QA Investigation Results

Pennsylvania Department of Health
EXCEL HOME CARE
Health Inspection Results
EXCEL HOME CARE
Health Inspection Results For:

This is the only survey for this facility

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed 6/13/2018, Excel Home Care 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 6/13/2018, Excel Home Care was found not to be in compliance with the following requirement(s) 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(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 review of direct care worker (DCW) personnel files (PF), and staff (EMP) interview, the agency failed to ensure two (2) of fourteen (14) DCW personnel files reviewed contained proof of residency (PF3 & PF4).

Findings included:

A review of DCW personnel files was conducted on 6/13/2018, between 9:30 a.m. and 12:00 p.m.

PF3 was hired on 1/30/2017 and contained a PA Driver's license but the license was issued on 10/07/2015; not 2 years preceeding the date of hire. PF contained no other documentation to show requirement was met.

PF4 was hired on 10/16/2017 and contained a PA Driver's license but the license was issued on 6/22/2016; not 2 years preceeding the date of hire. Pf contained no other documentation to show requirement was met.

Interview with EMP1 on 6/13/2018 at approximately 3:00 p.m. confirmed findings.




Plan of Correction:

Excel Home Care will complete a
complete physical audit of all
active care giver files to ensure
that proof of residency
documentation has been
obtained and is valid. Any
caregivers who do not have
proof of residency in their files,
and cannot produce valid
documentation, will be notified
by telephone and in writing that
they must initiate the
fingerprinting process
immediately. Any caregiver
who does not initiate the
fingerprinting process within 7
days of being notified will be
removed from all scheduled
shifts. If the caregiver does not comply within 21 days they will
be terminated from our employ.

If a caregiver is removed for non-compliance, the consumer will be notified as to why and a new caregiver will be scheduled for their case.

Excel Home Care will initiate immediate training on proper procedures to validate proof of residency to ensure that all future hires are properly vetted.

The location manager will be responsible for all audits and implementation of the CAP.

The compliance manager will initiate training on proof of residency and ensure annual re-training is performed.


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 direct care worker (DCW) personnel files (PF), and staff (EMP) interview, the agency failed to ensure three (3) of seven (7) DCW personnel files, employed greater than a year, contained an annual competency review (PF3, PF6 & PF8).

Findings included:

A review of DCW personnel files was conducted on 6/13/2018 between 9:30 a.m. and 12:00 p.m.

PF3 was hired on 1/30/2017 and contained no annual competency review (due 1/30/2018).

PF6 was hired on 2/08/2017 and contained no annual competency review (due 2/08/2018).

PF8 was hired on 4/11/2016 and contained no annual competency reviews (due 4/11/2017 and 4/11/2018).

Interview with EMP1 on 6/13/2018 at approximately 3:00 p.m. confirmed findings.





Plan of Correction:

Excel Homecare will complete a complete physical audit of all
active care giver files to identify all active caregivers employed greater than 1 year who have not undergone an annual competency survey. All caregivers will be contacted and competency surveys will be initiated immediately.
Excel Home Care will review the individual's competency to perform assigned duties through direct observation, testing, training, consumer feedback or other method approved by the Department or through a combination of methods. The competency review will annually 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.
Excel Home Care compliance manager will oversee training for all staff on the proper procedures for initial competency and on-going competency training require annually.
The database system will be utilized to track compliance and inform Excel Home Care staff of any care givers who require annual competency training.
Random audits of caregiver files will be performed by the branch manager and the results forwarded to the compliance manager for review to determine compliance with all regulations referring to annual competency training.
The branch manager will be responsible to ensure implementation and completion of the CAP is performed.



Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed 6/13/2018, Excel Home Care was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: