Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed July 19, 2024, Cornerstone Caregiving East Llc was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed July 19, 2024, Cornerstone Caregiving East Llc was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.
Plan of Correction:
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 a review of personnel files (PF) and employee interview (EMP) the agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for two (2) of seven (7) direct care worker personnel files (PF) reviewed (PF2 and PF3).
Findings included:
Personnel File (PF) reviews of Direct Care Workers (DCW) conducted on 7/19/24, at 11:32 a.m. revealed the following:
PF2 , Date of Hire 5/9/24, DCW file contained a West Virginia driver's license, and a work history of employment in West Virginia for the last five years. The PF did not contain a federal criminal history record and letter of determination from the Department of Aging.
PF3 , Date of Hire 5/15/24, DCW file contained an Ohio driver's License. The PF did not contain a federal criminal history record and letter of determination from the Department of Aging.
Interview with the Director of Operations (EMP1) conducted on 7/19/24, at approximately 1:07 p.m. confirmed the above findings.
Plan of Correction:Will obtain a federal background check on PF2 and PF3 along with any current and/or future caregivers that are out of state and have not been residents of PA for the last 2 years. Will audit employee files quarterly. Audits and corrections will be completed by 09/16/2024.
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 personnel files (PF) and employee interviews (EMP) the agency failed to ensure personal files contained two years proof of residency, for four (4) of seven (7) direct care worker personnel files (PF) reviewed (PF1, PF4, PF5, and PF7).
Findings include:
Personnel file (PF) reviews of Direct Care Workers (DCW) conducted on 7/19/24, at 11:32 a.m. revealed the following:
PF1, Date of Hire 3/27/24, DCW file contained a Pennsylvania identification card issued 9/18/23 (not two years preceding the date of hire).
PF4, Date of Hire 6/12/24, DCW file contained a Pennsylvania driver's license issued 11/7/22 (not two years preceding the date of hire).
PF5, Date of Hire 7/3/24, DCW file contained a Pennsylvania identification card issued 8/22/23 (not two years preceding the date of hire).
PF7, Date of Hire 3/28/24, DCW file contained a Pennsylvania driver's license issued 1/11/23 (not two years preceding the date of hire).
Interview with the Director of Operations (EMP1) conducted on 7/19/24, at approximately 1:07 p.m. confirmed the above findings.
Plan of Correction:Will obtain proof of residency of the last 2 years for PF1, PF4, PF5, and PF7 along with any current and future employees. Will have employees furnish proof of residency with one of the following: Housing records, Public utility records, local tax records, and/or signed tax return. Will audit employee files quarterly. Audits and corrections will be completed by 09/16/2024.
611.55(b) LICENSURE
Competency Requirements
Name - Component - 00
A competency examination or training program developed by an agency or registry for a direct care worker shall address, at a minimum, the following subject areas: 1. Confidentiality; 2. Consumer control and the independent living philosophy; 3. Instrumental activities of daily living; 4. Recoginizing changes in the consumer that need to be addressed; 5. Basic infection control; 6. Universal precautions; 7. Handling of emergencies; 8. Documentation; 9. Recognizing and reporting abuse or neglect; and 10. Dealing with difficult behaviors.
Observations:
Based on a review of personnel files (PF) and employee interviews (EMP) the agency failed to maintain within Direct Care Worker (DCW) Personnel files documentation of a completed competency examination or training program covering 1. Confidentiality; 2. Consumer control and the independent living philosophy; 3. Instrumental activities of daily living; 4. Recognizing changes in the consumer that need to be addressed; 5. Basic infection control; 6. Universal precautions; 7. Handling of emergencies; 8. Documentation; 9. Recognizing and reporting abuse or neglect; and 10. Dealing with difficult behaviors, for six (6) of seven (7) direct care worker personnel files (PF) reviewed (PF1, PF2, PF3, PF4, PF5, and PF7).
Findings included:
Personnel File (PF) reviews of Direct Care Workers (DCW) conducted on 7/19/24, at 11:32 a.m. revealed the following:
PF1, Date of Hire 3/27/24, DCW file did not contain documentation of a completed competency examination or training program.
PF2, Date of Hire 5/9/24, DCW file did not contain documentation of a completed competency examination or training program.
PF3, Date of Hire 5/15/24, DCW file did not contain documentation of a completed competency examination or training program.
PF4, Date of Hire 6/12/24, DCW file did not contain documentation of a completed competency examination or training program.
PF5, Date of Hire 7/3/24, DCW file did not contain documentation of a completed competency examination or training program.
PF7, Date of Hire 3/28/24, DCW file did not contain documentation of a completed competency examination or training program.
Interview with the Director of Operations (EMP1) conducted on 7/19/24, at approximately 1:07 p.m. confirmed the above findings.
Plan of Correction:Will develop a competency exam to be completed during the interview process. Competency exam will include the 10 subjects areas listed in Section 611.55(b). PF1-7 along with current employees will complete exam within the next 60 days. Will audit employee files quarterly. Audits and corrections will be completed by 09/16/2024.
611.55(c) LICENSURE
Competency Requirements
Name - Component - 00
A competency examination or training program developed by an agency or registry for a direct care worker who will provide personal care must address the following additional subject areas: 1. Bathing, shaving, grooming and dressing; 2. Hair, skin and mouth care; 3. Assistance with ambulation and transferring; 4. Meal preparation and feeding; 5. Toileting; 6. Assistance with self-administered medications.
Observations:
Based on a review of personnel files (PF) and employee interviews (EMP) the agency failed to maintain within Direct Care Worker (DCW) Personnel files documentation of a completed competency examination or training program covering 1. Bathing, shaving, grooming and dressing; 2. Hair, skin and mouth care; 3. Assistance with ambulation and transferring; 4. Meal preparation and feeding; 5. Toileting; 6. Assistance with self-administered medications for six (6) of seven (7) direct care worker personnel files (PF) reviewed (PF1, PF2, PF3, PF4, PF5, and PF7).
Findings included:
Personnel File (PF) reviews of Direct Care Workers (DCW) conducted on 7/19/24, at 11:32 a.m. revealed the following:
PF1, Date of Hire 3/27/24, DCW file did not contain documentation of a completed competency examination or training program.
PF2, Date of Hire 5/9/24, DCW file did not contain documentation of a completed competency examination or training program.
PF3, Date of Hire 5/15/24, DCW file did not contain documentation of a completed competency examination or training program.
PF4, Date of Hire 6/12/24, DCW file did not contain documentation of a completed competency examination or training program.
PF5, Date of Hire 7/3/24, DCW file did not contain documentation of a completed competency examination or training program.
PF7, Date of Hire 3/28/24, DCW file did not contain documentation of a completed competency examination or training program.
Interview with the Director of Operations (EMP1) conducted on 7/19/24, at approximately 1:07 p.m. confirmed the above findings.
Plan of Correction:Will develop a competency exam to be completed during the interview process. Competency exam will include the 6 subjects areas listed in Section 611.55(c). PF1,PF2,PF3,PF4,PF5,and PF7 along with current employees will complete exam within the next 60 days. Will audit employee files quarterly. Ongoing training will be completed ad documented. Will have corrections completed by 9/16/2024.
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 review of personnel files (PF), Centers for Disease Control (CDC) Guidelines, and staff (EMP) interview, the agency failed to ensure that each employee with direct consumer contact was screened for mycobacterium tuberculosis (TB) in accordance with CDC guidelines for seven (7) of seven (7) direct care worker personnel files (PF) reviewed (PF1, PF2, PF3, PF4, PF5, PF6 and PF7).
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 test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease....A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST within the previous 12 months, a single TST can be administered in the new setting. 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).
Personnel File (PF) reviews conducted on 7/19/24, at 11:32 a.m. revealed the following:
PF1, Date of Hire 3/27/24, There was a documented negative result TST completed 3/28/24. There was no evidence documented of a second TST completed in accordance with CDC guidelines.
PF2, Date of Hire 5/9/24, There was a documented negative result TST completed 7/20/24. There was no evidence documented of a second TST completed in accordance with CDC guidelines.
PF3, Date of Hire 5/15/24, There was a documented negative result TST completed 4/20/24. There was no evidence documented of a second TST completed in accordance with CDC guidelines.
PF4, Date of Hire 6/12/24, There was a documented negative result TST completed 6/26/24. There was no evidence documented of a second TST completed in accordance with CDC guidelines.
PF5, Date of Hire 7/3/24, There was no evidence documented of a baseline tuberculosis screening upon hire completed in accordance with CDC guidelines.
PF6, Date of Hire 5/10/24, There was a documented negative result TST completed 5/15/24. There was no evidence documented of a second TST completed in accordance with CDC guidelines.
PF7, Date of Hire 3/28/24, There was a documented negative result TST completed 10/16/23. There was no evidence documented of a second TST completed in accordance with CDC guidelines.
Interview with the Director of Operations (EMP1) conducted on 7/19/24, at approximately 1:07 p.m. confirmed the above findings.
Plan of Correction:Will set up a corporate account with a medical facility for PF1-7 and along with current and future employees to obtain TB testing required under the CDC guidelines.
Will audit current employees for correct TB testing and have it corrected by 9/16/2024. Employee education will be put into place for the HR person or persons that review the TB tests for the employee files, so they understand what a TB two step is, along with IGRA's and Xrays.
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 consumer files (CF) and staff (EMP) interview, the agency failed to maintain documentation on file at the agency to show compliance with the requirements of this section (611.57) which shall be available for the Department inspection for five (5) of (5) five consumer files reviewed (CF1, CF2, CF3, CF4 and CF5).
Findings include:
Per 611.57(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.
Review of consumer files (CF) on 4/11/24, at 10:07 a.m. revealed the following:
CF1, Start of Service, service agreement signed 6/20/24, did not contain documentation that the consumer was provided the following information: The hours when those services will be provided. The telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. 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.
CF2, Start of Service 6/17/24, service agreement signed 6/17/24, did not contain documentation that the consumer was provided the following information: The hours when those services will be provided. The telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. 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.
CF3 Start of Service 6/3/24 service agreement signed 6/4/24, did not contain documentation that the consumer was provided the following information: The hours when those services will be provided. The telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. 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.
CF4 Start of Service 2/27/24, service agreement signed 2/23/24, did not contain documentation that the consumer was provided the following information: The hours when those services will be provided. The telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. 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.
CF5 Start of Service 4/17/24, service agreement signed 4/15/24, did not contain documentation that the consumer was provided the following information: The hours when those services will be provided. The telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. 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.
Interview with the Director of Operations (EMP1) conducted on 7/19/24, at approximately 1:07 p.m. confirmed the above findings
Plan of Correction:Contract will be altered to include:
-8 days to 10 days for termination.
-Add Consumer Notice of Direct Care Worker Status to contract.
-Update PA Ombudsman phone numbers for all counties serviced.
-Add hours when services will be provided.
-Include competency requirements of direct care workers employed.
Will correct CF1-5
Will audit current files and correct the changes. If it affects the agreements, will have the clients resign the contracts by 09/16-2024
Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed July 19, 2024, Cornerstone Caregiving East Llc was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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