QA Investigation Results

Pennsylvania Department of Health
COMPASSIONATE HOMEMAKERS, LLC
Health Inspection Results
COMPASSIONATE HOMEMAKERS, LLC
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite follow-up survey completed 12/21/2022, Compassionate Homemakers, LLC had corrected only one (1) 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. Three (3) deficiencies remain uncorrected and continued to be deficient at the conclusion of this follow-up survey. The deficiencies were cited as a result of a State Licensure Survey completed 8/11/2022.





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 review of agency Plan of Correction, direct care worker (DCW) personnel files (PF) and staff (EMP) interview, The agency failed to obtain two satisfactory references prior to hiring direct care workers for eleven (11) of eleven (11) DCW personnel files reviewed (PF1 - PF3, PF6 & PF8 - PF14).

Findings included:

Review of agency plan of correction approved on 9/08/2022 revealed, "In addition to obtained references (PF1 - PF7 on 8/19/2022) moving forward the agency will alter its personal policies affective 08/2022... HR will continue to monitor the implementation plan of corrections."

A review of DCW personnel files was conducted on 12/21/2022 between 9:30 a.m. and 12:00 p.m.

PF1 was hired on 4/01/2022 and did not contain evidence to show that any references were obtained.

PF2 was hired on 12/20/2021 and did not contain evidence to show that any references were obtained.

PF3 was hired on 4/08/2022 and did not contain evidence to show that any references were obtained.

PF6 was hired on 1/29/2022 and did not contain evidence to show that any references were obtained.

PF8 was hired on 10/02/2022 and contained one reference dated 11/29/2022 (late, not prior to hire date). PF did not contain any documentation to show that the 2nd reference was obtained.

PF9 was hired on 9/06/2022 and contained one reference dated 11/29/2022 (late, not prior to hire date). PF did not contain any documentation to show that the 2nd reference was obtained.

PF10 was hired on 10/14/2022 and contained one reference dated 11/29/2022 (late, not prior to hire date). PF did not contain any documentation to show that the 2nd reference was obtained.

PF11 was hired on 10/31/2022 and did not contain evidence to show that any references were obtained.

PF12 was hired on 10/18/2022 and did not contain evidence to show that any references were obtained.

PF13 was hired on 10/26/2022 and did not contain evidence to show that any references were obtained.

PF14 was hired on 10/27/2022 and did not contain evidence to show that any references were 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. Based on review of DCW personnel files and an interview with agency Administrator on 12/21/2022 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:

An approved Plan of Correction is not on file.


611.52(a) LICENSURE
Criminal Background Checks

Name - Component - 00
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 eleven (11) of eleven (11) DCW personnel files reviewed (PF1 - PF3, PF6 & PF8 - PF14).

Findings included:

Review of agency plan of correction approved on 9/08/2022 revealed, "In addition to
obtaining the Pennsylvania State Police Criminal Record Check... (PF1 - PF6 on 8/19/2022) ... HR will monitor and ensure all new hire documentation has been completed before the employee is placed with (consumer)."

A review of DCW personnel files was conducted on 12/21/2022 between 9:30 a.m. and 12:00 p.m.

PF1 was hired on 4/01/2022 and did not contain documentation to show that a Pennsylvania State Police Criminal Record Check was obtained.

PF2 was hired on 12/20/2021 and did not contain documentation to show that a Pennsylvania State Police Criminal Record Check was obtained.

PF3 was hired on 4/08/2022 and did not contain documentation to show that a Pennsylvania State Police Criminal Record Check was obtained.

PF6 was hired on 1/29/2022 and did not contain documentation to show that a Pennsylvania State Police Criminal Record Check was obtained.

PF8 was hired on 10/02/2022 and did not contain documentation to show that a Pennsylvania State Police Criminal Record Check was obtained.

PF9 was hired on 9/06/2022 and did not contain documentation to show that a Pennsylvania State Police Criminal Record Check was obtained.

PF10 was hired on 10/14/2022 and did not contain documentation to show that a Pennsylvania State Police Criminal Record Check was obtained.

PF11 was hired on 10/31/2022 and did not contain documentation to show that a Pennsylvania State Police Criminal Record Check was obtained.

PF12 was hired on 10/18/2022 and did not contain documentation to show that a Pennsylvania State Police Criminal Record Check was obtained.

PF13 was hired on 10/26/2022 and did not contain documentation to show that a Pennsylvania State Police Criminal Record Check was obtained.

PF14 was hired on 10/27/2022 and did not contain documentation to show that a Pennsylvania State Police Criminal Record Check 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. Based on review of DCW personnel files and an interview with agency Administrator on 12/21/2022 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:

An approved Plan of Correction is not on file.


611.54(a)(4) LICENSURE
Provisional Hiring

Name - Component - 00
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 seven (7) of eight (8) DCW personnel files reviewed (PF1,PF8, PF9 & PF11 - PF14).

Findings included:

Review of agency plan of correction approved on 8/26/2022 revealed, "In addition to obtaining the Competency Requirements... (PF1, PF4 & PF5 on 8/19/2022) moving forward... Hr will monitor sign off and ensure all new hire documentation has been completed before... employee is placed with a (consumer)."

A review of DCW personnel files was conducted on 12/21/2022 between 9:30 a.m. and 12:00 p.m.

PF1 was hired provisionally and began providing services to consumers on 4/01/2022. PF did not contain evidence to show competency requirement was met prior to providing services to a consumer.

PF8 was hired provisionally and began providing services to consumers on 10/02/2022. PF did not contain evidence to show competency requirement was met prior to providing services to a consumer.

PF9 was hired provisionally and began providing services to consumers on 9/06/2022. PF did not contain evidence to show competency requirement was met prior to providing services to a consumer.

PF11 was hired provisionally and began providing services to consumers on 10/31/2022.
PF did not contain evidence to show competency requirement was met prior to providing services to a consumer.

PF12 was hired provisionally and began providing services to consumers on 10/18/2022. PF did not contain evidence to show competency requirement was met prior to providing services to a consumer.

PF13 was hired provisionally and began providing services to consumers on 10/26/2022. PF did not contain evidence to show competency requirement was met prior to providing services to a consumer.

PF14 was hired provisionally and began providing services to consumers on 10/27/2022. PF did not contain evidence to show competency requirement was met prior to providing services to a consumer.

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 8/26/2022. Based on review of DCW personnel files and an interview with agency Administrator on 12/21/2022 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:

OBSERVATIONS # 0504

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 were 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.


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 review of agency Plan of Correction, Centers for Disease Control and Preventive guidelines (CDC), 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 ten (10) of eleven (11) direct care worker personnel files reviewed (PF1 - PF3 & PF8 - PF14).

Findings included:

Review of agency plan of correction approved on 8/26/2022 revealed, "In addition to obtaining the Two-step TB test (PF1 - PF7), moving forward the agency will develop a Two-step process upon hiring. Agency will refer all new hires to quest diagnostics lab to obtain blood analysis (T-spot) testing. HR will make sure documentation is monitored, sign off and documented before service coordinator places new hire with (consumer)."

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 12/21/2022 between 9:30 a.m. and 12:00 p.m.

PF1 was hired on 4/01/2022. PF did not contain evidence to show that a baseline TB test was initiated or completed.

PF2 was hired on 12/20/2021. PF contained documentation of a two-step TB test that was completed in the previous 12 months while PF was employed elsewhere. There was no documentation to prove that the required second-step was initiated or completed in the new setting.

PF3 was hired on 4/08/2022. PF did not contain evidence to show that a baseline TB test was initiated or completed.

PF8 was hired on 10/02/2022. PF contained documentation of a one-step TB test that was completed in the previous 12 months while PF was employed elsewhere. There was no documentation to prove that the required second-step was initiated or completed in the new setting.

PF9 was hired on 9/06/2022. PF contained documentation of a one-step TB test that was completed 8/15/2022. There was no documentation to prove that the required second-step was initiated or completed.

PF10 was hired on 10/14/2022. PF did not contain evidence to show that a baseline TB test was initiated or completed.

PF11 was hired on 10/31/2022. PF did not contain evidence to show that a baseline TB test was initiated or completed.

PF12 was hired on 10/18/2022. PF did not contain evidence to show that a baseline TB test was initiated or completed.

PF13 was hired on 10/26/2022. PF did not contain evidence to show that a baseline TB test was initiated or completed.

PF14 was hired on 10/27/2022. PF did not contain evidence to show that a baseline TB test was initiated or completed.

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 8/26/2022. Based on review of DCW personnel files and an interview with agency Administrator on 12/21/2022 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:

OBSERVATIONS #: 0701

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 micro bacterium 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 TB 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.