QA Investigation Results

Pennsylvania Department of Health
FAMILY SUPPORT CIRCLE, INC.
Health Inspection Results
FAMILY SUPPORT CIRCLE, INC.
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite unannounced relicensure survey completed December 13, 2018, Family Support Circle Inc., 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 December 13, 2018, Family Support Circle Inc., 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(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 employee files, and interview with the administrator, it was determined that prior to hiring, the agency failed to obtain a face-to-face interview and two verifiable references that affirms the ability of a Direct Care Worker, (DCW), to provide home care services for ten, (10), of ten (10) employee files reviewed. (DCW #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10).

Findings include:

1. Review of personnel files on December 13, 2018 at approximately 10:30 a.m. revealed that DCW #1 was hired on April 8, 1016. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.

2. Review of personnel files on December 13, 2018 at approximately 10:39 a.m. revealed that DCW #2 was hired on July 28, 2016. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.

3. Review of personnel files on December 13, 2018 at approximately 10:48 a.m. revealed that DCW #3 was hired on October 12, 2014. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.

4. Review of personnel files on December 13, 2018 at approximately 10:57 a.m. revealed that DCW #4 was hired on September 13, 2018. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.

5. Review of personnel files on December 13, 2018 at approximately 11:06 a.m. revealed that DCW #5 was hired on April 20, 2017. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.

6. Review of personnel files on December 13, 2018 at approximately 11:15 a.m. revealed that DCW #6 was hired on July 18, 2014. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.

7. Review of personnel files on December 13, 2018 at approximately 11:24 a.m. revealed that DCW #7 was hired on June 8, 2018. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.

8. Review of personnel files on December 13, 2018 at approximately 11:33 a.m. revealed that DCW #8 was hired on February 23, 2015. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.

9. Review of personnel files on December 13, 2018 at approximately 11:42 a.m. revealed that DCW #9 was hired on June 15, 2016. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.

10. Review of personnel files on December 13, 2018 at approximately 11:51 a.m. revealed that DCW #10 was hired on August 17, 2017. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.

An interview with the Administrator on December 13, 2018 at 2:10 p.m. confirmed that the agency failed conduct a face-to-face interview, and to record two verifiable references for each DCW employed.











Plan of Correction:

Effective immediately, the administrator at Family Support Circle Inc (FSC), home care agency/home care registry will ensure that all 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 hired staff will be interviewed and have a face-to-face interview questionnaire completed and placed in their files. A face-to-face interview for future employees that will be hired will be conducted and the questionnaire with response will be placed on the employees' files. A review of the 10 previously hired employees will be done to ensure compliance. Verifiable references will be obtained for current and future hired staff. The administrator will conduct quarterly and annually file audits to ensure compliance.

All employee references will be conducted and obtained and placed in employees' files.


611.55(e) LICENSURE
Competency Requirements

Name - Component - 00
The competency review must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction.

Observations:


Based on review of personnel files, and interview with the Administrator, it was determined that prior to hiring, the agency failed to conduct an initial competency review, and complete annual competency reviews for eight, (8), of ten (10), Direct Care Worker, (DCW), employee files reviewed. (DCW #1, 2, 3, 5, 6, 8, 9 and 10).

Findings include:

1. Review of personnel files on December 13, 2018 at approximately 10:30 a.m. revealed that DCW #1 was hired on April 8, 1016. An initial competency test was conducted on January 20, 2016. There was no documented evidence that annual competencies were conducted for the year 2017, and 2018.

2. Review of personnel files on December 13, 2018 at approximately 10:39 a.m. revealed that DCW #2 was hired on July 28, 2016. There was a Certified Nurse Assistant certificate on file, dated June 21, 2016. There was no documented evidence that annual competencies were conducted for the year 2017, and 2018.

3. Review of personnel files on December 13, 2018 at approximately 10:48 a.m. revealed that DCW #3 was hired on October 12, 2014. There was no evidence that an initial competency test was conducted in 2014. Further review revealed no evidence that annual competencies had been conducted for year, 2015, 2016, 2017, and 2018.

4. Review of personnel files on December 13, 2018 at approximately 11:06 a.m. revealed that DCW #5 was hired on April 20, 2017. There was no evidence that an initial competency test had been conducted in 2017. Further review revealed no evidence that an annual competency had been conducted for year 2018.

5. Review of personnel files on December 13, 2018 at approximately 11:15 a.m. revealed that DCW #6 was hired on July 18, 2014. There was no evidence that an initial competency test was conducted in 2014. Further review revealed no evidence that annual competencies had been conducted for year, 2015, 2016, 2017, and 2018.

6. Review of personnel files on December 13, 2018 at approximately 11:33 a.m. revealed that DCW #8 was hired on February 23, 2015. There was no evidence that an initial competency test was conducted in 2015. Further review revealed no evidence that annual competencies had been conducted for year, 2016, 2017, and 2018.

7. Review of personnel files on December 13, 2018 at approximately 11:42 a.m. revealed that DCW #9 was hired on June 15, 2016. An initial competency test was conducted on April 14, 2016. There was no documented evidence that annual competencies were conducted for the year 2017, and 2018.

8. Review of personnel files on December 13, 2018 at approximately 11:51 a.m. revealed that DCW #10 was hired on August 17, 2017. There was no evidence that an initial competency test was conducted in 2017. Further review revealed no evidence that annual competencies had been conducted for the year, 2018.


An interview with the Administrator on December 13, 2018 at 2:10 p.m. confirmed that the agency failed conduct initial, and annual competency reviews for eight of 10 DCW, personnel files reviewed.











Plan of Correction:

The administrator and HR coordinator will ensure that current and newly hired employees receive the competency test prior to employments at Family Support Circle, Inc. All Direct Care Worker's files that have were reviewed (DCW #1, 2, 3, 5, 6, 8, 9 and 10) will receive an initial competency test and annual evaluation on their anniversary date of hire. All newly hired employees will receive annual evaluation and competency tests that will be conducted prior to employment and as needed thereafter.
The administrator will conduct quarterly and annual file audits to ensure compliance



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, Center for Disease Control, (CDC) guidelines, employee files, and administrator interview, it was determined the agency failed to ensure Direct Care Workers, (DCW) were screened and free from active mycobacterium tuberculosis (TB), (an infectious bacterial disease characterized by the growth of nodules (tubercles) in the tissues, especially the lungs), prior to the assignment to consumers for eight (8) of ten (10) DCW's reviewed. (DCW # 1, 2, 3, 5, 6, 7, 8 and 10)

Findings include:


CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005; (RR-17), revealed that "all Health Care Workers (HCW) should receive a baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, health care workers should receive TB screen annually. Health care workers with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease."


1. Review of personnel files on December 13, 2018 at approximately 10:30 a.m. revealed that DCW #1 was hired on April 8, 1016. A Chest-X-Ray conducted on February 29, 2016. There was no evidence or documentation that an annual screening for TB had been conducted.

2. Review of personnel files on December 13, 2018 at approximately 10:39 a.m. revealed that DCW #2 was hired on July 28, 2016. A Quantiferon Gold blood test was conducted on July 21, 2015. There was no evidence or documentation that an annual screening for TB had been conducted.

3. Review of personnel files on December 13, 2018 at approximately 10:48 a.m. revealed that DCW #3 was hired on October 12, 2014. A Two-Step TST was conducted on, September 8, 2017 and September 15, 2017. There was no evidence or documentation that an annual TST had been administered.

4. Review of personnel files on December 13, 2018 at approximately 11:06 a.m. revealed that DCW #5 was hired on April 20, 2017. A Two-Step TST was conducted on, October 25, 2016, and November 8, 2016. There was no evidence or documentation that an annual TST had been administered for the year 2017, and 2018.

5. Review of personnel files on December 13, 2018 at approximately 11:15 a.m. revealed that DCW #6 was hired on July 18, 2014. A Chest-X-Ray conducted on October 18, 2016. There was no evidence or documentation that an annual screening for TB had been conducted.

6. Review of personnel files on December 13, 2018 at approximately 11:24 a.m. revealed that DCW #7 was hired on June 8, 2018. There was no evidence that a Two-step TST had occured.

7. Review of personnel files on December 13, 2018 at approximately 11:33 a.m. revealed that DCW #8 was hired on February 23, 2015. A Chest-X-Ray conducted on January 19, 2018. There was no evidence or documentation that an annual screening for TB had been conducted.

8. Review of personnel files on December 13, 2018 at approximately 11:51 a.m. revealed that DCW #10 was hired on August 17, 2017. A Chest-X-Ray conducted on August 4, 2017. There was no evidence or documentation that an annual screening for TB had been conducted.

An interview with the Administrator on December 13, 2018 at 2:10 p.m. confirmed that the agency did not conduct an area TB risk assessment used as a provision not to screen personnel for TB. It was further confirmed that the agency failed to obtain TB screening for eight of ten DCW's reviewed.












Plan of Correction:

The administrator of the home care agency/home care registry will ensure that all of the current and new employees receive TB risk assessment, a Chest-X-Ray and/or a two step TST prior to hire and annually thereafter for all eight 1, 2, 3, 4, 5, 6, 7 and 8 DCW and any other employees hired.

The administrator will conduct quarterly and annually file audits to ensure that all employees receive the mandated requirements. This will allow the administrator at FSC to monitor all incoming and current staff's requirements to ensure compliance and all Health Care Workers (HCW) should receive a baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis and receive TB screen annually thereafter. Those DCWs with a positive baseline test for TB will submit a chest radiograph result. The administrator will conduct quarterly and annual file audits to ensure compliance and all employee has met the basic requirements for employment. This will be done effective 1/30/2019.


611.57(a) LICENSURE
Consumer Rights

Name - Component - 00
(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

Observations:


Based on review of agency welcome package, consumer record review, (CR), and Administrator interview, it was determined that the agency failed to advise consumers of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services for ten (10) of ten (10) Consumer files reviewed. (CR #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10).

Findings include:

On December 13, 2018 at approximately 12:00 p.m., a review of the agency admission packet entitled, Family Support Circle Inc., revealed no evidence in the agency welcome package or documentation in the consumer files that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

1. On December 13, 2018 at approximately 12:15 p.m., a review of CF #1, revealed a start of service on July 1, 2017. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

2. On December 13, 2018 at approximately 12:20 p.m., a review of CF #2, revealed a start of service on March 14, 2016. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

3. On December 13, 2018 at approximately 12:30 p.m., a review of CF #3, revealed a start of service on July 1, 2018. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

4. On December 13, 2018 at approximately 12:40 p.m., a review of CF #4, revealed a start of service on July 1, 2018. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

5. On December 13, 2018 at approximately 12:50 p.m., a review of CF #5, revealed a start of service on April 1, 2016. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

6. On December 13, 2018 at approximately 1:00 p.m., a review of CF #6, revealed a start of service on April 1, 2015. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

7. On December 13, 2018 at approximately 1:10 p.m., a review of CF #7, revealed a start of service on April 30, 2017. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

8. On December 13, 2018 at approximately 1:20 p.m., a review of CF #8, revealed a start of service on March 2, 2015. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

9. On December 13, 2018 at approximately 1:30 p.m., a review of CF #9, revealed a start of service on July 22, 2017. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

10.On December 13, 2018 at approximately 1:40 p.m., a review of CF #10, revealed a start of service on December 1, 2016. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

In an interview with the Administrator, on December 13, 2018, at approximately 2:10 p.m., it was confirmed that the facility failed to advise the Consumer of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.


Repeat deficiency 12/17/15









Plan of Correction:

The Administrator of the home care agency/home care registry is responsible to notify all new and current clients of the ten day notification to stop services while reviewing the intake service agreement and care plan package The administrator will ensure that all 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 clients and new clients receive a welcome package that includes a 10 calendar days advance written notice of the intent to terminate services. The welcome package will be provided prior to the start of services and annually thereafter during service renewal. All corrections and changes will be made and clients/individual serve will be contacted to review the documents. The administrator and quality assurance coordinator will conduct quarterly and annual file audits to ensure compliance and address any deficiencies in clients' file.This will be done effective 1/30/2019.


611.57(b) LICENSURE
Prohibitions

Name - Component - 00
(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

Observations:


Based on review of Consumer files, agency admission packet, and interview with Administration, the agency failed to notify the consumer that as a result of the individual's affiliation with a home care agency or home care registry, that they are prohibited from assuming power of attorney or guardianship over a consumer utilizing the services, and that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry. The agency failed to provide documentation on this prohibition for ten (10), of ten (10), consumer files, (CF), reviewed. (CF #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10).

On December 13, 2018, at approximately 12:00 p.m., a review of the agency's admission packet revealed no documented evidence that the agency is prohibited from assuming Power of Attorney while using the agency's services. There was no evidence that the Consumer, Power of Attorney, and/or a Responsible Party, was informed that the agency is prohibited from requiring Consumers to endorse checks to the agency.

On December 13, 2018, at approximately 12:02 p.m., a further review of the agency's admission packet revealed a a form entitled, "Service Agreement Signature Page," (no date), revealed in the second paragraph the following statement: "Please indicate whether or not you allow the assigned Family Support Circle, Inc. Personal Care and/companion/sitter staff member to have access to individual funds or consumer family/member care in order to carry the services included in the service agreement." Additional review of the service agreement form, revealed a "yes", "no", or "N/A line, followed by, "I authorize Family Support Circle, Inc. assigned staff to have access to the individual's money in order to provide some or all of the services included by this service agreement, (Note: All Family Support Circle, Inc., employees are bonded)"

1. On December 13, 2018 at approximately 12:15 p.m., a review of CF #1, revealed a start of service on July 1, 2017, under the Office of Long Term Living, (OLTL), Waiver program service plan. There was no evidence that the Consumer, the Power of Attorney, and/or a Responsible Party was informed that the Consumer may not be required to endorse checks to the agency, and the agency is prohibited from assuming Power of Attorney while using the agency's services. The agency statement with an option for consumers to sign an agreement to allow access to personal money was found in the consumer's file.

2. On December 13, 2018 at approximately 12:20 p.m., a review of CF #2, revealed a start of service on March 14, 2016, under the Office of Long Term Living, (OLTL), Waiver program service plan. There was no evidence that the Consumer, the Power of Attorney, and/or a Responsible Party was informed that the Consumer may not be required to endorse checks to the agency, and the agency is prohibited from assuming Power of Attorney while using the agency's services.The agency statement with an option for consumers to sign an agreement to allow access to personal money was found in the consumer's file.

3. On December 13, 2018 at approximately 12:30 p.m., a review of CF #3, revealed a start of service on July 1, 2018, under the Office of Long Term Living, (OLTL), Waiver program service plan. There was no evidence that the Consumer, the Power of Attorney, and/or a Responsible Party was informed that the Consumer may not be required to endorse checks to the agency, and the agency is prohibited from assuming Power of Attorney while using the agency's services. The agency statement with an option for consumers to sign an agreement to allow access to personal money was found in the consumer's file.

4. On December 13, 2018 at approximately 12:40 p.m., a review of CF #4, revealed a start of service on July 1, 2018, under the Office of Long Term Living, (OLTL), Waiver program service plan. There was no evidence that the Consumer, the Power of Attorney, and/or a Responsible Party was informed that the Consumer may not be required to endorse checks to the agency, and the agency is prohibited from assuming Power of Attorney while using the agency's services. The agency statement with an option for consumers to sign an agreement to allow access to personal money was found in the consumer's file.

5. On December 13, 2018 at approximately 12:50 p.m., a review of CF #5, revealed a start of service on April 1, 2016, under the Office of Long Term Living, (OLTL), Waiver program service plan. There was no evidence that the Consumer, the Power of Attorney, and/or a Responsible Party was informed that the Consumer may not be required to endorse checks to the agency, and the agency is prohibited from assuming Power of Attorney while using the agency's services. The agency statement with an option for consumers to sign an agreement to allow access to personal money was found in the consumer's file.

6. On December 13, 2018 at approximately 1:00 p.m., a review of CF #6, revealed a start of service on April 1, 2015, under the Office of Long Term Living, (OLTL), Waiver program service plan. There was no evidence that the Consumer, the Power of Attorney, and/or a Responsible Party was informed that the Consumer may not be required to endorse checks to the agency, and the agency is prohibited from assuming Power of Attorney while using the agency's services. The agency statement with an option for consumers to sign an agreement to allow access to personal money was found in the consumer's file.

7. On December 13, 2018 at approximately 1:10 p.m., a review of CF #7, revealed a start of service on April 30, 2017, under the Office of Long Term Living, (OLTL), Waiver program service plan. There was no evidence that the Consumer, the Power of Attorney, and/or a Responsible Party was informed that the Consumer may not be required to endorse checks to the agency, and the agency is prohibited from assuming Power of Attorney while using the agency's services. The agency statement with an option for consumers to sign an agreement to allow access to personal money was found in the consumer's file.

8. On December 13, 2018 at approximately 1:20 p.m., a review of CF #8, revealed a start of service on March 2, 2015, under the Office of Long Term Living, (OLTL), Waiver program service plan. There was no evidence that the Consumer, the Power of Attorney, and/or a Responsible Party was informed that the Consumer may not be required to endorse checks to the agency, and the agency is prohibited from assuming Power of Attorney while using the agency's services. The agency statement with an option for consumers to sign an agreement to allow access to personal money was found in the consumer's file.

9. On December 13, 2018 at approximately 1:30 p.m., a review of CF #9, revealed a start of service on July 22, 2017, under the Office of Long Term Living, (OLTL), Waiver program service plan. There was no evidence that the Consumer, the Power of Attorney, and/or a Responsible Party was informed that the Consumer may not be required to endorse checks to the agency, and the agency is prohibited from assuming Power of Attorney while using the agency's services. The agency statement with an option for consumers to sign an agreement to allow access to personal money was found in the consumer's file.

10. On December 13, 2018 at approximately 1:40 p.m., a review of CF #10, revealed a start of service on December 1, 2016, under the Office of Long Term Living, (OLTL), Waiver program service plan. There was no evidence that the Consumer, the Power of Attorney, and/or a Responsible Party was informed that the Consumer may not be required to endorse checks to the agency, and the agency is prohibited from assuming Power of Attorney while using the agency's services. The agency statement with an option for consumers to sign an agreement to allow access to personal money was found in the consumer's file.

In an interview with the Administrator, on December 13, 2018, at approximately 2:10 p.m., it was confirmed that the agency practiced offering an option for consumers to sign an agreement to allow access to personal money, and that the agency failed to inform the Consumer, the Power of Attorney, and/or a Responsible Party that the agency is prohibited from requiring a consumer to endorse checks to the agency, and that the agency is prohibited from assuming Power of Attorney while using the agency's services.

Repeat deficiency 12/17/15












Plan of Correction:

The administrator and the intake coordinator of Family Support Circle, Inc (FSC) as a Home Care agency/home care registry will ensure that all of the clients currently served and all new clients will receive an initial packet with service agreement that includes a statement that FSC or its employees are prohibited from assuming power of attorney or guardianship over the clients' services and clients cannot endorsed checks over to FSC or its employees. FSC and its employees are prohibited from assuming responsibilities to manage, care of or legally bound to represent the clients as legal guardian. This will include all 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 current clients and any future consumers.

The administrator and intake coordinator will ensure that clients 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 receive a new service agreement stating that the agency and employees are prohibited to receive power of attorney over consumers or endorse checks to the agency and staff. The administrator will conduct quarterly and annual reviews to ensure that this does not occur.

The administrator will further ensure that the service agreement and other documents are signed, dated and up to date in consumers' files. All clients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 are current clients and future consumers will receive the revise and update agreement and sign the acknowledgement form. The new care plan and service agreement will be specific and clear in content and will remove the excess information. The administrator will review the documents quarterly and annually to ensure that this does not occur. This will be done effective 1/30/2019.


Initial Comments:


Based on the findings of an onsite unannounced relicensure survey completed December 13, 2018, Family Support Circle Inc., was found not to be in compliance with the following requirement of 35 P.S. 448.809 (b).






Plan of Correction:




35 P. S. 448.809b LICENSURE
Photo Id Reg

Name - Component - 00
(1) The photo identification tag shall include a recent photograph of the employee, the employee's name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.



Observations:



Based on observation and interview with owner, agency failed to ensure a photo identification tag that would include the employee's full name and title, and the name of the agency for three (3) of three (3) employees observed.

Findings include:

During observation on December 13, 2018, at approximately 10:20 a.m., the office personnel, and office manager was not observed to wear a photo ID badge.

Review on December 13, 2018, at approximately 2:09 p.m., the administrator was observed not to wear a photo ID badge.

During interview at approximately 2:10 p.m., the administrator confirmed that everyone did not have a photo ID badge.




Plan of Correction:

The administrator of the home care agency/home care registry will ensure that all of the employees who have their ID badges to wear their ID badges in the office and in public.

All personnel will have ID badges and will wear them to identify who they are. This will be done effective 1/7/2019.