QA Investigation Results

Pennsylvania Department of Health
AMERISTAR HEALTHCARE SERVICES
Health Inspection Results
AMERISTAR HEALTHCARE SERVICES
Health Inspection Results For:

This is the only survey for this facility

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:



Based on the findings of an unannounced onsite state re-licensure survey conducted on March 27, 2024, Americare Healthcare Services, was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.






Plan of Correction:




Initial Comments:

Based on the findings of an unannounced onsite state re-licensure survey conducted on March 27, 2024, Americare Healthcare Services was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries.







Plan of Correction:




611.51(a) LICENSURE
Hiring or Rostering Prerequisites

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 employee files (EFs), new consumer enrollment package, and interview with agency staff, the agency failed to complete documentation of face-to-face (FTF) interviews in four (4) of four (4) EFs reviewed (EF#1-4); and failed to obtain and maintain documentation of two satisfactory references in in four (4) of four (4) EFs reviewed (EF#1-4).


Findings include:

Review conducted on March 27, 2024, at approximately 11:00 AM to 1:00 PM, of employee files (EFs) revealed:

EF#1 date of hire (doh) 7/30/22, FTF interview questions document is incomplete 2 of 10 questions answered; no name of interviewer; lacks interviewer's final evaluation of satisfactory or unsatisfactory FTF results; and no documentation of two satisfactory references.

EF#2 doh 2/3/21, FTF interview questions document is incomplete with missing answers to questions; lacks interviewer's FTF final evaluation of satisfactory or unsatifory results; and missing 1 satisfactory reference.

EF#3 doh 4/2/23, FTF interview questions document is incomplete 2 of 10 questions answered; no name of potential employee or interviewer; lacks interviewer's FTF final evaluation of satisfactory or unsatisfactory FTF results; and missing two documented satisfactory references.

EF#4 doh 4/15/20, FTF interview questions document is incomplete 1 of 10 questions answered; no name of interviewer; lacks interviewer's FTF final evaluation of satisfactory or unsatisfactory FTF results; and missing two documented satisfactory references.


Reviewed conducted on March 27, 2024, at approximately 1:00 PM, of new consumer enrollment package revealed document "Hiring and Competency requirements for direct care workers" with "Hiring Requirements To become part of the agency, each employee must pass the following: 1. Face to Face interview 2. Have positive two professional references."


Interview conducted on March 27, 2024, at approximately 1:10 PM, with agency assistant administrator revealed confirmation of above findings.










Plan of Correction:

Based on a review of employee files (EFs), new consumer enrollment package, and interview with agency staff, the agency failed to complete documentation of face-to-face (FTF) interviews in four (4) of four (4) EFs reviewed (EF#1-4); and failed to obtain and maintain documentation of two satisfactory references in in four (4) of four (4) EFs reviewed (EF#1-4).

POC
1. All employees listed EF#'s 1 to 4 have been directed to provide a satisfactory second reference no later than 21 days from date of audit. The Agency will document and follow up on the listed person and verify they are satisfactory.

2. The Agency shall implement an onboarding hiring check list for all employees to be checked off. The checklist in the employee file will ensure two satisfactory references are documented before hire. The checklist will ensure that the employee will have two positive verifiable references from a former employer or other person not related to the individual. A position will not be offered before all requirements are met on the checklist.

3. All current employee files will be audited to ensure compliance with this regulation and Agency Policy 2.003.2 Human Resources Classification of Personnel. The Agency has set a goal to guarantee that all employee files are compiled with the checklist to retain compliance within the Agency hiring practice and state regulations.
The Administrator will have this correction implemented on or by 5/26/24




611.55(e) LICENSURE
Competency Requirements

Name - Component - 00
The competency review must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction.

Observations:

Based on review of employee files (EFs), agency policy, new consumer enrollment package, and interview with agency staff, the agency failed to complete annual direct care worker competency evaluations in three (3) of four (4) EFs reviewed (EF#1-2, #4).


Findings include:


Review conducted on March 27, 24, at approximately 11:00 AM to 1:00 PM, of employee files (EFs) revealed:

EF#1 date of hire (doh) 7/30/22, missing annual documentation for 2023.

EF#2 doh 2/3/21, missing annual documentation for 2023.

EF#4 doh 4/15/20, missing annual documentation for 2022 and 2023.


Review conducted on March 27, 2024, at approximately 12:30 PM, of agency policy Competency Evaluation #2.009.1 revealed: "Procedure: 1. All field staff must be evaluated for competency with relation to their job description prior to receiving patient assignments. ... 4. Skills check must be completed annually."


Reviewed conducted on March 27, 2024, at approximately 1:00 PM, of new consumer enrollment package revealed document "Hiring and Competency requirements for direct care workers" with "Educational Requirements ... Then, every year, each Direct Care Worker, required to complete and satisfactory pass Annual Competency Exam."


Interview conducted on March 27, 24, at approximately 1:10 PM, with agency assistant administrator confirmed the above findings.












Plan of Correction:

Based on review of employee files (EFs), agency policy, new consumer enrollment package, and interview with agency staff, the agency failed to complete annual direct care worker competency evaluations in three (3) of four (4) EFs reviewed (EF#1-2, #4).

POC
1. An annual competency review will be completed in the office and accurately documented for all listed employees (EF#1-2, #4) no later than 21 days from date of audit.

2. The Agency shall stipulate that each employee is required to undergo an annual competency review one year subsequent to their date of hire. A competency review will be conducted to verify that the employee's ability to perform assigned duties has been evaluated by the agency.
This stipulation shall be incorporated into the operationalized hiring and onboarding checklist. Hence, in consideration of the offer of a position and prior to the employee delivering service to a customer, the employee acknowledges that they will be obligated to pass an annual competency examination in order to maintain their eligibility to continue servicing customers.

3. An audit of all existing employee files will be conducted to ensure compliance with this agency policy and Ameristar Healthcare Services, LLC competency requirement. An objective has been established to ensure that the checklist is adhered to when compiling employee files, in order to maintain compliance with state regulation and agency hiring practices.

The Administrator will have this correction implemented by no later than 05/26/24




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 Centers for Disease Control (CDC) guidelines, employee files (EFs), agency policy, new consumer enrollment package, and interview with agency administrator, the agency failed to ensure direct care workers (DCWs), prior to consumer contact, that the individual had been screened for and was free from active mycobacterium tuberculosis (TB) for two (2) of four (4) EFs reviewed (EF#3-4); and failed to ensure DCWs completed onhire TB risk assessment questionnaire (TB-RAQ) in two (2) of four (4) EFs reviewed (EF#1, #3).


Findings include:


Review conducted on March 27, 2024, at approximately 11:00 AM, of CDC "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005," "...Baseline testing for M. Tuberculosis infection is recommended for all newly hired health care workers [HCWs]...If TST [tuberculin skin testing] is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative...If the first-step TST result is negative, the second-step TST should be administered 1--3 weeks after the first TST result was read... ."

*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).


Review conducted on March 27, 2024, at approximately 11:00 AM to 1:00 PM, of employee files (EFs) revealed:

EF#1 date of hire (doh) 7/30/22, no onhire TB-RAQ document.

EF#3 doh 4/2/23, missing #2 TB (TST), and no onhire TB-RAQ document.

EF#4 doh 4/15/20, missing TB test results to be obtained once CV-19 waiver expired.


Review conducted on March 27, 2024, at approximately 1:15 PM, of agency policy Required Health Assessments and Maintain Health Records for Employees # 2.003.6 revealed: "Procedure (B) (4) Provide for a TB screening which shall be administered to all new employees who have direct patient contact and annually thereafter. ... Employee skin testing should be done by Mantoux Methods or other FDA approved in-vitro serologic test and follow-up for TB. ... (page 2) After baseline testing TB screening must: be completed annually; ... The home health agency must maintain documentation of TB evaluations showing that any person: i. working for the home health agency; or ii having direct patient contact; iii. has had a negative finding on a TB examination within the previous twelve (12) months."


Reviewed conducted on March 27, 2024, at approximately 1:00 PM, of new consumer enrollment package revealed document "Hiring and Competency requirements for direct care workers" with "Hiring Requirements To become part of the agency, each employee must pass the following: ... 4. PPD or chest x-ray as per CDC requirements."


Interview conducted on March 27, 2024, at approximately 1:10 PM, of agency assistant administrator revealed confirmation of above findings.












Plan of Correction:

The Agency has initiated communication with the listed employees. EF# 1 will have TB-RAQ document. EF#4 will furnish documentation of TB test. EF#3 has administered a TB risk assessment form after completing it. This must be accomplished no later than 21 days after the date of audit.
Prior to consumer contact, the Agency will require all employees and other office personnel who have direct contact with consumers to present supporting documentation demonstrating that they have undergone active mycobacterium tuberculosis screening and are free of the disease. This stipulation shall be incorporated into the operationalized hiring and onboarding checklist, preeminent to the employee delivering service to a customer and being extended an offer of employment.
The audit of all existing employee files will ensure compliance with this regulation and the Human Resources Classification of Personnel #2.003.6 policy of the agency. An objective has been established to ensure that the aforementioned checklist is utilized in the compilation of all employee files, in order to maintain adherence to state regulation and agency hiring practices.
The Administrator will have this correction implemented by no later than 05/26/2024.



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 review of Center for Disease and Control (CDC) guidelines, employee files (EFs), agency policy, and interview with the agency administrator, the agency failed to ensure each direct care worker completed annual tuberculosis (TB) risk education questionnaire for three (3) out of four (4) EFs reviewed (EF#1-2, #4).


Findings include:


Review conducted on March 27, 24, at approximately 11:00 AM, CDC guidelines revealed: ... "all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually." (CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.)

*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)."


Review conducted on March 27, 24, at approximately 11:00 AM to 1:00 PM, of EFs revealed:

EF#1 date of hire (doh) 7/30/22, missing TB annual education 2023.

EF#2 doh 2/3/21, missing TB annual education 2023.

EF#4 doh 4/15/20, missing TB annual education 2022, 2023.


Review conducted on March 27, 2024, at approximately 1:15 PM, of agency policy Required Health Assessments and Maintain Health Records for Employees # 2.003.6 revealed: "Procedure (B) (4) Provide for a TB screening which shall be administered to all new employees who have direct patient contact and annually thereafter. ... (page 2) After baseline testing TB screening must: be completed annually; ... The home health agency must maintain documentation of TB evaluations showing that any person: i. working for the home health agency; or ii having direct patient contact; iii. has had a negative finding on a TB examination within the previous twelve (12) months."


Interview conducted on March 27, 2024, at approximately 1:00 PM, with agency assistant administrator confirming above findings.












Plan of Correction:

This deficiency has been corrected and is now met. On 4/1/24, a Governing Body member re-educated the administrator regarding tuberculosis screening for new hire employees and requirement to review the agency Screening and Hiring policy.

By 5/12/24, the administrator will require EFs #1, #2, and #4 to complete the missing annual education for TB risk assessment questionnaire. These documents will be maintained in their employee files.
Starting 4/1/24, the Administrator will review all personnel files at hire and monthly until there is 100% compliance. Then they will be reviewed quarterly for one year. Thereafter all personnel files will be reviewed upon hire, at 90 days, and whenever there is a change in the policy and at the time of performance evaluation. The Administrator will use a personnel file audit tool to assist in this process. This process will be ongoing to ensure compliance.



611.57(a) LICENSURE
Consumer Rights

Name - Component - 00
(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

Observations:


Based on review of consumer files (CFs), new consumer enrollment package, agency policy, and interview with agency assistant administrator, the agency failed to provide new consumers with personal service agreement documents in four (4) out of five (5) CFs reviewed (CF#2-5); and failed to provide consumers with information requirement to receive written advance notice of at least 10 calendar days notice of the home care agency to terminate home care services in five (5) out of five (5) CFs reviewed (CF#1-5).


Findings include:


Review conducted on March 27, 2024, at approximately 1:30 PM to 3:30 PM, of consumer files (CFs) revealed:

CF#1 start of care (soc) 5/3/22, no documentation of required services termination time frame.

CF#2 soc 6/9/22, missing personal service agreement document and no documentation of required services termination time frame.

CF#3 soc 5/2/22, missing personal service agreement document and no documentation of required services termination time frame.

CF#4 soc 7/30/22, missing personal service agreement document and no documentation of required services termination time frame.

CF#5 soc 4/4/23, missing personal service agreement document and no documentation of required services termination time frame.


Review conducted on March 27, 2024, at approximately 10:40 AM, of agency new consumer enrollment package revealed no written information related to agency 10 day advance service termination.

Review conducted on March 27, 2024, at approximately 2:30 PM, of agency policy, Admission Criteria #1.009.1 revealed: "(A) An appropriate home care staff must prepare a care plan. The care plan must be developed after consultation with the client and the client's family, and must include services to be rendered, the frequency of visits or hours of service, identified problems, and method of intervention. The care plan must be reviewed and updated by all appropriate staff members involved in the client care at least annually."

Interview conducted on March 27, 2024, at approximately 3:00 PM, with agency assistant administrator revealed confirmation of above findings.








Plan of Correction:

1. On 4/1/24, the administrator revised the Consumer New Admission Packet to include the missing information element of consumer notification of at least 10 days calendar notice by home care agency to terminate home care services.

2. By 5/26/24, Administrator will receive endorsement of new information by consumers (CFs #1-5). Updated documents will be maintained in CFs #1-5 files.

3. By 5/26/24, Administrator or designee will review all current enrolled consumers and update consumer information with these individuals.

4. By 5/26/24, Administrator or designee will revise related agency policy to consumer enrollment.





611.57(b) LICENSURE
Prohibitions

Name - Component - 00
(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

Observations:


Based on review of employee handbook, new consumer enrollment package, consumer files (CFs), and interview with agency assistant administrator, the agency failed to show evidence consumer was informed home care agency or affiliated staff member is prohibited from assuming power of attorney (POA) or guardianship over a consumer and may not require consumer to endorse checks over to the agency/staff member for five (5) of five (5) CFs reviewed (CF#1-5).


Findings include:


Review conducted on March 27, 2024, at approximately 10:20 AM, of employee handbook revealed no written prohibition for agency/associated staff member from assuming POA or guardianship over a consumer and may not require consumer to endorse checks over to the agency/staff member.


Review conducted on March 27, 2024, at approximately 10:40 AM, of new consumer enrollment package revealed no written prohibition for agency/associated staff member from assuming POA or guardianship over a consumer and may not require consumer to endorse checks over to the agency/staff member.


Review conducted on March 27, 2024, at approximately 1:30 PM to 3:00 PM, of consumer files (CFs) revealed:

CF#1 start of care (soc) 5/3/22, no evidence of written prohibition for agency/associated staff member from assuming POA or guardianship over a consumer and may not require consumer to endorse checks over to the agency/staff member.

CF#2 soc 6/9/22, no evidence of written prohibition for agency/associated staff member from assuming POA or guardianship over a consumer and may not require consumer to endorse checks over to the agency/staff member.

CF#3 soc 5/2/22, no evidence of written prohibition for agency/associated staff member from assuming POA or guardianship over a consumer and may not require consumer to endorse checks over to the agency/staff member.

CF#4 soc 7/30/22, no evidence of written prohibition for agency/associated staff member from assuming POA or guardianship over a consumer and may not require consumer to endorse checks over to the agency/staff member.

CF#5 soc 4/4/23, no evidence of written prohibition for agency/associated staff member from assuming POA or guardianship over a consumer and may not require consumer to endorse checks over to the agency/staff member.


Interview conducted on March 27, 2024, at approximately 3:00 PM, with agency assistant administrator revealed confirmation of the above findings.

















Plan of Correction:

1. By 5/26/24, the Administrator or designee will update employee handbook, new consumer enrollment package, consumer files (CFs) to incorporated statement that home care agency (Ameristar Healthcare Services or affiliated staff member is prohibited from assuming power of attorney (POA) or guardianship over a consumer and may not require consumer to endorse checks over to the agency/staff member.

2. By 5/26/24, the Administrator or designee will notify and request endorsement by all current enrolled consumers (inclusive of CF#1-5) for this updated information and maintained in their agency files.

3. By 5/26/24, agency will use the revised Consumer Admission Packet will be used for all future enrolled consumers.



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 (CFs), new consumer enrollment package, agency policy, and interview with the agency administrator, the agency failed to provide the consumer, prior to commencement of services: no list of provided services in one (1) of five (5) reviewed CFs (CF#5); no listed identify of direct care worker in two (2) of five (5) CFs reviewed (CF#1, #4); no list of hours for services to be provided in four (4) of five (5) CFs reviewed (CF#1, #3, #4, #5); no clear written documentation of fees/costs owed by client for provided services in five (5) of five (5) CFs reviewed (CF#1-5); and, incomplete Consumer Notice of Direct Care Worker Status in one (1) of five (5) CFs reviewed (CF#5)


Findings include:


Review conducted on March 27, 2024, at approximately 1:30 PM to 3:30 PM, of consumer files revealed:

CF#1 start of care 5/3/22, no written documentation of DCW identity, no plan of care with list of service hours, and no clear written fees/costs owed by client for provided services.

CF#2 soc 6/9/22, no clear written fees/costs for provided services.

CF#3 soc 5/2/22, no list of service hours, and no clear written fees/costs for provided services.

CF#4 soc 7/30/22, no written documentation of DCW identity, no list of service hours, and no clear written fees/costs for provided services.

CF#5 soc 4/4/23, no list of provided services; no list of service hours, no clear written fees/costs for provided services, and incomplete Consumer Notice of Direct Care Worker Status form.


Review conducted on March 27, 2024, at approximately 3:00 PM, of new consumer enrollment package revealed: page 4, "Your Rights and Responsibilities as a Health Care Patient item 11. Know when and how each service will be provided and coordinated, the agency ownership, name and functions of any person and affiliated agency personnel providing care and services.; ... item 13. Be fully informed, orally and in writing, at the time of admission and in advance of care provided, a statement of services available by the agency, care and treatment provided by the agency and related charges. This must include those items and services for which you may be responsible for reimbursement."


Review conducted on March 27, 2024, at approximately 3:00 PM, of agency policy Admission Criteria revealed: ... "7. During the admission process the admitting staff member will provide the client or the client's representative with the at least the following: ... Name of the caregiver referred by the agency to provide the service; Statement clarifying the client's liability for cost of service if insurance does not cover the cost; Itemized billing statement; and Estimate of costs associated with the services provided."


Interview conducted on March 27, 2024, at approximately 3:00 PM, with agency assistant administrator revealed confirmation of the above findings.









Plan of Correction:

1. By 5/26/24, the Administrator will update CFs#1, #3, #4-5 Consumer New Admission packets for the missing cited information, obtain signed new personal service documents from each individual, and maintain these updated documents in their agency files.

2. By 5/26/24, the Administrator or designee will audit all other current enrolled consumers for same missing information requirements and initiate corrections with each consumer are needed.

3. By 5/26/24, the Administrator or designee will revise the Consumer New Admission packet to include all required consumer information and initiate use of newly revised form for all future enrolled consumers.



Initial Comments:


Based on the findings of an unannounced onsite state re-licensure survey conducted on March 27, 2024, Ameristar Healthcare Services was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: