QA Investigation Results

Pennsylvania Department of Health
ALSM AT HOME
Health Inspection Results
ALSM AT HOME
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite unannounced relicensure survey completed 4/16/2019, ALSM At Home 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 4/16/2019, ALSM At Home 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:




611.51(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 agency documents, personnel files (PF), and staff interview, it was determined the agency failed to conduct a face to face interview with the applicant for one (1) of eight (8) PF's reviewed (PF8).

Findings included:

A review of the agency's policies on 4/16/2019 at approximately 10:25 AM revealed: "New Hire/Rehire Process...Procedure: 2. Supervisor contacts applicant to schedule interview. a. Application is to be completed by the time of the interview. 3. After interview process, if decision is made to continue considering candidate, new hire or rehire, supervisor is to complete the steps below, otherwise, a denial letter is to be sent to the candidate..."

A review of the PFs conducted on 4/16/2019 approximately 11:15 AM to 1:20 PM revealed the following:

PF#8, date of hire (DOH) 11/12/2017. The PF did not contain evidence of a face to face interview having been completed by the agency.

An exit interview with the service manager and scheduler on 4/16/2019 at approximately 3:20 PM confirmed the above findings.
















Plan of Correction:

S200 Evidence of a face to face interview will be documented on the HR interview checklist per Human Resources New Hire policy.

The interview checklist on PF#8 has been corrected to reflect the date of interview.

An Audit of the Employee files will be completed to verify all face to face interviews are documented in the file using the current HR interview checklist.

The Manager will be responsible for compliance using audit tool and HR interview checklist to identify evidence of face-face interviews on current and future employees.



611.51(b) LICENSURE
Direct Care Worker Files

Name - Component - 00
Files for direct care workers employed or rostered shall include documentation of the date of the face-to-face interview with the individual and of references obtained. Direct Care Worker files also shall include other information as required by 611.52, 611.53, if applicable, 611.54, 611.55 and 611.56 (relating to criminal background checks, child abuse clearance, provisional hiring, competency requirements; and health evaluations).

Observations:



Based on review of agency policy, personnel files (PF) and staff interview, it was determined the agency failed to include documentation of the date of the face-to-face interview with the individual and/or of references obtained for two (2) of eight (8) PF's reviewed (PF4 and PF9).

Findings included:

A review of the agency's policies on 4/16/2019 at approximately 10:25 AM revealed: "New Hire/Rehire Process...Procedure: 2. Supervisor contacts applicant to schedule interview. a. Application is to be completed by the time of the interview. 3. After interview precess, if decision is made to continue considering candidate, new hire or rehire, supervisor is to complete the steps below, otherwise, a denial letter is to be sent to the candidate. a. Supervisor checks references-via phone or mail utilizing appropriate format..."

A review of the PFs conducted on 4/16/2019 approximately 11:15 AM to 1:20 PM revealed the following:

PF4, date of hire (DOH) 3/1/2017, PF4 did contain attempt of 2 personal reference. The PF4 contained evidence of a only one reference reference being completed and dated.

PF9, DOH 4/19/2016. There was a face to face interview form, interview checklist, that did not contain a date when the interview was conducted. No additional documentation was available to verify when the face-to-face interview was completed.

An exit interview with the service manager and scheduler on 4/16/2019 at approximately 3:20 PM confirmed the above findings.






















Plan of Correction:

0210 A review of the HR file on PF4 found a second verifiable reference. The file has been corrected.

PF9 The date of interview has been added to the interview checklist.

An Audit of the Employee files will be completed to verify all face to face interviews are documented in the file using the current HR interview checklist and additional audit tools.

The new hire was revised to include verification of two positive references.

A reference verification of "employment dates only" by companies is not acceptable.


The Manager will be responsible for compliance using audit tool and HR interview checklist to identify evidence of face-face interviews and dates of interviews on current and future employees.





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 a review of consumer records (CR) and staff (EMP) interview, the agency failed to provide required information in writing to consumers/consumer representatives prior to the commencement of services for three (3) of eight (8) CRs reviewed (CR2, CR6 and CR8).

Findings included:

A review of CR2 on 4/16/2019 at approximately 1:50 PM revealed start of services 10/18/2017. No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.

A review of CR6 on 4/16/2018 at approximately 2:24 PM revealed start of services 2/27/2019. No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.

A review of CR8 on 4/16/2018 at approximately 2:50 PM revealed start of services 6/17/2015. No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.

An exit interview with the service manager and scheduler on 4/16/2019 at approximately 3:20 PM confirmed the above findings.











Plan of Correction:

S8020
The current initial start of service form completed at enrollment has been revised to reflect changes in preferences of times, days of the week, etc. The form is to be initiated immediately.

Corrections to the client files, CR8, CR6, CR2 will be made in order to be consistent with S8020 regulation.

The nurse and scheduler will be responsible for documentation of the changes on the form or on documentation in the client file.

The nurse and scheduler will be educated on the revised form by the manager.

The manager and office staff will audit current client files to insure compliance and correct if necessary consistent with the days, times(hours) when services are to be provided.




Initial Comments:


Based on the findings of an onsite unannounced relicensure survey completed 4/16/2019, ALSM At Home was found to be in compliance with the requirements of 35 P.S. 448.809 (b).






Plan of Correction: