QA Investigation Results

Pennsylvania Department of Health
DALY CARE
Health Inspection Results
DALY CARE
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced state license survey completed December 8, 2021, Daly Care 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 license survey completed December 8, 2021, Daly Care 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:




611.55(a) LICENSURE
Compentency Requirements

Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.

Observations:


Based on review of agency policy, direct care worker (DCW) personnel files (PF), and staff (EMP) interview, the agency failed to ensure the DCW had completed a competency exam prior to providing services to consumers for five (5) of six (6) six personnel files reviewed (PF1-PF3, PF5, & PF6).

Findings included:

Review of agency policy on December 6, 2021, at 2 p.m. showed, "Competency Exam Process ... All employees are required to complete and pass the competency exam prior to working with individuals. The Staff Trainer or Manager will provide the competency exam via paper or through Snappii app. The Staff Trainer will collect all paper and electronic exams and score each exam."

Review of personnel files was conducted on December 6, 2021, at 10 a.m., and again on December 8, 2021, at 9:30 a.m. with human resource representative EMP3.

The following direct care workers had not completed a competency exam prior to providing services to consumers.

PF1 was hired on 11/5/2020 and began providing services to consumers on 12/14/2020.

PF2 was hired on 11/30/2020 and began providing services to consumers on 12/13/2020.

PF3 was hired on 10/16/2020 and began providing services to consumers on 12/13/2020.

PF5 was hired on 12/19/2019 and began providing services to consumers on 11/9/2021.

PF6 was hired on 5/12/2021 and began providing services to consumers on 6/25/2021.

EMP3 was present for the DCW personnel file review on December 8, 2021, at 9:30 a.m. and confirmed above findings.














Plan of Correction:

Actions Steps to Correct Finding and Date of Completion

1. The competency test process will be updated to include newly hired and acquired staff.
a. Responsible Person: Director of HR

2. Staff trainer(s) will be instructed on the updated competency test process.
a. Responsible Person: Director of HR

3. An item will be added to internal audit checklist to ensure that the competency test has been
received, reviewed and approved prior to employees working with individuals moving forward.
a. Responsible Person: Director of H


611.57(c) LICENSURE
Information to be Provided

Name - Component - 00
(c) Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.

Observations:



Based on review of consumer files (CF), and staff (EMP) interview, the agency failed to provide the consumer with required information in a format that was easily read and understood prior to commencement of services for three (3) of four (4) consumer files reviewed (CF1, CF2, & CF4).

Findings included:

Review of consumer files was conducted on December 6, 2021, at 9:30 a.m.

The review showed the agency failed to provide CF1, CF3, & CF4 with the following: (1) a listing of the available home care services that would be provided to the consumer by the direct care worker and the identity of the direct care worker who would provide the services; (2) the hours when those services would be provided; (3) fees and total costs for those services on an hourly or weekly basis; (4) who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry; (5) the Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA); (6) the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry; and (7) a disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.

CF1 started services on 12/19/2019 but CF1's service agreement (containing required above information) was not signed until 7/3/2021.

CF2 also started services on 12/19/2021 but CF2's service agreement was not signed until 6/11/2021.

CF4 started services on 5/12/2020 but CF4's service agreement was not signed until 7/2/2021.

An in-person interview with EMP1 and phone interview with EMP2 (administrator) on December 6, 2021, at 10:35 a.m. confirmed above findings.





Plan of Correction:

Actions Steps to Correct Finding and Date of completion

1.)Consumer manual will have a list of services that the agency provides and a meet and greet with consumer will be held prior to services being provided
a. Responsible Person: Field Manager

2.)Consumer manual will have a schedule page so consumer will be able to view their schedule on a weekly basis. Consumer will also have access to a family portal through a website that only family can view.
a. Responsible Person: Field Manager

3.)Fees and total cost will be in the consumer manual. Most of the consumer's services is paid through the waiver so that will be explained to the consumer.
a. Responsible Person: Field Manager

4.)Consumer manual will have a list of names with numbers on who to contact throughout the agency.

a. Responsible Person: Field Manager
5.)Department of Aging's local complaint hotline will be in the consumer manual
a. Responsible Person: Field Manager

6.)Competency requirement will be in the consumer manual under the compliance section of the consumer manual.
a. Responsible Person: Field Manager

7.)Obligations and other responsibilities with consumer and the home care agency will be identified in the consumer manual and explained to the consumer.
a. Responsible Person: Field Manager

8.)Any new or acquired client will be provided with a consumer manual prior to start of services
a. Responsible Person: Field Manager



Initial Comments:

Based on the findings of an onsite unannounced state license survey completed December 8, 2021, Daly Care was found to be in compliance with the requirement of 35 P.S. 448.809 (b).




Plan of Correction: