Initial Comments:Based on the findings of an unannounced onsite Medicare recertification and state re-licensure survey conducted on February 20-23, 2024, Centerwell Home Health. was found to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.
Plan of Correction:
Initial Comments:Based on the findings of an unannounced onsite Medicare recertification and state re-licensure survey conducted on February 20- 23, 2024, Centerwell Home Health was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.
Plan of Correction:
Initial Comments:Based on the finding of an unannounced, onsite home health agency state re-licensure survey conducted on February 20-23, 2024, Centerwell Home Health was found not to be in compliance with the requirements of 28 PA. Code, Part IV, Health Facilities, Subpart G. Chapter 601.
Plan of Correction:
601.21(f) REQUIREMENT
PERSONNEL POLICIES
Name - Component - 00
601.21(f) Personnel Policies.
Personnel practices and patient care
are supported by appropriate, written
personnel policies. Personnel records
include qualifications, licensure,
performance evaluations, health
examinations, documentation of
orientation provided, and job
descriptions, and are kept current.
Observations:
Based on review of employee files (EFs), agency policy, and interview with agency administrator, the agency failed to obtain/maintain a Pennsylvania (PA) State Police criminal history record (PATCH) at the time of new employee application for four (4) out of seven (7) EFs reviewed (EF#1-4).
Review conducted on February 20, 2024, at approximately 12:00 PM to 1:30 PM, of employee files (EFs) revealed:
EF#1 date of hire (doh) 2/2/2023, no onhire PATCH found.
EF#2 doh 11/14/2023, no onhire PATCH found.
EF#3 doh 10/9/2023, no onhire PATCH found.
EF#4 doh 2/20/2023, no onhire PATCH found.
Review conducted on February 23, 2024, at approximately 10:30 AM, of agency "Background Checks Policy" revealed: "1. Philosophy To protect its associated, clients, assets and reputation, Humana administers background checks consistently and in accordance with federal and state regulations, ...; 3. Policy Humana requires background checks for all candidates for employment and entities having a relationship with any aspect of the business.; "Pre-Employment Checks ... The following components comprise Humana's pre-employment background check process. Standard Package: Criminal Screen."
Interview conducted on February 23, 2024, at approximately 12:30 PM, with administrator revealed confirmation of missing PA PATCHs for EFs #1-4.
Plan of Correction:M1007
This standard will be met as evidenced by:
Corrective Action:
1) The administrator and/or designee will ensure #EF1, #EF2, #EF3, and #EF4 will have required
PATCH run (requested from vendor 2.22.24) and in employee file as required by requirement 28
PA. Code Part IV. Health Facilities. Subpart G Chapter 601.
Tag M1007 completion:
2) The administrator and/or designee will review all employee files to ensure the PATCH report
required has been run (requested from vendor 2.22.24) and is in place in employee record for all
employees currently employed to satisfy 28PA. Code Part IV. Health Facilities. Subpart G Chapter
601.
3) The administrator and or designee is working with the Legal /Regulatory team to ensure PA
state specific policy related to background screening includes the language from 28 PA. Code
Part IV. Health Facilities. Subpart G Chapter 601 requirement to satisfy this requirement.
Education:
1) The administrator and/or designee provided education specific to 28 PA. Code Part IV. Health
Facilities. Subpart G Chapter 601 requirements of PATCH report to all team members involved
in the onboarding of new clinicians on 2.23.24 to ensure Patch report has been run and is
present in the employee file to satisfy 28PA. Code Part IV. Health Facilities. Subpart G Chapter
601.
Monitor:
1) The administrator and/or designee will monitor 100% of new employees x 6 months or until
100% compliance achieved with findings reported out in quarterly QAPI; then ongoing monitor
with personnel record audits will be incorporated into quarterly QAPI and/or QAPI activity
ongoing to ensure PA regulation 28PA. Code Part IV. Health Facilities. Subpart G Chapter 601 is
satisfied.
Tag M1007 completion: 4.10.24
Initial Comments:Based on the findings of an unannounced onsite Medicare recertification and state re-licensure survey conducted on February 20-23, 2024, Centerwell Home Health 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 20-23, 2023, Centerwell Home Health was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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