Initial Comments:
Based on the findings of an unannounced onsite state licensure complaint survey completed November 9, 2022, Amazing Souls 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:
611.51(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 employee files (EF) and an interview with the agency Administrator, the agency failed to obtain not less than two satisfactory references and failed to ensure an interview was conducted for four (4) out of four (4) employee files (EF) reviewed (EF#1-EF#4).
Findings include:
A review of EFs was conducted on November 9, 2022 at approximately 10:00 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 10/17/2022: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable) nor of an interview prior to hire. Per the agency Administrator on 11/09/22 at approximately 11:30 a.m., "I cannot provide you with the employee file. I do not have this person's employee file here at the agency."
EF#2 DOH 10/18/2022: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable) nor of an interview prior to hire. Documentation provided of an undated interview being conducted.
EF#3 DOH 10/01/2022: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable) nor of an interview prior to hire. Documentation provided of an undated interview being conducted.
EF#4 DOH 10/04/2022: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable) nor of an interview prior to hire. Per the agency Administrator on 11/09/22 at approximately 11:30 a.m., "I cannot provide you with the employee file. I do not have this person's employee file here at the agency."
An interview conducted with agency Administrator on November 9, 2021 at approximately 12:30 p.m. confirmed the above findings.
*Repeat Deficiency.
Plan of Correction:For EF#1 DOH 10/17/2022, EF#2 DOH 10/18/22, EF#3 10/01/2022 and EF#4 DOH 10/04/2022.
1. We are going to obtain at least 2 references from previous employers or non-relatives which must be positively verifiable and keep them on the employees' files.
2. The Agency Director will conduct an audit of all employee files immediately to make sure that no other individuals have been affected by the same deficient practice.
3. The Head of Human Resources will create an employee checklist that will help track all errors and rectify them right away.
4. The Agency Director will audit 50% of employee files every 4 months to monitor that the deficiency practice does not recur.
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 employee files (EF) and an interview with the agency Administrator, the agency failed to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application for two (2) out of four (4) employee files (EF) reviewed (EF#3, EF#4).
Findings include:
A review of EFs was conducted on November 9, 2022 at approximately 10:00 a.m. Employee date of hire (DOH) is listed below.
EF#3 DOH 10/01/2022: No documentation provided of criminal history report being obtained at the time of application or within 1 year (365 days) immediately preceding the date of application.
EF#4 DOH 10/04/2022: No documentation provided of criminal history report being obtained at the time of application or within 1 year (365 days) immediately preceding the date of application. Per the agency Administrator on 11/09/22 at approximately 11:30 a.m., "I cannot provide you with the employee file. I do not have this person's employee file here at the agency."
An interview conducted with agency Administrator on November 9, 2021 at approximately 12:30 p.m. confirmed the above findings.
Plan of Correction:For EF# 3 DOH 10/01/2022 and EF#4 DOH 10/04/2022:
1. The Agency Director will conduct a criminal background check of the employees and update the employees' files to include the employees' current address, actual start dates and end dates of prior employment history.
2. The Head of Human Resources will audit all employee files to make sure that no other employee's file has similar deficiencies.
3. The Agency Director will create an employee's background criminal checklist that will help keep track of all employees' criminal history to avoid similar deficiencies.
4. The Agency Director will audit 50% of employee files every 6 months to monitor that the deficiency practice does not recur.
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 employee files (EF) and an interview with the agency Administrator, agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for three (3) out of four (4) employee files (EF) reviewed (EF#1, EF#3, EF#4).
Findings include:
A review of EFs was conducted on November 9, 2022 at approximately 10:00 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 10/17/2022: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Per the agency Administrator on 11/09/22 at approximately 11:30 a.m., "I cannot provide you with the employee file. I do not have this person's employee file here at the agency."
No proof of Pa. residency from 10/17/20-10/17/22.
EF#3 DOH 10/01/2022: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Identification Card issued 09/25/18 with an expiration date of 05/31/22. 'Employment Application' record was reviewed. 'Employment History' section blank with no entries.
No proof of Pa. residency from 05/31/22-10/01/22.
EF#4 DOH 10/04/2022: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Per the agency Administrator on 11/09/22 at approximately 11:30 a.m., "I cannot provide you with the employee file. I do not have this person's employee file here at the agency."
No proof of Pa. residency from 10/04/20-10/04/22.
An interview conducted with agency Administrator on November 9, 2021 at approximately 12:30 p.m. confirmed the above findings.
*Repeat Deficiency.
Plan of Correction:EF#1 DOH 10/17/2022, EF#3 DOH 10/01/2022 and EF#4 DOH 10/04/2022:
1. The Agency Director will obtain proof of PA Residency 2 years prior to hire date and criminal background check or conduct a federal criminal background check of the employee and obtain a letter of determination from the department of aging. We will update the employee file to include the employees' current address.
2. The Head of Human Resources will audit all employee files to make sure that no other employee's file has similar deficiencies.
3. The Agency Director will create an employee's background criminal checklist that will help keep track of all employees' criminal history to avoid similar deficiencies.
4. The Agency Director will audit 50% of employee files every 6 months to monitor that the deficiency practice does not recur.
611.55(a) LICENSURE
Compentency 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 employee files (EF) and an interview with the agency Administrator, the agency failed to ensure direct care workers, prior to providing services to consumers, completed/demonstrated an initial competency training covering all required sixteen (16) subject areas for two (2) of four (4) employee files (EF) reviewed (EF#1, EF#4).
Findings include:
A review of EFs was conducted on November 9, 2022 at approximately 10:00 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 10/17/2022: No documentation provided of initial competency training covering all required sixteen (16) subject areas prior to hire. Per the agency Administrator on 11/09/22 at approximately 11:30 a.m., "I cannot provide you with the employee file. I do not have this person's employee file here at the agency."
EF#4 DOH 10/04/2022: No documentation provided of initial competency training covering all required sixteen (16) subject areas prior to hire. Per the agency Administrator on 11/09/22 at approximately 11:30 a.m., "I cannot provide you with the employee file. I do not have this person's employee file here at the agency."
An interview conducted with agency Administrator on November 9, 2021 at approximately 12:30 p.m. confirmed the above findings.
Plan of Correction:For EF#1 DOH 10/17/2022 and EF#4 DOH 10/04/2022:
1. The Agency Director will ensure that the referenced employees obtain competency training that contains all (16) required areas listed in Chapter611.55 Competency.
2. The Agency Director will audit all employee health files to make sure that no other individuals have been affected by the same deficient practice.
3. The Agency Director will create an employees' initial competency training checklist that will help keep track of all employee's competency to avoid similar deficiencies.
4. The Agency Director will audit 50% of employee files every 6 months to monitor that the deficiency practice does not recur.
611.56(a) LICENSURE
Health Screening
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(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 employee files (EF) and an interview with the agency Administrator, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, was screened for and is free from active mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for two (2) out of four (4) EFs reviewed (EF#1, EF#4).
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, HCWs should receive TB screening annually. 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).
A review of EFs was conducted on November 9, 2022 at approximately 10:00 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 10/17/2022: No documentation provided of a symptom screen questionnaire nor an individual TB risk assessment upon hire. Per the agency Administrator on 11/09/22 at approximately 11:30 a.m., "I cannot provide you with the employee file. I do not have this person's employee file here at the agency."
EF#4 DOH 10/04/2022: No documentation provided of a symptom screen questionnaire nor an individual TB risk assessment upon hire. Per the agency Administrator on 11/09/22 at approximately 11:30 a.m., "I cannot provide you with the employee file. I do not have this person's employee file here at the agency."
An interview conducted with agency Administrator on November 9, 2021 at approximately 12:30 p.m. confirmed the above findings.
*Repeat Deficiency.
Plan of Correction:For EF#1 DOH 10/17/2022 and EF#4 DOH 10/04/2022:
1. The Agency Director will provide a TB symptom screening questionnaire and an individual TB risk assessment to the above referenced applicants. The results will be documented.
2. The Agency Director will audit all employee health files to make sure that no other individuals have been affected by the same deficient practice.
3. The Agency Director will create an employees' TB checklist that will help keep track of all employees' TB history to avoid similar deficiencies.
4. The Agency Director will audit 50% of employee files every 6 months to monitor that the deficiency practice does not recur.
611.57(a) LICENSURE
Consumer Rights
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(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 a review of consumer files and an interview with the agency Administrator, agency failed to ensure services were provided as agreed upon for one (1) of two (2) consumer files (CF) reviewed (CF#1).
Findings include:
A reviews of consumer files was conducted on November 9, 2022 at approximately 10:45 a.m. Consumer start of service (SOS) is listed below.
CF#1, SOS 10/04/2022: Documentation provided of this consumer being serviced under a waiver program. The service dates of 10/04/2022-10/31/2022 lists 'Hours per authorized period' "672". 'Notes' section states "..... total weekly hours = "168." (24 hours per day, 7 days per week).
Per the agency Administrator on 11/09/22 at approximately 11:30 a.m., the agency provides care to the consumer twenty-four (24) hours per day, seven (7) days per week.
No documentation provided of any back-up/alternate plan in place.
A review of EFs was conducted on November 9, 2022 at approximately 10:00 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 10/17/22: Documentation of 'Worker Weekly Visit Timesheet' for the week 10/10/22 - 10/16/22 was not provided. Per the Administrator, the time sheet is not here at the agency.
EF#2 DOH 10/18/22: Documentation of 'Worker Weekly Visit Timesheets' for the week 10/10/22 - 10/16/22 revealed eight (8) hours with CF#1. The agency 'Worker Weekly Visit Timesheet' was not utilized by EF#2. EF#2 wrote her time on a piece of paper with the dates and time of the shifts that were completed. 'Personal Care Tasks', 'Toilet/Elimination Tasks', Mobility Tasks', 'Precautions', 'and 'Other Tasks' (as stated on the consumer 'Service Plan') were not recorded.
EF#3 DOH 10/1/22: Documentation of 'Worker Weekly Visit Timesheet' for the week 10/10/22 - 10/16/22 revealed fifty-six (56) hours with CF#1.
EF#4 DOH 10/04/22: Documentation of 'Worker Weekly Visit Timesheet' for the week 10/10/22 - 10/16/22 revealed sixty-four (64) hours with CF#1.
According to documentation, '128 hours/168 hours' were provided for the week 10/10/22 - 10/16/22.
For the week of 10/10/22 - 10/16/22, no documentation of 'one hundred - sixty eight (168) hours' being provided as agreed upon nor could all agreed upon tasks (specified in the consumer Service Plan) be verified as being completed.
An interview conducted with agency Administrator on November 9, 2021 at approximately 12:30 p.m. confirmed the above findings.
Plan of Correction:For CF#1 SOS 10/04/2022 and CF#1 SOS 10/07/2022:
1. The Agency Director will update the consumer admission packet to include the backup plan/alternate coverage for the services being provided. We will also obtain documentation/timesheets of the provided services and keep them on consumers' files.
2. The Agency Director will audit all consumer files to make sure that no other consumers have been affected by the same deficient practice.
3. The Agency Director will create consumers' checklist that will help keep track of all consumers files to avoid similar deficiencies.
4. The Agency Director will audit 50% of consumer files every 6 months to monitor that the deficiency practice does not recur.
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 consumer files, the consumer admission packet, and an interview with the agency Administrator, the agency failed to provide the consumer, prior to the commencement of services, the hiring and competency requirements applicable to direct care workers and/or 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 Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) for two (2) out of four (4) consumer files (CF) reviewed (CF#1, CF#2).
Findings include:
A reviews of consumer files was conducted on November 9, 2022 at approximately 10:45 a.m. Consumer start of service (SOS) is listed below.
CF#1 SOS 10/07/22: No documentation provided of the agency providing the consumer, prior to the commencement of services, the hiring and competency requirements applicable to direct care workers.
CF#2 SOS 07/25/22: No documentation provided of the agency providing the consumer, prior to the commencement of services, the hiring and competency requirements applicable to direct care workers and/or 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 Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
An interview conducted with agency Administrator on November 9, 2021 at approximately 12:30 p.m. confirmed the above findings.
*Repeat Deficiency.
Plan of Correction:For CF#1 SOS 10/07/2022 and CF#2 SOS 07/25/2022:
1. The Agency Director will update the consumer admission packet to include the hiring competency requirements applicable to the direct care workers and the contact information of the licensure requirements 717 783 1379. We will also include in the consumer admission packet the phone number of the local area/county ombudsman 610 782 3034 and the complaint hotline number 1 – 800 - 254 – 5164.
2. The Agency Director will audit all consumer files to make sure that no other consumers have been affected by the same deficient practice.
3. The Agency Director will create consumers' checklist that will help keep track of all consumers files to avoid similar deficiencies.
4. The Agency Director will audit 50% of consumer files every 6 months to monitor that the deficiency practice does not recur.
611.57(d) LICENSURE
Documentation
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(d) The home care agency or home care registry shall maintain documentation on file at the agency or registry of compliance with the requirements of this section which shall be available for Department inspection.
Observations:
Based on a request of employee files to review and an interview with the agency Administrator, the agency failed to maintain documentation on file at the agency or registry of compliance with the regulatory requirements for two (2) of two (2) employee files (EF) requested (EF#1, EF#4).
Findings include:
Employee files were requested for review on November 9, 2022 at approximately 10:00 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 10/17/22: Employee file was requested for review. The agency could not locate the employee file. Per the agency Administrator on 11/09/22 at approximately 11:30 a.m., "I cannot provide you with the employee file. I do not have this person's employee file here at the agency."
EF#4 DOH 10/04/22: Employee file was requested for review. The agency could not locate the employee file. Per the agency Administrator on 11/09/22 at approximately 11:30 a.m., "I cannot provide you with the employee file. I do not have this person's employee file here at the agency."
An interview conducted with agency Administrator on November 9, 2021 at approximately 12:30 p.m. confirmed the above findings.
Plan of Correction:For EF#1 DOH 10/17/2022 and EF#4 DOH 10/04/2022:
1. The agency Director will locate the employees' files and securely lock them up in the file cabinet.
2. The Agency Director will audit all employee files to make sure that no other employees have been affected by the same deficient practice.
3. The Agency Director will create employees' checklist that will help keep track of all employee files to avoid similar deficiencies.
4. The Agency Director will audit 50% of consumer files every 6 months to monitor that the deficiency practice does not recur.
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