Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on March 7, 2024, Mc Cares, LLC, was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on March 7, 2024, Mc Cares, 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:
611.4(c) LICENSURE
Requirements for HCA and HCR
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Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.
Observations:
Based on review of personnel files (PF), and the Philadelphia Department of Public Health, Division (PDPH) of COVID-19 Containment Health Alert Dated 10/14/2021, the agency failed to provide documentation that six (6) of seven (7) PF's (PF#1, 2, 3, 4, 6, and 7 ) employees were vaccinated against COVID-19 or received a medical/religious exemption.
Findings include:
Philadelphia Department of Public Health, Division of COVID-19 Containment Health Alert Dated 10/14/2021, states "Exemptions: An individual may not simply opt out of vaccination. They must submit a medical or religious exemption to the Healthcare Institution where such individual works according to the policies set by the institution. The Institution will determine if an exemption applies. Healthcare Institutions and organizations that are granting exemptions must create appropriate exemption policies to implement this regulation. Institutions may establish stricter vaccination policies for their workers, contractors, and volunteers that exceed the requirements of the Vaccine Mandate Regulation, to the extent
otherwise permitted by applicable law.
A Healthcare Worker or Healthcare Institution Worker who is granted an exemption must strictly follow the applicable accommodation, including documenting their participation in the accommodation process that their employer or institution has agreed upon. Healthcare Institutions are required to keep records of vaccination status of all vaccinated individuals, exemptions requested and granted, and participation in accommodations granted. Records must be made available to PDPH upon request.
Self-employed Healthcare Workers must carefully document the need for exemption and ongoing compliance with routine testing as set forth below under " Accommodations for Exceptions. "
Medical
The Healthcare Worker or Healthcare Institution Worker may request an exemption by submitting a certification from a licensed healthcare provider to the appropriate Healthcare Institution. Medical exemptions must include a statement signed by a licensed healthcare provider that states the exemption applies to the specific individual submitting the certification because the COVID-19 vaccine is medically contraindicated for the individual. The certification must also be signed by the Healthcare Worker or Healthcare Institution Worker. For the purposes of the Vaccine Mandate Regulation a licensed healthcare provider means a physician, nurse practitioner, or physician assistant licensed by an authorized state licensing board.
Religious
The Healthcare Worker or Healthcare Institution Worker may request an exemption by submitting a signed statement in writing that the individual has a sincerely held religious belief that prevents them from receiving the COVID-19 vaccination. An institution may request the worker explain in the certification why the worker ' s religious belief prevents them receiving the COVID-19 vaccine. Philosophical or moral exemptions are not permitted.
A review of PF's was conducted on March 07, 2024, approximately 12:15 pm
PF #1, Date of Hire: 1/14/2024, did not contain any documentation that the employee received COVID-19 vaccination(s). The employee's file did not contain any documentation of exemption present to determine compliance with the PDPH COVID-19 guidelines. DCW is caring for consumers who live in Philadelphia.
PF #2, Date of Hire: 12/5/2023, did not contain any documentation that the employee received COVID-19 vaccination(s). The employee's file did not contain any documentation of exemption present to determine compliance with the PDPH COVID-19 guidelines. DCW is caring for consumers who live in Philadelphia.
PF #3 Date of Hire: 1/16/2024, did not contain any documentation that the employee received COVID-19 vaccination(s). The employee's file did not contain any documentation of exemption present to determine compliance with the PDPH COVID-19 guidelines. DCW is caring for consumers who live in Philadelphia.
PF #4, Date of Hire: 9/25/2018, did not contain any documentation that the employee received COVID-19 vaccination(s) in addition, the employee's file did not contain any documentation of exemption present to determine compliance with the PDPH COVID-19 guidelines. DCW is caring for consumers who live in Philadelphia.
PF #6, Date of Hire: 10/26/2023, did not contain any documentation that the employee received COVID-19 vaccination(s) in addition, the employee's file did not contain any documentation of exemption present to determine compliance with the PDPH COVID-19 guidelines. DCW is caring for consumers who live in Philadelphia.
PF #7, Date of Hire: 2/6/2024, did not contain any documentation that the employee received COVID-19 vaccination(s) in addition, the employee's file did not contain any documentation of exemption present to determine compliance with the PDPH COVID-19 guidelines. DCW is caring for consumers who live in Philadelphia.
An interview with the administer conducted on March 07, 2024, at approximately 2:30 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 including and specifically Personnel file #'s (PF#1, 2, 3, 4, 5, 6 & 7) as directed by Citation 0120.
The review showed the Agency does/did require its employees' to get vaccinated under as was required and directed by the CDC, State of PA and other related health organizations, including the Philadelphia Department of Public Health, Division of COVID-19 Containment Health Alert Dated 10/17/2022, but did not get the proof of such vaccination from the employees'.
Additionally, Agency through its legal counsel confirmed on 3/11/24; the Philadelphia Health Alert ended on 10/23/23; Agency counsel is sending Agency proof of such termination.
Nevertheless, to correct this error and to prevent similar failures from reoccurring this Agency shall require documented proof of vaccination from all it's employees' as required and directed the CDC, State of PA and other related health organizations. All deficiencies under Citation 0120 have been addressed. Our company corrections will be completed by 05/07/2024.
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
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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 Personal files (PF) and an interview with the administrator, the agency failed to ensure that prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (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 for three (3) of the seven (7) PF's, (PF # 1, 6 and 7).
Findings include:
A review of PF's was conducted on February 26, 2024 at approximately 11:35 am.
PF # 1 Date of Hire 1/14/24 did not contain any documentation of two satisfactory and verifiable references. One reference was from a relative.
PF # 6 Date of Hire 10/10/23 did not contain any documentation of two satisfactory and verifiable references.
PF # 7 Date of Hire 2/6/24 did not contain any documentation of two satisfactory and verifiable references. References were from relatives.
An interview with the administrator on March 7, 2024 at approximately 2:30 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 including and specifically Personnel file #'s (1, 6 and 7), as directed by Citation 0200.
The review showed the Agency policy is it must perform face to face interviews and reference checks for employees, but there was no professional reference check for employees' personnel #'s (1, 6 and 7) as required by 611.51(a).
To correct this error on March 11, 2024; the Admin asked the specified employees for Professional reference and begun contacting said refences for employees' personnel #'s (1, 6 and 7).
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 May 7, 2024; with the EPIP implementation, all employee Personnel file's including file #'s (1, 6 and 7),have all required reference checks and documents as directed by 611.51(a). All deficiencies under Citation 0200 have been addressed.
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 on a review of personnel files (PF), the Centers for Disease Control Guidelines, and an interview with the administrator, the agency failed to provide documentation of a two (2) step PPD being administered and initial tuberculosis screening questionnaire/risk assessment for seven (7) of seven (7) PF's reviewed, (PF #1, 2, 3, 4,5, 6, and 7).
Findings:
In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: receive baseline tuberculosis screening upon hire by using: a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB), or a negative chest x-ray to test for infection with tuberculosis. 2. Completion of a tuberculosis symptom questionnaire. And 3. Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCWs should receive TB education annually. HCWs with a baseline 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;(5-16-19)
A review of PF's was conducted on March 7, 2024 at approximately 12:15 pm.
PF #1 Date of Hire 1/14/2024, contained documentation of only a one-step tuberculosis skin test dated 11/13/2023. No initial TB Risk Assessment/ Symptom Screen and documentation that a 2 step PPD was administered upon hire or prior to assigning direct care worker (DCW) to consumers.
PF #2 Date of Hire 12/05/2023,contained documentation of only a one-step tuberculosis skin test dated 12/2/2023. No initial TB Risk Assessment/ Symptom Screen and documentation that a 2 step PPD was administered upon hire or prior to assigning direct care worker (DCW) to consumers.
PF #3 Date of Hire 1/16/2024, contained documentation of only a one-step tuberculosis skin test dated 12/03/2023. No initial TB Risk Assessment/ Symptom Screen and documentation that a 2 step PPD was administered upon hire or prior to assigning direct care worker (DCW) to consumers.
PF #4 Date of Hire 1/03/2024, contained documentation dated 11/19/2023 from a physician that PF#4 tuberculosis test was negative. However, the notification did not indicated the method in which the test was administered, only the results. No initial TB Risk Assessment/ Symptom Screen and documentation that a 2 step PPD was administered upon hire or prior to assigning direct care worker (DCW) to consumers.
PF #5 Date of Hire 11/15/2023, contained documentation of only a one-step tuberculosis skin test dated 10/12/2023. No initial TB Risk Assessment/ Symptom Screen and documentation that a 2 step PPD was administered upon hire or prior to assigning direct care worker (DCW) to consumers.
PF #6 Date of Hire 10/26/2023, contained documentation of only a one-step tuberculosis skin test dated 10/16/2023. No initial TB Risk Assessment/ Symptom Screen and documentation that a 2 step PPD was administered upon hire or prior to assigning direct care worker (DCW) to consumers.
PF #7 Date of Hire 2/6/2024, contained documentation of a negative QuantiFERON Gold test. No initial TB Risk Assessment/ Symptom Screen was completed upon hire or prior to assigning direct care worker (DCW) to consumers.
Interview with the administer on March 07, 2024 at approximately 2:30PM 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 including and specifically Personnel file #'s (PF# 1, 2, 3, 4, 5, 6 & 7) as directed by Citation 0701.
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 employees'.
To correct this error as of March 11, 2024; the Admin has contacted the identified employees' and (PF# 1, 2, 3, 4, 5, 6 & 7) and requested all 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 May 7th, 2024; with the EPIP implementation, all employee Personnel file's including file employees' and (PF# 1, 2, 3, 4, 5, 6 & 7) have all required documents as directed by 611.51(a). All deficiencies under Citation 0701 have been addressed.
611.57(c) LICENSURE
Information to be Provided
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(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, prior to the commencement of services, the home care agency did not provide to the consumer, the consumer's legal representative or a responsible family member (1) The identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (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 local Area Agency on Aging (AAA). (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 for five (5) of the five (5) CF's reviewed.
Findings include:
A review of CF's were conducted on March 07, 2024 starting at approximately 10:45 AM indicated the following:
CF#1 SOC 1/21/2024 did not contain the identity of the direct care worker who would be providing services and the hours when the services will be provided. Information was provided regarding 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 but no telephone number was listed. The telephone number of the local Area Agency on Aging (AAA) for Philadelphia was listed but the agency provides services to other consumers who reside in Bucks County. The Consumer Information Booklet contained the contact information for the local Area Agency on Aging (AAA) for all counties served. 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 was present but did not have all areas for the consumer to initial the appropriate sections.
CF#2 SOC 11/06/2023 did not contain the identity of the direct care worker who would be providing services and the hours when the services will be provided. Information was provided regarding 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 but no telephone number was listed. The telephone number of the local Area Agency on Aging (AAA) for Philadelphia was listed but the agency provides services to other consumers who reside in Bucks County. The Consumer Information Booklet contained the contact information for the local Area Agency on Aging (AAA) for all counties served. 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 was present but did not have all areas for the consumer to initial the appropriate sections.
CF#3 SOC 2/19/2024 did not contain the identity of the direct care worker who would be providing services and the hours when the services will be provided. Information was provided regarding 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 but no telephone number was listed. The telephone number of the local Area Agency on Aging (AAA) for Philadelphia was listed but the agency provides services to other consumers who reside in Bucks County. The Consumer Information Booklet contained the contact information for the local Area Agency on Aging (AAA) for all counties served. 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 was present but did not have all areas for the consumer to initial the appropriate sections.
CF#4 SOC 11/05/2023 did not contain the identity of the direct care worker who would be providing services and the hours when the services will be provided. Information was provided regarding 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 but no telephone number was listed. The telephone number of the local Area Agency on Aging (AAA) for Bucks County where the consumer resides a majority of the time. The Consumer Information Booklet contained the contact information for the local Area Agency on Aging (AAA) for Philadelphia County AAA, where the consumer resides on a part time basis. 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 was present but did not have all areas for the consumer to initial the appropriate sections.
CF#5 SOC 12/03/2023 did not contain the identity of the direct care worker who would be providing services and the hours when the services will be provided. Information was provided regarding 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 but no telephone number was listed. The telephone number of the local Area Agency on Aging (AAA) for Philadelphia was listed but the agency provides services to other consumers who reside in Bucks County. The Consumer Information Booklet contained the contact information for the local Area Agency on Aging (AAA) for all counties served. 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 was present but did not have all areas for the consumer to initial the appropriate sections.
An interview conducted with the administrator on March 7, 2024 starting at 2:30 PM confirmed the above findings.
Plan of Correction:A review of the Agency Patients files reveals the Agency does provide new Patients with the required Homecare Notices and Service requirements as required by chapter 611.57; however, a review of the Consumer Files revealed the Agency did provide State Required Consumers Disclosures Notices but some Notices ("Welcome Packages") had the incorrect contact information for the local Area Agency on Aging (AAA) for their respective county and some did not have the assigned DCW and related employee status.
To correct citation and ensure this Agency is in future compliance, the Admin has reviewed the Agency's entire Consumer files including and specifically Consumer Files as directed by Citation 0820.
On March 11. 2024; the Admin begun Contacting all Patients and providing them with updated Welcome Packages, that contain the correct contact information for the local Area Agency on Aging (AAA) for their respective counties and assigned DCW and related employee status.
To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP"). This Policy will ensure all Patient Welcome Packages are in compliance of 611.57. As of May 07, 2024; with the new process implementation, all Consumer file's have all been updated as directed by 611.57(d). All deficiencies under Citation 0820 have been addressed ), 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 an onsite unannounced home care agency state re-licensure survey conducted on March 7, 2024, Mc Cares, 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 a review of personnel files (PF) and an interview with the administrator, the agency did not provide photo identification badges in accordance with regulation for seven (7) of seven (7) PFs. PF# 1, 2, 3,4,5,6,and 7.
Findings include:
A review of personnel files (PF) was conducted on March 07, 2024 at 12:15 PM. The date of hire (DOH) is indicated below:
PF#1 DOH 1/14/2024 did not contain a photo identification badge.
PF#2 DOH 12/5/2023 did not contain a photo identification badge.
PF#3 DOH 1/16/2024 did not contain a photo identification badge.
PF#4 DOH 1/3/2024 did not contain a photo identification badge.
PF#5 DOH 11/15/2023 did not contain a photo identification badge.
PF#6 DOH 10/26/2023 did not contained a photo identification badge.
PF#7 DOH 2/6/2024 did not contain a photo identification badge.
An interview with the administrator on March 07, 2024 at 2:30PM confirmed that none of the employees were provided with a photo identification badge.
Plan of Correction:To ensure this Agency is in future compliance and to correct this error as of May 07, 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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