Initial Comments:
Based on the findings of an unannounced, on-site state re-licensure survey conducted on February 7, 2024, Independence Homecare-Harrisburg, 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 unannounced onsite state re-licensure survey conducted on February 7, 2024, Independence Homecare-Harrisburg, LLC was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries.
Plan of Correction:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
Name - Component - 00
Prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. (3) Require the individual to submit a criminal history report, in accordance with the requirements of § 611.52 (relating to criminal background checks), and a ChildLine verification, if applicable, in accordance with the requirements of § 611.53 (relating to child abuse clearance).
Observations:
Based on review of employee files (EFs), client information package, and interview with the administrator, the agency failed to obtain and complete documentation of two satisfactory references for four (4) of five (5) EFs reviewed (EFs #1-4).
Findings include:
Review conducted on February 7, 2024, at approximately 9:10 AM, of client information booklet revealed: Page 22 of 29 "E. Hiring and Competency Requirements for Direct Care Workers The direct care worker(s) who will be providing services has met the hiring and competency requirements in accordance with Pennsylvania's Home Care Licensing regulations."
Review conducted on February 7, 2024, at approximately 10:45 AM to 12:20 PM, of employee files (EFs) revealed:
EF#1 date of hire (doh) 12/7/23, one reference dated 11/28/23, with no completed evaluation/rating of reference or name of interviewee for reference; and no second reference found.
EF#2 doh 10/20/23, two references dated 10/20/23, with no evaluation/rating of interviewed individuals.
EF#3 doh 12/11/23, no references found.
EF#4, doh 9/25/23, missing evaluation/rating of interviewed individual on #2 reference.
Interview conducted on February 7, 2024, at approximately 1:00 PM, with administrator revealed confirmation of above findings.
Plan of Correction:1. The Administrator will hold a mandatory inservice for all administrative and management staff will be held by 03/06/2024 to educate the staff to the need to follow the state requirement and agency's Policy # HR-1.0 Selecting and Hiring Personnel that notes prior to being hired, the agency will obtain on all employees and complete documentation of two satisfactory references from two individuals who are either former employers or other people not related to the individual.
Staff sign-in sheet, agenda and training documentation will be available on site.
2. The agency Administrator will oversee that management staff has obtained and completed two satisfactory references for each Direct Care Worker (DCW) and these are documented on their Personnel File Checklist, (which proves their complete onboarding) prior to their consumer assignment.
3. In order to avoid this deficiency in the future, this element will be added to the agency's Quality Management Plan: 25% of the direct care worker's personnel files will be audited quarterly to verify that two positive verifiable references from two individuals who are either former employers or other people not related to the individual are completed prior to hire and are part of the personnel file for each direct care worker. Target Threshold = 100%.
The Administrator is responsible.
Corrective Action Completion Date: 03/08/2024
611.51(b) LICENSURE
Direct Care Worker Files
Name - Component - 00
Files for direct care workers employed or rostered shall include documentation of the date of the face-to-face interview with the individual and of references obtained. Direct Care Worker files also shall include other information as required by § 611.52, § 611.53, if applicable, § 611.54, § 611.55 and § 611.56 (relating to criminal background checks, child abuse clearance, provisional hiring, competency requirements; and health evaluations).
Observations:
Based on review of employee files (EFs), client information package, and interview with agency administrator, the agency staff failed to date the face-to-face interview in two (2) out of five (5) EFs reviewed (EFs#1-2).
Findings include:
Review conducted on February 7, 2024, at approximately 9:10 AM, of client information booklet revealed: Page 22 of 29 "E. Hiring and Competency Requirements for Direct Care Workers The direct care worker(s) who will be providing services has met the hiring and competency requirements in accordance with Pennsylvania's Home Care Licensing regulations."
Review conducted on February 7, 2024, at approximately 10:45 AM to 12:20 PM, of employee files (EFs) revealed:
EF#1 date of hire (doh), no date of face-to-face interview documented.
EF#2 doh 10/20/23, no date of face-to-face interview documented.
Interview conducted on on February 7, 2024, at approximately 1:00 PM, with administrator revealed verbal confirmation of above findings.
Plan of Correction:1.The Administrator will hold a mandatory inservice for all administrative and human resources staff is to be held by 03/06/2024 to educate them to the need to follow the state requirement and agency's Policy # HR-1.0-- Selecting and Hiring Personnel which reflects that the agency will always complete a face-to-face interview with the direct care worker prior to hire and document this and the date of the interview in order to maintain it in the personnel file on the agency's Face-to-Face Interview form.
Staff sign-in sheets, agenda and training documentation will be available on site.
2. The agency Administrator will oversee that management staff has completed a Face-to-Face Interview prior to hire with each Direct Care Worker (DCW) and this has been documented on their Personnel File Checklist, (which proves their complete onboarding) prior to their consumer assignment.
3.In order to avoid this deficiency in the future, this element will be added to the agency's Quality Management Plan: 25% of the direct care worker's personnel files will be audited quarterly to verify that there is a face-to-face interview form in the personnel file with the date of the interview noted and form completed in its entirety prior to their date of hire. Target Threshold = 100%.
The Administrator is responsible.
Corrective Action Completion Date: 03/08/2024
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 upon review of employee files (EFs), client information package, and an interview with the agency manager, agency failed to obtain a Federal criminal history record and a letter of determination from the Pennsylvania (PA) Department of Aging for one (1) out of five (5) employee files (EF#3).
Findings include:
Review conducted on February 7, 2024, at approximately 9:10 AM, of client information booklet revealed: Page 22 of 29 "E. Hiring and Competency Requirements for Direct Care Workers The direct care worker(s) who will be providing services has met the hiring and competency requirements in accordance with Pennsylvania's Home Care Licensing regulations."
Review conducted on February 7, at approximately 10:45 AM to 12:20 PM, of employee files (EFs) revealed:
EF#3 date of hire 12/11/23, PA driver license issued 2/17/22 to expiration 3/21/24; staff note stating "FBI results gone missing"; and IdentoGo document dated 11/10/23 with confirmed appointment for EF#3; no FBI report found.
Interview conducted on February 7, 2024, at approximately 1:00 PM, with administrator revealed confirmation of above finding.
Plan of Correction:1.The agency will require an individual being hired who has not been a resident of PA is for the 2 years immediately preceding the date of the request for a criminal history report, 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 the required procedure for the background check).
2. By 3/8/24, the Administrator will request EF#3 to perform a second FBI clearance background check.
3. By 3/6/24, the Administrator will conduct a mandatory inservice for all administrative staff on HR-8.0 Employee Background Checks.
Staff sign-in sheet, agenda and training documentation will be available on site.
4. By 3/8/24, as part of the agency's quality management plan, the Administrator will initiate quarterly audits of new employee files (25%):
a. to verify Pennsylvania state criminal background checks and any other background checks are completed prior to consumer assignment.
b. If not a resident of PA for 2 consecutive years prior to hire, 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)
c. A ChildLine Verification, as appropriate, if in a home where there is likelihood of contact with children.
Target Threshold = 100%.
The Administrator is responsible.
Corrective Action Completion Date: 03/08/2024
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 a review of employee files (EFs), client information booklet, and interview with agency administrator, the agency failed to require direct care workers to furnish proof of Pennsylvania (PA) residency for two years prior to date of hire through submission of any one of the following documents: (1) Motor vehicle records, such as a valid driver's license or a State-issued identification; (2) Housing records, such as mortgage records or rent receipts; (3) Public utility records and receipts, such as electric bills. (4) Local tax records; (5) A completed and signed Federal, State or local income tax return with the applicant's name and address preprinted on it; (6) Employment records, including records of unemployment compensation in one (1) of five (5) EFs reviewed (EF#3).
Findings include:
Review conducted on February 7, 2024, at approximately 9:10 AM, of client information booklet revealed: Page 22 of 29 "E. Hiring and Competency Requirements for Direct Care Workers The direct care worker(s) who will be providing services has met the hiring and competency requirements in accordance with Pennsylvania's Home Care Licensing regulations."
Review conducted on February 7, at approximately 10:45 AM to 12:20 PM, of employee files (EFs) revealed:
EF#3 date of hire 12/11/23, PA driver license issued 2/17/22 to expiration 3/21/24; staff note documented: "FBI results gone missing - new new [word can't be read clearly] added"; and IdentoGo document dated 11/10/23 with confirmed appointment for EF#3; no FBI report found.
Interview conducted on February 7, 2024, at approximately 1:00 PM, with administrator revealed confirmation of above findings.
Plan of Correction:1. The agency will require an individual being hired who has not been a resident of PA is for the 2 years immediately preceding the date of the request for a criminal history report, 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 the required procedure for the background check).
2. By 3/8/24, the Administrator will request EF#3 to perform a second FBI clearance background check.
3. By 3/6/24, the Administrator will conduct a mandatory inservice for all administrative staff on HR-8.0 Employee Background Checks.
Staff sign-in sheet, agenda and training documentation will be available on site.
4. By 3/8/24, as part of the agency's quality management plan, the Administrator will initiate quarterly audits of new employee files (25%):
a.to verify Pennsylvania state criminal background checks and any other background checks are completed prior to consumer assignment.
b. If not a resident of PA for 2 consecutive years prior to hire, 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)
c. A ChildLine Verification, as appropriate, if in a home where there is likelihood of contact with children.
Target Threshold = 100%.
The Administrator is responsible.
Corrective Action Completion Date: 03/08/2024
611.55(a) LICENSURE
Competency Requirements
Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.
Observations:
Based on review of employee files (EFs), client information booklet, and an interview with agency administrator, the agency failed to demonstrate, prior to assigning or referring a direct care worker (DCW) to provide services to a consumer, competency by passing an initial DCW competency examination for two (2) of five (5) EFs reviewed (EF#1, EF#4).
Findings include:
Review conducted on February 7, 2024, at approximately 9:10 AM, of client information booklet revealed: Page 22 of 29 "E. Hiring and Competency Requirements for Direct Care Workers The direct care worker(s) who will be providing services has met the hiring and competency requirements in accordance with Pennsylvania's Home Care Licensing regulations.; and page 23 of 29 In addition, the direct care worker(s), through competency examination and/or training program, has successfully completed the competency requirements ... ."
Review conducted on February 7, 2024, at approximately 10:45 AM to 12:20 PM, of EFs revealed:
EF#1 date of hire (doh) 12/07/23, no initial onhire competency found in EF file.
EF#4 doh 9/25/23, competency test 100% score, missing date of test, no EF name.
Interview conducted on February 7, 2024, at approximately 1:00 PM, with administrator revealed confirmation of above findings.
Plan of Correction:1. By 2/28/2024, the Administrator will require EFs #1 and #4 to complete direct care worker competency exams with the individual's name and date on this exam. These documents will be maintained in their employee files.
2. By 3/6/2024, the Administrator will provide a mandatory inservice to all administrative staff with review of requirements for initial Direct Care Competency Testing process for new employees.
Staff sign-in sheets, minutes and training documentation will be available on site.
3. Effective 3/8/24, the Administrator will add this element to the agency Quality Management plan with 25% of the direct care worker's personnel files audited quarterly to verify that: upon hire, all personnel will complete an initial competency training and testing by passing a Direct Care Competency Exam prior to consumer assignment to provide home care services. The completion of this will be documented on the competency evaluation checklist and personnel file checklist to ensure continued compliance with the PA regulations.
Target Threshold = 100%.
The Administrator is responsible.
Corrective Action Completion Date: 03/08/2024
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), client information booklet, and interview with agency administrator, the agency failed to complete and document individual Direct Care Worker (DCW) annual competency test in one (1) out of five (5) EFs reviewed (EF#5).
Findings Include:
Review conducted on February 7, 2024, at approximately 9:10 AM, of client information booklet revealed: Page 22 of 29 "E. Hiring and Competency Requirements for Direct Care Workers The direct care worker(s) who will be providing services has met the hiring and competency requirements in accordance with Pennsylvania's Home Care Licensing regulations.; and page 23 of 29 In addition, the direct care worker(s), through competency examination and/or training program, has successfully completed the competency requirements ... ."
Review conducted on February 7, 2024, at approximately 10:45 AM to 12:20 PM, of EFs revealed:
EF#5, date of hire 5/13/21, no 2023 competency documentation.
Interview conducted on February 7, 2024, at approximately 1:00 PM, with administrator revealed confirmation of above findings.
Plan of Correction:1. By 2/28/2024, the administrator will require EF#5 complete their 2023 annual competency evaluation and Direct Care Competency Exam. This document will be placed in their employee file.
2. By 3/6/2024, the administrator will perform a mandatory inservice for all administrative and management staff to review agency policy HR#-4.0 Competency Requirements with required 16 subject areas for direct care staff.
3. By 3/8/24, the administrator or designee will audit 100% of current personnel records for completion of annual competency exams. If any gaps are found, the individual will be required to complete the missing annual competency exam and document will be stored in their personnel file.
4. In order to avoid this deficiency in the future, the Administrator will add this element to the agency's Quality Management Plan with 25% of the direct care worker's personnel files audited quarterly to ensure completion of annual direct care staff competency with documentation on the competency evaluation checklist to comply with PA regulations.
Target threshold = 100%
The Administrator is responsible.
Accomplishment Date 03/08/2024
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), client information booklet, agency policy, and an interview with the agency administrator, the agency failed to ensure each direct care worker completed annual tuberculosis (TB) risk education for one (1) out of five (5) EFs reviewed (EF#5).
Findings include:
Review conducted on February 7, 2024, at approximately 9:10 AM, of client information booklet revealed: Page 22 of 29 "E. Hiring and Competency Requirements for Direct Care Workers The direct care worker(s) who will be providing services has met the hiring and competency requirements in accordance with Pennsylvania's Home Care Licensing regulations."
Review conducted on February 7, 2024, at approximately 12:30 PM, 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. 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 conducted on February 7, 2024, at approximately 10:45 AM to 12:20 PM, of EFs revealed:
EF#5 date of hire 5/13/21, missing annual TB education for 2023.
Review conducted on February 7, 2024, at approximately 12:50 PM, of agency policy HR-6.0 Tuberculosis Screening revealed: "Independence Homecare requires that applicants and person who are employed be tested for Mycobacterium Tuberculosis (M. Tuberculosis) be free from active M. Tuberculosis prior to client contact. This includes the completion of all initial and annual documentation including a screening risk assessment questionnaire."
Interview conducted on February 7, 2024, at approximately 1:00 PM, with administrator revealed confirmation of above findings.
Plan of Correction:1. The agency shall follow the state guidelines and the agency Policy # HR-6.0 Tuberculosis Screening to ensure each direct care worker, other office staff or contractors with direct consumer contact are provided with annual mycobacterium tuberculosis education.
2. The staff person noted under EF# 5 with date of hire 5/13/21, missing their annual TB education for 2023 will receive the 2023 annual mycobacterium tuberculosis education that was missed by 02/28/2024.
3. A mandatory inservice for all administrative and management staff is to be held by 03/06/2024 to educate staff to the need to follow the state requirement and agency's Policy # HR-6.0 Tuberculosis Screening to ensure each direct care worker, other office staff or contractors with direct consumer contact are provided with annual mycobacterium tuberculosis education.
Staff sign-in sheets, agenda and training documentation will be available on site.
4. 100% of current personnel records will be audited by the Administrator to ensure evidence that all direct care workers, other office staff or contractors with direct consumer contact received their mycobacterium tuberculosis (TB) education in 2023. Any staff found to be missing the education will be educated by 02/28/2024. The Administrator is responsible for completion of the audit and providing any missing education to staff by 02/28/2024. Target threshold = 100%.
In order to avoid this deficiency in the future, this element will be added to the agency's Quality Management Plan for 2024 with 25% of the direct care worker's personnel files audited quarterly to verify that: all direct care workers, other office staff or contractors with direct consumer contact received their annual mycobacterium tuberculosis (TB) education. Target Threshold = 100%.
The Administrator is responsible.
Corrective Action Completion Date: 03/08/2024
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 client information booklet, consumer files (CFs), and an interview with the agency administrator, the agency failed to provide the consumer, prior to commencement of services total fees/costs for services per hour or weekly basis in five (5) out of five (5) CFs reviewed (CFs#1-5).
Findings include:
Review conducted on February 7, 2024, at approximately 9:30 AM to 9:40 AM, agency client information booklet revealed no written statement of total services fees/costs for services per hour or weekly basis owed by consumer/client to agency.
Review conducted on February 7, 2024, at approximately 10:05 AM to 10:40 AM, of CFs revealed:
CF#1 start of care (soc) 10/21/23, no documentation services total fees/costs for services per hour or weekly basis owed by consumer/client to agency.
CF#2 soc 12/11/23, no documentation services total fees/costs for services per hour or weekly basis owed by consumer/client to agency.
CF#3 soc 7/10/22, no documentation services total fees/costs for services per hour or weekly basis owed by consumer/client to agency.
CF#4 soc 10/17/22, no documentation services total fees/costs for services per hour or weekly basis owed by consumer/client to agency.
CF#5 soc 10/6/23, no documentation services total fees/costs for services per hour or weekly basis owed by consumer/client to agency.
Interview conducted on February 7, 2024, at approximately 1:00 PM with administrator revealed confirmation of above findings.
Plan of Correction:1. The agency has updated the Consumer Service Agreement to include a listing of total fees/costs for services per hour to provide to all consumers prior to commencement of their services.
2. The following action will be taken with CFs # 1 through 5: all will receive the new updated Consumer Service Agreements which will include a listing of total fees/costs for services per hour, the agreement will be resigned with the new date when they are provided to the consumers which will be by 02/28/2024.
3. A mandatory inservice for all administrative and management staff is to be held regarding the need to provide agency Consumer Service Agreement to include a listing of total fees/costs for services per hour to provide to all consumers prior to commencement of their services.
Staff sign-in sheets, agenda and training documentation will be available on site.
4. All current agency consumers will receive new Consumer Service Agreements which will include a listing of total fees/costs for services per hour, their agreements will be resigned with the new date when they are provided to the consumer which will be by 03/08/2024.
The Administrator will oversee that all consumer files are audited and 100% of the records contain the new consumer service agreement. Target threshold = 100%.
5. Effective 02/22/2024 going forward, all new consumers admitted to the program will receive the new consumer service agreement which will include a listing of total fees/costs for services per hour.
The Administrator is responsible.
Corrective Action Completion Date: 03/08/2024
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey conducted on February 7, 2024, Independence Homecare-Harrisburg, LLC was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
|