Initial Comments:
Based on the findings of an onsite state re-licensure survey completed 1/18/2024, Carla's Caring Heart LLC was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite state re-licensure survey completed 1/18/2024, Carla's Caring Heart LLC was found not to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.
Plan of Correction:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
Name - Component - 00
Prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. (3) Require the individual to submit a criminal history report, in accordance with the requirements of § 611.52 (relating to criminal background checks), and a ChildLine verification, if applicable, in accordance with the requirements of § 611.53 (relating to child abuse clearance).
Observations:
Based on a review of personnel files (PF) and employee interviews (EMP), the agency failed to maintain documentation of Direct Care Worker (DCW) face-to-face interviews and at least two verifiable references for six (6) of seven (7) DCW files reviewed (PFs 1-3 and 5-7).
Findings include:
A personnel file review conducted on 1/17/24 between 1:30 pm to 4:00 pm found:
PF1: Date of Hire (DOH): 8/29/23, Start of Service (SOS): 8/29/23. Agency file did not contain documentation of a face-to-face interview and at least two verifiable references.
PF2: DOH: 8/16/23, SOS: 8/16/23. Agency file did not contain documentation of a face-to-face interview.
PF3: DOH: 11/8/23, SOS: 11/8/23. Agency file did not contain documentation of a face-to-face interview and at least two verifiable references.
PF5: DOH: 5/12/23, SOS: 5/12/23. Agency file did not contain documentation of a face-to-face interview.
PF6: DOH: 4/23/23, SOS: 4/23/23. Agency file did not contain documentation of a face-to-face interview and at least two verifiable references.
PF7: DOH: 7/14/23, SOS: 7/14/23. Agency file did not contain documentation of a face-to-face interview and at least two verifiable references.
During an interview with EMP1, administrator, on 1/17/24 at approximately 1:30 pm it was determined that face-to-face interviews were conducted at the time of hire but documentation was not maintained in employee files.
The findings were reviewed with EMP1, administrator, on 1/17/24 at approximately 4:00 pm.
Plan of Correction:PF1: No longer employed with agency.
PF2: Face-to-Face interview dated and filed, and two verifiable references completed via telephone.
PF3: No longer employed with agency.
PF5: Face-to-face interviewed dated and filed, two verifiable reference checks completed via telephone and filed.
PF6: Face-to-face interviewed filed and dated. Two verifiable reference check was conducted via telephone and filed.
PF7: Face-to-face interviewed dated and filed, two verifiable references conducted via telephone and filed.
(Owner) will implement, and monitor to sustain the following:
A new system was created for All face-to-face interviews with assuring all are interviews are properly dated and will be placed all DCW files.
A new system was created for making sure All DCW for Carla's Caring Heart provide (2) verifiable references. All references will be checked via telephone/text or letter by mail and filed in all DCW files.
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 a review of personnel files (PF) and employee interviews (EMP) the agency failed to maintain copies of criminal background checks obtained at the time of hire for seven (7) of seven (7) personnel files reviewed (PFs 1-7).
Findings include:
A personnel file review conducted onsite on 1/17/24 between approximately 1:30 pm to 4:00 pm found:
PF1: Date of Hire (DOH): 8/29/23, Start of Service (SOS): 8/29/23. Agency file did not contain a criminal background check.
PF2: DOH: 8/16/23, SOS: 8/16/23. Agency file did not contain a criminal background check.
PF3: DOH: 11/8/23, SOS: 11/8/23. Agency file did not contain a criminal background check.
PF4: DOH: 6/13/23, SOS: 6/13/23. Agency file did not contain a criminal background check.
PF5: DOH: 5/12/23, SOS: 5/12/23. Agency file did not contain a criminal background check.
PF6: DOH: 4/23/23, SOS: 4/23/23. Agency file did not contain a criminal background check.
PF7: DOH: 7/14/23, SOS: 7/14/23. Agency file did not contain a criminal background check.
During an interview conducted at approximately 1:30 pm on 1/17/24 EMP1, administrator, verified that criminal background checks were reviewed but copies were not kept in employee files at the agency.
Plan of Correction:PF1: No longer employed.
PF2: Criminal background completed, in file.
PF3: No longer employed.
PF4: Criminal background been completed in file.
PF5: Criminal background completed in file.
PF6: Criminal background completed in file, waiting on results. Provisional given, until records come back.
PF7: Criminal background completed in file.
(Owner)
will implement/monitor the following:
All DCW that are hired, will need to have a PA State criminal/child baseline clearance (if consumer is under 18 years of age)/if not living in PA for 2 years an FBI clearance will be needed. Provisional hiring will be put in place will be monitored until clearances are back. All will be place in DCW worker file.
All DCW/PA clearances will be conducted thru PA state police batch.
All DCW living in PA under two years will be conducted in Homestead, PA for FBI clearance.
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 a review of personnel files (PF) and employee interviews (EMP), the agency failed to maintain copies of employee ' s proof of two-year Pennsylvania residency for seven (7) of seven (7) personnel files reviewed (PFs 1-7).
Findings include:
A personnel file review conducted on 1/17/24 between approximately 1:30 pm to 4:00 pm found:
PF1: Date of Hire (DOH): 8/29/23, Start of Service (SOS): 8/29/23. Agency file did not contain documents providing proof of Pennsylvania residency two years prior to date of hire.
PF2: DOH: 8/16/23, SOS: 8/16/23. Agency file did not contain documents providing proof of PA residency two years prior to date of hire.
PF3: DOH: 11/8/23, SOS: 11/8/23. Agency file contained a Pennsylvania Driver ' s License (PADL) with an issue date of 11/02/23. Less than two years prior to the date of hire.
PF4: DOH: 6/13/23, SOS: 6/13/23. Agency file did not contain documents providing proof of PA residency two years prior to date of hire.
PF5: DOH: 5/12/23, SOS: 5/12/23. Agency file did not contain documents providing proof of PA residency two years prior to date of hire. PADL with an issue date of 9/30/21 (less than two years prior to date of hire).
PF6: DOH: 4/23/23, SOS: 4/23/23. Agency file did not contain documents providing proof of PA residency two years prior to date of hire. PADL with an issue date of 3/2/23 (less than two years prior to the date of hire).
PF7: DOH: 7/14/23, SOS: 7/14/23. Agency file did not contain documents providing proof of PA residency two years prior to date of hire. PADL with an issue date of 9/8/22 (less than two years prior to the date of hire).
The onsite personnel file review findings were reviewed with EMP1, administrator, on 1/17/24 at approximately 4:00 pm.
Plan of Correction:PF1: No longer employed with agency.
PF2: Copy of PA D/L in file, verify on date three years old, being a PA resident.
PF3: No longer employed with agency.
PF4: Copy of D/L in file, verified last 10 years of being a PA resident.
PF5: Copy of PA S/ID, verified PA resident for two years from rental lease.
PF6: Copy of PA D/L and information to verified in PA for over two years.
PF7: Copy of PA D/L in file, and old
cna license for in PA over two years.
(Owner)will implement and maintain the following to ensure proper filing for all DCW are in place.
IF state ID is not within two years of hire date, the following information will need to be provided to the following to assure they have lived in PA for two or more years:
copy of tax records, lease, rent or mortgage, utilities. If none can be provided DCW will be required to have a FBI clearance/provisional hired will be in place. All information will be filed in DCW file.
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 a review of personnel files (PF) and employee interviews (EMP), the agency failed to maintain documentation in agency files of Direct Care Worker (DCW) competency through examination or certification for five (5) of seven (7) DCW files reviewed (PFs 1,3 and 5-7).
Findings include:
During an interview on 1/17/24 at approximately 3:00 pm EMP1, administrator, stated that PFs 5, 6, and 7 were Certified Nursing Assistants (CNA) but proof of licensure was not maintained in agency files.
A review of personnel files conducted on 1/17/24 between approximately 1:30 pm and 4:00 pm found:
PF1: Date of Hire (DOH): 8/29/23, Start of Service (SOS): 8/29/23. Agency file did not contain documentation of DCW competency examination.
PF3: DOH: 11/8/23, SOS: 11/8/23. Agency file contained ungraded, incomplete test dated 11/15/23, seven days after the start of service date.
PF5: DOH: 5/12/23, SOS: 5/12/23. Agency file did not contain documentation of a completed DCW competency examination or CNA certification.
PF6: DOH: 4/23/23, SOS: 4/23/23. Agency file did not contain documentation of a completed DCW competency examination or CNA certification.
PF7: DOH: 7/14/23, SOS: 7/14/23. Agency file did not contain documentation of a completed DCW competency examination. Proof of current CNA certification with an original issue date of 6-11-99.
The finding was reviewed with EMP1, administrator, on 1/17/24 at approximately 4:00 pm.
Plan of Correction:PF1: No longer employed with agency.
PF3: No longer employed with agency.
PF5: State Competency test completed 01/22/2024 in file.
PF6: State Competency test completed 01/22/2024 in file.
PF7: Updated CNA license on file.
(Owner)
(Office Manager)
will implement and conduct the following to maintain with all DCW if they do not have an update PA cna license files.
Competency Testing done annually, along with annually training on:
Bathing, Shaving, grooming and dressing.
Dealing/understanding behaviors of consumer.
Hair, Skin and mouth care.
Basic infection control.
Confidentiality
Documentation
Instrumental activities for daily living.
Recognizing needs of the consumer that needs addressed.
Recognizing and reporting abuse.
Universal precautions.
Meal prep/feeding
Toileting.
Assistant with self-administrating medications.
All new hire/annual DCW will be required to take testing and training. All will be placed in DCW files.
611.56(a) LICENSURE
Health Screening
Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.
Observations:
Based on a personnel file review (PF), CDC guidelines, and employee interviews (EMP), the agency failed to obtain required preemployment tuberculosis health screening documentation for employees with consumer contact for six (6) of seven (7) personnel files reviewed (PFs 1-3 and 5-7).
Findings include:
CDC guidelines state, " all health care personnel should be screened for (mycobacterium tuberculosis) TB upon hire (i.e., preplacement). TB screening is a process that includes: A baseline individual TB risk assessment , TB symptom evaluation, a TB test (e.g., TB blood test or a TB skin test), and additional evaluation for TB disease as needed ... " (TB Screening and Testing of Health Care Personnel, Updated August 30, 2022). (www.cdc.gov/tb/topic/testing/healthcareworkers.htm)
A personnel file review conducted on 1/17/24 between approximately 1:30 pm and 4:00 pm found:
PF1: Date of Hire (DOH): 8/29/23, Start of Service (SOS): 8/29/23. Agency file did not contain documentation of CDC recommended TB health screening.
PF2: DOH: 8/16/23, SOS: 8/16/23. Agency file did not contain documentation of CDC recommended TB health screening.
PF3: DOH: 11/8/23, SOS: 11/8/23. Agency file did not contain documentation of CDC recommended TB health screening.
PF5: DOH: 5/12/23, SOS: 5/12/23. Agency file did not contain documentation of CDC recommended TB health screening.
PF6: DOH: 4/23/23, SOS: 4/23/23. Agency file did not contain documentation of CDC recommended TB health screening.
PF7: DOH: 7/14/23, SOS: 7/14/23. Agency file did not contain documentation of CDC recommended TB health screening.
The finding was reviewed with EMP1, administrator, on 1/17/24 at approximately 4:00 pm.
Plan of Correction:PF1: No longer employed with agency.
PF2: All paperwork given for a two-step TB testing/Xray and questionnaire.
PF3: No longer employed with agency.
PF5: TB test paperwork submitted was not accepted. TB/Xray paperwork given to have medical personnel fill out.
PF6: Tb two-step test/Xray paperwork given and questionnaire.
PF7: TB two-step TB/Xray given with questionnaire.
(Owner) will implement and maintain following:
All DCW will be required to have an Annually TB/Xray updated. If DCW does not have an updated TB, DCW will be required to have a 2-step TB test completed upon hiring. DCW will also be provided with a questionnaire for their PCP to fill out, along with information/reading material on Tuberculosis will be provided to DCW.
All will be filed in DCW files.
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 a review of consumer records (CR), agency documentation, and employee interviews (EMP), the agency failed to provide consumers with an information packet listing: (1) Who to contact at the Department for information about licensure requirements for a home care agency/registry (2) The department's complaint hotline and telephone number of the ombudsman program with the local Area Agency on Aging (3) the hiring and competency requirements applicable to direct care workers and (4) a Consumer Notice of Direct Care Worker status for five (5) of five (5) CRs reviewed CRs 1 - 5.
Findings Include:
Agency document titled Caregiver Agreement was reviewed on 1/17/24 at approximately 12:00 pm and did not contain the following information: the Department of Health ' s complaint hotline, the licensure department ' s contact information, the telephone number of the ombudsman program with the local Area Agency on Aging, the hiring and competency requirements applicable to direct care workers, or the Consumer Notice of Direct Care Worker (DCW) status.
An interview on 1/17/24 at approximately 12:00 pm with EMP1, Administrator, verified that the Caregiver Agreement and a sheet listing the names of the DCW and services to be provided were the only documentation provided to the consumer at the start of service.
An onsite CR review performed on 1/17/24 between approximately 12:00 pm and 1:30 pm revealed:
CR1: Start of Service (SOS): 11/23/23. CR contained an agency document titled Service Contract signed on 11/23/23. The information packet did not contain: 1. contact information for the Department of Health complaint hotline, local ombudsman, or licensure department 2. information related to the agency ' s hiring and competency requirements for Direct Care Workers 3. A Consumer Notice of DCW status.
CR2: SOS: 9/20/23. CR contained an agency document titled Service Contract signed on 9/20/23. The information packet did not contain: 1. contact information for the Department of Health complaint hotline, local ombudsman, or licensure department 2. information related to the agency ' s hiring and competency requirements for Direct Care Workers 3. A Consumer Notice of DCW status.
CR3: SOS: 9/11/23. CR contained an agency document titled Service Contract signed on 9/11/23. The information packet did not contain: 1. contact information for the Department of Health complaint hotline, local ombudsman, or licensure department 2. information related to the agency ' s hiring and competency requirements for Direct Care Workers 3. A Consumer Notice of DCW status.
CR4: SOS: 12/1/23. CR contained an agency document titled Service Contract signed on 12/1/23. The information packet did not contain: 1. contact information for the Department of Health complaint hotline, local ombudsman, or licensure department 2. information related to the agency ' s hiring and competency requirements for Direct Care Workers 3. A Consumer Notice of DCW status.
CR5: SOS: 10/9/23. CR contained an agency document titled Service Contract signed on 10/9/23. The information packet did not contain 1. contact information for the Department of Health complaint hotline, local ombudsman, or licensure department 2. information related to the agency ' s hiring and competency requirements for Direct Care Workers 3. A Consumer Notice of DCW status.
The findings were reviewed with EMP1, administrator, during an interview on 1/17/24 at approximately 4:00 pm.
Plan of Correction:CR1: Contact information given on DOH complaint hotline, signed copy in file.
CR1: Copy of hiring and competency requirements for direct care worker. Also, a consumer notice of DCW status was provided to consumer.
CR2: Contact information given on DOH complaint hotline, signed copy in consumer file. Copy of hiring and competency requirements for direct care worker was provided to consumer filed and DCW status.
CR3: Services completed with consumer. Temporary case, consumer had knee replacement. No longer needed services. Provided copy of DOH hotline and a copy of hiring and competency requirement for direct care worker and DCW status for
future use.
CR4: Provided consumer with copy of DOH hotline, signed copy in file. Copy of hiring and competency requirements for direct care worker was provided and in consumer file. Provided to consumer a copy of DCW status.
CR5: Consumer Deceased on 01/30/2024. Provided spouse with a copy of DOH hotline, and a copy of hiring and competency requirement for direct care worker on 01/26/2024. Provided copy of hiring and competency requirements for direct care worker and a copy of DCW status.
(Owner)
Will implement and maintain the following for each Consumer current/New:
provide:
The Department of Aging phone number and information.
The DOH hotline for complaints/abuse
Plan of care
Competency requirements of DCW
Outline in consumer contract with Carla's Caring Heart: Plan of care detailed.
Personal care assistance sheets/signed weekly by consumer.
Provide consumers with Notice of DCW status.
Emergency person/family member if DCW is not available.
All will be given to consumer and a copy kept in their files.
611.57(d) LICENSURE
Documentation
Name - Component - 00
(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 review of consumer records (CR) and interviews with staff (EMP), the agency failed to maintain documentation in agency files of direct care worker (DCW) visits and services provided for three (3) of five (5) consumer records reviewed (CRs 1,2 and 5).
Findings include:
During an interview with EMP 1, administrator, at approximately 12:30 pm it was determined that the agency did not utilize an Electronic Visit Verification (EVV) system. EMP1 stated that services provided were recorded in notebooks at the consumer homes.
Consumer record (CR) reviews conducted on 1/17/24 between approximately 12:00 pm - 1:30 pm revealed the following:
CR1: Start of Service (SOS): 11/23/23, contained a Service Agreement signed on 11/23/23. The CR did not contain evidence of visits or services provided.
CR2: SOS: 9/20/23, contained a Service Agreement signed on 9/20/23. The CR did not contain evidence of visits or services provided.
CR5: SOS: 10/9/23, contained a Service Agreement signed on 10/9/23. The CR did not contain evidence of visits or services provided.
The finding was reviewed with EMP1, Administrator, during an interview on 1/17/24 at approximately 4:00 pm.
Plan of Correction:CR1: Provided consumer with copies of a daily care plan visit sheets for DCW to fill and have consumer sign weekly: with time and date and services provided.
CR2: Provided consumer with copies of a daily care plan visit sheets for DCW to fill out and have consumer sign weekly: with time and date and services provided.
CR5: Deceased on 01/30/2024.
(Owner)
the following will be implemented and maintain the following:
Provide each current/new consumer with a Personal Case assistant service sheet on a weekly basis, which will outline all care provided by the DCW.
Will have DCW fill out daily and have Consumer sign at the end of the week. A copy will be given to consumer for their records, and one filed in each consumer file.
Initial Comments:
Based on the findings of an onsite state re-licensure survey completed 1/18/24, Carla's Caring Heart was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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