Initial Comments:
Based on an unannounced, onsite home care agency state relicensure survey conducted on February 2, 2024, Home to Home, was found to be in compliance with requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on an unannounced, onsite home care agency state relicensure survey conducted on February 2, 2024, Home to Home, 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
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 upon review of employee files (EFs) and interview with agency manager (EMP #1), agency failed to provide documentation of two satisfactory, references for three (3) of ten (10) EFs reviewed. (EF# 1, EF# 7 and EF# 9)
Findings include:
Review of EFs conducted on February 2, 2024 between approximately 11:30 a.m. and 1:30 p.m. revealed the following:
EF# 1, Date of Hire (DOH), 11/30/2023: no documentation of two satisfactory references conducted prior to hire. One reference conducted on 11/11/2023. One family reference conducted on 11/11/2023.
EF# 7, DOH, 5/5/2023: no documentation of two satisfactory references conducted prior to hire.
EF# 9, DOH, 3/6/2023: no documentation of two satisfactory references conducted prior to hire. First shift completed on 3/16/2023. One reference conducted on 3/7/2023.
An interview with the agency EMP #1 conducted on February 2, 204 at approximately 2:30 p.m. confirmed the above findings.
Plan of Correction:In order to comply with regulation 611.51(a) Licensure related to documentation needed per observation Home to home llc has check list for potential new hire caregivers to ensure documentation is completed and in compliance to show the following. Reference will be logged as well as the dates the reference were checked properly before hiring.
Administrator have implemented a schedule to examine all documents for completion and check off tasks on a list, that will ensure complience with the regulation.
Home to Home Llc going to call and get two reference check for EF#3, EF#6, EF#9.
611.52(c) LICENSURE
Federal Criminal History Record
Name - Component - 00
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 upon review of employee files (EFs) and interview with agency manager (EMP #1), agency failed to 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) for three (3) of ten (10) EFs reviewed. (EF# 3, EF# 6, and EF# 9)
Findings include:
Review of EFs conducted on February 2, 2024 between approximately 11:30 a.m. and 1:30 p.m. revealed the following:
EF# 3, Date of Hire (DOH), 3/24/2023: No Federal criminal history record and a letter of determination obtained from the Department of Aging.
EF# 6, DOH, 12/19/2023: No Federal criminal history record and a letter of determination obtained from the Department of Aging.
EF# 9, DOH, 3/6/2023: No Federal criminal history record and a letter of determination obtained from the Department of Aging.
An interview with the agency EMP #1 conducted on February 2, 204 at approximately 2:30 p.m. confirmed the above findings.
Plan of Correction:1.HOME TO HOME , LLC will ensure , all the new hires who has been a resident of this common wealth for last 2 years preceding the date of the request for a criminal history report, will obtain state police criminal record prior to the date of hire.
2. Home TO HOME, LLC will make sure he overview all the interview package and make sure Pennsylvania state police criminal history record are obtained prior to the date of hire (DOH).A administrator will sign off each employee folder and make sure Pennsylvania state police criminal history record are obtained and kept in the employee folder prior to the date of hire(DOH). No new hires will be done with out obtaining a state police criminal history record. An administrator will also implement different procedures as needed if one mentioned above is not effective, and make sure evidence of Pennsylvania state patch are obtained and are kept in employees folder prior to the date of hire (DOH).
3. Home TO HOME, LLC administrator of this Agency to monitor and ensure all the state police criminal history report, are obtain prior to the date of hire for all new hires on or after 02/02/2024. A president will make sure no employees will be hired without obtaining a successful criminal record.
4. Home to Home LLC will make sure that all employees provide 2 year proof of residency which include but not limited Housing records, such as mortgage records or rent receipts; Public utility records and receipts .
5. Home to Home LLC will obtain FBI and proof of residency.
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 upon review of employee files (EFs) and interview with agency manager (EMP #1), agency failed to ensure proof of residency for three (3) of ten (10) EFs reviewed. (EF# 3, EF# 6, and EF# 9)
Findings include:
Review of EFs conducted on February 2, 2024 between approximately 11:30 a.m. and 1:30 p.m. revealed the following:
EF# 3, Date of Hire (DOH), 3/24/2023: Agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained Pennsylvania Drivers License issued 6/30/2023-11/11/2025.
EF# 6, DOH, 12/19/2023: Agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained Pennsylvania Drivers License issued 9/22/2022-11/21/2026.
EF# 9, DOH, 3/6/2023: Agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained Pennsylvania Drivers License issued 11/17/2020-11/18/2024.
An interview with the agency EMP #1 conducted on February 2, 204 at approximately 2:30 p.m. confirmed the above findings.
Plan of Correction:The Administrator of Home to Home, LLC review all emplyoee files for those with less than 2 years of Pennsylania resident or those living out of state. For employees that fall in this category, the agency will conduct a Federal Criminal History Check as required by regulation.Proof of Residency will be determined by requesting, documenting and examining one or more of the following: Valid driver's license; State-issued identification card; Motor vehicle registration
Completion Date:
Status:
No POC
Date:
Housing records, such as mortgage records or rent receipts; Public utility records and receipts,
such as electric bills: Local tax records: Emplovment records, including records of unemployment compensation; a completed signed, Federal, State or Local income tax return with the applicant's name and address preprinted on it. An in service will be conducted by the Administrator for all office employees involved in the hiring process of personal care workers. The in-service will occur no later than April 2, 2024. During the in-service, the Administartor will review Federal Criminal History Record regulations and stress the importance of ensuring that all parts of the regulations are met.The Administrator will review the agencies Policy regarding Criminal Background Checks and the requirements or the regulations witch states that an FBi criminal history check must be obtamed for all employees who has not been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application for employment or currently lives out of state. The administrator will explain the consequences of not following all parts of the Federal Criminal History Record regulation.
The administrator will ensure that the in-service occurs and that all files are corrected no later than April2, 2024.
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 upon review of employee files (EFs) and interview with agency manager (EMP #1), it was determined agency failed to demonstrate, prior to assigning or referring a direct care worker to provide services to a consumer, competency by passing a competency examination for one (1) of ten (10) EFs reviewed. (EF# 4)
Findings include:
Review of EFs conducted on February 2, 2024 between approximately 11:30 a.m. and 1:30 p.m. revealed the following:
EF# 4, Date of Hire (DOH), 12/1/2023: No documentation provided initial competency completed prior to assigning or referring a direct care worker to provide services to a consumer.
An interview with the agency EMP #1 conducted on February 2, 204 at approximately 2:30 p.m. confirmed the above findings.
Plan of Correction:The Administrator of Home to Home, LLC will first review all employee personnel files to determine employees previously hired without documentation of an Annual Competency Review.Once those employee files are identified, the office manager with the help of the Human Resources and Clinical Staff department will complete an Annual Review for each employee working over a year from their date of hire. An in-service will be conducted by the Administrator for all office employees involved in annual competency review of personal care workers. The in-service will occur no later than April 2 2024. During the in-service, the Administrator will review Competency Requirements Regulations and stress the importance of ensuring that ALL parts of the regulations are met.The Administrator will explain that the regulation requires the agency to complete an annual competency review at least once a year for each employee after initial competency is established and must be documented in their personnel file.The administrator will also inform staff that competency reviews should also occur more frequently when discipline or other sanction is imposed because of a quality of care infraction. The administrator will explain the consequences of not following all parts of the Direct Care Worker Files regulation.The administrator will ensure that the in- service occurs and that all personnel files identified not in compliance are corrected and updated no later than April 2, 2024. The administrator is responsible for conducting the in-service and making sure that all direct care worker files reviewed are corrected and that all future hires meet the hiring prerequisites regulation to ensure proper compliance.
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 upon review of employee files (EFs) and interview with agency manager (EMP #1), agency failed to ensure each direct care worker and other staff or contractors with direct consumer contact, prior to consumer contact, were screened for and are free from active mycobacterium tuberculosis using a two-step tuberculin skin test or a single blood assay to test for infection with tuberculosis for one (1) of ten (10) EFs reviewed (EF# 8); failed to ensure each direct care worker and other staff or contractors with direct consumer contact, prior to consumer contact, completed an individual TB risk assessment (TB) for ten (10) of ten (10) EFs reviewed. (EF# 1, EF# 2, EF# 3, EF# 4, EF# 5, EF# 6, EF# 7, EF# 8, EF# 9 and EF# 10)
Findings include:
Review of EFs conducted on February 2, 2024 between approximately 11:30 a.m. and 1:30 p.m. revealed the following:
EF# 1, Date of Hire (DOH), 11/30/2023: No documentation provided of completed individual TB risk assessment.
EF# 2, DOH, 2/27/2023: No documentation provided of completed individual TB risk assessment.
EF# 3, DOH, 3/24/2023: No documentation provided of completed individual TB risk assessment.
EF# 4, DOH, 12/1/2023: No documentation provided of completed individual TB risk assessment.
EF# 5, DOH, 3/24/2023: No documentation provided of completed individual TB risk assessment.
EF# 6, DOH, 12/19/2023: No documentation provided of completed individual TB risk assessment.
EF# 7, DOH, 5/5/2023: No documentation provided of completed individual TB risk assessment.
EF# 8, DOH, 3/24/2023: No documentation provided of TB testing using a two-step tuberculin skin test or a single blood assay to test for infection with tuberculosis. One TST conducted on 3/21/2023-3/23/2023. No documentation provided of completed individual TB risk assessment.
EF# 9, DOH, 3/6/2023: No documentation provided of completed individual TB risk assessment.
EF# 10, DOH, 12/19/2023: No documentation provided of completed individual TB risk assessment.
An interview with the agency EMP #1 conducted on February 2, 204 at approximately 2:30 p.m. confirmed the above findings.
Plan of Correction:The Administrator of Home to Home, LLC reviews all employee files to ensure that a TB risk assessment Health screening is documented in each personnel fileFor employees found not
being compliant with the TB
Screening regulations, a TB
Risk assessment will be sent
to each employee
immediately. The
Administrator of Home to
Home LLC will conduct an
in-service for the office staff
by April 2, 2024. The In-
service is to review the
agency's TB Health
screening procedure to
ensure that all employees
receive a TB Health
screening risk assessment at
the of hire or prior to
assigning a direct care
worker to consumers.
During the in-service, the
Administrator will stress the
importance of ensuring that
all employees follow the
policy and procedure for TB
Health screening. Ensuring
that appropriate questions
are asked, and procedures
being followed based on
responses is a priority
addressed to the entire staff
during the service. The
Administrator will also
stress the importance of
proper documentation to
ensure lot screenings. The
Administrator of Home to
Home, LLC will ensure that
the policy and procedure is
implemented immediately
and that the policy and
procedure for TB Health
screening will be updated no
later than by April 2, 2024.The administrator will
include in quarterly reviews
employee file audits that
review employee files
requirements for
employment including initial
TB screening and early
screenings to ensure
ongoingcompliance with
state and federal regulations
and to correct any errors if
found. The administrator is
also responsible for ensuring
that the in-service is
conducted no later than by
April 2, 2024. The
Administrator will host and
lead the re-education effort
with all office staff. The
Administrator, with the help
of the office staff will be
responsible for ongoing
monitoring and managing
compliance with the goal of
eliminating
reoccurrence.The deficiency
will be corrected no later
than by April 2, 2024.
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 upon review of consumer files (CFs) and interview with agency manager (EMP #1), it was determined agency failed to provide, prior to the commencement of services, to the consumer the identity of the direct care worker who will provide the services to five (5) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5); failed to provide a listing of the available home care services that will be provided to the consumer by the direct care worker to one (1) of five (5) CFs reviewed (CF# 2); failed to provide the hours when those services will be provided to five (5) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5); failed to provide 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 to five (5) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5); failed to provide the hiring and competency requirements applicable to direct care workers employed by the home care agency to five (5) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5); and failed to provide 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 one (1) of five (5) CFs reviewed. (CF# 2)
Findings include:
Review of CFs conducted on February 2, 2024 between approximately 10:00 a.m. and 10:45 a.m. revealed the following:
CF# 1, Start of Service (SOS), 11/22/2023: No documentation of the identity of direct care worker being provided to consumer; of providing the hours when those services will be provided; of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information about a particular home care agency or home care registry; of providing the hiring and competency requirements applicable to direct care workers employed by the home care agency;
CF# 2, SOS, 10/13/2023: No documentation of the identity of direct care worker being provided to consumer; of providing a listing of the available home care services that will be provided to the consumer by the direct care worker; of providing the hours when those services will be provided; of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information about a particular home care agency or home care registry; of providing the hiring and competency requirements applicable to direct care workers employed by the home care agency; and and of providing 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
CF# 3, SOS, 7/13/2023: No documentation of the identity of direct care worker being provided to consumer; of providing the hours when those services will be provided; of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information about a particular home care agency or home care registry; of providing the hiring and competency requirements applicable to direct care workers employed by the home care agency;
CF# 4, SOS, 3/15/2023: No documentation of the identity of direct care worker being provided to consumer; of providing the hours when those services will be provided; of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information about a particular home care agency or home care registry; of providing the hiring and competency requirements applicable to direct care workers employed by the home care agency;
CF# 5, SOS, 2/27/2023:No documentation of the identity of direct care worker being provided to consumer; of providing the hours when those services will be provided; of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information about a particular home care agency or home care registry; of providing the hiring and competency requirements applicable to direct care workers employed by the home care agency;
An interview with the agency EMP #1 conducted on February 2, 204 at approximately 2:30 p.m. confirmed the above findings.
Plan of Correction:The administrator will make sure that direct care worker identification document provided to consumer and hours for services as well direct care worker status of tax.
New schedule documentation created.
Administrate or will make sure that Home to Home LLC is in compliance with it before 04/02/2024.
Home to home Llc making sure forms are updated and all consumer and employee sign again and maintain their files.
Initial Comments:
Based on an unannounced, onsite home care agency state relicensure survey conducted on February 2, 2024, Home to Home, was found not to be in compliance with 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 review of photo ID badge regulations and interview with agency manager (EMP #1), it was determined agency failed to provide Identification Badges (ID) for thirty-two (32) of thirty-two (32) Direct Care Workers (DCW). (DCW#1-32).
Findings include:
Review of photo ID badges conducted on February 2, 2024 between approximately 1:00 p.m. and 1:30 p.m. revealed the following:
No photo ID badges were provided for Direct Care Workers.
An interview with the agency EMP #1 conducted on February 2, 2024 at approximately 2:30 p.m. confirmed the above findings.
Plan of Correction:Home To Home LLC in compliance with 35 P. S. § 448.809b LICENSURE Photo Id Reg: The center will comply with the standard each employee will have their picture, name, title, and facility name printed on their ID tag to be in accordance with the photo Indentification specification and regulations.
The Administrator will be responsible to ensure all employees have Employee Picture Identification Badges. The Administrator will ensure the employee badge are accurate and monitored yearly with their picture, name, and title printed on their ID badge.
|