Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey completed on March 13, 2024, Worthy Love and Care Homecare, 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 state re-licensure survey completed on March 13, 2024, Worthy Love and Care Homecare, 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 personnel files (PF) and employee (EMP) interview the agency failed to ensure that a face-to-face interview was conducted for four (4) of four (4) PFs reviewed (PF1-4). The agency also failed to obtain two satisfactory references prior to hiring/rostering a direct care worker for three (3) of four (4) PFs reviewed (PF2-4).
Findings included:
Review of PFs conducted on March 13, 2024, between approximately 12:00pm and 1:00pm revealed:
PF1, date of hire (DOH)10/10/23, start of services (SOS) 11/2/23, failed to include evidence of face-to-face interview.
PF2, DOH 12/19/23, SOS 12/19/23, failed to include evidence of face-to-face interview and two satisfactory references.
PF3, DOH 10/28/23, SOS 10/26/23, failed to include evidence of face-to-face interview and two satisfactory references.
PF4, DOH 10/10/23, SOS 10/12/23, failed to include evidence of face-to-face interview and two satisfactory references.
Findings confirmed at exit interview with Owner on March 13, 2024, at approximately 2:30pm.
Plan of Correction:Moving forward Worthy Love and Care Home care will provide documentation of face to face interview. Face to Face interview form has been created and will also include a section in which describes appearance to verify in person contact has been made.
In addition to the creation and implementation of interview forms for new hires, a reference verification form will be completed by the interviewer confirming dates, times, and a series of reference questions that will be included in the employee file and verification documentation.
To ensure that this this process is not overlooked and this non-compliant practice doesn't continue, a final onboarding/hiring review will be completed by agency CEO before first day of work. This process will be monitored and reviewed initially during the hiring process and onboarding process for all potential employees in addition to this it will also be reviewed in on the monthly basis by agency CEO to ensure that all employee files remain in compliance
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 personnel files (PF) and employee (EMP) interview the agency failed to obtain a federal criminal history report and a letter of determination from the Department of Aging for two (2) of four (4) PFs reviewed who did not have evidence of residence of the Commonwealth within the preceding two years of hire (PF1 & 3).
Findings included:
Review of PFs conducted on March 13, 2024, between approximately 12:00pm and 1:00pm revealed:
PF1, date of hire (DOH)10/10/23, start of services (SOS) 11/2/23, PF failed to contain evidence of residency in the state of Pennsylvania for the 2 years immediately preceding hire, failed to contain evidence of a federal criminal history report and a letter of determination from the Department of Aging obtained upon application or within 12 months preceding hire.
PF3, DOH 10/28/23, SOS 10/26/23, PF failed to contain evidence of residency in the state of Pennsylvania for the 2 years immediately preceding hire, failed to contain evidence of a federal criminal history report and a letter of determination from the Department of Aging obtained upon application or within 12 months preceding hire.
Findings confirmed at exit interview with Owner on March 13, 2024, at approximately 2:30pm.
Plan of Correction:Moving forward Worthy Love and Care Home Care will be sure to confirm that all onboarding employees who is unable to provide proof of PA residency for 2 years to obtain additional documents such as a utility or tax return from the previous year. In the event that these documents are unable to be provided an FBI check will be required.
To ensure that this practice will not reoccur, Worthy Love and Care will add the legal residency requirements to the new hire onboarding checklist in which all accepted documents will be listed for reference.
To ensure that these practices are being followed and to prevent these sort of non compliant practices the CEO of the agency will be responsible for preforming a final review of employee file prior to start date of work to ensure 2 years of residency has been established OR required documents to suffice has been provided.
This review will be completed finalizing the initial onboarding and hiring process with an approved start date to begin work. In addition to this final review CEO will monitor files on the monthly basis moving forward to ensure that all employees remain in compliance.
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 personnel files (PF) and employee (EMP) interview the agency failed to obtain proof of residency for two (2) of four (4) PFs reviewed (PF1 & 3).
Findings included:
Review of PFs conducted on March 13, 2024, between approximately 12:00pm and 1:00pm revealed:
PF1, date of hire (DOH)10/10/23, start of services (SOS) 11/2/23, revealed a Pennsylvania driver's license with an issued date of 7/2/22. The agency could provide no other documentation to prove residence of this commonwealth for two years preceding the date of hire.
PF3, DOH 10/28/23, SOS 10/26/23, revealed a Pennsylvania identification with an issued date of 5/1/23. The agency could provide no other documentation to prove residence of this commonwealth for two years preceding the date of hire.
Findings confirmed at exit interview with Owner on March 13, 2024, at approximately 2:30pm.
Plan of Correction:In the event that proof of residence is unable to be provided by potential employee during the hiring and onboarding process, Worthy Love and Care will require proof of a utility bill, tax document, unemployment employment document, or previous mortgage or rent receipts.
In the event that these documents are not able to be produced by the employee, then a Federal Background Check will need to be completed to suffice for 2 established years of residency and will be required before start of employment.
Moving forward, to ensure that agency remains compliant and to avoid non complaint practices , agency CEO will implement a new hire check list and this checklist will be reviewed and finalized with a official start date of work by CEO. Monitoring of this practice will be annually.
Employee files will be reviewed by agency CEO post hire on the ongoing monthly basis with checklist tool to ensure compliance and to catch potential non compliance issues.
611.56(a) LICENSURE
Health Screening
Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.
Observations:
Based on a review of personnel files (PF), the Centers for Disease Control (CDC) guidelines, and an interview with the owner, the agency did not ensure that each direct care worker with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis for three (3) of four (4) PF reviewd (PF1, 2 & 4).
Findings included:
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 PFs conducted on March 13, 2024, between approximately 12:00pm and 1:00pm revealed:
PF1, date of hire (DOH)10/10/23, start of services (SOS) 11/2/23, failed to include evidence of tuberculosis screening upon hire or one year proceeding. No evidence of tuberculosis screening prior to consumer contact..
PF2, DOH 12/19/23, SOS 12/19/23, included negative chest x-ray for tuberculosis dated 12/20/23, dated after consumer contact.
PF4, DOH 10/10/23, SOS 10/12/23, included negative tuberculosis screening dated 3/11/24, dated after consumer contact.
Findings confirmed at exit interview with Owner on March 13, 2024, at approximately 2:30pm.
Plan of Correction:Moving forward Worthy Love and Care Homecare will be sure that there is documented record of TB screening upon hire and prior to consumer contact. We will be sure that all Screenings are dated prior to consumer contact and have been issued within one year.
To avoid these practices in the future, CEO will be sure to obtain these documents during the hiring and onboarding process making sure that Test are withing correct dates and time span and are in compliance with CDC along with annual TB education. Proceeding this monthly a review will be conducted by CEO to ensure dates remain complaint.
To ensure that TB test are actually compliant an agency TB test form and TB annual education and screening form will be created by agency CEO and will be used as a tool during the hiring process for all employees to ensure dates are compliant before start date of work and remain in compliance annually.
This will be implemented and reviewed during the initial hiring process and annually by agency CEO. Screening, risk assessment, and education will be provided and documented by CEO . Acknowledgement of education and signature will be obtained by the employee.
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 (CDC) guidelines, and an interview with the owner, the agency failed to ensure that tuberculosis screening be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings for three (3) of four (4) PF reviewd (PF1, 2 & 4).
Findings included:
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 PFs conducted on March 13, 2024, between approximately 12:00pm and 1:00pm revealed:
PF1, date of hire (DOH)10/10/23, start of services (SOS) 11/2/23, failed to include evidence of tuberculosis screening upon or within 1 year preceeding hire.
PF3, DOH 10/28/23, SOS 10/26/23, failed to include evidence of second step of tuberculosis screening upon hire.
PF4, DOH 10/10/23, SOS 10/12/23, failed to include evidence of second step of tuberculosis screening.
Findings confirmed at exit interview with Owner on March 13, 2024, at approximately 2:30pm.
Plan of Correction:Moving forward Worthy Love and Care Homecare will be sure that all employees have a 2 step TB screening upon hire or within 1 year proceeding hire and before having any contact with any employees.
Worthy Love and Care Homecare will educate employees annually with symptom screening, risk assessment, and training adhering to CDC Health Care Workers requirements.
To avoid this practice from reoccurring, all TB screenings will be obtained and verified during the hiring and onboarding process and before having any direct contact with any consumers. Final review and start date of work will be conducted and provided to employee by Agency CEO if TB is compliant .
Employee Files will be reviewed during the onboarding and hiring process with TB form check list created by agency CEO as a tool for accuracy.
Files will also be reviewed and monitored monthly by agency CEO to ensure dates remain complaint until annual date approaches where education and training will be provided as well by CEO.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey completed on March 13, 2024, Worthy Love and Care Homecare, Llc was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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