Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on April 17, 2025, Carvel Health Services, Inc., was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced re-licensuse survey conducted on April 17, 2025, Carvel Health Services, Inc., was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries.
Plan of Correction:
611.52(b) LICENSURE
State Police Criminal History Record
Name - Component - 00
If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.
Observations:
Based on a review of personnel files (PF) and an interview with the Office Manager, the agency failed to provide documentation of a Pennsylvania (PA) State Police Criminal Background Check (PATCH) at the time of application or within 1 year immediately preceding the date of application for one (1) of seven (7) PF's reviewed, (PF #4).
Findings include:
A review of Personal Files were conducted on April 17, 2025 at approximately 11:30 am reavealed the following:
PF#4 - Date of Hire: 1/29/2024. PF contained a Pennsylania Criminal Background dated for 11/30/2023 for the purpose of "Elder Care Act 169" instead of Employment.
An interview with the Office Manager conducted on April 17, 2025 at approximately 12:30 pm confirmed the above findings.
Plan of Correction:Effective immediately a criminal background check will be run for the identified individual with the correct "purpose of request" for Employment Screening.
All office staff will be instructed to review policies for accepting documents run outside our office and the policies regarding PATCH certificates.
100% of Employee files will be reviewed to ensure all criminal checks are timely and have an accurate purpose. Any identified as inaccurate will be immediately have the criminal check redone.
Supervisor will conduct audits of new employee files to ensure quality assurance is maintained.
611.52(c) LICENSURE
Federal Criminal History Record
Name - Component - 00
If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code § 15.144(b) (relating to procedure).
Observations:
Based on a review of employee files and an interview with the Office Director, the agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for one (1) out of seven (7) Personal Files (PF) reviewed (PF#6).
Findings include:
A review of Personal Files were conducted on April 17, 2025 at approximately 11:30 am reavealed the following:
PF#6 - Date of Hire: 12/9/2024 - Application on file indicated that the direct care worker checked off no to the question of "Have you been a resident of Pennsylvania for the last 2 years." A copy of a United States Employment Card issued 6/15/2024 was on file.
An interview with the Office Manager conducted on April 17, 2025 at approximately 12:30 pm confirmed the above findings.
Plan of Correction:Upon further review we were able to ascertain that a Federal criminal history certificate was obtained but misfiled awaiting a better quality copy. Additionally, during the interview it was determined that the employee did reside in PA over 2 years but mismarked the check box on the form.
Effective immediately 100% of Employee files will be reviewed to ensure all forms are accurate and the required documents are obtained in accordance with 6 Pa. Code § 15.144(b). Any employees identified as inaccurate will be required to have the federal criminal check completed immediately.
All office staff will be instructed to review policies for all required documents for new employees and the policies regarding federal criminal checks to ensure adherence to the requirements set forth.
Supervisor will conduct audits of new employee files to ensure quality assurance is maintained.
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 (PF) and an interview with the Office Manager, determined that the agency failed to document proof of Pennsylvania (PA) residency preceding date of hire 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 for four (4) of seven (7) PF's reviewed, (PF#1, 3, 5 and 6)
Findings include:
A review of Personal Files were conducted on April 17, 2025 at approximately 11:30 am reavealed the following:
PF#1 - Date of Hire: 12/17/2024. PF did not contain documentation to show that the applicant was a resident of Pennsylvania (Pa) for the 2 years immediately preceding application for employment. Pa Driver's License issued 7/29/2023 on file.
PF#3 - Date of Hire: 11/13/2023.PF did not contain documentation to show that the applicant was a resident of Pennsylvania (Pa) for the 2 years immediately preceding application for employment. Pa Driver's License issued 5/30/2023 on file.
PF#5 - Date of Hire: 1/10/2025 - PF did not contain documentation to show that the applicant was a resident of Pennsylvania (Pa) for the 2 years immediately preceding application for employment. Pa Driver's License issued 11/15/2023 on file.
PF#6 - Date of Hire: 12/9/2024 - PF did not contain documentation to show that the applicant was a resident of Pennsylvania (Pa) for the 2 years immediately preceding application for employment. United States Employment card on file issued 6/15/2024.
An interview with the Office Manager conducted on April 17, 2025 at approximately 12:30 pm confirmed the above findings.
Plan of Correction:Effective immediately all of the identified individuals will be requested to submit proof of residency through submission of one of the documents listed in Code 611.52(d) or a federal criminal check will be completed as per policies set forth if residency cannot be established.
All office staff will be instructed and as well as to review policies and procedures regarding the documentation required for all new employees to establish residency. If residency cannot be established thru documents a federal criminal check is required.
Employees hired within the last 2 years will be audited and any identified as not having established residency of 2 years minimum will immediately have the federal criminal check completed.
Supervisor will conduct audits of new employee files to ensure quality assurance is maintained.
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 a review of personnel files (PF), Centers for Disease Control Guidelines, and an interview with the Office Manager, the agency failed to provide documentation that the direct care worker was screened for and free from active mycobacterium tuberculosis upon hire for seven (7) of seven (7) PF's, (PF#1,2,3,4, 5, 6 and 7).
Findings include:
In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. 2. Completion of a tuberculosis symptom questionnaire. 3. Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCWs should receive TB education annually. HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(5-16-19)
A review of Personal Files were conducted on April 17, 2025 at approximately 11:30 am reavealed the following:
PF#1 - Date of Hire: 12/17/2024. PF did not contain documentation that a symptom screening/risk assessment was completed upon hire.
PF#2 - Date of Hire: 5/16/2023. PF contain documentation that a one (1) step PPD was dated for 5/24/2023. No evidence that a second step PPD was obtained. File did not contain documentation that a symptom screening/risk assessment was completed upon hire.
PF#3 - Date of Hire: 11/13/2023. PF contain documentation that a one (1) step PPD was dated for 9/5/2023. No evidence that a second step PPD was obtained. File did not contain documentation that a symptom screening/risk assessment was completed upon hire.
PF#4 - Date of Hire: 1/29/2024. PF did not contain documentation that a symptom screening/risk assessment was completed upon hire.
PF#5 - Date of Hire: 1/10/2025. PF did not contain documentation that a symptom screening/risk assessment was completed upon hire.
PF#6 - Date of Hire: 12/9/2024. PF did not contain documentation that a symptom screening/risk assessment was completed upon hire.
PF#7 - Date of Hire: 1/16/2025. PF did not contain documentation that a symptom screening/risk assessment was completed upon hire.
An interview with the Office Manager conducted on April 17, 2025 at approximately 12:30 pm confirmed the above findings.
Plan of Correction:The 2 employees identified as not having (PF#2 and PF#3) will have a blood test completed immediately.
Effective immediately all newly hired employees will complete a tuberculosis risk assessment and symptom questionnaire, in addition to the current screening to ensure they are free from active mycobacterium tuberculosis via 2-step TST or single blood assay for TB, or a chest x-ray(if prior positive PPD). The questionnaire will be added to the new hire packet for employees.
Additionally, all employee files will be reviewed to ensure compliance with CDC guidelines as described in Ch. 611.56(a) Anyone with an incomplete health screening will be required to be tested immediately in order to continue employment.
Supervisor will conduct audits of employee files to ensure quality assurance.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on April 17, 2025, Carvel Health Services, Inc., was found not to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
35 P. S. § 448.809b LICENSURE
Photo Id Reg
Name - Component - 00
Law amended July 11, 2022 Act 79 2022 HB 2604
(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.
(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) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.
(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.
Observations:
Based on a review of personnel files (PF) and an interview with the Office Manager, the agency did not provide photo identification badges in accordance with regulation for seven (7) of seven (7) PFs. (PF# 1, 2, 3,4,5,6,and 7).
Findings include:
A review of Personal Files were conducted on April 17, 2025 at approximately 11:30 am revealed the following:
PF#1 - Date of Hire: 12/17/2024. PF did not contain a photo identification badge.
PF#2 - Date of Hire: 5/16/2023. PF did not contain a photo identification badge.
PF#3 - Date of Hire: 11/13/2023. PF did not contain a photo identification badge.
PF#4 - Date of Hire: 1/29/2024. PF did not contain a photo identification badge.
PF#5 - Date of Hire: 1/10/2025. PF did not contain a photo identification badge.
PF#6 - Date of Hire: 12/9/2024. PF did not contain a photo identification badge.
PF#7 - Date of Hire: 1/16/2025. PF did not contain a photo identification badge.
An interview with the Office Manager conducted on April 17, 2025 at approximately 12:30 pm confirmed the above findings.
Plan of Correction:Effective immediately the identified employees as well as all (100%) employees of Carvell will be re-issued an identification badge with a current photo and all of the required fields in accordance with regulation 35P.S.§ 448.809(b).
Additionally, effective immediately All newly hired employees will be issued a photo ID prior to providing direct care services. A copy of the Id will be placed in the personnel file for evidence and audit purposes.
Supervisor/Manager will conduct audits of new hires to ensure quality assurance is maintained.
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