Initial Comments:
Based on the findings of an on-site unannounced state relicensure survey completed February 16, 2023, Verity Home Health LLC, 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 on-site unannounced state relicensure survey completed February 16, 2023, Verity Home Health LLC, 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(d) LICENSURE
Competency Requirements
Name - Component - 00
(d) The home care agency or home care registry shall include documentation of the direct care worker's satisfactory completion of competency requirements in the direct care worker's file.
Observations:
Based on review of personnel files, and interview with the Office manager, it was determined that the agency failed to maintain documentation of initial and annual competency reviews for five (5), of five (5) Direct Care Worker, (DCW), personnel files reviewed. (DCW #1, 2, 3, 4, and #5).
Findings include:
1. Review of personnel files on February 16, 2023, at approximately 11:00 a.m., revealed that DCW #1 was hired on March 9, 2015. There was no documented evidence of an initial competency. There was no documented evidence of annual competency exams for the years, 2016 through years 2022.
2. Review of personnel files on February 16, 2023, at approximately 11:30 a.m., revealed that DCW #2 was hired on March 15, 2022. There was no documented evidence of an initial competency.
3. Review of personnel files on February 16, 2023, at approximately 11:50 a.m., revealed that DCW #3 was hired on May 5, 2017. An initial competency was conducted on December 9, 2016. There was no documented evidence that an annual competency had been conducted for the year 2017, through 2022.
4. Review of personnel files on February 16, 2023, at approximately 12:10 p.m., revealed that DCW #4 was hired on August 27, 2015. An annual competency was conducted on October 6, 2016, (one year and two months later, without documented evidence of an initial training). There was no evidence that annual trainng were conducted for year 2018. There was no documented evidence that an annual competency had been conducted for the years 2020 and 2021.
5. Review of personnel files on February 16, 2023, at approximately 12:30 p.m., revealed that DCW #5 was hired on November 6, 2018. There was no documented evidence that an annual competency had been conducted for the year 2021, and 2022.
An interview with the Administrator on February 16, 2023, at 2:25 p.m., it was confirmed that the agency had failed to maintain documentation of competencies in the file. The office manager reported that DCW's had completed competencies, but "The files had been slimmed."
Plan of Correction:A complete internal audit will be conducted of all employee files, initial competency training documentation and annual training documentation.
This review will be conducted every 6 months to ensure that all employees are compliant with the regulations.
All employees will also be required to complete mandatory competency training prior to providing any services to participants. Documentary evidence of completion will be kept in employee files at all times.
Rehires will also be required to complete all mandatory competency trainings
Staff responsible for implementing POC: Office Manager
Supervisor: Director/CEO
Initial Comments:
Based on the findings of an on-site unannounced state relicensure survey completed February 16, 2023, Verity Home Health LLC, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
|