Initial Comments:
Based on the findings of an off-site relicensure survey completed March 20, 2023, You'Re Family Home Care LLC, 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 off-site relicensure survey completed March 20, 2023, You'Re Family Home Care LLC, 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:
611.52(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 personnel files, telephone messages and email notices with the Administrator, it was determined that the agency failed to provide proof of residency for, (5), of five, (5), Direct Care Workers, (DCW), personnel files reviewed. (DCW #1, 2, 3, 4, and 5).
Findings include:
1. On March 20, 2023 at approximately 9:55 a.m., a review of the agency personnel files revealed that DCW #1 was hired on September 29, 2022. There was no documented evidence that the agency had established proof of residency through 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
2. On March 20, 2023 at approximately 10:10 a.m., a review of the agency personnel files revealed that DCW #2 was hired on September 3, 2019. There was no documented evidence that the agency had established proof of residency through 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
3. On March 20, 2023 at approximately 10:25 a.m., a review of the agency personnel files revealed that DCW #3 was hired on May 29, 2021. There was no documented evidence that the agency had established proof of residency through 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
4. On March 20, 2023 at approximately 10:45 a.m., a review of the agency personnel files revealed that DCW #4 was hired on September 28, 2022 . There was no documented evidence that the agency had established proof of residency through 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
5. On March 20, 2023 at approximately 10:55 a.m., a review of the agency personnel files revealed that DCW #5 was hired on December 19, 2020. There was no documented evidence that the agency had established proof of residency through 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
On March 20, 2023, at 11:00 a.m., it was confirmed via telephone messages and emails that the agency had failed to provide proof of Residence for the personnel listed above.
Plan of Correction:Correction of Findings:
As required by 611.52(d) Proof of Residency, 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. The agency has provided the following:
1.The agency only provided a local tax withholding form for DCW#1. The form did not include the phone number and email for the DCW. The agency will correct all missing fields and place in DCW #1 file immediately. The agency has other forms of Proof of Residency documentation in accordance to 611.52(d) for DCW#1 in their personnel file and will continue to monitor the DCW file.
2.The agency only provided a local tax withholding form for DCW#2. The form did not include the date the form was signed, phone number, and email for the DCW. The agency will correct all missing fields and place in DCW #2 file immediately. The agency has other forms of Proof of Residency documentation in accordance to 611.52(d) for DCW#2 in their personnel file and will continue to monitor the DCW file.
3.The agency only provided a local tax withholding form for DCW#3. However, the agency has other forms of Proof of Residency documentation in accordance with 611.52(d) for DCW#3 in their personnel file and will continue to monitor the DCW file.
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4.The agency only provided a local tax withholding form for DCW#4. The form did not include the phone number and email for the DCW. The agency will correct all missing fields and place in DCW #4 file immediately. The agency has other forms of Proof of Residency documentation in accordance to 611.52(d) for DCW#4 in their personnel file and will continue to monitor the DCW file.
5.The agency only provided a local tax withholding form for DCW#5. The form did not include the phone number and email for the DCW. The agency will correct all missing fields and place in DCW #5 file immediately. The agency has other forms of Proof of Residency documentation in accordance to 611.52(d) for DCW#5 in their personnel file and will continue to monitor the DCW file.
You're Family Home Care, LLC will continue to obtain and monitor 611.52(d) Proof of Residency for each DCW to remain in compliance and ensure no future reoccurrences of deficiencies.
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, telephone and email notices with the Administrator, it was determined that the agency failed to conduct a competency review at least once per year after initial competency was established for three, (3), of five, (5), Direct Care Worker, (DCW), personnel files reviewed. (DCW #2, 3, and 5).
Findings include:
On March 20, 2023, at approximately 9:00 a.m., a review of the agency Policy Titled, "Competency Requirements For Direct Care Workers," revealed that, "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."
1. On March 20, 2023 at approximately 10:10 a.m., a review of the agency personnel files revealed that DCW #2 was hired on September 3, 2019. There was no documented evidence that an annual competency was conducted from the year 2021 and 2022.
2. On March 20, 2023 at approximately 10:25 a.m., a review of the agency personnel files revealed that DCW #3 was hired on May 29, 2021. There was no documented evidence that an annual competency was conducted for the year 2022.
3. On March 20, 2023 at approximately 10:55 a.m., a review of the agency personnel files revealed that DCW #5 was hired on December 19, 2020. There was no documented evidence that an annual competency was conducted for the year 2021.
On March 20, 2023, at 11:00 a.m., it was confirmed via telephone messages and emails that the agency had failed to conduct annual competency reviews for the personnel named above.
Plan of Correction:Correction of Findings:
1.As required by 611.55(e) Competency Requirements, 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. The agency only provided year 2023 completion of competency for DCW #2. The agency has documentation of annual competency for year 2021 and 2022 in DCW#2 personnel file and will continue to provide annual competency training and exams to all DCW's.
2. As required by 611.55(e) Competency Requirements, 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. The agency only provided year 2023 completion of competency for DCW #3. The agency has documentation of annual competency for year 2022 in DCW#3 personnel file and will continue to provide annual competency training and exams to all DCW's.
3. As required by 611.55(e) Competency Requirements, 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. The agency only provided year 2023 completion of competency for DCW #5. The agency has documentation of annual competency for year 2021 in DCW#5 personnel file and will continue to provide annual competency training and exams to all DCW's.
You're Family Home Care, LLC provides annual trainings and exams to all DCW's. Certificates of completion are documented placed in personnel files. The agency will continue to obtain and monitor 611.55(e) Competency Requirements for each DCW to remain in compliance and ensure no future reoccurrences of deficiencies.
Initial Comments:
Based on the findings of an off-site relicensure survey completed March 20, 2023, You'Re Family Home Care LLC, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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