Initial Comments:
Based on the findings of an offsite state re-licensure survey conducted on July 24, 2023,With Compassion 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 offsite state re-licensure survey conducted on July 23, 2024 WIth Compassion 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:
611.56(a) LICENSURE
Health Screening
Name - Component - 00
The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.
Observations:
Based upon review of personnel files (PF) and an interview with the administrator, the agency did not ensure Tuberculosis (TB) symptom screen and an individual Tuberculosis (TB) risk assessment was completed for four (4) of four (4) PFS: PF# 1, 2, 3, and 4; did not contatin baseline testing for TB for two (2) of four (4) PFs: PF#1 and 2; and did not contain annual TB education for one (1) of four (4) PF: PF#2.
Findings Include:
The CDC (Centers for Disease Control and Prevention) guidelines state baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or tuberculin skin test (TST), shall include a symptom screen questionnaire and an individual tuberculosis (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 PF's was conducted on July 24, 2023 at 9:45 AM. The date of hire (DOH) is indicated below.
PF#1 DOH 11/21/22 did not contain a second TST and did not contain a TB symptom screen and an individual TB risk assessment.
PF#2 DOH 1/15/21 did not contain a second TST and did not contain a TB symptom screen and an individual TB risk assessment and did not contain annual TB education.
PF#3 DOH 8/31/22 did not contain a TB symptom screen and an individual TB risk assessment.
PF#4 DOH 11/10/22 did not contain a TB symptom screen and an individual TB risk assessment.
An interview with the administrator on July 24, 2023 at 2:20 PM confirmed the above findings.
Plan of Correction:WCHC will ensure that all employees will complete a Tuberculosis (TB) symptom screen and an individual Tuberculosis (TB) risk assessment upon hire. During the the initial New Hire Training WCHC's HR Manager will ensure that all new hire training include Tuberculosis education and Tuberculosis (TB) symptom screen education. WCHC HR Manager will also ensure that all annual in-service training will include Tuberculosis education and Tuberculosis (TB) symptom screen education, with the appropriate documentation to support the training.
WCHC will ensure that all new hire employees receive a 2-step tuberculosis screening. HR Manager and Quality Management Officer will complete quarterly file reviews to ensure to ensure that this objective is maintained.
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 a review of consumer files (CF) and an interview with the administrator, the agency did not provide the Department's complaint Hot Line (800-254-5164) and telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) to the consumer or consumer's legal representative prior to commencement of services for four (4) of four (4) CFs. CF# 1, 2, 3, and 4.
Findings include:
A review of CFs was conducted on July 24, 2023 at 10:30 AM. The start of care (SOC) date is indicated below:
CF#1 SOC 12/6/22 did not contain the Department's complaint hot line telephone number on the document, "Important Contact Information Acknowledgement". The number 800 254-5164 is listed as "DOH License/Agency Verification" and not as the Department complaint hot line.
CF#2 SOC 3/20/23 did not contain the Department's complaint hot line telephone number on the document, "Important Contact Information Acknowledgement". The number 800 254-5164 is listed as "DOH License/Agency Verification" and not as the Department complaint hot line.
CF#3 SOC 8/31/22 did not contain the Department's complaint hot line telephone number on the document, "Important Contact Information Acknowledgement". The number 800 254-5164 is listed as "DOH License/Agency Verification" and not as the Department complaint hot line. CF#3 resides in Montgomery county. File did not include telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) for Montgomery county.
CF#4 SOC 11/10/22 did not contain the Department's complaint hot line telephone number on the document, "Important Contact Information Acknowledgement". The number 800 254-5164 is listed as "DOH License/Agency Verification" and not as the Department complaint hot line.
An interview with the administrator on July 24, 2023 at 2:20PM confirmed the above findings.
Plan of Correction:In initial response to this citation WCHC will update the contact information for Department's complaint Hot Line Ombudsman Program located with the local Area Agency on Aging (AAA). WCHC will also ensure that all Pennsylvania counties that are services by WCHC will be included on all consumers packets.
Quality Manager Officer will ensure that all current consumers receive the updated "List of Important Phone Number". This will be monitored while completing quarterly file reviews.
Initial Comments:
Based on the findings of an offsite state re-licensure survey conducted on July 24, 2023, With Compassion 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 observation of Identification badges (ID) and an interview with the administrator, agency failed to format/issue ID badges per regulatory requirements for one (1) of one (1) observation (Observation #1).
Findings include:
Observation #1: Observation of employee Identification Badge (ID) on July 24, 2023 at approximately 2:20 PM revealed the current ID badge did not contain the employee's job title (Direct Care Worker).
An interview conducted with agency Administrator on July 24, 2023 at approximately 2:30 PM confirmed the above findings.
Plan of Correction:With Compassion Home Care, HR Manager will ensure that all current employee receive updated employee ID Badges including name and position immediately.
WCHC HR Manger will updated to current employee badge template to reflect employee name and job title.
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