Initial Comments:
Based on the findings of a State Re-Licensure Survey conducted onsite on January 23, 2024 and offsite on January 24, 2024, Southwood Home Services, 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 a State Re-Licensure Survey conducted onsite on January 23, 2024 and offsite on January 24, 2024, Southwood Home Services 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 show evidence that face to face interviews were performed, references were obtained, and criminal history background checks were conducted for five (5) of five (5) PF's reviewed: PF#1, PF#2, PF#3, PF#4, and PF#5.
Findings include:
An interview was conducted with the administrator on January 23, 2024 at approximately 12:15 PM. The administrator stated that s/he conducts face to face interviews and obtains references, but does not maintain documentation of those activities in the PF or any other files. Further, the administrator stated that s/he conducts a criminal history background check via the Pennsylvania Access to Criminal History (PATCH) website on the day that s/he interviews a direct care worker, but the administrator does not print or maintain a copy of the PATCH report in the PF or any other files.
A review of personnel files (PF) was conducted on January 23, 2024 starting at 11:10 AM. The date of hire (DOH) is indicated below.
PF#1 DOH 06/25/2023 did not contain evidence that a face to face interview was performed, references were obtained, or a criminal history background check was conducted. There was also no evidence of the above documents in any other agency files.
PF#2 DOH 01/02/2024 did not contain evidence that a face to face interview was performed, references were obtained, or a criminal history background check was conducted. There was also no evidence of the above documents in any other agency files.
PF#3 DOH 06/08/2023 did not contain evidence that a face to face interview was performed, references were obtained, or a criminal history background check was conducted. There was also no evidence of the above documents in any other agency files.
PF#4 DOH 10/03/2023 did not contain evidence that a face to face interview was performed, references were obtained, or a criminal history background check was conducted. There was also no evidence of the above documents in any other agency files.
PF#5 DOH 06/05/2023 did not contain evidence that a face to face interview was performed, references were obtained, or a criminal history background check was conducted. There was also no evidence of the above documents in any other agency files.
An interview held with the administrator on January 23, 2024 starting at 12:15 PM confirmed the above findings.
Plan of Correction:To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files, as directed by Citation 0200. The review showed it is Policy of this Agency to perform face to face interviews and reference checks for employees, but there was no face-to-face interview or a reference check for employees' personnel as required by 611.51(a). To correct this error on January 25, 2024; the Admin conducted begun doing face to face interviews along with contacting the refences for employees' all personnel along with pulling the PATCH Criminal Record Checks for all current employees.
To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP").This Policy will ensure all new hiring requirements of 11.51(a), have been met before a new employee can provide service consumers. EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation.
As of February 9, 2024; with the EPIP implementation, all employee Personnel file's will have all required documents as directed by 611.51(a). All deficiencies under Citation 0200 have been addressed.
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 review of personnel files (PF) and an interview with the administrator, the agency failed to document proof of Pennsylvania (PA) residency for two (2) consecutive years immediately preceding date of hire 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 for three (3) of five (5) PF's reviewed: PF#1, PF#2, and PF#5.
Findings include:
A review of personnel files was conducted on January 23, 2024 starting at approximately 11:10 AM. The date of hire (DOH) is indicated below.
PF#1 DOH 06/25/2023 contained no evidence of Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire.
PF#2 DOH 01/02/2024 contained a Pennsylvania Driver's license issued on 11/13/2023. There was no proof of Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire from 01/02/2022 to 01/02/2024.
PF#5 DOH 06/05/2023 contained a Pennsylvania Driver's license issued on 04/15/2023. There was no proof of Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire from 06/05/2021 to 06/05/2023.
An interview held with the administrator on January 23, 2024 starting at 12:15 PM confirmed the above findings.
Plan of Correction:To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files, as directed by Citation 0320. The review showed it is the Policy of the Agency to perform PATCH background checks for all employees, but the Agency did not conduct a background check for employees' Personnel as required by 611.52(c).
To correct this error as of January 25, 2024; the Admin begun obtaining federal criminal history records and Letter(s) of Determination from the Department of Aging, to ensure all employees are cleared to work as require by as required by 611.52(c). To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP"). This Policy will ensure all new hiring requirements of 611.52(c) including ensuring all federal criminal history records and Letter(s) of Determination from the Department of Aging, have been met before a new employee can provide service consumers. EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation.
As of February 9, 2024; with the EPIP implementation, all employee Personnel file's have all required documents as directed by 611.52(c). All deficiencies under Citation 0320 have been addressed.
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 direct care worker personnel files (PF) and an interview with the administrator, the home care agency failed to ensure that the direct care worker completed initial competency requirements prior to assigning the direct care worker (DCW) to a consumer for the provision of services. Five (5) of five (5) PF's did not meet the requirement: PF#1, PF#2, PF#3, PF#4, and PF#5.
Findings include:
A review of PF's was conducted on January 23, 2024 starting at approximately 11:10 AM. The date of hire (DOH) is indicated below.
PF#1 DOH 06/25/2023 did not contain evidence that initial competency requirements were met by the DCW prior to providing services to the consumer. The PF contained a completed competency exam, but there was no (DCW) name on the exam, no date as to when the exam was taken, and the exam was not graded or scored.
PF#2 DOH 01/02/2024 did not contain any evidence that initial competency requirements were met by the DCW prior to providing services to the consumer.
PF#3 DOH 06/08/2023 did not contain evidence that initial competency requirements were met by the DCW prior to providing services to the consumer. The PF contained a completed competency exam dated 06/08/2023, but the exam was not graded or scored. The competency exam states, "there are 59 questions with a perfect score totaling 100. A score of 80% or better (47 correct) must be answered correctly in order to pass. Any questions incorrectly answered should prompt additional training of the CTOP (Competency Training Orientation Program)." There was no evidence denoting whether the DCW passed or failed the exam.
PF#4 DOH 10/03/2023 did not contain evidence that initial competency requirements were met by the DCW prior to providing services to the consumer. The PF contained a completed competency exam dated 10/03/2023, but the exam was not graded or scored. The competency exam states, "there are 59 questions with a perfect score totaling 100. A score of 80% or better (47 correct) must be answered correctly in order to pass. Any questions incorrectly answered should prompt additional training of the CTOP (Competency Training Orientation Program)." There was no evidence denoting whether the DCW passed or failed the exam.
PF#5 DOH 06/05/2023 did not contain evidence that initial competency requirements were met by the DCW prior to providing services to the consumer. The PF contained a completed competency exam dated 06/05/2023, but the exam was not graded or scored. The competency exam states, "there are 59 questions with a perfect score totaling 100. A score of 80% or better (47 correct) must be answered correctly in order to pass. Any questions incorrectly answered should prompt additional training of the CTOP (Competency Training Orientation Program)." There was no evidence denoting whether the DCW passed or failed the exam.
An interview held with the administrator on January 23, 2024 starting at 12:15 PM confirmed the above findings.
Plan of Correction:To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files as directed by Citation 0600.
The review showed it is the Policy of this Agency to require and provide employees with a Competency Training and Test prior to employees servicing customers', but did not provide said testing and related documentation for any employees' personnel as required by 611.51(a).
To correct this error as of January 25, 2024; the Admin has provided Competency Training and the related testing and ensured all employees have the required documentation for all employees' personnel.
To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP"). This Policy will ensure all new hiring requirements of 11.51(a), have been met before a new employee can provide service consumers. EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation. As of
February 9, 2024; with the EPIP implementation, all employees including file # (1), have all completed the required Competency Training and relating testing as directed by 611.51(a). All deficiencies under Citation 0600 have been addressed.
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 review of personnel files (PF), the Centers for Disease Control and Prevention (CDC) guidelines, and an interview with the administrator, the home care agency (HCA) did not provide documentation that a direct care worker (DCW), upon hire, was screened for and free from active mycobacterium tuberculosis for five (5) of five (5) PF's reviewed: PF#1, PF#2, PF#3, PF#4, and PF#5, and did not provide documentation of a tuberculosis (TB) symptom screen questionnaire and TB risk assessment completed upon hire for five (5) of five (5) PF's reviewed: PF#1, PF#2, PF#3, PF#4, and PF#5.
Findings include:
The Centers for Disease Control and Prevention (CDC) and the National TB Controllers Association released updated recommendations for Tuberculosis (TB) screening, testing, and treatment of health care personnel on May 17, 2019. These recommendations update the health care personnel screening and testing section of the 2005 CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings. All health care personnel should be screened for TB upon hire (i.e., preplacement). TB screening is a process that includes: a baseline individual TB risk assessment, a TB symptom evaluation, and a TB test (e.g., a TB single blood assay test or a two-step tuberculin skin test (TST), and additional evaluation for TB disease as needed. Health care personnel with a positive TB test result should receive a symptom evaluation and a chest x-ray to rule out TB disease. Additional workup may be needed based on those results. All health care personnel should receive TB education annually. TB education should include information on TB risk factors, the signs and symptoms of TB disease, and TB infection control policies and procedures. (CDC/MMWR/May 17, 2019/Vol.68/No.19).
A review of PF's was conducted on January 23, 2024 starting at approximately 11:10 AM. The date of hire (DOH) is indicated below.
PF#1 DOH 06/25/2023 did not contain any evidence that a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB) or a chest radiograph (if the DCW had a baseline positive or newly positive test for tuberculosis infection) was obtained upon hire, nor was there documentation of a tuberculosis symptom screen questionnaire or tuberculosis risk assessment completed upon hire.
PF#2 DOH 01/02/2024 did not contain any evidence that a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB) or a chest radiograph (if the DCW had a baseline positive or newly positive test for tuberculosis infection) was obtained upon hire, nor was there documentation of a tuberculosis symptom screen questionnaire or tuberculosis risk assessment completed upon hire.
PF#3 DOH 06/08/2023 did not contain any evidence that a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB) or a chest radiograph (if the DCW had a baseline positive or newly positive test for tuberculosis infection) was obtained upon hire, nor was there documentation of a tuberculosis symptom screen questionnaire or tuberculosis risk assessment completed upon hire.
PF#4 DOH 10/03/2023 did not contain any evidence that a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB) or a chest radiograph (if the DCW had a baseline positive or newly positive test for tuberculosis infection) was obtained upon hire, nor was there documentation of a tuberculosis symptom screen questionnaire or tuberculosis risk assessment completed upon hire.
PF#5 DOH 06/05/2023 did not contain any evidence that a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB) or a chest radiograph (if the DCW had a baseline positive or newly positive test for tuberculosis infection) was obtained upon hire, nor was there documentation of a tuberculosis symptom screen questionnaire or tuberculosis risk assessment completed upon hire.
An interview held with the administrator on January 23, 2024 starting at 12:15 PM confirmed the above findings.
Plan of Correction:To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files as directed by Citation 0700.
The review showed the Agency does require employees to provide test results for mycobacterium tuberculosis according to the Center for Disease Control (CDC) guidelines, including the the TB 2 Step test process but did not provide the required symptom screen questionnaire and an individual TB risk assessment for all/any employees'. To correct this error as of Jan 24, 2024; the Admin has contacted the identified employees' and (PF# 1, 2, 3, 4 and 5, ) and requested all current employees' provide test documents that a 2nd step Test was completed including completing any missing required documentation for the mycobacterium tuberculosis symptom screen questionnaire and individual TB risk assessment.
To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP"). This Policy will ensure all new hiring requirements of 11.51(a), have been met before a new employee can provide service consumers. EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation.
As of February 9, 2024; with the EPIP implementation, all employee Personnel file's including file employees' and (PF# 1, 2, 3, 4, and 5) have all required documents as directed by 611.51(a). All deficiencies under Citation 0700 have been addressed.
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 review of consumer files (CF) and an interview with the administrator, the agency failed to provide the following information to the consumer, the consumer's legal representative, or a responsible family member prior to the start of services: a listing of the available home care services that would be provided to the consumer by the direct care worker (DCW) for one (1) of five (5) CF's reviewed: CF#1; the identity of the DCW providing the services for two (2) of five (5) CF's reviewed: CF#1 and CF#4; the hours when the services were to be provided for two (2) of five (5) CF's reviewed: CF#1 and CF#5; the fees and total costs for services on an hourly or weekly basis for four (4) of five (5) CF's reviewed: CF#1, CF#3, CF#4, and CF#5; the telephone number of the ombudsman program located with the local Area Agency on Aging for five (5) of five (5) CF's reviewed: CF#1, CF#2, CF#3, CF#4, and CF#5; and a disclosure addressing the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency for two (2) of five (5) CF's reviewed: CF#1 and CF#4.
Findings include:
A review of CF's was conducted on January 23, 2024 starting at 10:10 AM. The start of care (SOC) is indicated below.
CF#1 SOC 06/02/2023 did not contain evidence that the consumer, the consumer's legal representation or a responsible family member, prior to the start of services, received information regarding the listing of services and the identity of the DCW who would be providing the services, the hours when the services were to be provided, and the fees for the services to be provided. The consumer, who resides in Bucks County, did not receive the telephone number of the ombudsman program located with the local area agency on aging for Bucks County. The section of the disclosure form intended to address the tax and insurance obligations and other responsibilities of the consumer and the home care agency was not completed.
CF#2 SOC 11/26/2022 did not contain evidence that the consumer, who resides in Bucks County, received the telephone number of the ombudsman program located with the local area agency on aging for Bucks County, prior to the start of services.
CF#3 SOC 03/23/2022 did not contain evidence that, prior to the start of services, the consumer was provided information concerning the fees for the services to be provided. The consumer, who resides in Bucks County, did not receive the telephone number of the ombudsman program located with the local area agency on aging for Bucks County.
CF#4 SOC 07/24/2023 did not contain evidence that the consumer, prior to the start of services, received information regarding the identity of the DCW who would be providing the services, and the fees for the services to be provided. The consumer, who resides in Bucks County, did not receive the telephone number of the ombudsman program located with the local area agency on aging for Bucks County. The section of the disclosure form intended to address the tax and insurance obligations and other responsibilities of the consumer and the home care agency was not completed.
CF#5 SOC 12/27/2023 did not contain evidence that the consumer, prior to the start of services, received information regarding the hours when the services were to be provided, and the fees for the services to be provided. The consumer, who resides in Bucks County, did not receive the telephone number of the ombudsman program located with the local area agency on aging for Bucks County.
An interview conducted with the administrator on January 23, 2024 starting at 12:15 PM confirmed the above findings.
Plan of Correction:A review of the Agency Consumer files reveals the Agency does provide new Patients with all required Consumer Protection notices which outlines their Rights as required by chapter 611.57; however, the above finding revealed that the Agency did not provide Consumers with proper information regarding who to contact at the Department for information regarding the HCA's compliance and licensure requirements, along with not providing the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA)" within its Welcome Guide & Consumer Rights.
To ensure this Agency is in future compliance, on January 25, 2024, the Agency updated its Consumer Welcome Guide & Consumer Rights package along with the Admin reviewing the Agency's entire Consumer files including and specifically Consumer File #'s (2, 3, 4 and 5) as directed by Citation 0820.
To correct this error on May 10, 2023; the Admin begun contacting consumers' specifically Consumer files #'s (1, 2, 3, 4 and 5) to provide them with the updated Welcome Guide & Consumer Rights which addresses who to contact at the Department for information regarding the HCA's compliance and licensure requirements, along with the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
As of February 9, 2024; with the updated Policy and implementation, all consumer file's including file #'s (2, 3, 4 and 5), have all required documents and notices as directed by 611.57 and PA Bulletin issued February 10, 2010. All deficiencies under Citation 0820 have been addressed.
Initial Comments:
Based on the findings of a State Re-Licensure Survey conducted onsite on January 23, 2024 and offsite on January 24, 2024, Southwood Home Services, 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 observation and correspondence with the administrator, the agency failed to provide evidence of an identification card that included a photograph of the employee.
Findings include:
Correspondence with the administrator on January 23, 2024 and January 24, 2024, and observation of the identification card being used by the agency noted that the agency failed to provide an identification card that included a photograph of the individual. The identification card contained the agency name, employee name and title, but there was no photograph of the individual on the identification card.
The above findings were confirmed with the administrator on January 24, 2024 at 12:00 PM.
Plan of Correction:To ensure this Agency is in future compliance and to correct this error as of January 25, 2024; the Admin has contacted all employees' and provided them with a photo identification badge.
To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP").
This Policy will ensure all new hiring requirements of 11.51(a), have been met before a new employee can provide service consumers.
EPIP Review will be overseen and conducted by the Admin quarterly and annually. All employee have been provided with the proper photo identification badge as directed by 611.51(a). All deficiencies under Citation 0010 have been addressed.
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