Initial Comments:
Based on the findings of a state licensure survey completed on May 2, 2025, Community Resources for Independence, 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 home care agency state re-licensure survey completed on May 2, 2025, Community Resources for Independence, 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 the review of employee/direct care worker personnel files (PF) and interview with the regional manager, the agency failed to obtain a State Police criminal history record for seven (7) of seven (7) personnel files. (PF#1, PF#2, PF#3, PF#4, PF#5, PF#6, and PF#7).
Findings:
Review of Act 169 of 1996 May 2, 2025 approximately 1:00 p.m. through 4:00 p.m. revealed:
Older Adults Protective Services Act (OAPSA) updates 2016 web address: https://www.pa.gov/content/dam/copapwp-pagov/en/aging/documents/resources-for-aging-professionals/Acts%20Three%20Panel%20OAPSA%20updated%202016.pdf : ..."Criminal History Background Checks- (Act 169 of 1996) Purpose: Requires criminal history background checks for employees of NH, PCH, Dom Care, Home Health and ADC. Employees: An employee is defined as any applicant or new employee who has been hired since July 1, 1998. Includes contract employees with direct contact with residents or unsupervised access to their personal living quarters. Also includes persons employed or contracted to provide care to a care dependent individual for monetary consideration in the individual ' s residence... Facility: The types of facilities covered by the Act are as follows: domiciliary care homes, home health agencies, long-term care nursing facilities, adult day
care facilities, and personal care homes. The Act also includes any private or
public organization which provides care to a care-dependent person in their
residence..."
Review of personnel files (PF) on April 29, 2025 from approximately 12:00 pm to 1:00 pm revealed:
PF#1 date of hire (DOH): 10-28-24; contained a Pennsylvania Access to Criminal History (PATCH) criminal background check with a date of request: 10-9-24 and a purpose of request: Elder Care Act. 'Employment' Purpose of request for PF#1 was not chosen by facility when requesting the PATCH.
PF#2 date of hire (DOH): 1-29-24; contained a Pennsylvania Access to Criminal History (PATCH) criminal background check with a date of request: 1-30-24 and a purpose of request: Elder Care Act. 'Employment' Purpose of request for PF#2 was not chosen by facility when requesting the PATCH.
PF#3 date of hire (DOH): 1-29-24; contained a Pennsylvania Access to Criminal History (PATCH) criminal background check with a date of request: 1-31-24 and a purpose of request: Elder Care Act. 'Employment' Purpose of request for PF#3 wasnot chosen by facility when requesting the PATCH.
PF#4 date of hire (DOH): 7-30-24; contained a Pennsylvania Access to Criminal History (PATCH) criminal background check with a date of request: 7-30-24 and a purpose of request: Elder Care Act. 'Employment' Purpose of request for PF#4 was not chosen by facility when requesting the PATCH.
PF#5 date of hire (DOH): 6-4-24; contained a Pennsylvania Access to Criminal History (PATCH) criminal background check with a date of request: 6-4-24 and a purpose of request: Elder Care Act. 'Employment' Purpose of request for PF#5 was not chosen by facility when requesting the PATCH.
PF#6 date of hire (DOH): 1-19-24; contained a Pennsylvania Access to Criminal History (PATCH) criminal background check with a date of request: 1-19-24 and a purpose of request: Elder Care Act. 'Employment' Purpose of request for PF#6 was not chosen by facility when requesting the PATCH.
PF#7 date of hire (DOH): 1-10-24; contained a Pennsylvania Access to Criminal History (PATCH) criminal background check with a date of request: 1-10-24 and a purpose of request: 'Elder Care Act'. 'Employment' Purpose of request for PF#7 was not chosen by facility when requesting the PATCH.
Interview with the regional manager on April 29, 2025 at approximately 1:45 pm confirmed the above findings and stated... "The company must have an account set up for the background check to default to purpose of Elder Care Act. It has always been done this way." Interview with the general manager on April 29, 2023 at approximately 1:45 p.m. confirmed that the applicant did not have documentation of a PATCH with purpose of employment.
Plan of Correction:CRI will change its Purpose of Request effective 5/16/2025 from "Elder Care Act" to "EMPLOYMENT", when completing Pennsylvania Access to Criminal History (PATCH) criminal background checks, per regulation cited.
CRI's HR Director will be responsible to train HR staff on this change and to implement CRI's new PATCH criminal background checks procedure.
CRI's Quality Manager will conduct a sampling audit of employee PATCH criminal background checks over the next three (3) months to ensure newly implemented procedure is being completed and will be responsible to monitor the continued implementation of this corrective action plan.
Initial Comments:
Based on the findings of an unannounced onsite state relicensure survey completed May 2, 2025, Community Resources for Independence Inc. - Clearfield, 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 an observation (OBS) of Identification badges (ID), review of healthcare facilities act, review of facility personnel policy handbook, chapter 611 definitions and an interview with the agency Regional Manager, agency failed to format/issue ID badges per regulatory requirements for one (7) of one (7) observation (OBS#1-#7).
Findings include:
Review of Chapter 611 on April 29, 2025 at approximately 10:30 a.m. revealed: 'Home Care Agencies and Home Care Registries' 611.5 'Definitions' "Direct Care Worker- The individual employed by a home care agency or referred by a home care registry to provide home care services to a consumer."
Review of Health Care Facilities Act on May 2, 2025 at approximately 11:00 a.m. revealed: "Section 809.2. Photo identification tag regulations...(b) to require employees to wear a photo identification tag when the employee is working. The following shall apply: (1) The photo identification tag shall include a recent photograph of the employee, the employee's first name, the employee's title...(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..."
Review of "Community Resources for Independence Personnel Policy Handbook" on April 29, 2025 at approximately 12:00 p.m. revealed: "... page5... II. General Policies, "Direct Care Worker" or DCW is used to describe any staff providing hands-on care to consumers ina home or community based setting including Personal Care Attendants, Home Care Attendants, Support Service Workers, and /or Habilitation Aides...". "... page 24... D. Direct Care Workers (DCW) CRI operates 24-hours a day, seven days a week. If you accept the position of Direct Care Worker (DCW)..."
OBS#1 on April 29, 2025 at approximately 10:00 a.m. revealed the current ID badge that employee (EMP) #1 title is identified as "Attendant". The employee's actual title is 'Direct Care Worker'.
OBS#2 on May 2, 2025 at approximately 1:00 p.m. revealed the current ID badge that employee (EMP) #2 title is identified as "Attendant". The employee's actual title is 'Direct Care Worker'.
OBS#3 on May 2, 2025 at approximately 1:00 p.m. revealed the current ID badge that employee (EMP) #3 title is identified as "Attendant". The employee's actual title is 'Direct Care Worker'.
OBS#4 on May 2, 2025 at approximately 1:00 p.m. revealed the current ID badge that employee (EMP) #4 title is identified as "Attendant". The employee's actual title is 'Direct Care Worker'.
OBS#5 on May 2, 2025 at approximately 1:00 p.m. revealed the current ID badge that employee (EMP) #5 title is identified as "DCW Supervisor" The employee's actual title is 'Direct Care Worker Supervisor'.
OBS#6 on May 2, 2025 at approximately 1:00 p.m. revealed the current ID badge that employee (EMP) #6 title is identified as "Attendant". The employee's actual title is 'Direct Care Worker'.
OBS#7 on May 2, 2025 at approximately 1:00 p.m. revealed the current ID badge that employee (EMP) #7 title is identified as "Attendant". The employee's actual title is 'Direct Care Worker'.
An interview conducted with the agency Regional Manager on April 29, 2025 at approximately 1:45 p.m. confirmed the above findings.
Plan of Correction:CRI will modify its current Identification Badges (ID) it issues for employees effective 5/16/2025 from "ATTENDANT" to read "Direct Care Worker" in order to reflect employee's actual title, per regulations cited.
This title of "Direct Care Worker" 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, per regulation.
CRI's HR Director will be responsible to train HR staff on this modification and to implement the new Identification Badge procedure, per the corrective action date.
CRI's Quality Manager will conduct a sampling audit of new employee Identification Badges over the next three (3) months to ensure newly implemented procedure is being completed and will be responsible to monitor the continued implementation of this corrective action.
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