Initial Comments:
Based on the findings of an onsite unannounced State relicensure and complaint investigation survey completed 4/14/2022, Community Resources For Independence Inc. was found not to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
51.3 (f) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification
(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.
Observations:
Based on review of Pennsylvania (Pa.) Department of Health (DOH) Event Reporting System (ERS) and staff (EMP) interview the agency failed to ensure event reporting to the Pennsylvania (Pa.) Department of Health ERS system for eleven (11) staff and six (6) consumers who were diagnosed COVID-19 positive from March 2020 to 4/13/2022.
Findings Included:
Review of the departments event reporting system guide on 4/14/2022 at approximately 3:30 PM revealed, "Health department Reportable Diseases COVID-19 Quick Start Guide COVID-19 records are reportable within 24 hours after being diagnosed ...Health Department Reportable Diseases (Covid-19) - If you select Event Type = Health Department Reportable Diseases and Event-Sub-type = Covid-19, the Reportable Disease Detail section will appear. You will be required to add at least one Reportable Disease Detail record before submitting the event to DOH. There are two ways to enter information. It should be noted that both methods can be used during the same event. You can manually enter data and/or upload a spreadsheet/s..."
During an interview with EMP2 on 4/13/2022 at approximately 1:10 PM, staff did not provide documentation to confirm Covid-19 positive staff or client being reported through the Pennsylvania Department of Health Event Reporting System system.
An exit interview was conducted on 4/14/2022 at approximately 1:05 PM with the supervisor which confirmed the findings.
Plan of Correction:The office supervisor is responsible for reporting all COVID-19 testing and results to the HR Department. The HR Department, as a part of its tracking mechanism, will ensure the Regional Manager, or his designee, enters the information into ERS in the event a staff or consumer receives a positive result.
Furthermore, the HR Director is responsible for periodically checking the Online Licensing message board to ensure all updates to reporting requirements are being followed.
This new procedure is effective immediately.
Initial Comments:
Based on the findings of an onsite unannounced state relicensure and complaint investigation survey completed 4/14/2022, Community Resources For Independence 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:
611.52(d) LICENSURE
Proof of Residency
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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 agency policy, personnel files (PF) and staff interview, the agency failed to verify proof of residency for two (2) of seven (7) PF reviewed (PF4 and PF5).
Findings included:
A review of the agency consumer information packet on 4/13/2022 at approximately 11:07 AM revealed, "...(Agency) Hiring Requirements for Direct Care Workers...Background Checks...Direct care Workers who swear and affirm in writing that they have not been convicted of certain criminal convictions prohibited by the Older Adult Protective Services Act and PA Code 15.143 are permitted to work for up to 30 days (if PA resident for 2+ years) or up to 90 days (if PA resident for less than 2 years while awaiting results of the background checks..."
A review of the agency employee handbook was conducted on 4/13/2022 at approximately 11:07 which revealed, "MANDATORY REQUIREMENTS Employee MUST provide (agency) with...Original Act 33 Clearance (Child Abuse History Clearance) to (agency) office within thirty (30) days...(To comply with this deadline, employees will be required to complete their clearances online.) (All Employees) According to Department of Health Regulations, this form must be returned within thirty (30 ) Days of the employee's hire date.)...If you have NOT lived in the State of Pennsylvania for the past two (2) years prior to employment at (agency), you must provide (agency) with a FBI Background Check within sixty (60) days form date of hire. (All employees)-Must provide proof that you have lived in PA for the past two years..."
A review of PF4 was conducted on 4/13/2022 at approximately 2:00 PM, the date of hire (DOH) was 3/15/2022. A Pennsylvania driver's license issued 8/17/2021, also a tax form W-2 from 2020 was provided as proof of residency. There was no additional documentation made available by the agency to verified proof of residency in this Commonwealth for two (2) years immediately preceding DOH.
A review of PF5 was conducted on 4/13/2022 at approximately 2:10 PM, the date of hire (DOH) was 3/15/2022. A Pennsylvania driver's license issued 7/22/2021, also a tax form W-2 from 2020 was provided as proof of residency. There was no additional documentation made available by the agency to verified proof of residency in this Commonwealth for two (2) years immediately preceding DOH.
An exit interview was conducted on 4/14/2022 at approximately 1:05 PM with the supervisor which confirmed the findings.
Plan of Correction:PF#4 and PF#5 with a hire date of 3/15/2022 have since provided satisfactory proof of residency.
Going forward CRI will alter its systems to ensure that the problem does not recur by: In addition to, and as a backup to, the facility DCW supervisory staff and secretarial staff tracking the proof of residency, corporate HR will review incoming new employee hire information to double-check that satisfactory proof of residency has been obtained by the facility. This additional check has already been implemented.
The facility secretary shall review the proof of residency in the files of current staff. Any current staff without acceptable proof of residency as per the above shall be required to provide acceptable proof of residency else submit to a Federal criminal history record check. The correction date for this action shall be by May 31, 2022.
Initial Comments:
Based on the findings of an onsite unannounced State relicensure and complaint investigation survey completed 4/14/2022, Community Resources for Independence Inc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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