QA Investigation Results

Pennsylvania Department of Health
CHRISTIAN COMPANION SENIOR CARE-CUMBERLAND PA
Health Inspection Results
CHRISTIAN COMPANION SENIOR CARE-CUMBERLAND PA
Health Inspection Results For:


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Initial Comments:


Based on the findings of an unannounced, onsite state re-licensure survey conducted on June 4, 2024, Christian Companion Senior Care, was found to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.




Plan of Correction:




Initial Comments:


Based on the findings of an unannounced, onsite state re-licensure survey conducted on June 4, 2024, Christian Companion Senior Care, 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:




611.51(a) LICENSURE
Hiring or Rostering Prerequisites

Name - Component - 00
Prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. (3) Require the individual to submit a criminal history report, in accordance with the requirements of 611.52 (relating to criminal background checks), and a ChildLine verification, if applicable, in accordance with the requirements of 611.53 (relating to child abuse clearance).

Observations:


Based on review of employee files (EFs) and interview with agency general manager (EMP #1), it was determined agency failed to maintain documentation of two satisfactory references prior to hiring or rostering direct care workers for seven (7) of ten (10) EFs reviewed. (EF# 1, EF# 3, EF# 4, EF# 7, EF# 8, EF# 9 and EF# 10)
Findings include:
Review of EFs conducted on June 4, 2024 between approximately 10:00 a.m. and 11:15 a.m. revealed the following:
EF# 1, Date of Hire (DOH), 1/11/2024: No documentation of two references being verified prior to hiring or rostering direct care worker. Contained two references that were not dated.
EF# 3, DOH, 1/11/2024: No documentation of two references being verified prior to hiring or rostering direct care worker. Contained two references that were not dated.
EF# 4, DOH, 7/25/2023: No documentation of two references being verified prior to hiring or rostering direct care worker. First shift was on 8/1/2023. Two references conducted on 8/2/2023.
EF# 7, DOH, 2/14/2023: No documentation of two references being verified prior to hiring or rostering direct care worker. First shift was on 2/21/2023. Two references conducted on 3/12/2023.
EF# 8, DOH, 6/14/2023: No documentation of two references being verified prior to hiring or rostering direct care worker. First shift was on 6/19/2023. Two references conducted on 6/23/2023.
EF# 9, DOH, 11/14/2023: No documentation of two references being verified prior to hiring or rostering direct care worker. Contained two references that were not dated.
EF# 10, DOH, 12/19/2023: No documentation of two references being verified prior to hiring or rostering direct care worker. First shift was on 12/28/2023. Two references conducted on 12/30/2023.
An interview conducted with EMP# 1 on June 4, 2024 at approximately 2:00 p.m. confirmed the above findings.







Plan of Correction:

Documentation of two satisfactory references will be obtained for EF #1,3, 4,7,8,9 & 10.

EMP #1 & 2 will review all active EF to ensure they contain documentation of references and obtain any found to be missing.

EMP #1 & 2 will both review obtained references, signatures and dates to ensure completion before filing.

EMP #2 will audit 2 charts each quarter for completion of references and maintain a logbook of this task.


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 review of employee files (EFs) and interview with agency general manager (EMP #1), it was determined agency failed to obtain a PA State Police criminal history record within 1 year immediately preceding the date of application for one (1) of ten (10) EFs reviewed. (EF# 2)
Findings include:
Review of EFs conducted on June 4, 2024 between approximately 10:00 a.m. and 11:15 a.m. revealed the following:
EF# 2, Date of Hire (DOH), 8/31/2023: No documentation provided of PA State Police criminal history record within 1 year immediately preceding the date of application. Contained a PA State Police criminal history dated 11/2/2020.

An interview conducted with EMP# 1 on June 4, 2024 at approximately 2:00 p.m. confirmed the above findings.










Plan of Correction:

Agency will obtain a PA State Police criminal history record for EF #2.

EMP #1 & 2 will audit all active EF to ensure criminal history records are within 1 year of date of hire.

Agency will have EMP #2 review completed new hire file to ensure date of criminal history record is satisfactory, before filing.

EMP #2 will audit 2 charts each quarter to ensure criminal history record is satisfactory and maintain a logbook.


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 review of employee files (EFs) and interview with agency general manager (EMP #1), it was determined agency failed to 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) for five (5) of ten (10) EFs reviewed. (EF# 2, EF# 3, EF # 5, EF# 9 and EF# 10)
Findings include:
Review of EFs conducted on June 4, 2024 between approximately 10:00 a.m. and 11:15 a.m. revealed the following:
EF# 2, Date of Hire (DOH), 8/31/2023: No Federal criminal history record and/or a letter of determination obtained from the Department of Aging.
EF# 3, DOH, 1/11/2024: No Federal criminal history record and/or a letter of determination obtained from the Department of Aging.
EF# 5, DOH, 3/26/2023: No Federal criminal history record and/or a letter of determination obtained from the Department of Aging.
EF# 9, DOH, 11/14/2023: No Federal criminal history record and/or a letter of determination obtained from the Department of Aging.
EF# 10, DOH, 12/19/2023: No Federal criminal history record and/or a letter of determination obtained from the Department of Aging.
An interview conducted with EMP# 1 on June 4, 2024 at approximately 2:00 p.m. confirmed the above findings.









Plan of Correction:

EF #3 & 5 are no longer are employed by agency.
EF #2 & 10 will furnish proof of residency for the 2 years immediately prior date of hire, to accompany the PA State Police criminal history record.
EF #9 will obtain a federal criminal history record and a letter of determination from the Department of Aging.

EMP #1 & 2 will audit all active EF to determine if any additional federal criminal history records are needed.

EMP #1 will educate EMP #2 on specific current regulations to ensure required materials are obtained for each EF. EMP #2 will review completed new hire EF to ensure federal criminal history record is present, if required, before filing.

EMP #2 will audit 2 charts each quarter for federal criminal history records and maintain logbook.




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 employee files (EFs) and interview with agency general manager (EMP #1), it was determined agency failed to 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) for five (5) of ten (10) EFs reviewed. (EF# 2, EF# 3, EF # 5, EF# 9 and EF# 10)
Findings include:
Review of EFs conducted on June 4, 2024 between approximately 10:00 a.m. and 11:15 a.m. revealed the following:
EF# 2, Date of Hire (DOH), 8/31/2023: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained Pa. Drivers License issued 2/3/2023-2/2/2027.
EF# 3, DOH, 1/11/2024: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained Pa. Drivers License issued 10/31/2023-12/6/2027.
EF# 5, DOH, 3/26/2023: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained Pa. Drivers License issued 2/24/2023-2/11/2027.
EF# 9, DOH, 11/14/2023: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained Pa. Drivers License issued 3/14/2023-3/19/2027.
EF# 10, DOH, 12/19/2023: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained Pa. Drivers License issued 12/14/2022-4/21/2027 and W2 form for the year of 2021.
An interview conducted with EMP# 1 on June 4, 2024 at approximately 2:00 p.m. confirmed the above findings.












Plan of Correction:

EF #3 & 5 no longer are employed by agency.
EF #2 will obtain proof of residency for the immediate 2 years prior DOH of 8/31/2023.
EF #9 will obtain a federal criminal history record and a letter of determination from the Department of Aging, in lieu of providing proof of residency for immediate 2 years prior DOH of 11/14/2023.
EF #10 will provide w-2/tax statement for year of 2022 to complete the proof of residency requirement.

EMP #1 & 2 will audit all active EF to determine if any additional proof of residency is required.

EMP #1 will update 'Employee Info Sheet' to include proof of residency requirements on checklist, which is maintained in the front of each EF.

EMP #2 will review Employee Info Sheet for completion before filing new hire EF, after EMP #1 has reviewed entire EF for all necessary information.


611.57(c) LICENSURE
Information to be Provided

Name - Component - 00
(c) Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.

Observations:


Based on review of consumer files (CFs) and interview with agency general manager (EMP #1), it was determined agency failed to provide, prior to the commencement of services, to the consumer the identity of the direct care worker who will provide the services to three (3) of seven (7) CFs reviewed (CF# 1, CF# 2 and CF# 3); and failed to provide a listing of the available home care services that will be provided to the consumer by the direct care worker for five (5) of seven (7) CFs reviewed (CF# 1, CF# 3, CF# 4, CF# 6 and CF# 7); and failed to provide the hours when those services will be provided for two (2) of seven (7) CFs reviewed (CF# 3 and CF# 7);
Findings include:
Review of CFs conducted on June 4, 2024 between approximately 11:20 a.m. and 12:10 p.m. revealed the following:
CF# 1, Start of Services, (SOS), 8/29/2023: No documentation of the identity of the direct care worker who will provide the services; of providing a listing of the available home care services that will be provided to the consumer by the direct care worker.
CF# 2, SOS, 2/27/2023: No documentation of the identity of the direct care worker who will provide the services.
CF# 3, SOS, 2/19/2024: No documentation of the identity of the direct care worker who will provide the services; of providing a listing of the available home care services that will be provided to the consumer by the direct care worker; and of providing the hours when those services will be provided.
CF# 4, SOS, 4/1/2024: No documentation of providing a listing of the available home care services that will be provided to the consumer by the direct care worker.
CF# 6, SOS, 11/9/2023: No documentation of providing a listing of the available home care services that will be provided to the consumer by the direct care worker.
CF# 7, SOS, 2/27/2023: No documentation of providing a listing of the available home care services that will be provided to the consumer by the direct care worker; and of providing the hours when those services will be provided.

An interview conducted with EMP# 1 on June 4, 2024 at approximately 2:00 p.m. confirmed the above findings.








Plan of Correction:

CF # 1,2 & 4 are no longer with agency.
Sales agreement will be updated (including newly obtained consumer signature/date) to reflect the name of initial caregiver providing services to CF #3.
Sales agreement will be updated (including newly obtained consumer signature/date) to reflect the planned services that will be provided to consumer for CF #3, 6 & 7.
Sales agreement will be updated (including newly obtained client signature/date) to reflect the planned hours of services provided for CF #3 & 7.

EMP #1 & 2 will audit all active CF to ensure the initial direct care worker is identified, services provided are listed and hours of service are indicated on sales agreement signed and dated by consumer.

When meeting with each consumer face to face, to discuss care plan & payment, EMP #1 will document initial direct care worker identity, services being provided and hours of provided services on the 'Care Schedule' line on current form, before having consumer sign and date the sales agreement.

EMP #2 will audit 2 charts a quarter to ensure the sales agreement contains the identity of direct care worker, services being provided and hours of services provided on the signed and dated sales agreement.


Initial Comments:


Based on the findings of an unannounced, onsite state re-licensure survey conducted on June 4, 2024, Christian Companion Senior Care, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: