Initial Comments:
Based on the findings of an onsite Follow-Up and Complaint Investigation Survey completed 4/26/2023, Compassionate Homemakers, LLC had not corrected all of the deficiencies cited under PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries. The deficiencies were cited as a result of a State Licensure Survey completed on 8/11/2022 and again on a Follow-Up Survey completed 12/21/2022.
Plan of Correction:
611.52(a) LICENSURE
Criminal Background Checks
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The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.
Observations:
Based on review of agency Plan Of Correction, direct care worker (DCW) personnel files (PF) and staff (EMP) interview,The agency failed to obtain a criminal history report at the time of application and/or within 1 year immediately preceding the date of application for one (1) of four (4) DCW active personnel files reviewed (PF6).
Findings included:
Review of agency Plan Of Correction approved on 2/06/2023 revealed, "Compassionate Homemakers, LLC has submitted a criminal history report in accordance with the requirements of Chapter 611.52 (relating to criminal background checks). For the following individuals including but not limited to PF1 through PF3, PF6, and PF8 through PF14 on 12/21/2022 and completed on 1/18/2023 since State Licensure Survey completed 12/21/22. In addition to correcting these deficiencies, the agency will continue to monitor its PF files and CF files to their entirety, to ensure proper quality management and remain compliant with State regulations and guidelines."
A review of DCW personnel files was conducted on 4/26/2023 between 9:30 a.m. and 11:00 a.m.
PF6 was hired on 1/29/2022 and did not contain documentation to show that a Pennsylvania State Police Criminal Record was obtained.
This deficiency was originally cited as a result of a State Licensure Survey completed 8/11/2022. Agency submitted a Plan Of Correction with a corrective action date of 8/19/2022, which was approved on 9/08/2022. This same deficiency was cited again during a Follow-Up Survey completed 12/21/2022. Agency submitted another Plan Of Correction with a corrective action date of 1/21/2023, which was approved on 2/06/2023. Based on review of DCW personnel files and an interview with agency Administrator on 4/26/2023 at approximately 2:00 p.m., agency was unable to provide documentation to show that the aforementioned Plan Of Correction had been implemented or that the deficiency had been corrected.
Plan of Correction:After the findings on 04/26/2023 the agency submitted a PA State Criminal Record for PF 6 on 04/26/2023 @ 09:29 a.m. and has been completed on 05/05/2023 @ 09:02 a.m.
611.54(a)(4) LICENSURE
Provisional Hiring
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The home care agency or home care registry may not assign or refer the provisionally hired applicant until that person has met the requirements of § 611.55 (relating to competency requirements).
Observations:
Based on review of agency Plan Of Correction, direct care worker (DCW) personnel files (PF) and staff (EMP) interview, the agency failed to ensure that the provisionally hired applicant met the competency requirements prior to assignment to a consumer for one (1) of four (4) DCW active personnel files reviewed (PF11).
Findings included:
Review of agency plan of correction approved on 2/06/2023 revealed, "Based on findings of the State Licensure Survey completed 12/21/2022, Compassionate Homemakers, LLC has added as an addition to our provisional hiring process reference located in its agency policies and procedure manuals, has since then obtained competency requirements for all but not limited to PF1, PF8 through PF14, and will continue to show competency requirements are met prior to providing services to a consumer. In addition to correcting these deficiencies, the agency will continue to monitor its PF files and CF files to their entirety, to ensure proper quality management and remain compliant with State regulations and guidelines."
A review of DCW Personnel files was conducted on 4/26/2023 between 9:30 a.m. and 11:00 a.m.
PF11 was hired on 10/31/2022 and did not contain documentation to show that a Initial Competency was evaluated prior to assignment to a consumer.
This deficiency was originally cited a a result of a State Licensure Survey completed 8/11/2022. Agency submitted a Plan of Correction with a corrective action date of 8/19/2022, which was approved on 8/26/2022. This same deficiency was cited again during a Follow-UP Survey completed 12/21/2022. Agency submitted another Plan Of Correction with a corrective action date of 12/21/2023, which was approved on 2/06/2023. Based on review o DCW personnel files ad an interview with agency Administrator on 4/26/2023 at approximately 2:00 p.m., agency was unable to provide documentation to show that the aforementioned Plan Of Correction had been implemented or that the deficiency had been corrected.
Plan of Correction:After the finding on 04/26/2023 PF11 has completed the competency requirements on 04/27/2023.
The following employees have been terminated PF1-PF8, PF9-PF10, and PF12-PF14.
611.56(a) LICENSURE
Health Screening
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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 review of agency Plan Of Correction, direct care worker (DCW) personnel files (PF) and staff (EMP) interview, the agency failed to ensure screenings for mycobacterium tuberculosis (TB) were conducted in accordance with CDC guidelines for one (1) of four (4) DCW active personnel files reviewed PF1.
Findings included:
Review of agency Plan Of Correction approved on 2/06/2023 revealed, "Compassionate Homemakers, LLC has since the findings of the State Licensure Survey completed on 12/21/2022 submitted results for the screening in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in Healthcare settings for the following individuals PF1 through PF3, and PF8 through PF14. All individuals must report to the designated facility for a scheduled blood draw referred to as T-Spot and have been completed on 1/18/2023. In addition to correcting these deficiencies, the agency will continue to monitor its PF files and CF files to their entirety, to ensure proper quality management and remain compliant with State regulations and guidelines."
According to the CDC Guidelines for preventing the 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. "The CDC guidelines state that all Health Care Workers (HCW) should receive 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...HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease...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."
A review of DCW Personnel files was conducted on 4/26/2023 between 9:30 a.m. and 11:00 a.m.
PF1 was hired on 4/01/2022 and did not contain evidence to show that a baseline TB test was completed.
This deficiency was originally cited a a result of a State Licensure Survey completed 8/11/2022. Agency submitted a Plan of Correction with a corrective action date of 8/19/2022, which was approved on 8/26/2022. This same deficiency was cited again during a Follow-UP Survey completed 12/21/2022. Agency submitted another Plan Of Correction with a corrective action date of 12/21/2023, which was approved on 2/06/2023. Based on review o DCW personnel files ad an interview with agency Administrator on 4/26/2023 at approximately 2:00 p.m., agency was unable to provide documentation to show that the aforementioned Plan Of Correction had been implemented or that the deficiency had been corrected.
Plan of Correction:After the findings on 04/26/2023, the agency obtained TB Screening for PF1 on 04/26/2023. First step completed on 04/28/2023. Second step and or retake scheduled for 05/19/2023 at 11:00 a.m.
The agency will continue to monitor PF1 status. Once the results have been received,the agency director or supervisor will sign off as completed.
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