QA Investigation Results

Pennsylvania Department of Health
GARDEN SPOT VILLAGE AT HOME, LLC
Health Inspection Results
GARDEN SPOT VILLAGE AT HOME, LLC
Health Inspection Results For:


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Initial Comments:


Based on the findings of an unannounced onsite state re-licensure survey conducted on February 15, 2019, Garden Spot Village at Home, 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 15, 2019, Garden Spot Village at Home, 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:




611.52(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 upon review of employee files (EFs) and an interview with the agency administrator, agency failed to ensure proof of residency in Pennsylvania (Pa.) for the entire two years (without interruption) immediately preceding the date of application. for three (3) of seven (7) employees (EF#2, EF#7, EF#9).


Findings include:

A review of EFs was conducted on February 15, 2019 between approximately 9:30 a.m. and 2:00 p.m. Employee date of hire (DOH) is listed below.


EF#2 DOH 08/31/18: Agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Pa. drivers license issued 10/2/17 - 12/18/21. Employment application was reviewed. Employer listed with a Pa. address with 'Start Date' of "11/7/17" and 'End Date' of "8/31/18". No documentation provided for proof of Pa. residency between 08/31/16 - 10/2/17.

EF#7 DOH 10/11/17 : Agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Pa. drivers license issued 02/24/17 - 02/11/21. Employment application was reviewed. No Pa. employment listed between 10/11/15 - 2/24/17. No documentation provided for proof of Pa. residency between 10/11/15 - 02/24/17.

EF#9 DOH 05/01/17: Agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Pa. drivers license issued 07/20/16 - 09/08/20. Employment application was reviewed. Employer listed with a Pa. address with 'Dates of Employment' from "08/21/2000" to "04/15/16". No documentation provided for proof of Pa. residency between 04/15/16 - 07/20/16.


An interview with the agency administrator conducted on February 15, 2019 at approximately 2:30 p.m. confirmed the above findings.

















Plan of Correction:

0330
1. For EF # 2, Human Resources obtained proof of residency through residential lease and income tax filing for 2016 and 2017, for dates cited, 8/31/16-10/2/17.
For EF#7, Human Resources obtained residential lease and proof of lease payment for dates
cited, 10/11/15-2/24/17.

For EF#9, Human Resources obtained income tax records for 2016 for dates cited, 4/15/16- 7/20/16.

2. Human Resources will verify that all present employees will have proof of residency, through submission of 1.) Motor Vehicle records, such as a valid driver's license or a state issued identification, 2.) Housing records, such as a mortgage record or rent receipt, 3. Public utility records and receipts, such as electric bills, 4.) Local tax records, 5.) a completed and signed federal state and local tax return with the applicant's name and address, pre-printed on it, 6. Employment records, including employment records of unemployment compensation.
3. Human Resources will obtain the following information prior to hiring, 1.) Motor Vehicle records, such as a valid driver's license or a state issued identification, 2.) Housing records, such as a mortgage record or rent receipt, 3. Public utility records and receipts, such as electric bills, 4.) Local tax records, 5.) a completed and signed federal state and local tax return with the applicant's name and address, pre-printed on it, 6. Employment records, including employment records of unemployment compensation.
4. Agency Administrator will complete a review of new employee files following completion by Human
resoures of proof of residency verification, prior to making an offer of employment. Administrator will document the review in the agency scheduling system, which can be verified and printed at anytime. Agency Administrator will Administrator will review new hires during monthly meeting with Supervisor, agency COO.



611.55(a) LICENSURE
Compentency 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 upon review of employee files (EFs) and an interview with the agency administrator, the agency failed to provide documentation of direct care worker demonstrating competency prior to consumer contact, in four (4) of ten (10) employees (EF#1, EF#5, EF#7, EF#9).


Findings include:

A review of EFs was conducted on February 15, 2019 between approximately 9:30 a.m. and 2:00 p.m. Employee date of hire (DOH) is listed below.

EF#1 DOH 10/08/18: No documentation provided of direct care worker demonstrating competency prior to consumer contact. Documentation provided of direct care worker completing a written competency test on 10/29/18.

EF#5 DOH 01/21/15: No documentation provided of direct care worker demonstrating competency prior to consumer contact. Documentation provided of direct care worker completing a written competency test on 04/22/15.

EF#7 DOH 10/11/17: No documentation provided of direct care worker demonstrating competency prior to consumer contact. Documentation provided of direct care worker completing a written competency test on 12/4/17.

EF#9 DOH 05/01/17: No documentation provided of direct care worker demonstrating competency prior to consumer contact. Documentation provided of direct care worker completing a written competency test on 06/27/17.


An interview with the agency administrator conducted on February 15, 2019 at approximately 2:30 p.m. confirmed the above findings. Per the administrator, the newly hired direct care worker "shadows" another direct care worker for approximately two weeks. The newly hired direct care worker does "provide hands on care during this time".









Plan of Correction:

0600
1. EF#1, EF# 5, EF#7 and EF#9 have completed their competency test.
2. All direct care staff will successfully complete the agency written competency test prior to job shadowing.
3. Agency Administrator will monitor all new employees and ensure that written competency test is successfully completed prior to being scheduled for a shadowing program. Administrator will document this into the scheduling system,upon completion and prior to scheduling job shadowing.
4. Agency Administrator will present evidence of completed written competency test during monthly meeting with Supervisor, agency COO.



Initial Comments:


Based on the findings of an unannounced onsite state re-licensure survey conducted on February 15, 2019, Garden Spot Village at Home, Llc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: