Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on February 1, 2024, Care Assured Home Health Care, 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 home care agency state re-licensure survey conducted on February 1, 2024 and offsite on February 2, 2024, Care Assured Home Health Care, 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:
611.52(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 agency administrator, it was determined the agency failed to obtain proof of residency for two (2) of seven (7) PF's reviewed, (PF #4 and 5).
Findings include:
A review of PF's conducted on February 1, 2024 from approximately 9:40 am to 10:15 am and on February 2, 2024 from approximately 2:30 pm to 2:45 pm, revealed the following:
PF #4, Date of Hire: 5/15/2023, did not contain any documentation showing proof of PA residency for the two years preceding the date of hire.
PF #5, Date of Hire: 4/5/2023, did not contain any documentation showing proof of PA residency for the two years preceding the date of hire.
An interview with the agency administrator on February 1, 2024 at approximately 11:00 am confirmed the above findings.
Plan of Correction:For the personnel files identified, the Agency will add documentation to verify proof of residency.
For personnel not identified in the observation, the Agency will add documentation to verify proof of residency.
To ensure the deficient practice does not recur, the Onboarding Process will be updated to include the completion of Residency verification and retain copies of documentation used.
This corrective action will be monitored by the Administrator by (1) reviewing the update to the Onboarding Process, (2) Adding an additional item to the New Hire Checklist currently used in the Personnel File to validate the verification of Proof of Residency. This documentation will be reviewed monthly for new hires.
This corrective action will be completed 4/01/2024
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 personnel files (PF), The Centers for Disease Control Guidelines, and an interview with the administrator, the agency failed to provide documentation of an initial tuberculosis screening for two (2) of seven (7) PF's reviewed, (PF #4 and 5).
Findings:
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 conducted on February 1, 2024 from approximately 9:40 am to 10:15 am and on February 2, 2024 from approximately 2:30 pm to 2:45 pm, revealed the following:
PF #4, Date of Hire: 5/15/2023, did not contain any documentation of tuberculosis screening at hire.
PF #5, Date of Hire: 4/5/2023, did not contain any documentation of
tuberculosis screening at hire.
An interview with the administrator conducted on February 1, 2024 at approximately 11:00 am confirmed the above findings.
Plan of Correction:For the personnel files identified, the Agency will instruct all Direct Care Workers to receive baseline tuberculosis screening, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis.
For personnel not identified in the observation, the Agency will verify if the baseline tuberculosis screening has been received. If the baseline tuberculosis screening is not in the personnel file, the Direct Care Worker will be instructed to receive baseline tuberculosis screening, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis.
To ensure the deficient practice does not recur, the New Hire Process will be reviewed monthly to verify that the baseline tuberculosis screening, tuberculosis symptom questionnaire and tuberculosis risk assessment have been completed and added to the Employee file.
This corrective action will be monitored by the Administrator by reviewing each New Hire file before adding the employee to the schedule to validate the baseline tuberculosis screening, tuberculosis symptom questionnaire and tuberculosis risk assessment have been completed.
This corrective action will be completed 4/1/2024
Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on February 1, 2024, Care Assured Home Health Care, LLC., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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