Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed June 8, 2021, Always Best Care, was found NOT to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.
Plan of Correction:
601.3 REQUIREMENT
COMPLIANCE W/ FED, ST, & LOCAL LAWS
Name - Component - 00
601.3 COMPLIANCE WITH FEDERAL,
STATE AND LOCAL LAWS.
The home health agency and its staff
are in compliance with all applicable
Federal, State and Local Laws and
regulations.
Observations:
Based on a review of personnel files, and interview with Administrative staff , the home health agency failed to be in compliance with all State laws, for three, (3), of seven, (7), employee Clinical Records, CR), reviewed. (CR #2, #5, and #6)
Findings include:
State Act 169 requires a Pennsylvania State Police criminal history check for new employees of licensed health care facilities is performed within the first thirty (30) days of employment.
On June 8, 2021, at approximately 1:55 p.m., a review of CR #2 revealed a date of hire on February 8, 2019. This surveyor received a Pennsylvania State Police criminal background report, requested on June 8, 2021 at 2:00 p.m., (day of the survey). A previous Pennsylvania State Police criminal history check was not available for this employee.
On June 8, 2021, at approximately 2:05 p.m., a review of CR #5 revealed a date of hire, (contractual), September 2020. A document titled, "ADP (not an acronym) was received from the Administrator. Under the Subtitle, "Criminal Records Search," The document revealed a that "Types of criminal offenses report will vary by jurisdiction, and by specific search ordered. There was no evidence or documentation to support the search outcome of, "No Records Found."
On June 8, 2021, at approximately 2:55 p.m., a review of CR #6 revealed a date of hire, (contractual), for April 2020. A document titled, "ADP (not an acronym) was received from the Administrator. Under the Subtitle, "Criminal Records Search," The document revealed a that "Types of criminal offenses report will vary by jurisdiction, and by specific search ordered. There was no evidence or documentation to support the search outcome of, "No Records Found."
On June 8, 2021, at approximately 3:55 p.m., in an interview conducted with the Clinical Manager, it was confirmed that the agency had not conducted Criminal Background Checks as per State Act 169. requires a Pennsylvania State Police criminal history check for new employees .
Plan of Correction:A. In accordance to satisfying 601.3 REQUIREMENT COMPLIANCE W/ FED, ST, & LOCAL LAWS: PA. Act 169 requires a Pennsylvania State Police criminal history check for new employees of licensed health care facilities is performed within the first (30) days of employment. The Clinical Director according to the facility's Policy No. 1-025, Personnel Record Contents (Attached) in reference to Clinical Record #2 with a date of hire 2/8/2019 will initiate a chart audit on 100% of the facilities Human Resource files of all current employees, by the Clinical Director or designee. The result of POC findings will be analyzed in the Biannual PAC meeting to ensure regulatory compliance is maintained. This corrective action will be completed on 08/01/2021.
B. The Clinical Director in accordance with facility Policy No. 1-0125, Personnel Record Contents (Attached), and in reference to Clinical Records #5 and #6, contractual staff, with hire dates of September 2020 and April 2020, contacted all Therapy Agencies currently under contract with the facility and requested that they send the facility a Pennsylvania State Police criminal history check in accordance with State Act 169 for all therapists. Clinical Director informed all contracted Therapy Agencies that going forward, they would need to send the Pennsylvania State Police criminal history check prior to any new contracted therapy staff treating patients for the facility.
C. The Clinical Director spoke directly with the owner of the Therapy Agency, and informed him that the document titled ADP is not accepted under PA Act 169, as a valid criminal history check, and all criminal history checks need to be reported via the Pennsylvania State Police.
Initial Comments:
Based on the findings of an onsite unannounced relicensure survey completed June 8, 2021, Always Best 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 relicensure survey completed June 8, 2021, Always Best Care, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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