Initial Comments:
Based on the findings of an onsite unannounced State relicensure survey completed 5/26/2021, Alleghenies Unlimited Care Providers 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 5/26/2021, Alleghenies Unlimited Care Providers was found not to be in compliance with the following requirement 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:
611.55(d) LICENSURE
Competency Requirements
Name - Component - 00
(d) The home care agency or home care registry shall include documentation of the direct care worker's satisfactory completion of competency requirements in the direct care worker's file.
Observations:
Based on review of the agency policy, personnel files (PF) and staff (EMP) interviews, it was determined that the agency failed to ensure PF contained documentation to show satisfactory completion of initial competency requirements upon hire for four (4) of five (9) direct care worker personnel files (PF3, PF6, PF7 and PF8).
Findings included:
Review of agency policy on 5/26/2021 at approximately 11:30 AM revealed, "CONSUMER SERVICE MANUAL...2020-2021 FISCAL YEAR...Employee Training and Screening...All new employees are required to complete comprehensive personal care procedures and techniques training as well as a thorough review of agency policies and procedures prior to working with any participant. The agency also requires mandatory continued training a yearly basis. (Agency) has developed a comprehensive training program per Pennsylvania Department of Health's Regulations; including, but not limited to, the following competencies: Confidentiality, Consumer control and the independent living philosophy, instrumental activities of daily living, recognizing charges in the consumer that need to be addressed, basic infection control, universal precautions, handling of emergencies, documentation, recognizing and reporting abuse or neglect, dealing with difficult behaviors, bathing, shaving, grooming and dressing, hair, skin and mouth, assistance with ambulation and transferring, meal preparation and feeding, toileting and assistance with self-administered medication.
A review of the agency policy on 5/26/2021 at approximately 2:30 PM revealed, "Policy for Competency Requirements...Alleghenies Unlimited Care Providers requires that applicants and direct care workers employed/rostered to demonstrate competency in specific subject areas in accordance with Chapter 611 of the Health Care Facilities Act and the applicant's prospective or direct care worker's job assignment(s); the agency/registry will consider an applicant's previous training and experience; an employee/rostered direct care worker's competency documentation is transferable...8.1. All documentation of the direct care worker's successful completion of training, testing, annual reviews will be maintained in the worker's file. If certificates of completion are awarded, the worker will receive the original and, at the worker ' s request a copy may be maintained in the worker's file..."
A review of the PFs conducted on 5/26/2021 at approximately 10:20 AM to 11:40 AM revealed the following:
PF #3, date of hire (DOH) 6/23/2020, the PF did contain evidence of initial competency exam taken on 6/23/2020. The competency exam score was not documented to confirm satisfactory completion of initial competency requirements.
PF #6, date of hire (DOH) 11/18/2019, the PF did contain evidence of initial competency exam taken on 11/21/2019. The competency exam score was not documented to confirm satisfactory completion of initial competency requirements.
PF #7, date of hire (DOH) 3/1/2021, the PF did contain evidence of initial competency exam taken on 3/4/2021. The competency exam score was not documented to confirm satisfactory completion of initial competency requirements.
PF #8, date of hire (DOH) 1/11/2021, the PF did contain evidence of initial competency exam taken on 1/13/2021. The competency exam score was not documented to confirm satisfactory completion of initial competency requirements.
An exit interview was conducted with the deputy director, director of services recruitment and training and director of human resources on 5/26/2021 at approximately 1:00 PM which confirmed the above findings.
Plan of Correction:Action Steps to Correct Finding and Date of Completion
1. The competency test results of the 4 audited DCWs will be reviewed, and the score will be documented on the front of the test.
a. Responsible Person: Director of HR
2. A section on the competency test will be added on the front page for the trainer to document the test score.
a. Responsible Person: Director of HR
3. The competency test results for all active staff will be reviewed to ensure that all scores are documented properly.
a. Responsible Person: Director of HR
4. Staff trainer(s) will be instructed on proper documentation of competency test scores.
a. Responsible Person: Director of HR
5. Competency test score review will be added to internal audit checklist to ensure scores are documented moving forward.
a. Responsible Person: Director of HR
Initial Comments:
Based on the findings of an onsite unannounced State relicensure survey completed 5/26/2021, Alleghenies Unlimited Care Providers was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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