Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on October 16, 2024, A Daughter's Love, 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 onsite unannounced home care agency state re-licensure survey conducted on October 16, 2024, A Daughter's Love, 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:
611.51(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 employee files (EFs), agency policy, and interview with the administrator, it was determined that the agency failed to document face-to-face interviews for seven (7) of seven (7) EFs reviewed (EFs #1-7); and failed to document two satisfactory references for six (6) of seven (7) EFs reviewed (EFs #2-7).
Findings include:
Review conducted on October 16, 2024, at approximately 9:45 AM, of employee files revealed:
EF #1 date of hire (doh) 10/4/23, missing face-to-face (FTF) documentation.
EF#2 doh 7/25/24, missing FTF and 2 references documentation.
EF#3 doh 5/15/24, missing FTF and 2 references documentation.
EF#4 doh 9/19/24, missing FTF and 2 references documentation.
EF#5 doh 7/24/24, missing FTF and 2 references documentation.
EF#6 doh 7/29/24, missing FTF and 2 references documentation.
EF#7 doh 11/9/23, missing FTF and 2 references documentation.
Review conducted on October 16, 2024, at approximately 12:00 PM, of agency policy 611.51 (Rostering Direct Care Workers) revealed: "2. Conduct and document a face-to-face interview. 3. Obtain and document a minimum of two satisfactory references."
Interview conducted October 16, 2024, at approximately 12:05 PM, with agency administrator revealed confirmation of above findings.
Plan of Correction:1. On 12/15/2024, agency administrator revised the new
employee/contractor application packet to
include: A new separate interview face-to-face
form including applicant's name, interview date,
interviewer name with completion date, and
evaluation comment space; and a new separate
form for the required two reference checks
including reference individual name/relationship,
date of review, interviewer name, and related
comments. These new forms will also be utilized
with all new applicants.
2. On 12/15/2024, agency administrator created
individual letters for all employees/contractors
inclusive of EFs#4-7. stating the
employee/contractor's file was audited during a
Pennsylvania Department of Health Home survey
on 10/16/24 and found the on hire face-to-face and
two satisfactory references were not completed.
These audit findings letters will be stored in each
employee/contractor's personnel file.
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 upon review of employee files (EFs), agency policy, and an interview with the agency administrator, agency failed to obtain a Federal criminal history record and a letter of determination from the Pennsylvania (PA) Department of Aging for four (4) out of seven (7) employee files (EFs #2-4, #6).
Findings include:
Review conducted on October 16, 2024, at approximately 10:00 AM, of agency's employee files (EFs) revealed:
EF#2 date of hire (doh) 7/25/24, Pennsylvania (PA) driver license issued 10/26/23 with expiration 10/14/27, insufficient proof of PA residency, no Federal criminal history record/PA Department of Aging letter found.
EF#3 doh 5/15/24, PA driver license issued 5/2/24 with expiration 11/7/27, insufficient proof of PA residency, no Federal criminal history record/PA Department of Aging letter found.
EF#4 doh 9/19/24, PA driver license issued 4/24/23 with expiration 4/26/27, insufficient proof of PA residency, no Federal criminal history record/PA Department of Aging letter found.
EF#6 doh 7/29/24, PA driver license issued 5/29/24 with expiration 5/31/28, insufficient proof of PA residency, no Federal criminal history record/PA Department of Aging letter found.
Review conducted on October 16, 2024, at approximately 12:00 PM, of agency policy 611.52 (Criminal Background Checks) revealed: "... Applicants will also be required to furnish proof of residency through submission of one or more of the following: Valid drivers license or state issued ID, Public utility records such as utility bills, Local tax records, Housing records such as mortgage or rent receipts, Employment, unemployment compensation, or school records; ... 3. Records shall be maintained ... which includes copies of State Police Criminal History records or the Federal criminal history records. These records will be available for Department inspection."
Interview conducted on October 16, 2024, at approximately 12:15 PM, with agency administrator revealed confirmation of above findings.
Plan of Correction:1. On 12/15/2024, agency administrator revised
caregiver checklist face page to include a
space/line to note issue date of Pennsylvania
driver's license or state ID card for at least a two
year prior date to ensure two-year PA residency
proof. Other PA approved residency documents
are local tax records, utility bill, housing records,
employment/unemployment records, and must
reflect a two year prior date.
2. On 12/15/2024, agency administrator revised
applicant check list page to include separate lines
related to PA residency, Federal criminal
background check, and Child Abuse clearances.
3. Starting 12/15/2024, agency administrator will audit
current caregiver files and if two-year PA
residency cannot be proven, a federal background
check will be required/completed and added to
employee/subcontractor file. These new practices
will be utilized with all new applicants.
4. By 12/15/2024, agency administrator will require
EF#2-4, #6 to submit PA approved documents to
prove PA residency for two years prior to hire
date. If no documents are available, EFs#2-4, #6
will be required to obtain a Federal criminal
background check as soon as possible. These
results will be stored in the employee/contractor's
personnel file.
5. By 12/15/2024, agency administrator will audit all
current employees/contractors for proof of PA
residency documents – two years prior to hire
date. If any other employees/contractors are
missing this documentation, each individual will
be required to to obtain a Federal criminal
background check as soon as possible. These
results will be stored in the employee/contractor's
personnel file.
6. Starting 12/15/2024 and to ensure future compliance
with PA residency documents, agency administrator will perform audits every six
months on all new employees/contractors. If gaps
are noted, agency administrator will address the
findings.
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 a review of employee files (EFs), agency policy, and interview with agency administrator, the agency failed to require direct care workers to furnish proof of residency for two years prior to 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) EFs reviewed (EFs #2-4, #6).
Findings include:
Review conducted on October 16, 2024, at approximately 10:00 AM, of agency's employee files (EFs) revealed:
EF#2 date of hire (doh) 7/25/24, Pennsylvania (PA) driver license issued 10/26/23 with expiration 10/14/27, insufficient proof of PA residency, no Federal criminal history record/Department of Aging letter found.
EF#3 doh 5/15/24, PA driver license issued 5/2/24 with expiration 11/7/27, insufficient proof of PA residency, no Federal criminal history record/Department of Aging letter found.
EF#4 doh 9/19/24, PA driver license issued 4/24/23 with expiration 4/26/27, insufficient proof of PA residency, no Federal criminal history record/Department of Aging letter found.
EF#6 doh 7/29/24, PA driver license issued 5/29/24 with expiration 5/31/28, insufficient proof of PA residency, no Federal criminal history record/Department of Aging letter found.
Review conducted on October 16, 2024, at approximately 12:00 PM, of agency policy 611.52 (Criminal Background Checks) revealed: "... Applicants will also be required to furnish proof of residency through submission of one or more of the following: Valid drivers license or state issued ID, Public utility records such as utility bills, Local tax records, Housing records such as mortgage or rent receipts, Employment, unemployment compensation, or school records; ... 3. Records shall be maintained ... which includes copies of State Police Criminal History records or the Federal criminal history records. These records will be available for Department inspection."
Interview conducted on October 16, 2024, at approximately 12:15 PM, with agency administrator revealed confirmation of above findings.
Plan of Correction:1. On 12/15/2024, agency administrator revised
caregiver checklist face page to include a
space/line for submission of approved
Pennsylvania (PA) proof of residency documents
to prove PA residency for two-years prior to
individual's date of hire.
2. By 12/15/2024, agency administrator will audit
current caregiver files and if two-year PA
residency cannot be proven, a federal background
check will be required/completed and added to
employee/subcontractor file. These new practices
will be utilized with all new applicants.
3. By 12/15/2024, agency administrator will require
EF#2-4, #6 to submit PA approved documents to prove PA residency for two years prior to hire
date. If no documents are available, EFs#2-4, #6
will be required to obtain a Federal criminal
background check as soon as possible. These
results will be stored in the employee/contractor's
personnel file.
4. Starting 12/15/2024and to ensure future compliance
with PA residency documents, agency
administrator will perform audits every six
months on all new employees/contractors. If gaps
are noted, agency administrator will address the
findings.
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 review of employee files (EFs), agency policy, and an interview with the agency administrator, the agency failed to ensure, prior to assigning a direct care worker (DCW) to provide services to a consumer, competency by passing an initial DCW competency examination for one (1) of of seven (7) EFs (EF#5).
Findings include:
Review conducted on October 16, 2024, at approximately 9:45 AM, of employee files (EFs) revealed:
EF #5, date of hire 7/24/24, missing initial DCW competency exam.
Review conducted on October 16, 2024, at approximately 12:00 PM, of agency policy 611.55 (Competency Requirements) revealed: "Daughter's Love will require direct care workers ensure competency through corresponding exam and skills test identified or developed by agency ... ; A Daughter's Love will include documentation or direct care worker's satisfactory completion of testing ... Such documents will be kept in direct care worker's confidential file/folder."
Interview conducted on October 16, 2024, at approximately 12:05 PM, with agency administrator revealed confirmation of above findings.
Plan of Correction:S 0600
1. Starting 12/15/2024, agency administrator will
require potential applicants to demonstrate direct
care worker competency by passing agency's
competency examination which meets related
requirements of PA Chapter 611.55 subsections
(b) and (c) prior onhire and annually thereafter.
2. By 12/15/2024, agency administrator will audit
current caregiver files to ensure that initial
competency testing is completed and stored in their personnel file.
3. By 12/15/2024, agency administrator will create an
annual review form which includes annual review
of competency testing to include date and score,
performance evaluation, and yearly TB
questionnaire (potentially requiring two step retest).
4. By 12/15/2024, agency administrator will require
EF#5 to complete 2024 competency exam and
store document in their employee file.
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 Centers for Disease Control (CDC) guidelines, employee files (EFs), agency policy, and interview with agency administrator, the agency failed to ensure direct care workers (DCWs), prior to consumer contact, that the individual had been screened for and was free from active mycobacterium tuberculosis (TB) for five (5) of seven (7) EFs reviewed. (EFs #1-4, #7); and failed to require DCWs to complete onhire TB risk assessment questionnaire (TB-RAQ) for five (5) of seven (7) EFs reviewed ( (EF#1-2, #4-6).
Findings include:
Review conducted on September 27, 2024, at approximately 9:45 AM, of Centers for Disease Control (CDC) Guidelines for "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019" revealed: "1) TB screening with an individual risk assessment and symptom evaluation at baseline (preplacement); 2) TB testing with an interferon-gamma release assay (IGRA) or a tuberculin skin test (TST) for persons without documented prior TB disease or latent TB infection (LTBI); ... 5) annual symptom screening for health care personnel with untreated LTBI; and 6) annual TB education of all health care personnel.; ... Baseline (preplacement) screening and testing. All U.S. health care personnel should have baseline TB screening, including an individual risk assessment (Box), which is necesfor interpreting any test result. The 2005 guidelines state that baseline test results provide a basis for comparison in the event of a potential or known exposure to M. tuberculosis, facilitate detection and treatment of LTBI or TB disease in health care personnel before placement, and reduce the risk to patients and other health care personnel (1). The risk assessand symptom evaluation help guide decisions when interpreting test results."
CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005, revealed: "...Baseline testing for M. Tuberculosis infection is recommended for all newly hired health care workers [HCWs]...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 TST result is negative, the second-step TST should be administered 1--3 weeks after the first TST result was read...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 result within the previous 12 months, a single TST can be administered in the new setting...This additional TST represents the second stage of the two-step testing..."
Review conducted on October 16, 2024, at approximately 9:45 AM, of employee files (EFs) revealed:
EF #1 date of hire (doh) 10/4/23, missing onhire TST #2 result and TB-RAQ document.
EF#2 doh 7/25/24, missing onhire TST #2 result and TB-RAQ document.
EF#3 doh 5/15/24, missing onhire TST #2 result.
EF#4 doh 9/19/24, missing onhire TST #2 result and TB-RAQ document.
EF#5 doh 7/24/24, missing onhire TB-RAQ document.
EF#6 doh 7/29/24, missing onhire TB-RAQ document.
EF#7 doh 11/9/23, missing onhire TST #2 result.
Review conducted on October 16, 2024, at approximately 12:00 PM, of agency policy 611.56 (Health Screening) revealed: "... 4. Caregiver will then provide doucmentation of PPD testing results ...; A Daughter's Love will include documentation of direct care worker's satisfactory completion of related testing in rostered individual's personnel chart."
Interview conducted on October 16, 2024, at approximately 12:05 PM, with agency administrator revealed confirmation of above findings.
Plan of Correction:S 0700
1. Beginning 12/15/2024, agency administrator will
require potential applicants to provide either a
two-step TB test or a TB blood test to ensure that
each potential caregiver has been screened for and
is free from active mycobacterium TB. Related
TB questionnaire will also be completed by
applicant prior to start date as well as annually
thereafter.
2. By 12/15/2024, agency administrator will audit
current caregiver files to ensure that
appropriate/required onhire TB testing results,
and onhire and annual TB risk assessment
questionnaire(s) are present. If any gaps in
required documents are found, agency
administrator will require each individual to
obtain new TB 2-step Mantoux test results as
soon as possible and complete any missing TB
documentation
3. Starting 12/15/2024, agency administrator will add
an annual review form which includes yearly TB
risk assessment questionnaire. This document will
be stored in each individual's personnel file.
4. By 12/15/2024, agency administrator will require
EFs #2-7 to complete TB blood test and/or two
step TB test results and or 2024 TB risk
assessment questionnaire form based on survey
findings. These TB test results and forms will be
stored in each individual's personnel file.
5. Starting 12/15/2024, agency administrator will
ensure that that all new
employees have completed the on hire TB
requirements by adding related forms to packet. Annual review date will also be noted at time of hire for following year to complete corresponding TB questionnaire and new test if necessary.
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 review of consumer files (CFs), consumer information & personal service agreement package, agency policy, and interview with the agency administrator, the agency failed to provide the consumer, prior to commencement of services, written identification of assigned direct care worker (DCW) in five (5) out of five (5) CFs reviewed (CF#1-5); failed to document hiring and competency requirements applicable to DCW employed by the home care agency in five (5) out of five (5) CFs reviewed (CF#1-5); and failed provided consumer with Department of Pennsylvania (PA) Consumer Notice of Direct Care Worker Status document in five (5) out of five (5) CFs reviewed (CF#1-5).
Findings include:
Review conducted on October 16, 2024, at approximately 12:45 PM, of consumer files (CFs) revealed:
CF#1 start of care (soc) 3/7/24, no documentation for assigned DCW, no description of hiring and competency requirements applicable to DCW, and no PA Consumer Notice of DCW status documentation.
CF#2 soc 11/4/23, no documentation for assigned DCW, no description of hiring and competency requirements applicable to DCW, and no PA Consumer Notice of DCW status documentation.
CF#3 soc 11/20/20, no documentation for assigned DCW, no description of hiring and competency requirements applicable to DCW, and no PA Consumer Notice of DCW status documentation.
CF#4 soc 7/2/24, no documentation for assigned DCW, no description of hiring and competency requirements applicable to DCW, and no PA Consumer Notice of DCW status documentation.
CF#5 soc 2/2/24, no documentation for assigned DCW, no description of hiring and competency requirements applicable to DCW, and no PA Consumer Notice of DCW status documentation.
Review conducted on October 16, 2024, at approximately 9:25 AM, of consumer information and personal service agreement revealed no description of hiring and competency requirements applicable to DCW, no documentation space for identity of assigned DCW, and no PA Consumer Notice of DCW status document included in consumer package.
Review conducted on October 16, 2024, at approximately 1:00 PM, of agency policy 611.57 (Consumer Protection) revealed: "... 4. All consumers, responsible family members, or consumer's legal representative will receive the following information in understandable/concise manner: ... b. Notification of the identity of the direct care worker(s) that will be providing the services; ... g. Requirements and competencies of direct care workers; h. Disclosure of direct care workers insurance and/or tax obligations... ."
Interview conducted on October 16, 2024, at approximately 1:15 PM, with agency administrator revealed confirmation of above findings.
Plan of Correction:S 0820
1. By 12/15/2024, agency administrator updated the
consumer service agreement by adding a text
line/space for identification of assigned caregiver.
2. By 12/15/2024, agency administrator updated The
welcome letter has also been updated to include
information indicating that all direct care workers
employed or contracted with the agency are
required to:
- Complete criminal background check
- Complete competency and skill test
- Complete health screening including two step
TB test
- Provide a minimum of two satisfactory
references
- Participate in face-to-face interview
3. By 12/15/2024, agency administrator will provide all
current consumers with an updated Pennsylvania
Consumer Notice of Direct Care Worker Status Form.
Consumers and agency administrator will
sign and date the each completed form.
Consumers will be given a copy of this form, and
another signed copy will be stored in their agency
consumer file.
4. Starting 12/15/2024, agency administrator will
include all revised documents in the new
consumer welcome packets.
5. By 12/15/2024, agency administrator will visit all
current consumers (inclusive of CF#1-5) to
receive updated consumer information and obtain
Pennsylvania Consumer Notice of Direct Care
Worker Status Form signed document.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on October 16, 2024, A Daughter's Love, LLC was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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