QA Investigation Results

Pennsylvania Department of Health
ARCADIA HOME CARE & STAFFING
Health Inspection Results
ARCADIA HOME CARE & STAFFING
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite unannounced State relicensure survey completed 11/4/2022, Arcadia Home Care & Staffing 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 state relicensure survey completed 11/4/2022, Arcadia Home Care & Staffing 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 a review of the agency policy, personnel files (PFs) and staff (EMP) interview it was determined the agency failed to show proof of residency in this Commonwealth for the 2 years preceding the date of hire (DOH) for one (1) of seven (7) PFs reviewed (PF7).

Findings included:

Review of the agency policy and procedures on 11/3/2022 at approximately 10:45 AM revealed, Employee handbook "BACKGROUND CHECKS Background checks and investigations may be performed by the Company, at the Company's discretion, but in all cases subject to applicable state and federal laws..."

A review of PF7 on 11/3/2022 at approximately 2:01 PM, date of hire (DOH) 1/22/2022 revealed: There was a Pennsylvania Driver's License with an issue date of 1/28/2021. A copy of a 2020 Wage and Tax Statement W-2 was provided as a proof of residence. The document did not confirm the direct care worker (DCW) date of hire or period of employment. There was no additional documentation in PF to confirm the agency verified proof of residency in this Commonwealth for two (2) years immediately preceding the date of hire.

An exit interview was conducted on 11/3/2022 at approximately 2:15 PM the director, service coordinator and office manager which confirmed the findings.





















Plan of Correction:

1. If PF7 (DOH: 1/22/22) has not been a resident of PA 2-years immediately preceding hire or cannot produce an acceptable 2 year proof of residency, the employee will obtain a Federal criminal history record and a letter of determination from the Department of Aging. These documents will be maintained in the employee's personnel file. Office staff will be re-educated on the hiring requirement regarding the Federal Criminal History Record, as stated in our Personnel Policy 3.5: Applicants who have been a resident of PA for 2 years immediately preceding the request of the PA State Criminal Record (which is required prior to hire) must furnish proof of residency through submission of proof of residency. Acceptable proof of residency can be any of the following: Motor vehicle records, such as a valid driver's license or a state-issued identification. - Housing records such as mortgage records or rent receipts. - Public Utility records and receipts, such as electric bills. - Local tax records. - A completed and signed, federal, state or local income tax return with the applicant's name and address preprinted on it. - Employment records, including records of unemployment compensation. Our agency's 2-year proof document is being updated to include the requirement that a copy of the 2-year proof of residency of Pennsylvania must be kept along with the form, in the new hire's file. If the applicant has not been a resident of Pennsylvania for two (2) years immediately preceding the request, the applicant shall obtain a Federal Criminal History Record (FBI Background Check) and a Letter of Determination from the Department of Aging, based on the individual's Federal Criminal History Record, in accordance with 6 Pa. Code 15.144(b). All personnel files will be audited to ensure compliance regarding this requirement. This will be completed by 12/18/2022. New employee files will be reviewed by both the Office Coordinator and the Service Coordinator, using the New Hire Documentation Checklist, to ensure compliance, going forward.


611.57(a) LICENSURE
Consumer Rights

Name - Component - 00
(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

Observations:



Based on a review of the agency consumer records (CR) and staff (EMP) interview, the agency failed to involve the consumer in the service planning process and to receive services with reasonable accommodation of individual needs and preferences for two (2) of five (5) CR's reviewed (CR2 and CR3).

Findings included:

Review of the agency consumer admission packet on 11/3/2022 at approximately 10:35 AM revealed, "CLIENT BILL OF RIGHTS As a client of our services, you are entitled to...Be informed of the services offered including a written explanation of the service being provided, the schedule of services delivery and the individual delivering those services...Participate in the development of your care plan and/or family involvement in the development of your care plan..."

A review of CR2 on 11/3/2022 at approximately 12:20 PM revealed start of services 5/24/2021. The hours when services would be provided per the agency documentation dated 5/20/2021 was Monday through Friday from 12:00 PM to 2:00 PM. Services that were provided during the month of October of 2022, were Monday through Thursday 10:00AM to 3:00 PM and Fridays 10:00 AM to 4:00 PM. The surveyor could not confirm from the agency documentation that scheduled changes in times were reviewed with the consumer or consumer representative. The surveyor requested any additional documentation that changes were agreed upon, no other documentation was provided.

A review of CR3 on 11/3/2022 at approximately 12:30 PM revealed start of services 7/12/2021. The hours when services would be provided per the agency documentation dated 7/27/2021 was Monday 1.0 hour, Wednesday 1.5 hours and Friday 1.5 hours. No times for services were provided. The surveyor could not confirm from the agency documentation that scheduled times were reviewed with the consumer or consumer representative. The surveyor requested any additional documentation that times for services were agreed upon, no other documentation was provided

An exit interview was conducted on 11/3/2022 at approximately 2:15 PM the director, service coordinator and office manager which confirmed the findings.


















Plan of Correction:

Staff will be re-educated on following the agency's Care Plan Policy as well as the agency's Missed Visit Policy which include: All clients will be scheduled per the Authorization provided by the client's Case Manager. Any schedule changes, deviations or missed services must be communicated to the client and documented on a Missed Visit Report sent to the client's Case Manager as well as permanently maintained in the client's file. These changes will also be noted in the agency's scheduling database for that client. This will be completed by 12/18/2022. The Agency Director will review all consumer files, for the months of October and November, to ensure there is documentation to account for the services authorized for each client. This will be completed by 12/18/2022. Going forward, the Agency Director will run a monthly report to identify services not provided and will verify in our system that the clients were notified and were part of the care planning process.


Initial Comments:


Based on the findings of an onsite unannounced State relicensure survey completed 11/4/2022, Arcadia Home Care & Staffing was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: