QA Investigation Results

Pennsylvania Department of Health
AIDING ANGELS HOME CARE, LLC
Health Inspection Results
AIDING ANGELS HOME CARE, LLC
Health Inspection Results For:

This is the only survey for this facility

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of a State relicensure survey initiated onsite January 11, 2024 and completed offsite January 29, 2024, Aiding Angels Home Care, Llc was found not to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Subpart A, Chapter 51.





























Plan of Correction:




51.3 (a) LICENSURE
NOTIFICATION

Name - Component - 00
51.3 Notification

(a) A health care facility shall
notify the Department in writing at
least 60 days prior to the intended
commencement of a health care service
which has not been previously provided
at that facility.

Observations:


Based on review of Department records, surveyor observation, and staff (EMP) interview, the agency failed to maintain standards required by State authorities, specifically, the agency failed to be subject to an unannounced inspection by authorized representatives of the Department during agency set office hours and failed to notify the Department in writing at least 60 days prior to the intended commencement of a health care service which has not been previously provided at that facility.

Per 35 P.S. 448.813, "...Authorization.--For the purpose of determining the suitability of the applicants and of the premises or for determining the adequacy of the care and treatment provided or the continuing conformity of the licensees to this act and to applicable local, State and Federal regulations, any authorized agent of the department may enter, visit and inspect the building, grounds, equipment and supplies of any health care facility licensed or requiring a license under this act and shall have full and free access to the records of the facility and to the patients and employees therein and their records, and shall have full opportunity to interview, inspect, and examine such patients and employees..."

Findings include:

A review of Department records on 1/9/24 at approximately 1:30 p.m. to 2:30 p.m. in preparation for an onsite State relicensure survey to be conducted on 1/11/24 found agency current office hours listed as 8:00 a.m. to 4:00 p.m. as listed by agency owner via email on 11/9/22. Also provided in the email of 11/9/22 contact number: (412) 851-3455. Also provided in that email was Administrator contact number (412) 506-2842. Surveyor had reached out to Administrator on 10/10/23, 10/24/23, 11/27/23 and 12/4/23, 12/29/23. 1/8/24, 1/10/24 to confirm address, phone number and business hours for the agency. On 1/10/24 Administrator returned a call with hours of operation Monday-Friday 8:00 a.m. to 5:00 p.m. and relays that the address is 406 Russellwood Avenue, McKees Rocks, PA. In the system, address is listed as 24 Furnace Street Extension McKees Rocks, PA.

On 1/11/24, Surveyors onsite at 24 Furnace St Extension McKees Rocks, PA as listed in this system. At 9:28 a.m. Surveyor called to speak with Administrator at phone number 412-851-3455. Went to voicemail. Called second number 412-506-2843. Went to voicemail. Left message to return call. At 9:45 a.m. surveyors entered building and inquired with receptionist the location for office for Abiding Angels Home Care. Receptionist stated, "She moved out of here May of 2023." Surveyors drove to second location listed in this system. 406 Russellwood Ave McKees Rocks, PA. In residential area. No signage for agency noted. Surveyor knocked on the door. No answer. Surveyors left at 10:00 a.m. At approximately 11:19 a.m. Administrator left voicemail. Surveyor returned call to Administrator, "I have been very busy. I am not able to meet with you today. I wished I knew you were coming." Surveyor listed multiple attempts of efforts by surveyor to get in touch with her. "I am just so busy."






Plan of Correction:

In relation to your review by the Department records, surveyor observation, and staff (EMP) interview the agency Aiding Angels will keep updated records of office locations and hours of agency sent to the Departement of Health and any other relevant organizations that require this information. We will make sure that staff are prompt and available during these hours. We will work to hire office responsible parties who can participate and assist and state authorities in conducting inspections.

2. We plan to monitor this performance by implementing organizational changes updating policies and procedures. Assigning office task to resposible parties and makings sure those task are being carried out accurately.



3. Date effective 3/29/24


The agency will keep office hours/location records updated in order for the patient to always have updated locations/office information. In case, there were any reason for patient to vist office location during hours.




Initial Comments:


Based on the findings of a State relicensure survey initiated onsite January 11, 2024 and completed offsite January 29, 2024, Aiding Angels Home 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:




611.4(c) LICENSURE
Requirements for HCA and HCR

Name - Component - 00
Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.

Observations:


Based on review of Department records, surveyor observation, and staff (EMP) interview, the agency failed to maintain standards required by State authorities, specifically, the agency failed to be subject to an unannounced inspection by authorized representatives of the Department during agency set office hours.

Per 35 P.S. 448.813, "...Authorization.--For the purpose of determining the suitability of the applicants and of the premises or for determining the adequacy of the care and treatment provided or the continuing conformity of the licensees to this act and to applicable local, State and Federal regulations, any authorized agent of the department may enter, visit and inspect the building, grounds, equipment and supplies of any health care facility licensed or requiring a license under this act and shall have full and free access to the records of the facility and to the patients and employees therein and their records, and shall have full opportunity to interview, inspect, and examine such patients and employees..."

Findings include:

A review of Department records on 1/9/24 at approximately 1:30 p.m. to 2:30 p.m. in preparation for an onsite State relicensure survey to be conducted on 1/11/24 found agency current office hours listed as 8:00 a.m. to 4:00 p.m. as listed by agency owner via email on 11/9/22. Also provided in the email of 11/9/22 contact number: (412) 851-3455. Also provided in that email was Administrator contact number (412) 506-2842. Surveyor had reached out to Administrator on 10/10/23, 10/24/23, 11/27/23 and 12/4/23, 12/29/23. 1/8/24, 1/10/24 to confirm address, phone number and business hours for the agency. On 1/10/24 Administrator returned a call with hours of operation Monday-Friday 8:00 a.m. to 5:00 p.m. and relayed that the address: 406 Russellwood Avenue, McKees Rocks, PA. as listed was incorrect. Address given during call: 24 Furnace Street Extension McKees Rocks, PA.

On 1/11/24, Surveyors attempted onsite visit at address provided 24 Furnace St Extension McKees Rocks, PA as listed in this system. At 9:28 a.m. Surveyor called to speak with Administrator at phone number 412-851-3455. Went to voicemail. Called second number 412-506-2843. Went to voicemail. Left message to return call. At 9:45 a.m. surveyors entered building and inquired with receptionist the location for office for Abiding Angels Home Care. Receptionist stated, "She moved out of here May of 2023." Surveyors drove to second location listed in this system. 406 Russellwood Ave McKees Rocks, PA. In residential area. No signage for agency noted. Surveyor knocked on the door. No answer. Surveyors left at 10:00 a.m. At approximately 11:19 a.m. Administrator left voicemail. Surveyor returned call to Administrator, "I have been very busy. I am not able to meet with you today. I wished I knew you were coming." Surveyor listed multiple attempts of efforts by surveyor to get in touch with her. "I am just so busy."


























Plan of Correction:

In relation to your review by the Department records, surveyor observation, and staff (EMP) interview the agency Aiding Angels will keep updated records of office locations and hours of agency sent to the Departement of Health and any other relevant organizations that require this information. We will make sure that staff are prompt and available during these hours. We will work to hire office responsible parties who can participate and assist and state authorities in conducting inspections.
2. We plan to monitor this performance by implementing organizational changes updating policies and procedures. Assigning office task to resposible parties and makings sure those task are being carried out accurately. We will make sure the hours office locations are update for patient purposes in case anty office visits are needed on daily basis


3. Date effective 3/29/24


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 personnel files (PF), review of employee handbook and interview with agency staff (EMP), the agency failed to provide accurate information to DCW personnel and the agency failed to conduct a face to face interview with the individual prior to hiring or rostering DCW for seven (7) of seven (7) DCW personnel files reviewed (PF1- PF7) and/or failed to obtain no less than two satisfactory references prior to hiring or rostering direct care workers (DCW) for seven (7) of seven (7) DCW personnel files reviewed (PF1- PF7).

Findings include:

Review of agency employee handbook on 1/19/24 at approximately 3:00 p.m. revealed: pages 18, 28, 29, 30 and 32 include the name of another home care agency that is not associated with this agency. Page 18 lists "Michigan State Police-Michigan Criminal History Record." Page 43 lists "The Participates Care Management is funded through...the state Older Michigan Act..." "Michigan Department of Community Health Medicaid funded Home and Community Based Medicaid Waiver Program for the Elderly and Disabled
(MI Choice). "

Personnel file (PF) reviews conducted on 1/19/24 between approximately 3:00 p.m. and 3:10 p.m. and on 1/25/24 between approximately 1:15 p.m. and 2:00 p.m. revealed:

PF1, date of hire 7/18/22. Start of care 7/18/22. There was no documented evidence of a face to face interview being conducted and no documented evidence of at least two satisfactory references completed.

PF2, date of hire 11/29/22. Start of care 11/29/22. There was no documented evidence of a face to face interview being conducted and no documented evidence of at least two satisfactory references completed.

PF3, date of hire 6/6/22. Start of care 6/6/22. There was no documented evidence of a face to face interview being conducted and no documented evidence of at least two satisfactory references completed.

PF4, date of hire 10/24/22. Start of care 10/24/22. There was no documented evidence of a face to face interview being conducted and no documented evidence of at least two satisfactory references completed.

PF5, date of hire 3/23/23. Start of care 3/23/23. There was no documented evidence of a face to face interview being conducted and no documented evidence of at least two satisfactory references completed.

PF6, date of hire 6/5/23. Start of care 6/5/23. There was no documented evidence of a face to face interview being conducted and no documented evidence of at least two satisfactory references completed.

PF7, date of hire 11/9/23. Start of care 11/9/23. There was no documented evidence of a face to face interview being conducted and no documented evidence of at least two satisfactory references completed.

Email regarding survey exit was sent to Administrator on 1/29/24 at approximately 3:58 p.m.







































































































































































































Plan of Correction:

In accordance with state regulations we will ensure to maintain proper documentation for face to face interviews for any new hires and to obtain no less than two satisfactory references prior to hiring or rostering direct care workers also maintain current records appropiately for personnel files that pertain to individuals for (PF1-PF7)

2. We will update/maintain policies and procedures

3. Also ensure that face to face interviews are being conducted by internal audits and analysis.

We will make sure that we are conducting face to face interviews and to obtain no less than two satisfactory references prior to hiring or rostering direct care workers also screening any potential employee for patient safety and employee/employer integrity and best practices.

Responsible personnel will conduct face to face interview and obtain no less than 2 satisfactory references prior to hiring.

We will monitor the progress by internal audits and best practices record keeping so the decifient practice foes not recur.



Date effective 3/29/24


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 personnel files (PF) and interview with agnecy staff (EMP) it was determined the agency failed to obtain criminal history records at time of application or a report obtained within 1 year immediately preceding date of application for six (6) of seven (7) direct care worker personnel files reviewed. (PF1, PF3, PF4, PF5, PF6, PF7).

Findings include:

Personnel file (PF) reviews conducted on 1/19/24 between approximately 3:00 p.m. and 3:10 p.m. and on 1/25/24 between approximately 1:15 p.m. and 2:00 p.m. revealed:
PF1, date of hire 7/18/22. Start of care 7/18/22. PF1 contained a Pennsylvania State Police Criminal Record Check final report dated 7/23/22.

PF3, date of hire 6/6/22. Start of care 6/6/22. PF3 contained a Pennsylvania State Police Criminal Record Check final report dated 6/7/22.

PF4, date of hire 10/24/22. Start of care 10/24/22. PF4 contained a Pennsylvania State Police Criminal Record Check final report dated 10/25/22.

PF5, date of hire 3/23/23. Start of care 3/23/23. PF5 contained a Pennsylvania State Police Criminal Record Check with no documented evidence of a final report.

PF6, date of hire 6/5/23. Start of care 6/5/23. PF6 contained no documented evidence of a Pennsylvania State Police Criminal Record Check.

PF7, date of hire 11/9/23. Start of care 11/9/23. PF7 contained no documented evidence of a Pennsylvania State Police Criminal Record Check.

Email regarding survey exit was sent to Administrator on 1/29/24 at approximately 3:58 p.m.

















































Plan of Correction:

n accordance with state regulations 611.52 we will ensure to maintain proper documentation for criminal backgrounc checks and ensure that criminal backgorund checks are being conducted at the time of application or a report obtained within 1 year preceding date of application. We will continue to maintain proper documenation of personnel files for (PF1 PF3-PF7)


2. We will update/maintain policies and procedures

3. Also ensure that criminal background checks are being conducted at the time of application or a report obtained within 1 year by internal audits and analysis. This task to conduct background reports will be assigned to responsible parties and we will check to see if this task is being done timely and accurately

Criminal background checks will be ran as part of hiring integrity and also to maintain best practices for patient safety.

4. Date effective 3/29/24


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 interview with agency staff (EMP), the agency failed to verify proof of residency in Pennsylvania for 2 years prior to date of hire for six (6) of seven (7) direct care worker (DCW) personnel files reviewed (PF1, PF2, PF3, PF4 PF5, PF7).

Findings include:

Personnel file (PF) reviews conducted on 1/19/24 between approximately 3:00 p.m. and 3:10 p.m. and on 1/25/24 between approximately 1:15 p.m. and 2:00 p.m. revealed:
PF1, date of hire 7/18/22. Start of care 7/18/22. PF contained no documented evidence to verify proof of PA residency for the two years immediately preceding the date of hire. PF contained PA identification card dated 12/1/21.
PF2, date of hire 11/29/22. Start of care 11/29/22. PF contained no documented evidence to verify proof of PA residency for the two years immediately preceding the date of hire. PF contained PA driver's license dated 8/25/21.
PF3, date of hire 6/6/22. Start of care 6/6/22. PF contained no documented evidence to verify proof of PA residency for the two years immediately preceding the date of hire.
PF4, date of hire 10/24/22. Start of care 10/24/22. PF contained no documented evidence to verify proof of PA residency for the two years immediately preceding the date of hire. PF contained PA driver's license dated 9/1/21.
PF5, date of hire 3/23/23. Start of care 3/23/23. PF contained no documented evidence to verify proof of PA residency for the two years immediately preceding the date of hire. PF contained PA driver's license dated 5/23/23.
PF7, date of hire 11/9/23. Start of care 11/9/23. PF contained no documented evidence to verify proof of PA residency for the two years immediately preceding the date of hire.
Email regarding survey exit was sent to Administrator on 1/29/24 at approximately 3:58 p.m.










































































Plan of Correction:

In accordance with state regulations 611.52 we will ensure to maintain proper documentation verification of PA state residency and make sure that this information is being recieved a the time of hire for 2 years prior to date of hire. for any new hires and also maintain current records appropiately for personnel files that pertain to individuals for (PF1-PF5 and PF7)

2. We will update/maintain policies and procedures to uphold employer integrity and enusure patient safety

3. Also assign tasks to responsible parties and make sure that tasks are being carried out by having internal audits and analysis.

PA Residency will be reviewed as part of the hiring process per state regulations and employer integtity for best practices keeping in mind patient safety and security.

4. Date effective 3/29/24


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 personnel files (PF), and interview with agency staff (EMP), the agency failed to ensure direct care workers (DCW) met minimum competency requirements prior to assigning DCWs to provide services to a consumer for seven (7) of seven (7) direct care worker personnel files reviewed (PF1-PF7).

Findings include:

Personnel file (PF) reviews conducted on 1/19/24 between approximately 3:00 p.m. and 3:10 p.m. and on 1/25/24 between approximately 1:15 p.m. and 2:00 p.m. revealed:
PF1, date of hire 7/18/22. Start of care 7/18/22. There was no documented evidence of minimum competency requirements being conducted at the time of hire. PF contained PA DHS Adult Residential Licensing Certificate of Completion DCS Training Course and Competency dated 12/2/2020.
PF2, date of hire 11/29/22. Start of care 11/29/22. There was no documented evidence of minimum competency requirements being conducted at the time of hire.
PF3, date of hire 6/6/22. Start of care 6/6/22. There was no documented evidence of minimum competency requirements being conducted at the time of hire.
PF4, date of hire 10/24/22. Start of care 10/24/22. There was no documented evidence of minimum competency requirements being conducted at the time of hire.
PF5, date of hire 3/23/23. Start of care 3/23/23. There was no documented evidence of minimum competency requirements being conducted at the time of hire.
PF6, date of hire 6/5/23. Start of care 6/5/23. There was no documented evidence of minimum competency requirements being conducted at the time of hire.
PF7, date of hire 11/9/23. Start of care 11/9/23. There was no documented evidence of minimum competency requirements being conducted at the time of hire.
Email regarding survey exit was sent to Administrator on 1/29/24 at approximately 3:58 p.m.



























Plan of Correction:

In accordance with state regulations we will ensure to maintain proper documentation for DCS completion for any new hire. We will make sure individuals are completing the DCS training Course and Competencty online and maintaining records. The steps that will be taken will include

1. Implementing organizational changes updated policies/procedures
2. Educate the person assigned to carry out trainings on best practices.
3. Ensuring corrective action through internal auditiing and planned interabl audits for proper record keeping and documentation to ensure task are being carried out accurately.

3. Date effective 3/29/24

4. Also ensure that face to face interviews are being conducted by internal audits and analysis.


We will make organizational changes to our hiring process in order to keep employee/employer integrity and maintain the best practices for patient safety and security.



611.55(e) LICENSURE
Competency Requirements

Name - Component - 00
The competency review must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction.

Observations:


Based on review of personnel files (PF), and interview with agency staff (EMP), the agency failed to review the direct care worker's competency at least once per year for four (1) of seven (7) personnel files of direct care workers (DCW) who have been employed at agency for more than one year (PF1, PF2, PF3, PF4).

Findings include:

Personnel file (PF) reviews conducted on 1/19/24 between approximately 3:00 p.m. and 3:10 p.m. and on 1/25/24 between approximately 1:15 p.m. and 2:00 p.m. revealed:
PF1, date of hire 7/18/22. Start of care 7/18/22. There was no documented evidence of an annual competency review completed in 2023.
PF2, date of hire 11/29/22. Start of care 11/29/22. There was no documented evidence of an annual competency review completed in 2023.
PF3, date of hire 6/6/22. Start of care 6/6/22. There was no documented evidence of an annual competency review completed in 2023.
PF4, date of hire 10/24/22. Start of care 10/24/22. There was no documented evidence of an annual competency review completed in 2023.
Email regarding survey exit was sent to Administrator on 1/29/24 at approximately 3:58 p.m.


































































Plan of Correction:

In accordance with state regulations we will review competnecy fo any worker that has been working for atleast 1 year. We will ensure that (PF1-PF4) who have been at our agency for more than one year are tested for compentency.

1. Implementing organizational changes updated policies/procedures
2. Educate the person assigned to carry out trainings on best practices.
3. Ensuring corrective action through internal auditiing and planned interabl audits for proper record keeping and documentation to ensure task are being carried out accurately.

4. Date effective 3/29/24


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 review of personnel files (PF), interview with agency staff (EMP) and review of CDC Guidelines, the agency failed to ensure each direct care worker, prior to consumer contact, was screened for and free from active mycobacterium tuberculosis for seven (7) of seven (7) direct care worker (DCW) personnel files reviewed (PF1-PF7).

Findings include:

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. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease (CDC Guidelines for Preventing 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).
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).

Personnel file (PF) reviews conducted on 1/19/24 between approximately 3:00 p.m. and 3:10 p.m. and on 1/25/24 between approximately 1:15 p.m. and 2:00 p.m. revealed:
PF1, date of hire 7/18/22. Start of care 7/18/22. No documented evidence of a tuberculosis screening completed. No documented evidence that PF1 completed an individual risk assessment and symptom evaluation prior to hire.
PF2, date of hire 11/29/22. Start of care 11/29/22. No documented evidence of a tuberculosis screening completed. No documented evidence that PF2 completed an individual risk assessment and symptom evaluation prior to hire. PF2 contained a Quantiferon TB Gold form with value negative result with no date or name of the individual tested.
PF3, date of hire 6/6/22. Start of care 6/6/22. No documented evidence of a tuberculosis screening completed. No documented evidence that PF3 completed an individual risk assessment and symptom evaluation prior to hire. PF3 contained a one step PPD plant date 6/1/22, read 6/3/22 with a negative result. PF3 contained a Quantiferon TB Gold form with value negative result with no date or name of the individual tested.
PF4, date of hire 10/24/22. Start of care 10/24/22. No documented evidence of a tuberculosis screening completed. No documented evidence that PF4 completed an individual risk assessment and symptom evaluation prior to hire. PF4 contained a Quantiferon TB Gold form with value negative result with no date or name of the individual tested.
PF5, date of hire 3/23/23. Start of care 3/23/23. No documented evidence of a tuberculosis screening completed. No documented evidence that PF5 completed an individual risk assessment and symptom evaluation prior to hire. PF5 contained a Quantiferon TB Gold form with value negative result with no date or name of the individual tested.
PF6, date of hire 6/5/23. Start of care 6/5/23. No documented evidence of a tuberculosis screening completed. No documented evidence that PF6 completed an individual risk assessment and symptom evaluation prior to hire. PF6 contained a Quantiferon TB Gold form with value negative result with no date or name of the individual tested.
PF7, date of hire 11/9/23. Start of care 11/9/23. No documented evidence of a tuberculosis screening completed. No documented evidence that PF7 completed an individual risk assessment and symptom evaluation prior to hire.
Email regarding survey exit was sent to Administrator on 1/29/24 at approximately 3:58 p.m.




















Plan of Correction:

Per CDC guidlines will we ensure that each DCW is tested for TB are kept in a safe and secured location that only higher level personnel have access to. Also results shown are negative prior to hiring along with risk assessment and symtom evaluation prior to hire. Steps to be taken will include


1. Implementing organizational changes updated policies/procedures
2. Educate the person assigned to carry out these tasks on best practices.
3. Ensuring corrective action through internal auditing and planned internal audits to ensure proper record keeping and documentation to ensure task are being carried out accurately.

4. Date effective 3/29/24

We will make organizational changes to our hiring/screening process in order to keep employee/employer integrity and maintain the best practices for patient safety and security.



611.56(b) LICENSURE
Health Screening

Name - Component - 00
(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.

Observations:


Based on review of personnel files (PFs) and interview with agency staff (EMP) it was determined that the agency failed to ensure each direct care worker with direct consumer contact, were provided with annual mycobacterium tuberculosis education for personnel files of direct care workers (DCW) who have been employed at agency for more than one year for four (4) of seven (7) PFs reviewed (PF1, PF2, PF3, PF4).

Findings include:

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 or newly 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; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.)
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).

Findings include:

Personnel file (PF) reviews conducted on 1/19/24 between approximately 3:00 p.m. and 3:10 p.m. and on 1/25/24 between approximately 1:15 p.m. and 2:00 p.m. revealed:
PF1, date of hire 7/18/22. Start of care 7/18/22. There was no documented evidence of annual mycobacterium tuberculosis education completed in 2023.

PF2, date of hire 11/29/22. Start of care 11/29/22. There was no documented evidence of annual mycobacterium tuberculosis education completed in 2023.

PF3, date of hire 6/6/22. Start of care 6/6/22. There was no documented evidence of annual mycobacterium tuberculosis education completed in 2023.

PF4, date of hire 10/24/22. Start of care 10/24/22. There was no documented evidence of annual mycobacterium tuberculosis education completed in 2023.

Email regarding survey exit was sent to Administrator on 1/29/24 at approximately 3:58 p.m.









Plan of Correction:

Per CDC guidlines will we ensure that each DCW is tested for TB are kept in a safe and secured location that only higher level personnel have access to. Also results shown are negative prior to hiring along with risk assessment and symtom evaluation prior to hire. Screening will include questionaire and will be updated every year-2years. Steps to be taken will include


1. Implementing organizational changes updated policies/procedures
2. Educate the person assigned to carry out these tasks on best practices.
3. Ensuring corrective action through internal auditing and planned internal audits to ensure proper record keeping and documentation to ensure task are being carried out accurately.

4. Date effective 3/29/24


611.57(a) LICENSURE
Consumer Rights

Name - Component - 00
(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

Observations:


Based on review of consumer files (CFs) and interview with agency owner (EMP) it was determined the agency failed to ensure consumers were informed of the right (1) to be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk for two (2) of five (5) consumer files reviewed (CF1, CF5) (2) to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services. Less than 10 days advance written notice may be provided the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in the arrears, or if the health and welfare of the direct care worker is at risk for three (3) of five (5) consumer files reviewed (CF1, CF2, CF5).

Findings include:

Consumer file (CF) reviews conducted on 1/19/24 between approximately 2:30 p.m. and 3:00 p.m. and on 1/25/24 between approximately 2:05 p.m. and 3:00 p.m. revealed:
CF1, start of services 10/10/23. No documented evidence of consumer being informed of the right to be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. No documented evidence of consumer being informed of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services. Less than 10 days advance written notice may be provided the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in the arrears, or if the health and welfare of the direct care worker is at risk.

CF2, start of services 6/12/23. No documented evidence of consumer being informed of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services. Less than 10 days advance written notice may be provided the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in the arrears, or if the health and welfare of the direct care worker is at risk.

CF5, start of services 6/9/22. No documented evidence of consumer being informed of the right to be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. No documented evidence of consumer being informed of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services. Less than 10 days advance written notice may be provided the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in the arrears, or if the health and welfare of the direct care worker is at risk. No consumer file was provided.

Email regarding survey exit was sent to Administrator on 1/29/24 at approximately 3:58 p.m.










































Plan of Correction:

Per state guidlines we will ensure that the consumer reviewed the consumer handbook with the consumer with assistance from staff personnell which informs him or her of the right (1) to be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. Consumer has the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services. Less than 10 days advance written notice may be provided the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in the arrears, or if the health and welfare of the direct care worker is at risk. CF1, CF2, CF5 will also be delivered packet containing this information

These are the steps the agency will take in order to correct this deficiency

1. Implementing organizational changes updated procedures

2. Educate the person assigned to carry out these tasks on best practices.

3. Ensuring corrective action through internal auditing and planned internal audits to ensure proper record keeping and documentation to ensure task are being carried out accurately.

4. Date effective 3/29/24


611.57(b) LICENSURE
Prohibitions

Name - Component - 00
(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

Observations:


Based on review of consumer files (CFs) and interview with agency staff (EMP) the agency failed to inform consumer of rights of (b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry for five (5) of five (5) consumer files reviewed (CF1-CF5). The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry for five (5) of five (5) consumer files reviewed. (CF1-CF5).

Findings include:

Consumer file (CF) reviews conducted on 1/19/24 between approximately 2:30 p.m. and 3:00 p.m. and on 1/25/24 between approximately 2:05 p.m. and 3:00 p.m. revealed:
CF1, start of services 10/10/23. Contained no documented evidence to show that the consumer was provided consumer rights information of no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. Contained no documented evidence the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

CF2, start of services 6/12/23. Contained no documented evidence to show that the consumer was provided consumer rights information of no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. Contained no documented evidence the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

CF3, start of services 12/29/22. Contained no documented evidence to show that the consumer was provided consumer rights information of no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. Contained no documented evidence the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

CF4, start of services 12/16/22. Contained no documented evidence to show that the consumer was provided consumer rights information of no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. Contained no documented evidence the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

CF5, start of services 6/9/22. Contained no documented evidence to show that the consumer was provided consumer rights information of no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. Contained no documented evidence the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry. No consumer file was provided.

Email regarding survey exit was sent to Administrator on 1/29/24 at approximately 3:58 p.m.






























































































Plan of Correction:

Per state guidlines we will ensure that the consumer reviewed the consumer handbook with the consumer with assistance from staff personnell which informs consumer of (b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry per state regulations. In addition The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry. This information will be given to any new consumer at the time of application and delivered to consumers (CF1-CF5)


These are the steps the agency will take in order to correct this deficiency

1. Implementing organizational changes updated procedures

2. Educate the person assigned to carry out these tasks on best practices.

3. Ensuring corrective action through internal auditing and planned internal audits to ensure proper record keeping and documentation to ensure task are being carried out accurately.

4. Date effective 3/29/24


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), review of consumer information packet and interview with agency staff (EMP) the agency failed to provide, prior to the commencement of services, the following information in a form that was easily read and understood in the consumer information packet:
(1) The list of available home care services that will be provided to the consumer by the direct care worker for two (2) of five (5) consumer files reviewed (CF1, CF5) and the identity of the direct care worker who will provide the services for five (5) of five (5) consumer files reviewed (CF1-CF5).
(2) The hours when those services will be provided for two (2) of five (5) consumer files reviewed (CF1, CF5).
(3) Fees and total costs for those services on an hourly or weekly basis for two (2) of five (5) consumer files reviewed (CF1, CF5).
(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 for five (5) of five (5) consumer files reviewed (CF1-CF5).
(5) The Department's complaint Hot Line (1-800-254-5164) for five (5) of five (5) consumer files reviewed (CF1- CF5) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) for five (5) of five (5) consumer files reviewed (CF1-CF5).
(6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry for five (5) of five (5) consumer files reviewed (CF1-CF5).
(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 for five (5) of five (5) consumer files reviewed (CF1-CF5).

Findings include:

Consumer file (CF) reviews conducted on 1/19/24 between approximately 2:30 p.m. and 3:00 p.m. and on 1/25/24 between approximately 2:05 p.m. and 3:00 p.m. revealed:

CF1, Start of services 10/10/23. Contained no documented evidence of (1) The list of 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.

CF2, start of services 6/12/23. Contained no documented evidence of (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.

CF3, start of services 12/29/22. Contained no documented evidence of (1) the identity of the direct care worker who will provide the services. (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.

CF4, start of services 12/16/22. Contained no documented evidence of (1) the identity of the direct care worker who will provide the services. (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.


CF5, start of services 6/9/22. Contained no documented evidence of (1) The list of 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. No consumer file was provided.

Email regarding survey exit was sent to Administrator on 1/29/24 at approximately 3:58 p.m.









































































Plan of Correction:

Per guidelines we will review the consumer information with consumer with an agency staff member thoroughly at the time of the initial interview with consumer. Including (1) The list of available home care services that will be provided to the consumer by the direct care worker for two (2) of five (5) consumer files reviewed (CF1, CF5) 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) 6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry7) 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 to all consumers and will be signed and kept in records.
1. Implementing organizational changes updated policies/procedures
2. Educate the person assigned to carry out trainings on best practices.
3. Ensuring corrective action through internal auditing and planned internal audits for proper record keeping and documentation to ensure task are being carried out accurately.
4. Date effective 3/29/24
This information will me reviewed with consumers for educational and reference purposes surrounding their services.



Initial Comments:


Based on the findings of a State relicensure survey initiated onsite January 11, 2024 and completed offsite January 29, 2024, Aiding Angels Home Care, Llc was found not to be in compliance with the requirements of 35 P.S 448.809 b.












Plan of Correction:




35 P. S. § 448.809b LICENSURE
Photo Id Reg

Name - Component - 00
Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.


(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.



Observations:


Based on email response from Administrator at surveyor request to send ID badge to surveyor as part of offsite relicensure survey, it was determined that the agency failed to ensure staff had a photo identification (ID) badge that contained the employee's name, the employee's title, and the name of the health care facility or employment agency in accordance with regulatory guidelines.

Findings include:

On 1/19/24, at 12:52 p.m, surveyor received email from Administrator, "We do not provide agency badges, I was unaware that this was a requirement for agencies to provide ID badges for caregivers."





















Plan of Correction:

Badges will be given to any newly hired caregivers and also delivered to DCW which will include the employee's name, the employee's title, and the name of the health care facility or employment agency in accordance with regulatory guidelines.

1. We will ensure that badges are assigned upon hiring as part of hiring process.


2. A responsible person will be assigned to carry out this task.


3. We will keep records as badges are assigned and as caregiver are hired/terminated.


4. Date effective 3/29/24