Initial Comments:
Based on the findings of an unannounced complaint investigation survey completed 2/12/24, Patriot Home 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 unannounced onsite complaint investigation survey completed 2/12/24, Patriot Home Care was found not to be in compliance with the 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:
611.52(f) LICENSURE
Records Maintained
Name - Component - 00
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 a review of personnel files (PF), policy review, and staff interviews (EMP) the agency did not follow its policy to maintain copies of criminal history records for one (1) out of five (5) PFs reviewed. (PF5)
Findings include:
A review of policy "Criminal Background Checks" obtained 6/1/23 revealed, "Procedures...all applicants must complete and sign an authorization and consent for Background Checks during the application process. ...All applicants must undergo a state police criminal background check..."
During a personnel file review conducted on 2/12/24 between 1:00 to 2:00 pm the following was revealed:
PF5: Date of Hire: 11/1/23, Start of Care 11/1/23. PF5 contained an electronically signed document titled Authorization to Request Criminal History Record which stated, " Pursuant to Pennsylvania state law regulating home care agencies [agency] is required to obtain your criminal history report from the Pennsylvania State Police. " PF5 did not contain a Pennsylvania State Police criminal history record.
During an interview on 2/12/24 at approximately 2:00 pm, EMP1 (office manager) verified that PF5 did not have a PSP Criminal Report.
The above finding was reviewed with EMP1 (office manager) on 2/12/24 at approximately 3:45 pm.
Plan of Correction:The following corrective action steps will be taken regarding the failure to ensure prior to hiring the direct care worker has met all prerequisites; including maintaining a State Police criminal history record.
Education will be provided to management staff of their responsibility to ensure that all individuals have met the hiring requirements prior to receiving a schedule.
The Criminal Background Check policy, procedures and tracking resources will be reviewed and revised to ensure alignment with the Departments requirements and the provider's mission.
Annually the provider will review all policies and update as needed.
To prevent further occurrence the following steps will take place.
All administrative staff will be provided with education on the hiring requirements regarding Criminal Background Checks policies, procedures, forms and tracking requirements for each individual being considered for employment, including their detailed responsibilities in following this policy and procedure.
All current employees are being audited for successful completion of all criminal background requirements, including the State Police criminal history record. Audits will be completed, and records corrected with the next 120 days.
To ensure compliance the Agency Director and/or trained designee will audit 100% of new hires each month to ensure that all criminal background requirements have been successfully met prior to patient care. Evidence has been placed in the employees' personnel file.
Audits will continue monthly until 100% compliance is achieved and maintained for 3 consecutive months.
Oversight will be completed by the Compliance Department.
Any areas of non-compliance will be reported to the Compliance Department. An action plan will be put in place for any negative trends and reported as part of the QMP. Findings will be included in the quarterly board meeting report.
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