Achilles Home Health

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on a review of clinical records (CR), agency policy, and an interview with the Administrator. The agency failed to follow the agency’s personnel policies as evidenced by the following not being documented in the personnel files (PF): Employment Interviews, Employment Reference Checks, Pennsylvania State Criminal Background Checks (PATCH), Child Abuse clearances, New Hire Orientation, Initial Competency Evaluation, Annual Competency Evaluation, Hepatitis B Vaccination Declination/Acceptance Form and Tuberculosis Symptom Screening and Risk Assessment for four (4) of four (4) PF’s reviewed. (PF#1, 2, 3, 4). Findings include: A review of the Home Health Agency policies and procedures were reviewed on June 10, 2026 at approximately 2:00 pm revealed the following: Policy 4.1 Personnel File Management …Personnel records include job descriptions, qualifications, licensure, performance evaluations, health examinations and documentation of orientation provided. Records are kept current. Policy 4.2 Required Information …Personnel File Components…2. Evidence of a pre-employment interview…4. Two positive written references…signed and dated by individual calling for reference). 6…b. Prior to licensing, the agency was required to have all individuals employed by the agency…to obtain clearance from the child abuse registry, in accordance with 23 Pa. C.S. Ch. 63 (relating to child protective services) if the agency provides services to persons under the age of 18. This information is maintained on file in the agency….8. Health Information which is acquired prior to referral to the patient for all staff with direct patient contact…b. Initial, and annual, TB screening requirements, c. TB results, D. Hepatitis acceptance/declination form, proof of immunization, if accepted…23. For direct care staff, skills competencies checklist, 24. Annual observation of job duties Policy 4.7 Background, Sex Offender, and OIG Checks Statement of Standard: Personnel meet the organization’s hiring criteria defined in the position description and policies. Applicable health screenings, criminal background checks, and verification of employment eligibility (I-9) are completed in accordance with local, state and federal law and regulation. Responsibility of Organization: The organization should conduct criminal background checks for all employees, and contract staff, who have access to patients. 2. Prior to an offer of employment, the organization searches….the Child Abuse Central Index, to determine if that person has committed certain conduct including abuse, neglect, or mistreatment of a patient of an agency, or a facility…5. Outcomes of all aspects of the criminal background check will be placed I the Personnel Record.Position Description: Home Health Aide Position Summary: The home health aide (HHA) is a paraprofessional staff member educated to provide personal care and to assist with activities of daily living, exercise programs, and related services in the home for sick and disable, when no family member can assume this responsibility…VII. Qualifications: …F. Holds current CPR Card Position Description: Registered Nurse Position Summary: The registered nurse is a licensed health care professional who administers skilled nursing care to adult patients requiring part-time, intermittent visits and assesses consumers for personal care and non-clinical activities. Tuberculosis Infection Control Plan Purpose: To establish policy and procedures for the Agency’s employees’ protection related to prevention, exposure, and transmission of mycobacterium tuberculosis (TB)…. Section 7: Staffing & Personnel – Policy Title: Staffing & Personnel Management -Policy Number HR-001. Policy Statement -Achilles Home Health…All personnel, including family members serving as HHAs, shall meet applicable qualifications standards, complete required training, demonstrate competency, and comply with all regulatory requirements established by the Pennsylvania Department of Health…Policy Requirements…3. Conduct background checks per Pennsylvania law, 4. Provide orientation and ongoing training, 5. Validate competency before independent work,…7. Maintain personnel files with required documentation…Procedures: A. Requirement & Hiring – 1. All candidates shall undergo: Application review, interview, reference checks…B. Background Checks (Mandatory) – 1. All employees must complete: Criminal background checks, Child abuse clearance (for pediatric cases), Health screening for communicable diseases (Tuberculosis)…D. Competency Validation – 1. Staff must demonstrate competency before providing care, 2. Competency evaluation includes: Skills demonstration…3. Competency shall be: Validated at hire, Reassessed annually… 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) <https://www.cdc.gov/tb/topic/testing/healthcareworkers.htm> A review of PF was conducted on June 10, 2026 at approximately 1:30 pm revealed the following: PF#1- Date of Hire: 10/15/2025. PF did not contain a CPR certification and file did not contain evidence that an interview was completed upon hire. PF#2- Date of Hire: 5/5/2025 – PF did not contain evidence that an interview was completed upon hire, PA criminal background check, no annual competency completed for 2026. No evidence that a Hepatitis B Declination/Acceptance Form on file and no evidence that a TB Symptom Screening and Risk Assessment was completed upon hire and for 2026. PF#3- Date of Hire: 1/12/2026 – PF did not contain evidence that an interview was completed upon hire and no evidence that a child abuse clearance was obtained upon hire. File did not contain evidence of a CPR certification. File did not contain a completed Tuberculosis Risk Assessment PF#4- Date of Hire: 3/31/2026 – PF did not contain evidence that an interview and employment reference checks were completed upon hire. An interview conducted on June 12, 2026 at approximately 3:45 pm confirmed the above findings.”