QA Investigation Results

Pennsylvania Department of Health
CHRISTIAN STANDARDS FOR CHRISTIAN CARE
Health Inspection Results
CHRISTIAN STANDARDS FOR CHRISTIAN CARE
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite unannounced relicensure survey completed January 23, 2020, Christian Standards for Christian 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 relicensure survey completed January 23, 2020, Christian Standards for Christian 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:




611.51(b) LICENSURE
Direct Care Worker Files

Name - Component - 00
Files for direct care workers employed or rostered shall include documentation of the date of the face-to-face interview with the individual and of references obtained. Direct Care Worker files also shall include other information as required by 611.52, 611.53, if applicable, 611.54, 611.55 and 611.56 (relating to criminal background checks, child abuse clearance, provisional hiring, competency requirements; and health evaluations).

Observations:


Based on review of employee files, and interview with the administrator, it was determined that prior to hiring, the agency failed to obtain two verifiable references that affirms the ability of a Direct Care Worker, (DCW), to provide home care services for ten (10) of ten (10) employee files reviewed. (DCW # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10).


Findings include:


1. Review of personnel files on January 23, 2020 at approximately 10:30 a.m. revealed that DCW #1 was hired on January 8, 2020. There was no documented evidence that one or two verifiable references were obtained by the facility.

2. Review of personnel files on January 23, 2020 at approximately 10:40 a.m. revealed that DCW #2 was hired on September 14, 2018. There was no documented evidence that one or two verifiable references were obtained by the facility.

3. Review of personnel files on January 23, 2020 at approximately 10:50 a.m. revealed that DCW #3 was hired on September 5, 2017. There was no documented evidence that one or two verifiable references were obtained by the facility.

4. Review of personnel files on January 23, 2020 at approximately 11:00 a.m. revealed that DCW #4 was hired on July 17, 2018. There was no documented evidence that one or two verifiable references were obtained by the facility.

5. Review of personnel files on January 23, 2020 at approximately 11:10 a.m. revealed that DCW #5 was hired on May 17, 2016. There was no documented evidence that one or two verifiable references were obtained by the facility.

6. Review of personnel files on January 23, 2020 at approximately 11:20 a.m. revealed that DCW #6 was hired on July 23, 2018. There was no documented evidence that one or two verifiable references were obtained by the facility.

7. Review of personnel files on January 23, 2020 at approximately 11:30 a.m. revealed that DCW #7 was hired on October 8, 2018. There was no documented evidence that one or two verifiable references were obtained by the facility.

8. Review of personnel files on January 23, 2020 at approximately 11:40 a.m. revealed that DCW #8 was hired on May 1, 2019. There was no documented evidence that one or two verifiable references were obtained by the facility.

9. Review of personnel files on January 23, 2020 at approximately 11:50 p.m. revealed that DCW #9 was hired on February 16, 2019. There was no documented evidence that one or two verifiable references were obtained by the facility.

10. Review of personnel files on January 23, 2020 at approximately 12:00 p.m. revealed that DCW #10 was hired on April 15, 2019. There was no documented evidence that one or two verifiable references were obtained by the facility.

An interview with the Administrator on January 23, 2020 at approximately 2:30 p.m., confirmed that the agency failed to record two verifiable references for each DCW employed.









Plan of Correction:

Christian Standards for Christian Care has created a reference questions form to document answers given by references of new hire. The form will be completed by the administrator during the application process of each new hire. If a new hire's reference(s) is unable to be contacted, Christian Standards for Christian Care will request additional reference(s) until two references have been successfully interviewed. Christian Standards for Christian Care will include the reference questions form in all current and new employees' files. The administrator will review all caregivers' files each quarter to insure full compliance with 611.51(b). These corrective actions will be completed by March 09, 2020.


611.57(a) LICENSURE
Consumer Rights

Name - Component - 00
(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

Observations:


Based on review of agency welcome package, consumer file review, (CF), and Administrator interview, it was determined that the agency failed to advise consumers of the right to receive at least a 10 calendar days advance written notice of the intent of the home care agency to terminate services for ten (10) of ten (10) Consumer files reviewed. (CF #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10).

Findings include:

On December 23, 2018 at approximately 12:10 p.m., a review of the agency admission packet entitled, Family Support Circle Inc., revealed no evidence in the agency welcome package or documentation in the consumer files that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

1. On January 23, 2020, at approximately 12:30 p.m., a review of CF #1, revealed a start of service on September 1, 2019. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

2. On January 23, 2020, at approximately 12:40 p.m., a review of CF #2, revealed a start of service on Novemeber 27, 2019. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

3. On January 23, 2020, at approximately 12:50 p.m., a review of CF #3, revealed a start of service on October 30, 2019. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

4. On January 23, 2020, at approximately 1:00 p.m., a review of CF #4, revealed a start of service on September 1, 2019. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

5. On January 23, 2020, at approximately 1:10 p.m., a review of CF #5, revealed a start of service on May 1, 2018. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

6. On January 23, 2020, at approximately 1:20 p.m., a review of CF #6, revealed a start of service on July 1, 2017. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

7. On January 23, 2020, at approximately 1:30 p.m., a review of CF #7, revealed a start of service on October 17, 2019. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

8. On January 23, 2020, at approximately 1:40 p.m., a review of CF #8, revealed a start of service on June 8, 2019. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

9. On January 23, 2020, at approximately 1:50 p.m., a review of CF #9, revealed a start of service on January 1, 2020. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

10. On January 23, 2020, at approximately 2:00 p.m., a review of CF #10, revealed a start of service on February 16, 2018. There was no evidence in the agency welcome package or documentation in the consumer files, that the consumer was advised of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency to terminate services.

In an interview with the Administrator, on January 23, 2020, , at approximately 2:30 p.m., it was confirmed that the facility failed to advise the Consumer of the right to receive at least a 10 calendar days advance written notice of the intent of the home care agency to terminate services. Administrator corrected the information during the survey.












Plan of Correction:

Christian Standards for Christian Care has updated the service agreement for new consumers. Updated service agreement states consumers have the right to receive at least a 10 calendar days advance written notice of the intent of the home care agency to terminate services. All current consumers will receive this information and it will be documented in their file. The administrator will review all consumer files quarterly to insure compliance with 611.57(a). The plan of correction to bring all current consumers' files compliant will be completed by March 09, 2020.


Initial Comments:


Based on the findings of an onsite unannounced state relicensure survey completed January 23, 2020, Christian Standards for Christian Care was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: