Initial Comments:
An offsite follow-up survey completed on February 23, 2024 found that Compassionate Home Care Services, Inc. had not corrected the deficiencies cited under the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries.
The deficiencies were cited as a result of a state re-licensure survey completed on December 28, 2023.
Plan of Correction:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
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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 the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure the Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice and the Administrator will train the HR assistant to use the new employee onboarding checklist, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 02/23/2024 at approximately 8:30 a.m., approved by the Department on 01/19/2024, revealed the following:
"....... 2. The Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice. 3. The Administrator will train the HR assistant to use the new employee onboarding checklist to ensure the deficient practice does not recur."
Corrective action date: 01/28/2024.
Documentation review #1: Documentation was requested via email on 02/12/24. No response from the agency. Documentation requested a second time via email on 02/16/24. Agency responded via email on 02/18/24 stating "........ Here is part of the documents requested. I will continue to upload the rest." Documentation was requested a third time on 02/20/24. No response from the agency.
No documentation provided of stated "The Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice and the Administrator will train the HR assistant to use the new employee onboarding checklist."
Email correspondence on February 23, 2024 at approximately 9:45 a.m. with the agency Administrator confirmed the above findings.
Plan of Correction:1. The Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice.
2. The Administrator will train the HR assistant to use the new employee onboarding checklist to ensure the deficient practice does not recur.
3. This corrective plan of action will be completed by April 8, 2024.
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 a review of the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure the Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice and the Administrator will train the HR assistant to use the new employee onboarding checklist, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 02/23/2024 at approximately 8:30 a.m., approved by the Department on 01/19/2024, revealed the following:
" ...... 2. The Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice. 3. The Administrator will train the HR assistant to use the new employee onboarding checklist to ensure the deficient practice does not recur."
Corrective action date: 01/28/2024.
Documentation review #1: Documentation was requested via email on 02/12/24. No response from the agency. Documentation requested a second time via email on 02/16/24. Agency responded via email on 02/18/24 stating "........ Here is part of the documents requested. I will continue to upload the rest." Documentation was requested a third time on 02/20/24. No response from the agency.
No documentation provided of stated "The Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice and the Administrator will train the HR assistant to use the new employee onboarding checklist."
Email correspondence on February 23, 2024 at approximately 9:45 a.m. with the agency Administrator confirmed the above findings.
Plan of Correction:1. The Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice.
2. The Administrator will train the HR assistant to use the new employee onboarding checklist to ensure the deficient practice does not recur.
3. The Administrator or designee shall review every new employee file before they are assigned for orientation in addition to auditing 10% of every employee files quarterly.
611.52(c) LICENSURE
Federal Criminal History Record
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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 the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure the Administrator or designee shall request the stated employees in deficiency statement will need Dept of Aging criminal checks conducted and a paid receipt/pending appt will be needed, the Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice, and the Administrator will train the HR assistant to use the new employee onboarding checklist to ensure the deficient practice does not recur,
as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 02/23/2024 at approximately 8:30 a.m., approved by the Department on 01/26/2024, revealed the following:
"1. The Administrator or designee shall request the stated employees in deficiency statement will need Dept of Aging criminal checks conducted and a paid receipt/pending appt will be needed..
2. The Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice.
3. The Administrator will train the HR assistant to use the new employee onboarding checklist to ensure the deficient practice does not recur."
Corrective action date: 02/05/2024.
Documentation review #1: Documentation was requested via email on 02/12/24. No response from the agency. Documentation requested a second time via email on 02/16/24. Agency responded via email on 02/18/24 stating "........ Here is part of the documents requested. I will continue to upload the rest." Documentation was requested a third time on 02/20/24. No response from the agency.
No documentation provided of stated "The Administrator or designee shall request the stated employees in deficiency statement will need Dept of Aging criminal checks conducted and a paid receipt/pending appt will be needed, the Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice, and the Administrator will train the HR assistant to use the new employee onboarding checklist.
Email correspondence on February 23, 2024 at approximately 9:45 a.m. with the agency Administrator confirmed the above findings.
Plan of Correction:1. The Administrator or designee shall request the stated employees in deficiency statement will need Dept of Aging criminal checks conducted and a paid receipt/pending appt will be needed.
2. The Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice.
3. The Administrator will train the HR assistant to use the new employee onboarding checklist to ensure the deficient practice does not recur.
4. This corrective plan of action will be completed by April 8, 2024.
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 plan of correction and email correspondence with the agency Administrator, the agency failed to ensure the Administrator will revise the competency test to include the following missing required subjects: Hair Care, ......, Shaving, Toileting; in addition to ensuring that stated employees must complete revised required initial competencies, the Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice, and the Administrator will train the HR assistant to use the new employee onboarding checklist,
for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 02/23/2024 at approximately 8:30 a.m., approved by the Department on 01/26/2024, revealed the following:
"1. The Administrator will revise the competency test to include the following missing required subjects: Hair Care, Mouth Care, Shaving, Toileting; in addition to ensuring that stated employees must complete revised required initial competencies
2. The Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice.
3. The Administrator will train the HR assistant to use the new employee onboarding checklist to ensure the deficient practice does not recur."
Corrective action date: 02/05/2024.
Documentation review #1: Documentation was requested via email on 02/12/24. No response from the agency. Documentation requested a second time via email on 02/16/24. Agency responded via email on 02/18/24 stating "........ Here is part of the documents requested. I will continue to upload the rest." Documentation was requested a third time on 02/20/24. No response from the agency.
No documentation provided of stated "The Administrator will revise the competency test to include the following missing required subjects: Hair Care, ..... Shaving, Toileting; in addition to ensuring that stated employees must complete revised required initial competencies, the Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice, and the Administrator will train the HR assistant to use the new employee onboarding checklist."
Email correspondence on February 23, 2024 at approximately 9:45 a.m. with the agency Administrator confirmed the above findings.
Plan of Correction:1. The Administrator will revise the competency test to include the following missing required subjects: Hair Care, Mouth Care, Shaving, Toileting; in addition to ensuring that stated employees must complete revised required initial competencies
2. The Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice.
3. The Administrator will train the HR assistant to use the new employee onboarding checklist to ensure the deficient practice does not recur.
4. This corrective plan of action will be completed by April 8, 2024.
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 the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure the Administrator or designee shall ensure that stated employees must complete the stated missing tasks as well as request documentation of a TB test, an individual TB risk assessment, a TB symptom screen ......,
the Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice, and the Administrator will train the HR assistant to use the new employee onboarding checklist, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 02/23/2024 at approximately 8:30 a.m., approved by the Department on 01/26/2024, revealed the following
"1.The Administrator or designee shall ensure that stated employees must complete the stated missing tasks as well as request documentation of a TB test, an individual TB risk assessment, a TB symptom screen prior to sending an offer of acceptance to be hired.
2. The Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice.
3. The Administrator will train the HR assistant to use the new employee onboarding checklist to ensure the deficient practice does not recur."
Corrective action date: 02/05/2024.
Documentation review #1: Documentation was requested via email on 02/12/24. No response from the agency. Documentation requested a second time via email on 02/16/24. Agency responded via email on 02/18/24 stating "........ Here is part of the documents requested. I will continue to upload the rest." Documentation was requested a third time on 02/20/24. No response from the agency.
No documentation provided of stated "The Administrator or designee shall ensure that stated employees must complete the stated missing tasks as well as request documentation of a TB test, an individual TB risk assessment, a TB symptom screen ......, the Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice, and the Administrator will train the HR assistant to use the new employee onboarding checklist."
Email correspondence on February 23, 2024 at approximately 9:45 a.m. with the agency Administrator confirmed the above findings.
Plan of Correction:1.The Administrator or designee shall ensure that stated employees must complete the stated missing tasks as well as request documentation of a TB test, an individual TB risk assessment, a TB symptom screen.
2. The Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice.
3. The Administrator will train the HR assistant to use the new employee onboarding checklist to ensure the deficient practice does not recur.
4. This corrective plan of action will be completed by April 8, 2024.
611.57(c) LICENSURE
Information to be Provided
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(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 a review of the agency plan of correction and email correspondence with the agency Administrator, the agency failed to ensure the Administrator or designee shall provide the stated consumers with updated and revised required material of who to contact at the Department (717-783-1379) 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, the Department's complaint Hotline (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) the hiring and competency requirements, the Administrator will conduct an audit of the entire client files to identify and ensure no other clients have been affected by the same deficient practice, and the Administrator or designee will use the new client onboarding checklist, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 02/23/2024 at approximately 8:30 a.m., approved by the Department on 01/26/2024, revealed the following:
"1. The Administrator or designee shall provide the stated consumers with updated and revised required material of who to contact at the Department (717-783-1379) 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, the Department's complaint Hotline (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) the hiring and competency requirements
2. The Administrator will conduct an audit of the entire client files to identify and ensure no other clients have been affected by the same deficient practice.
3. The Administrator or designee will use the new client onboarding checklist to ensure the deficient practice does not recur."
Corrective action date: 02/05/2024.
Documentation review #1: Documentation was requested via email on 02/12/24. No response from the agency. Documentation requested a second time via email on 02/16/24. Agency responded via email on 02/18/24 stating "........ Here is part of the documents requested. I will continue to upload the rest." Documentation was requested a third time on 02/20/24. No response from the agency.
No documentation provided of stated "The Administrator or designee shall provide the stated consumers with updated and revised required material of who to contact at the Department (717-783-1379) 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, the Department's complaint Hotline (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) the hiring and competency requirements, the Administrator will conduct an audit of the entire client files to identify and ensure no other clients have been affected by the same deficient practice, and the Administrator or designee will use the new client onboarding checklist."
Email correspondence on February 23, 2024 at approximately 9:45 a.m. with the agency Administrator confirmed the above findings.
Plan of Correction:The Administrator or designee shall provide the stated consumers with updated and revised required material of who to contact at the Department (717-783-1379) 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, the Department's complaint HotLine (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) the hiring and competency requirements
The Administrator will conduct an audit of the entire client files to identify and ensure no other clients have been affected by the same deficient practice.
3. The Administrator or designee will use the new client onboarding checklist to ensure the deficient practice does not recur.
4. This corrective plan of action will be completed by April 8, 2024.
Initial Comments:
An offsite follow up survey completed on February 23, 2024 found that Compassionate Home Care Services, Inc. corrected the deficiency cited under the requirements of 35 P.S. 448.809 (b).
The deficiency was cited as a result of a state re-licensure survey completed on December 28, 2023.
Plan of Correction:
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