Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed March 20, 2024, Caring Grace Home Care Agency, Llc. was found to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed March 20, 2024, Caring Grace Home Care Agency, Llc. 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:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
Name - Component - 00
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 employee files and an interview with the agency Administrator, the agency failed to obtain not less than two satisfactory references, prior to hire, for three (3) out of four (4) employee files (EF) reviewed (EF#1-EF#3).
Findings include:
A review of EFs was conducted on March 20, 2024 at approximately 9:15 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 02/24/24: One positive/verifiable reference was dated 01/26/24. One positive but not verified reference was dated 02/05/24. No documentation provided of obtaining not less than two satisfactory references (positive, verifiable).
EF#2 DOH 08/08/23: One positive/verifiable reference was dated 08/08/23. One positive but not verified reference was dated 08/18/23. One positive but not verified reference was dated 08/12/23. No documentation provided of obtaining not less than two satisfactory references (positive, verifiable).
EF#3 DOH 07/12/23: One positive/verifiable reference was undated. One positive but not verified reference was dated 08/18/23. Two positive but not verified references were dated 02/14/24. No documentation provided of obtaining not less than two satisfactory references (positive, verifiable).
An interview conducted with the agency Administrator on March 20, 2024 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:EF#1 DOH 02/24/2024; EF#2 DOH 08/08/2023;EF#3DOH 07/12/2023
1. Corrective action to be accomplished:
The agency Administrator will obtain two to three satisfactory references; positive and verifiable for all current and potential employees.
2. To identify other individuals having the potential to be affected by the same deficient practice, the Administrator will ensure to conduct an audit of employee application files to ensure no other individuals have been affected by the same deficient practice.
3. Measures to be put in place to ensure that deficient practice does not recur: every employee file will have a new checklist of all required document/forms. The employee application reference section will be updated to capture previous job start date and end date.
4. How will corrective action be monitored:
The Administrator will conduct a quarterly audit of all employee files to monitor that the deficient practice will not recur.
611.52(d) LICENSURE
Proof of Residency
Name - Component - 00
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 employee files and an interview with the agency Administrator, agency failed to obtain proof of Pennsylvania residency for two (2) out of four (4) employee files (EF) reviewed (EF#2, EF#3).
Findings include:
A review of EFs was conducted on March 20, 2024 at approximately 9:15 a.m. Employee date of hire (DOH) is listed below.
EF#2 DOH 08/08/23: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Pa. Identification Card issued 11/09/21 with an expiration date of 11/30/25. 'Job/Employment Application for a Home Care Assistant Position' record was reviewed. 'Reference Information' 'Work Related #1 (Last Position) has employer listed with a Pa. address. 'Length of Employment' lists "1 year." No defined date range included. No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 08/08/21-11/09/21.
EF#3 DOH 07/12/23: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Pa. Drivers License issued 01/01/23 with an expiration date of 02/21/27. 'Job/Employment Application for a Home Care Assistant Position' record was reviewed. 'Reference Information' 'Work Related #1 (Last Position) has employer listed with an incomplete address. 'Length of Employment' lists "3 years." No defined date range included. No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 07/12/21-01/01/23.
An interview conducted with the agency Administrator on March 20, 2024 at approximately 12:45 p.m. confirmed the above findings.
Repeat deficiency.
Plan of Correction:EF#2 DOH 08/08/2023; EF#3 DOH 07/12/2023
1. Corrective action to be accomplished:
The Administrator will obtain proof of residency for 2 years through a FBI fingerprint process with the Pennsylvania Department of aging.
2. To identify other individuals having the potential to be affected by the same deficient practice, the Administrator will ensure to conduct an audit of employee's files to ensure no other individuals have been affected by the same deficient practice.
3. Measures to be put in place to ensure that deficient practice does not recur: every employee file will have a new checklist of all required document/forms, a paid inservice will be implemented to boost employees' morale, employee who does not follow or willingly refused to comply will be reprimanded as per Agency's legal guidelines and policy.
4. How will corrective action be monitored:
The Administrator will conduct a quarterly audit of all employee files to monitor that the deficient practice will not recur.
611.55(a) LICENSURE
Competency 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 a review of employee files and an interview with the agency Administrator, the agency failed to ensure documentation showing direct care workers, prior to providing services to consumers, completed/demonstrated an initial competency training covering all required sixteen (16) subject areas for four (4) of four (4) employee files (EF) reviewed (EF#1 - EF#4).
Findings include:
A review of EFs was conducted on March 20, 2024 at approximately 9:15 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 02/24/24: Documentation provided of a 'Care Academy' 'Certificate of Completion' dated 03/18/24. Documentation provided of ten (10) 'Relias' 'Certificates of Completion' dated 11/18/23 and two (2) 'Relias' 'Certificate of Completion' dated 11/27/23.
No documentation provided of initial competency training containing all sixteen (16) required elements.
EF#2 DOH 08/08/23: Documentation provided of one (1) 'Care Academy' 'Certificate of Completion' dated 12/12/23, one (1) dated 03/17/24, and two (2) dated 03/18/24.
No documentation provided of initial competency training containing all sixteen (16) required elements.
EF#3 DOH 07/12/23: Documentation provided of two (2) 'Care Academy' 'Certificate of Completion' dated 03/18/23 and two (2) dated 03/19/24. Documentation provided of a training form with 'Training Title' and 'Brief Description of Topic' with dates ranging from 07/28/23 - 12/29/23.
No documentation provided of initial competency training containing all sixteen (16) required elements.
EF#4 DOH 10/24/22: Documentation provided of one (1) 'Care Academy' 'Certificate of Completion' dated 12/04/22. Documentation provided of a training form with 'Training Title' and 'Brief Description of Topic' with dates ranging from 12/04/22 - 12/18/23.
No documentation provided of initial competency training containing all sixteen (16) required elements.
An interview conducted with the agency Administrator on March 20, 2024 at approximately 12:45 p.m. confirmed the above findings.
Repeat deficiency.
Plan of Correction:Plan of correction for EF#! DOH 02/24/2024;EF#2 DOH 08/08/2023; EF#3 DOH 07/12/2023;EF#4 DOH 10/24/2022
1. Corrective action to be accomplished:
All identified stated employees will obtain required competencies.
2. To identify other individuals having the potential to be affected by the same deficient practice, the Administrator will conduct an audit of all employee files to ensure no other individuals have been affected by the same deficient practice.
3. Measures to be put in place to ensure that deficient practice does not recur: every employee file will have a new checklist of all required document/forms,signatures to ensure no other individuals have been affected by same deficient practice.
4. How will corrective action be monitored:
The Administrator will conduct a quarterly audit of all employee files to monitor that the deficient practice will not recur.
611.55(e) LICENSURE
Competency Requirements
Name - Component - 00
The competency review must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction.
Observations:
Based on a review of employee files and an interview with the agency Administrator, agency failed to provide documentation showing annual competency review covering all required sixteen (16) subject areas for one (1) of one (1) employee files (EF) annual documentation reviewed (EF#4).
Findings include:
A review of EFs was conducted on March 20, 2024 at approximately 9:15 a.m. Employee date of hire (DOH) is listed below.
EF#4 DOH 10/24/22: No documentation provided of a 2023 annual competency review containing all sixteen (16) required elements.
An interview conducted with the agency Administrator on March 20, 2024 at approximately 12:45 p.m. confirmed the above findings.
Repeat deficiency.
Plan of Correction:EF#4 DOH 10/21/22 (corrected)
1. Corrective action to be accomplished:
The Administrator will obtain proof of annual competency review covering all required sixteen (16) subject areas.
2. To identify other individuals having the potential to be affected by the same deficient practice, the Administrator will ensure to conduct an audit of employee's files to ensure no other individuals have been affected by the same deficient practice.
3. Measures to be put in place to ensure that deficient practice does not recur: every employee file will have a new checklist of all required document/forms, a paid inservice will be implemented to boost employees' morale to comply with training mandate. employee who does not follow or refused to comply will be reprimanded as per Agency's legal guidelines and policy.
4. How will corrective action be monitored:
The Administrator will conduct a quarterly audit of all employee files to monitor that the deficient practice will not recur.
611.56(a) LICENSURE
Health Screening
Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.
Observations:
Based on a review of employee files and an interview with the agency Administrator, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, was screened for and is free from active mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for four (4) out of four (4) employee files (EF) reviewed (EF#1-EF#4).
Findings Include:
The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. (CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.)
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
A review of EFs was conducted on March 20, 2024 at approximately 9:15 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 02/24/24: No documentation provided of an individual TB risk assessment nor a TB symptom screen upon hire.
EF#2 DOH 08/08/23: No documentation provided of an individual TB risk assessment nor a TB symptom screen upon hire. Documentation provided of a one step TB TST being conducted on 08/09/23. No documentation provided of obtaining the second step TB TST.
EF#3 DOH 07/12/23: No documentation provided of an individual TB risk assessment nor a TB symptom screen upon hire.
EF#4 DOH 10/24/22: Documentation provided of an individual TB risk assessment with an incomplete date listed as "2023."
An interview conducted with the agency Administrator on March 20, 2024 at approximately 12:45 p.m. confirmed the above findings.
Repeat deficiency.
Plan of Correction:EF#! DOH 02/24/2024; EF2 DOH 08/08/2023; EF#3 DOH 07/12/2023;EF#4 DOH 10/24/2022
1. Corrective action to be accomplished:
The Administrator will obtain and document a completed TB test result,TB risk assessment form and proof of TB education for all employees.
2. To identify other individuals having the potential to be affected by the same deficient practice, the Administrator will ensure to conduct an audit of all employee files to ensure no other individuals have been affected by the same deficient practice.
3. Measures to be put in place to ensure that deficient practice does not recur: every employee file will have a new checklist of all required TB documentation/forms.
4. How will corrective action be monitored:
The Administrator will conduct a quarterly audit of all employee files to monitor that the deficient practice will not recur.
611.56(b) LICENSURE
Health Screening
Name - Component - 00
(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.
Observations:
Based on a review of employee files and an interview with the agency Administrator, agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, were provided with annual mycobacterium tuberculosis education, for one (1) of one (1) employee files (EF) annual documentation reviewed (EF#4).
Findings Include:
The CDC (Center for Disease and Control) guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. ........ HCWs with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. (CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.)
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
A review of EFs was conducted on March 20, 2024 at approximately 9:15 a.m. Employee date of hire (DOH) is listed below.
EF#4 DOH 10/24/22: No documentation provided of 2023 annual TB education.
An interview conducted with the agency Administrator on March 20, 2024 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:EF#4 DOH 10/24/22 -
1. Corrective action to be accomplished:
EF#4 will obtain TB education
2. To identify other individuals having the potential to be affected by the same deficient practice, the Administrator will ensure to conduct an audit of employee's files to ensure no other individuals have been affected by the same deficient practice.
3. Measures to be put in place to ensure that deficient practice does not recur: every employee file will have a new checklist of all required document/forms to ensure completion of file.
4. How will corrective action be monitored:
The Administrator will conduct a quarterly audit of all employee files to monitor that the deficient practice will not recur.
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 a review of consumer files, the consumer admission packet, and an interview with the agency Administrator, the agency failed to provide the consumer, prior to the commencement of services, all or segments of the following: The identity of the direct care worker who will provide the services, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (717-783-1379), the Department of Health complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging, the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry, and 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, for five (5) out of five (5) consumer files (CF) reviewed (CF#1-CF#5).
Findings include:
A review of CFs was conducted on March 20, 2024 at approximately 9:15 a.m. Consumer start of service (SOS) is listed below.
CF#1 SOS 01/14/24: No documentation provided of the agency providing the consumer, prior to the commencement of services, the identity of the direct care worker who will provide the services, the hiring and competency requirements applicable to direct care workers, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (number labeled incorrectly as "Licensure number", the Department of Health complaint Hot Line (number labeled incorrectly as ".....Emergency Number: Event Reporting System ...., and the telephone number of the Ombudsman Program located with the local Area Agency on Aging, and 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 (form incomplete).
CF#2 SOS 08/01/22: No documentation provided of the agency providing the consumer, prior to the commencement of services, the identity of the direct care worker who will provide the services, the hiring and competency requirements applicable to direct care workers, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (number labeled incorrectly as "Licensure number", the Department of Health complaint Hot Line (number labeled incorrectly as ".....Emergency Number: Event Reporting System ...., and the telephone number of the Ombudsman Program located with the local Area Agency on Aging, and 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 (form incomplete).
CF#3 SOS 08/18/23: No documentation provided of the agency providing the consumer, prior to the commencement of services, the identity of the direct care worker who will provide the services, the hiring and competency requirements applicable to direct care workers, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (number labeled incorrectly as "Licensure number", the Department of Health complaint Hot Line (number labeled incorrectly as ".....Emergency Number: Event Reporting System ...., and the telephone number of the Ombudsman Program located with the local Area Agency on Aging, and 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 (form incomplete).
CF#4 SOS 08/07/23: No documentation provided of the agency providing the consumer, prior to the commencement of services, the identity of the direct care worker who will provide the services, the hiring and competency requirements applicable to direct care workers, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (number labeled incorrectly as "Licensure number", the Department of Health complaint Hot Line (number labeled incorrectly as ".....Emergency Number: Event Reporting System ...., and the telephone number of the Ombudsman Program located with the local Area Agency on Aging, and 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 (form incomplete).
CF#5 SOS 09/13/21: No documentation provided of the agency providing the consumer, prior to the commencement of services, the identity of the direct care worker who will provide the services, the hiring and competency requirements applicable to direct care workers, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (number labeled incorrectly as "Licensure number", the Department of Health complaint Hot Line (number labeled incorrectly as ".....Emergency Number: Event Reporting System ...., and the telephone number of the Ombudsman Program located with the local Area Agency on Aging, and 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 (form incomplete).
An interview conducted with the agency Administrator on March 20, 2024 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:CF#! SOS 01/14/2024; CF#2 SOS 08/01/2022; CF#3 SOS 08/18/2023; CF#3 SOS 08/18/2023; CF#4 SOS 08/07/2023; CF#5 SOS 09/13/2021
1. Corrective action to be
accomplished:
Agency will ensure to provide consumers with the:
a. Identity of the direct care worker who will provide services
b.Information of who to contact the department for information about licensure requirements for home care/home care registry
c.Department of health complaint Hotline and the telephone number of the Area Agency on Aging (AAA)Ombudsman program
d.Direct Care worker competency requirement
e. Complete and accurate disclosure addressing employee and independent contractor status
2. How to identify other individuals having the potential to be affected by the same deficient practice:
An audit of all consumers files will be conducted. All information provided to the consumers will be corrected with accurate descriptions for all current and future consumers.
3. Measures to be put in place to to ensure that deficient practice does not recur. To avoid the circulation of inaccurate information, an audit of all consumer files will be conducted by the administrator to ensure the accuracy of information provided. A checklist will be created to document time, date of audit, findings and corrections.
4. corrective action will be monitored
by conducting a quarterly audit of all consumer file by agency administrator.
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed March 20, 2024, Caring Grace Home Care Agency, Llc. 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 observation of Identification badges (ID) and an interview with the agency Administrator, agency failed to format/issue ID badges per regulatory requirements for one (1) of one (1) observation (Observation #1).
Findings include:
Observation #1: Observation of employee Identification Badge (ID) on March 20, 2024 at approximately 10:30 a.m. revealed the current ID badge employee title does not occupy the bottom 1/2" of the badge, as large as possible. The employee title is approximately 1/8" tall and is located towards the left bottom of the badge. The employee title is also labeled incorrectly as "Home Health Aide". The correct employee title is 'Direct Care Worker.'
An interview conducted with the agency Administrator on March 20, 2024 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:
Observation#1
The Agency will update it's ID badge to the correct font size, spacing and appropriate label for all Direct Care Workers. All employees will be provided with the updated badge.
|