Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on January 10, 2024, Proper Care, 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 state re-licensure survey conducted on January 10, 2024, Proper Care, 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 review of employee files (EFs) and interview with agency President (EMP #1), it was determined agency failed to maintain documentation of verification of two satisfactory references prior to hiring or rostering direct care workers for two (2) of ten (10) EFs reviewed. (EF# 4 and EF# 9)
Findings include:
Review of EFs conducted on January 10, 2024 between approximately 10:00 a.m. and 12: 00 p.m. revealed the following:
EF# 4, Date of Hire (DOH), 6/5/2023: No documentation provided two references being verified prior to hiring or rostering direct care worker. Contained one reference dated 6/5/2023 and contained one reference not dated.
EF# 9, DOH: 4/10/2023: No documentation provided two references being verified prior to hiring or rostering direct care worker. Contained two references that were not dated.
An interview with the agency EMP #1 conducted on January 10, 2024 at approximately 1:45 p.m. confirmed the above findings.
Plan of Correction:1. For EF# 4 and EF# 9, will correct and maintain missing references documentation.
2. Will conduct an internal audit of entire employee files to make sure no other employees have been affected by the same deficient practice.
3. Will create a new check list that will be used to ensure deficient practice does not recur.
4. The Agency Administrator will audit files every 6 months to monitor that the deficient practice will not recur.
Agency Administrator will be responsible for monitoring and check lists and tracking documentation will be retained every 6 months.
5. The corrections will be completed by 03/07/2024.
611.52(b) LICENSURE
State Police Criminal History Record
Name - Component - 00
If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.
Observations:
Based on review of employee files (EFs) and interview with agency President (EMP #1), it was determined agency failed to obtain a PA State Police criminal history record within 1 year immediately preceding the date of application for one (1) of ten (10) EFs reviewed. (EF# 1)
Findings include:
Review of EFs conducted on January 10, 2024 between approximately 10:00 a.m. and 12: 00 p.m. revealed the following:
EF# 1, Date of Hire (DOH), 4/12/2023: No documentation provided of PA State Police criminal history record within 1 year immediately preceding the date of application.
An interview with the agency EMP #1 conducted on January 10, 2024 at approximately 1:45 p.m. confirmed the above findings.
Plan of Correction:1. For EF# 1, will obtain Police Criminal History Record (State Patch).
2. Will conduct an internal audit of entire employee files to make sure no other employees have been affected by the same deficient practice.
3. Will create a new check list that will be used to ensure deficient practice does not recur.
4. The Agency Administrator will audit files every 6 months to monitor that the deficient practice will not recur.
Agency Administrator will be responsible for monitoring and check lists and tracking documentation will be retained every 6 months.
5. The corrections will be completed by 03/07/2024.
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 on review of employee files (EFs) and interview with agency President (EMP #1), it was determined 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) within 1 year immediately preceding the date of application for two (2) of ten (10) EFs reviewed. (EF# 5 and EF# 9)
Findings include:
Review of EFs conducted on January 10, 2024 between approximately 10:00 a.m. and 12: 00 p.m. revealed the following:
EF# 5, Date of Hire (DOH), 4/10/2023: No Federal criminal history record and a letter of determination obtained from the Department of Aging within 1 year immediately preceding the date of application. Contained Federal criminal history record and a letter of determination obtained from the Department of Aging dated 12/13/2021.
EF# 9, DOH, 4/10/2023: No Federal criminal history record and a letter of determination obtained from the Department of Aging within 1 year immediately preceding the date of application. Contained Federal criminal history record and a letter of determination obtained from the Department of Aging dated 12/8/2021.
An interview with the agency EMP #1 conducted on January 10, 2024 at approximately 1:45 p.m. confirmed the above findings.
Plan of Correction:1. For EF# 5 and EF# 9, will obtain recent Federal criminal history record and a letter of determination.
2. Will conduct an internal audit of entire employee files to make sure no other employees have been affected by the same deficient practice.
3. Will create a new check list that will be used to ensure deficient practice does not recur.
4. The Agency Administrator will audit files every 6 months to monitor that the deficient practice will not recur.
Agency Administrator will be responsible for monitoring and check lists and tracking documentation will be retained every 6 months.
5. The corrections will be completed by 03/07/2024.
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 employee files (EFs) and interview with agency President (EMP #1), it was determined agency failed to maintain documentation of proof of residency for two (2) of ten (10) EFs reviewed. (EF# 5 and EF# 9)
Findings include:
Review of EFs conducted on January 10, 2024 between approximately 10:00 a.m. and 12: 00 p.m. revealed the following:
EF# 5, Date of Hire (DOH), 4/10/2023: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained Pa Drivers License issued: 12/17/2021-10/24/2025.
EF# 9, DOH, 4/10/2023: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained Pa Drivers License issued: 9/20/2022-1/2/2027.
An interview with the agency EMP #1 conducted on January 10, 2024 at approximately 1:45 p.m. confirmed the above findings.
Plan of Correction:1. For EF# 5 and EF# 9, will obtain documentation of proof of PA residency for the entire two years (without interruption)
2. Will conduct an internal audit of entire employee files to make sure no other employees have been affected by the same deficient practice.
3. Will create a new check list that will be used to ensure deficient practice does not recur.
4. The Agency Administrator will audit files every 6 months to monitor that the deficient practice will not recur.
Agency Administrator will be responsible for monitoring and check lists and tracking documentation will be retained every 6 months.
5. The corrections will be completed by 03/07/2024.
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 review of employee files (EFs) and interview with agency President (EMP #1), it was determined agency 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:
The CDC guidelines state that 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. HCWs with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. (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 of EFs conducted on January 10, 2024 between approximately 10:00 a.m. and 12: 00 p.m. revealed the following:
EF# 1, Date of Hire (DOH), 4/12/2023: No documentation provided of completed individual TB risk assessment.
EF# 2, DOH: 10/18/2023: No documentation provided of completed individual TB risk assessment.
EF# 3, DOH: 9/20/2023: No documentation provided of completed individual TB risk assessment.
EF# 4, DOH: 6/5/2023: No documentation provided of completed individual TB risk assessment.
EF# 5, DOH: 4/10/2023: No documentation provided of completed individual TB risk assessment.
EF# 6, DOH: 10/4/2023: No documentation provided of completed individual TB risk assessment.
EF# 7, DOH: 10/13/2023: No documentation provided of completed individual TB risk assessment.
EF# 8, DOH: 4/10/2023: No documentation provided of completed individual TB risk assessment.
EF# 9, DOH: 4/10/2023: No documentation provided of completed individual TB risk assessment.
EF# 10, DOH: 9/18/2023: No documentation provided of completed individual TB risk assessment.
An interview with the agency EMP #1 conducted on January 10, 2024 at approximately 1:45 p.m. confirmed the above findings.
Plan of Correction:1. For EF# 1-10, will provide complete individual TB risk assessment.
2. Will conduct an internal audit of entire employee files to make sure no other employees have been affected by the same deficient practice.
3. Will create a new check list that will be used to ensure deficient practice does not recur.
4. The Agency Administrator will audit files every 6 months to monitor that the deficient practice will not recur.
Agency Administrator will be responsible for monitoring and check lists and tracking documentation will be retained every 6 months.
5. The corrections will be completed by 03/07/2024.
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 consumer files (CFs) and interview with agency President (EMP #1), it was determined agency failed to inform the consumer that the home care agency or home care registry may not require them to endorse checks over to the home care agency or home care registry and failed to inform the consumer that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer for five (5) of five (5) CFs reviewed. (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5).
Findings include:
Review of CFs conducted on January 10, 2024 between approximately 12:00 p.m. and 12: 45 p.m. revealed the following:
CF# 1, Start of Services, (SOS): 7/1/2023: No documentation of consumer notification that 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 and no documentation of consumer notification that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer.
CF# 2, SOS: 10/4/2023: No documentation of consumer notification that 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 and no documentation of consumer notification that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer.
CF# 3, SOS: 7/1/2023: No documentation of consumer notification that 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 and no documentation of consumer notification that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer.
CF# 4, SOS: 10/18/2023: No documentation of consumer notification that 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 and no documentation of consumer notification that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer.
CF# 5, SOS: 8/22/2023: No documentation of consumer notification that 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 and no documentation of consumer notification that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer.
An interview with the agency EMP #1 conducted on January 10, 2024 at approximately 1:45 p.m. confirmed the above findings.
Plan of Correction:1. For CF# 1-5, will provide documentation of consumer notification that 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 and no documentation of consumer notification that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer.
2. Will conduct an internal audit of entire consumers files to make sure no other consumers have been affected by the same deficient practice.
3. Will create a new check list that will be used to ensure deficient practice does not recur.
4. The Agency Administrator will audit files every 6 months to monitor that the deficient practice will not recur.
Agency Administrator will be responsible for monitoring and check lists and tracking documentation will be retained every 6 months.
5. The corrections will be completed by 03/07/2024.
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 on review of consumer files (CFs) and interview with agency President (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 the hours when those services will be provided for five (5) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5); failed to provide the fees and total costs for those services on an hourly or weekly basis for five (5) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5); and 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 for five (5) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5).
Findings include:
Review of CFs conducted on January 10, 2024 between approximately 12:00 p.m. and 12: 45 p.m. revealed the following:
CF# 1, Start of Services, (SOS): 7/1/2023: 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 fees and total costs for those services on an hourly or weekly basis; and 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.
CF# 2, SOS: 10/4/2023: 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 fees and total costs for those services on an hourly or weekly basis; and 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.
CF# 3, SOS: 7/1/2023: 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 fees and total costs for those services on an hourly or weekly basis; and 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.
CF# 4, SOS: 10/18/2023: 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 fees and total costs for those services on an hourly or weekly basis; and 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.
CF# 5, SOS: 8/22/2023: 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 fees and total costs for those services on an hourly or weekly basis; and 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.
An interview with the agency EMP #1 conducted on January 10, 2024 at approximately 1:45 p.m. confirmed the above findings.
Plan of Correction:1. For CF# 1-5, will provide 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 fees and total costs for those services on an hourly or weekly basis; and 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.
2. Will conduct an internal audit of entire consumers files to make sure no other consumers have been affected by the same deficient practice.
3. Will create a new check list that will be used to ensure deficient practice does not recur.
4. The Agency Administrator will audit files every 6 months to monitor that the deficient practice will not recur.
Agency Administrator will be responsible for monitoring and check lists and tracking documentation will be retained every 6 months.
5. The corrections will be completed by 03/07/2024.
Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on January 10, 2024, Proper Care, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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