Initial Comments:
Based on the findings of an onsite, state re-licensure survey conducted on July 25, 2024, Associated Family Care Services was found to be in compliance with the requirements of 28 Pa. Code, Health and Safety, Part IV, Health Facilities, Subpart A. Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite, state re-licensure survey conducted on July 25, 2024, Associated Family Care Services was found not to be in compliance with the following requirements of Title 28 Health and Safety Part IV, Health Facilities, Subpart H. Chapter 611 Home Care Agencies and Home Care Registries.
Plan of Correction:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
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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 agency documentation, consumer (agency) and personnel files, and based on interview with the office manager (Employee #7) and the owner/administrator (Employee #6), the agency failed to ensure documentation was maintained in the personnel file which provided evidence that two (2) satisfactory references had been obtained prior to the assignment of two (2) of four (4) direct care workers (DCW) who were assigned to provide home care services after July 14, 2021. (Employees #4 and #5)
Findings include:
On July 25, 2024 at approximately 9:31 AM, review of the welcome packet revealed consumer notifications included that DCW hiring requirements would be in compliance with the state licensure requirements.
Consumer #5: On July 25, 2024 at approximately 10:48 AM, review of the consumer file revealed a DCW's (Employee #4) provided home care services between 04/29/2024 and 06/30/2024 and that a second DCW (Employee #5) provided home care services between 07/01/2024 and 07/13/2024.
On July 25, 2024 at approximately 11:32 AM, review of personnel files revealed the following:
Employee #4: The date of hire of the DCW was 04/22/2024 and that a second satisfactory reference was obtained on 05/02/2024 which was after the first date of assignment to provide home care services to Consumer #5.
Employee #5: The date of hire of the DCW was 07/01/2024 and that two (2) satisfactory references were obtained on 07/08/2024 which was after the first date of assignment to provide home care services to Consumer #5.
During interview conducted on July 25, 2024 at approximately 1:42 PM, the office manager and owner/administrator confirmed two (2) satisfactory references had not been obtained prior to the assignment of Employees #4 and #5 to provide home care services.
Plan of Correction: Moving forward all references will be performed before employee goes on a visit.
Personel files will be audit quarterly by Staff Coordinator and Adm. .
611.52(f) LICENSURE
Records Maintained
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The home care agency or home care registry shall maintain files for direct care workers and members of the office staff which include copies of State Police criminal history records or Department of Aging letters of determination regarding Federal criminal history records. The files shall be available for Department inspection. The agency or registry shall maintain copies of the criminal history report for the agency or registry owners, which shall be available for department inspection.
Observations:
Based on review of agency documentation, consumer (agency) and personnel files, and based on interview with the office manager (Employee #7) and the owner/administrator (Employee #6), the agency failed to ensure documentation was maintained in the personnel file which provided evidence that a Pennsylvania Department of Aging (PA DOA) letter of determination regarding the Federal Bureau of Investigation (FBI) criminal history record had been obtained for one (1) of two (2) active direct care workers (DCW) for whom proof of residency in PA was less than 24 months prior to the date of hire. (Employee #3)
Findings include:
On July 25, 2024 at approximately 9:31 AM, review of the welcome packet revealed consumer notifications included that DCW hiring requirements would be in compliance with the state licensure requirements.
Consumer #4: On July 25, 2024 at approximately 10:39 AM, review of the consumer file revealed the DCW (Employee #3) provided home care services in June and July 2024.
On July 24, 2024 at approximately 11:32 AM, review of personnel files revealed the following:
Employee #3: The date of hire of the DCW was 05/08/2023, the DCW's proof of residency (driver's license) was issued on 03/21/2022 and that two (2) previous employers listed on the employment application were located in Florida.
There was no documentation in the personnel file which provided evidence that a PA DOA letter of determination regarding the FBI criminal history record had been included in the personnel file prior to 07/25/2024.
During interview conducted on July 25, 2024 at approximately 1:41 PM, the office manager reported that a PA DOA letter of determination regarding the FBI criminal history record had been obtained by the DCW but confirmed that a copy of the letter of determination had not been included in the personnel file prior to 07/25/2024.
During interview conducted on July 25, 2021 at approximately 1:42 PM, the owner/administrator confirmed a copy of the PA DOA letter of determination regarding the FBI criminal history record had not been included in the personnel file prior for Employee #3 prior to 07/25/2024.
Plan of Correction:Attention to when Pa driver's license was issued,if less than 2 years, an FBI criminal background will be performed prior to employment. Currently arrangements have been made for the one employee for fingerprinting we were unable to recieve a copy from prior employer This will be monitor at time of apply for employment by Staff Coordinator or Adm
Initial Comments:
Based on the findings of an onsite, state re-licensure survey conducted on July 25, 2024, Associated Family Care Services was found not to be in compliance with the following requirement of 35 P.S. 448.809 (b).
Plan of Correction:
35 P. S. § 448.809b LICENSURE
Photo Id Reg
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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 upon observation of a direct care worker (DCW) photo identification (ID) badge, and based on interview with owner/administrator (Employee #6), the agency failed to ensure the job title, which occupied a one-half inch tall strip as close to the bottom edge of the photo ID badge as practicable, had been included on the photo ID badge for one (1) of one (1) direct care worker (DCW) whose photo ID badge was available for review. (Employee #8)
Findings include:
On July 25, 2024 at approximately 9:30 AM, observation of the photocopy of the photo ID badge for a DCW (Employee #8) revealed the job title was abbreviated to DCW and the abbreviated job title was located near the center/mid-portion of the badge. There was no evidence that the job title of Direct Care Worker occupied the one-half inch tall strip as close to the bottom edge of the photo ID badge as practicable.
During interview conducted on July 25, 2024 at approximately 1:42 PM, the owner/administrator confirmed the job title of Direct Care Worker did not occupy a one-half inch tall strip as close to the bottom edge of the photo ID badge as practicable for Employee #8.
Plan of Correction:All employee name badges will be done to meet the state requirements. Job descriptions will be measured for the one-half inch before they are issued to employees This will be monitored regularly when badges are ready to be distrubed to employees by Adm and Staff Coordinator.
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