Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on January 22, 2024, Debre Home Care LLC., 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 home care agency state re-licensure survey conducted on January 22, 2024, Debre 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
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 an interview with the administrator, the agency failed to provide documentation of obtaining two satisfactory and verifiable references for two (2) of the six (6) PF's, (PF # 2 and 5).
Findings include:
A review of PF's was conducted on January 22, 2024 from approximately 10:15 am to 11:10 am.
PF #2 Date of Hire 5/14/2021 did not contain any documentation of two satisfactory and verifiable references.
PF # 5 Date of Hire 12/02/2022 contain documentation of two references that were family members.
An interview with the administrator on January 22, 2024 at approximately 11:20 am confirmed the above findings.
Plan of Correction:1. The Agency will require that 2 references be submitted for all employees who are missing two positive satisfactory references. This will be conducting by written or verbal from former employer or other person not related to the individual. The agency hiring manager will add a two verifiable references request document requirement to the checklist of elements and on all employment application needed for any hired employee.
2. The agency hiring manager will conduct an audit of employee files to ensure compliance.
3. The agency HR manager will conduct two positive satisfactory reference checks, and these results will be documented in writing or via checklist format. The form or checklist will include date, and time of person contacted.
4. The agency administrator will be required to review all of the employee hire checklists before the employee is deployed to clients home. Employees will not be allowed to work unless all items on the checklist are complete.
5. This shall be completed by March 15, 2024.
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 a review of personnel files (PF), recommendations from the Centers for Disease Control (CDC), the agency did not contain documentation that the individual has completed annual TB education for six (6) of six (6) PF's reviewed, (PF #1, 2, 3, 4, 5 and 6).
Findings include:
CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings: "....https://www.cdc.gov/tb/topic/testing/healthcareworkers.htm for updated guidances. 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 PFs was conducted on January 22, 2024 from approximately 10:15 am to 11:25 am..
PF #1, Date of Hire: 1/22/2022, did not contain any documentation of a completed annual TB education for 2023 and 2024.
PF #2, Date of Hire: 5/14/2021, did not contain any documentation of a completed annual TB education for 2022 and 2023.
PF #3, Date of Hire: 1/25/2023, did not contain any documentation of a completed annual TB education for 2024.
PF #4, Date of Hire: 7/29/2021, did not contain any documentation of a completed annual TB education for 2022 and 2023.
PF #5, Date of Hire: 12/2/2022, did not contain any documentation of a completed annual TB education for 2023.
PF #6, Date of Hire: 5/10/2021, did not contain any documentation of a completed annual TB education for 2022 and 2023.
An interview with the administrator on January 22, 2024 at approximately 11:35 am confirmed the above findings.
Plan of Correction:1. Agency Training manager shall conduct annual TB education for the starting year
2024 -2025 for all individuals who have not been educated on annual TB education and it will be documented and placed on employee file.
2. The agency training manager will audit all employee training files to ensure compliance.
3. The agency training slides shall be updated to include annual TB education and the date of training of all future employees shall be recorded on employee hire checklist. The agency training manager will be responsible for these tasks as well as overseen and monitored by the agency training manager.
4. The corrective action plan will be completed by 03/15/2024.
4.
Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on January 22, 2024, Debre 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 an interview with the administrator, it was determined that the Agency failed to provide evidence of photo identification tags that would include the employee's name, title, picture and name of the Agency.
Findings include:
During discussion with the administrator on January 22, 2024 at approximately 11:25 a.m., the administrator was asked if the Agency is using photo identification tags for employees. The administrator stated that the Agency is not using photo identification tags.
In an interview conducted with the administrator on January 22, 2024 at approximately 11:30 a.m., the above findings were confirmed.
Plan of Correction:1. All employees shall have their ID badges issued, per the ID regulation at the start of their employment with the agency.
2. All employee badges shall be created and issued.
3. The agency will implement badge format to ensure that the badge title is in compliance.
4. The hiring manager shall be in charge of issuing and monitoring that the badges meet requirements. They must sign off on each badge issued, and require standards.
5. This corrective action shall be completed by 03/15/2024.
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