annual Refresher Training: Schedule annual refresher training sessions to ensure ongoing compliance and address any updates in CDC guidelines.
TB Screening Process:
Pre-Hire TB Screening: Implement a process where all new hires must complete the TB screening before their official hire date. This process should include the two-step TST or IGRA, the TB symptom questionnaire, and the TB risk assessment.
Documentation: Ensure that all components of the TB screening are documented using standardized forms and stored in the employee's personnel file.
Compliance Monitoring:
Pre-Hire Checklist: Implement a pre-hire checklist that includes a section for verifying the completion of the TB screening. This checklist must be completed and signed off by the hiring manager before extending an offer of employment.
Audits: Conduct quarterly audits of personnel files to ensure compliance with the updated policy. Any discrepancies should be immediately addressed and corrective actions taken.
Documentation and Record-Keeping:
Feedback Mechanism: Establish a feedback mechanism for HR staff and health personnel to report any challenges faced during the TB screening process. Use this feedback to continuously improve the hiring process.
Policy Review: Review and update the TB screening policy annually to ensure it remains compliant with CDC guidelines and addresses any identified gaps.
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 upon review of agency documentation, consumer records and interview, it was determined, the Agency failed to provide services according to the service plan for one (1) of five (5) consumer records (CR) reviewed. (CR # 4)
Findings included:
A review of consumer records was conducted on 7/25/24 at approximately 11:15 AM and again on 7/26/24 at approximately 12:00 P.M which revealed the following:
CR #1: First day agency provided services: 7/8/24, In reviewing HHA Exchange, consumer's service authorization paperwork has a start date of 4/22/24 and stated 50 hours of direct care worker (DCW) services weekly. Initial paperwork to start services with the agency was signed on 4/22/24 by the consumer. A review of DCW hours revealed ONLY the following days serviced by the agency: 7/8/24, 7/15/24, 7/18/24, 7/22/24. Agency was unable to provide any documentation about the above missing/reduced DCW service hours, communication with service coordinator, or communication with the consumer about the delayed start of services.
Interview with administrator on 7/25/24 at approximately 12:00PM stated that agency was actively looking for a direct care worker for the consumer but was unable to find anyone except for one DCW starting in July for approximately 3 hours daily, 7 days per week.
An interview was conducted with the agency's administrator on 7/25/24 at approximately 1:00 PM. who confirmed the above findings.
Plan of Correction:Action Plan:
Policy Revision and Implementation:
Revise Service Delivery Policy: Update the service delivery policy to ensure that all services are provided according to the service plan. Include specific procedures for tracking service hours and communicating with consumers and service coordinators about any delays or changes in service delivery.
Service Authorization Verification: Implement a process to verify that service authorizations and start dates are accurately documented and adhered to in the HHA Exchange system.
Training:
Staff Training: Conduct mandatory training sessions for all staff on the updated service delivery policy and procedures. Emphasize the importance of providing services according to the service plan and documenting any deviations.
Annual Refresher Training: Schedule annual refresher training sessions to ensure ongoing compliance and address any updates in regulations or procedures.
Service Coordination and Documentation:
Service Start Verification: Ensure that all initial paperwork and service authorizations are verified and documented before the start of services. This includes confirming the start date, hours of service, and the assigned direct care worker.
Daily Service Log: Implement a daily service log for direct care workers to document the hours of service provided. This log should be reviewed weekly by supervisors to ensure compliance with the service plan.
Communication Log: Maintain a communication log to document all interactions with service coordinators and consumers regarding service delivery issues, delays, or changes.
Compliance Monitoring:
Weekly Review: Conduct weekly reviews of consumer records and service logs to ensure that services are being provided according to the service plan. Any discrepancies should be immediately addressed and corrective actions taken.
Audits: Conduct quarterly audits of consumer records and service logs to ensure compliance with the updated policy. Any discrepancies should be immediately addressed and corrective actions taken.
Documentation and Record-Keeping:
Electronic Record Management: Utilize an electronic record management system (ERMS) to securely store and manage consumer records, including service authorization paperwork and service logs. Ensure all staff are trained on how to use the ERMS effectively.
Backup and Recovery: Ensure that all electronic records are backed up regularly and can be easily retrieved in case of an audit or review.
Continuous Improvement:
Feedback Mechanism: Establish a feedback mechanism for staff to report any challenges faced during service delivery. Use this feedback to continuously improve the process and address any issues promptly.
Policy Review: Review and update the service delivery policy annually to ensure it remains compliant with state regulations and addresses any identified gaps.
Responsible Parties:
Case Coordinator: Responsible for ensuring that all services are provided according to the service plan and for maintaining documentation in consumer records.
Supervisors: Responsible for reviewing daily service logs and communication logs to ensure compliance with the service plan.
Administrator: Oversees the implementation of the action plan and ensures all staff adhere to the updated policies and procedures.
Timeline:
Immediate Action: Revise service delivery policy and update the service authorization verification process by 8/25/24.
Training: Conduct initial training sessions by 9/10/24.
Weekly Review: Begin weekly reviews of consumer records and service logs by 9/24/24.
Audits: Begin quarterly audits starting by 9/24/24.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on July 25, 2024 and concluded offsite on July 26, 2024, Abacares Services, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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