Initial Comments:
Based on the findings of an off-site state relicensure survey completed February 22, 2023, Eden 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 off-site state relicensure survey completed February 22, 2023, Eden Home Care 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 the office manager, it was determined that prior to hiring, the agency failed to conduct a face-to-face interview and to obtain two verifiable references that affirms the ability of a Direct Care Worker, (DCW), to provide home care services for three, (3), of seven (7) employee files reviewed. (DCW # 1, 2, and
#3).
Findings include:
1. Review of personnel files on February 22, 2023 at approximately 10:30 a.m. revealed that DCW #1 was hired on November 15, 2021. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility prior to a Consumer assignment.
2. Review of personnel files on February 22, 2023, at approximately 10:39 a.m. revealed that DCW #2 was hired on November 1, 2021. There was no documented evidence that a face-to-face interview had been conducted by the facility prior to a Consumer assignment.
3. Review of personnel files on February 22, 2023, at approximately 10:48 a.m. revealed that DCW #3 was hired on January 1, 2023. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility prior to a Consumer assignment.
A telephone exit interview with the Office Manager on February 27, 2023 at 2:10 p.m. confirmed that the agency failed to conduct a face-to-face interview and to obtain two verifiable references for each DCW employed.
Plan of Correction:Our facility did conduct face-to-face interviews with DCW's #1, #2, and #3 to come into compliance. This was done via a Facetime conference. In the future this will be done prior to scheduling the DCW for any shifts. Our Human Resource Director will be responsible for ensuring this process is completed as stated.
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 office manager, it was determined that the agency failed to administer a competency review at least once per year after initial competency is established for three, (3), of seven, (7), Direct Care Worker, (DCW), personnel files reviewed. (DCW #1, 2, and #3).
Findings include:
Review of personnel files on February 16, 2023, at approximately 10:30 a.m., revealed that DCW #1 was hired on November 15, 2021. There was no evidence of an annual competency review for the year of 2022.
2. Review of personnel files on February 22, 2023, at approximately 10:39 a.m. revealed that DCW #2 was hired on November 1, 2021. There was no evidence of an annual competency review for the year of 2022.
3. Review of personnel files on February 22, 2023, at approximately 10:48 a.m. revealed that DCW #3 was hired on January 1, 2023. There was no evidence of an annual competency review for the year of 2022.
A telephone exit interview with the Office Manager on February 27, 2023 at 2:10 p.m. confirmed that the agency failed to conduct an annual competency review for each DCW employed over a year prior.
Plan of Correction:Our facility has administered and graded annual competency exams for DCW#1 and DCW#3. DCW #2 will be administerd and graded within 10 days. In the future, our HR Director will ensure that these competency reviews will be done before the mandatory 1 year anniversary of the previous review. We are using software reminders to give us a two-week alarm before the due date to ensure none are missed.
Initial Comments:
Based on the findings of an off-site state relicensure survey completed February 22, 2023, Eden Home Care was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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