Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on December 20, 2023, Amity Home Care Services, was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on December 20, 2023, Amity Home Care Services, 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 review of personnel files (PF) and interview with agency administrator and compliance manager, it was determined the agency failed to ensure that two (2) verifiable references were obtained prior to hiring each direct care worker for four (4) of ten (10) files reviewed. (PF# 3, 7-9)
Review of personnel files (PF) conducted on 12/20/23 from 1:50 PM-3:05 PM revealed the following:
PF # 3, Date of hire (DOH): 7/29/23; had no documentation of verifiable references being verified.
PF # 7, Date of hire (DOH): 12/5/23; had documentation of only one (1) reference being verified.
PF # 8, Date of hire (DOH): 11/1/23; had no documentation of verifiable references being verified.
PF # 9, Date of hire (DOH): 11/1/23; had documentation of only one (1) reference being verified.
An interview with the agency administrator and compliance manager conducted on December 20, 2023 at approximately 3:40 PM confirmed the above findings.
Plan of Correction:1. Personnel Files missing Documentation of Verified References.
POC Response:
Within 10 days of POC approval, the Administrator will ensure that Amity Home Care Services (the "Agency") revises its Background Check Policy to provide that reference checks for new direct care workers may be obtained from individuals other than a former employer, provided that the reference checks affirm the ability of the individual to provide home care services.
Within 10 days of POC approval, the Administrator will train the HR Manager on the revised Background Check Policy.
Within 30 days of POC approval, the Administrator will obtain sufficient verifiable references for the personnel files of PF # 3, PF # 7, PF # 8 and PF # 9.
Within 60 days of POC approval, the Administrator will conduct an audit of all existing personnel files to identify files missing sufficient verifiable references and ensure that sufficient verifiable references are obtained.
For the next year, the Administrator will conduct quarterly audits of personnel files to confirm that sufficient reference documentation is in place.
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 review of personnel files (PF) and interview with agency administrator and compliance manager, it was determined the agency failed to ensure that direct care workers had a screening for mycobacterium tuberculosis and testing upon hire in ten (10) of ten (10) files reviewed. (PFs # 1-# 10)
Findings included:
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) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screen annually. HCWs with a baseline 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.
Review of Next Move Family Homecare, LLC Tuberculosis Screening Company Policy on 12/20/23 at approximately 1:00 PM revealed: Purpose: " Next Move Family Homecare, LLC has established and maintains a policy to comply with regulations pertaining to current and new office staff, .....and employees regarding Tuberculosis testing and pre-hire (TB) screening. " Policy: " All Next Move Family Homecare, LLC employees ....who have direct patient contact and ....will be tested for active tuberculosis utilizing a two-step process in accordance with Centers for Disease Control (CDC) guidelines prior to patient contact and screened annually thereafter .... " ; " This agency requires all staff .....to be tested for TB prior to patient contact ....and additionally screened in accordance with directives from the Centers for Disease Control and Prevention of the United States Department of Health and Human Services May 16, 2019 updated guidelines. "
Review of personnel files (PF) conducted on 12/20/23 from 1:50 PM-3:05 PM revealed the following:
PF # 1, Date of hire (DOH): 11/4/22; the file did not contain documentation that TB risk assessment or screening was completed upon hire.
PF # 2, Date of hire (DOH): 12/29/22; the file did not contain documentation that TB risk assessment or screening was completed upon hire.
PF # 3, Date of hire (DOH): 7/29/23; the file did not contain documentation that TB risk assessment or testing was completed upon hire. Documentation of one (1) step testing dated 7/25/23.
PF # 4,Date of hire (DOH): 8/12/23; the file did not contain documentation that TB risk assessment or screening was completed upon hire.
PF # 5,Date of hire (DOH): 8/17/23; the file did not contain documentation that TB risk assessment or screening was completed upon hire.
PF # 6,Date of hire (DOH): 9/1/23; the file did not contain documentation that TB risk assessment or screening was completed upon hire.
PF # 7, Date of hire (DOH): 12/5/23; the file did not contain documentation that TB risk assessment or screening was completed upon hire.
PF # 8, Date of hire (DOH): 11/1/23; the file did not contain documentation that TB risk assessment or screening was completed upon hire.
PF # 9, Date of hire (DOH): 11/1/23; the file did not contain documentation that TB risk assessment or screening was completed upon hire.
PF # 10, Date of Hire( DOH): 11/10/23; the file did not contain documentation that TB risk assessment or screening was completed upon hire.
An interview with the agency administrator and compliance manager conducted on December 20, 2023 at approximately 3:40 PM confirmed the above findings.
Plan of Correction:2. Personnel Files missing Tuberculosis Screening Documentation.
POC Response:
i. Within 30 days of POC approval, the Administrator will ensure that the personnel files PF # 1 through PF # 10 have sufficient documentation showing a negative two-step TST or negative first-step TST with proof of a negative TB screening within the prior 12 months.
Within 10 days of POC approval, the Administrator will train the HR Manager on the need to obtain documentation prior to hiring any employee who could have direct contact with consumers of a negative two-step TST or a negative first-step TST with proof of a negative TB screening within the last 12 months.
Within 60 days of POC approval, the Administrator will conduct an audit of all existing personnel files to identify files missing sufficient TB screening documentation and ensure it is obtained and the related employees take the necessary tests.
For the next year, the Administrator will conduct quarterly audits of personnel files to confirm that proper TB screening documentation is in place.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on December 20, 2023, Amity Home Care Services, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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