Initial Comments:
Based on the findings of an onsite unannounced relicensure survey completed June 23, 2021, Signature Home Care 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 onsite unannounced state relicensure survey completed June 23, 2021, Signature Home Care 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, agency policy, and interview with the administrator, it was determined that the agency failed to include complete documentation that prior to assigning a Direct Care Workers, to a consumer, a satisfactory completion of competency requirements was achieved for three, (3), of eight, (8), Direct Care Workers, (DCW), personnel files reviewed. (DCW #1, 4, and 5).
Findings include:
On June 24, 2021 at approximately 10:30 a.m., a review of agency policy entitled, "Staff Training Policy," page 1 of 1, revealed that, "All potential employees of Signature Home Care will be required to complete a competency test.... All applicants must pass the competency test with 90% or higher."
1. A review of the agency personnel files conducted on June 23, 2021 at approximately 11:45 a.m., revealed that DCW #1 was hired on April 19, 2021. The personnel file for DCW #1 contained a completed competency multiple choice test. There was no evidence that the test was reviewed, (scoring), or of a date the test was administered.
2. A review of the agency personnel files conducted on June 23, 2021 at approximately 12:30 p.m., revealed that DCW #4 was hired on October 18, 2019. The personnel file for DCW #4 contained a completed competency multiple choice test. There was no evidence that the test was reviewed, (scoring), or of a date the test was administered.
3. A review of the agency personnel files conducted on June 23, 2021 at approximately 12:45 p.m., revealed that DCW #5 was hired on May 11, 2020. The personnel file for DCW #5 contained a completed competency multiple choice test. There was no evidence that the test was reviewed, (scoring), or of a date the test was administered.
In an interview with the administrator on June 23, 2021, at approximately 2:30 p.m., it was confirmed that the agency failed to provide documented proof, (dates and scores), that prior to assignment to a consumer, the direct care workers had satisfactorily completed competency evaluations.
Plan of Correction:All new hires will be directed to complete the PA Direct Care Worker Training before being assigned to a client. http://services.dpw.state.pa.us/pch_comptest/
On completion, new hires will submit the dated certificate of completion. If a Signature Home Care competency test is needed for any reason, it will be completed online using Google Workspace which will grade and timestamp the test responses on submission and the caregiver will be issued a certificate.
New Hire Competency completion certificates will be uploaded to the current electronic records management system used by Signature Home Care, LLC as well as a printed copy kept in caregiver personnel file.
Jazmin Rodriguez and Constance Courduff will be responsible for monitoring this process.
611.55(e) LICENSURE
Competency Requirements
Name - Component - 00
(e) The home care agency or home care registry also shall include documentation in the direct care worker's file that the agency or registry has reviewed the individual's competency to perform assigned duties through direct observation, testing, training, consumer feedback or other method approved by the Department or through a combination of methods.
Observations:
Based on review of personnel files, agency policy, and interview with the administrator, it was determined that the agency failed submit documentation in the direct care worker's file that the agency or registry had reviewed the individual's competency to perform assigned duties for three,(3), of eight, (8), Direct Care Workers, (DCW), personnel files reviewed. (DCW #1, 4, and 5).
Findings include:
On June 24, 2021 at approximately 10:30 a.m., a review of agency policy entitled, "Staff Training Policy," page 1 of 1, revealed that, "All potential employees of Signature Home Care will be required to complete a competency test.... All applicants must pass the competency test with 90% or higher."
1. A review of the agency personnel files conducted on June 23, 2021 at approximately 11:45 a.m., revealed that DCW #1 was hired on April 19, 2021. The personnel file for DCW #1 contained a competency multiple choice test. There was no evidence that the test was reviewed, (scoring), or of a date the test was administered.
2. A review of the agency personnel files conducted on June 23, 2021 at approximately 12:30 p.m., revealed that DCW #4 was hired on October 18, 2019. The personnel file for DCW #4 contained a competency multiple choice test. There was no evidence that the test was reviewed, (scoring), or of a date the test was administered.
3. A review of the agency personnel files conducted on June 23, 2021 at approximately 12:45 p.m., revealed that DCW #5 was hired on May 11, 2020. The personnel file for DCW #5 contained a competency multiple choice test. There was no evidence that the test was reviewed, (scoring), or of a date the test was administered.
In an interview with the administrator on June 23, 2021, at approximately 2:30 p.m., it was confirmed that the agency failed to provide proof that the agency or registry had reviewed the individual's competency to perform assigned duties.
Plan of Correction:All caregivers will be directed to complete the PA Direct Care Worker Training annually http://services.dpw.state.pa.us/pch_comptest/
On completion, caregivers will submit the dated certificate of completion. If a Signature Home Care Annual Education module is needed for any reason, it will be completed online using Google Classroom which will grade and timestamp the test responses on submission and the caregiver will be issued a certificate.
Annual Education completion certificates will be uploaded to the current electronic records management system used by Signature Home Care, LLC as well as a printed copy kept in caregiver personnel file.
Jazmin Rodriguez and Constance Courduff will be responsible for monitoring this process.
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 review of personnel files, agency policy, and interview with the administrator, it was determined that the agency failed to conduct a competency review at least once per year after initial competency for for ,(4), of eight, (8), Direct Care Workers, (DCW), personnel files reviewed. (DCW #3, 4, 5, and 8).
Findings include:
On June 24, 2021 at approximately 10:30 a.m., a review of agency policy entitled, "Staff Training Policy," page 1 of 1, revealed that, "All employees will take a competency test on a yearly basis after being hired, and are required to obtain 90% or higher.
1. A review of the agency personnel files conducted on June 23, 2021 at approximately 12:15 a.m., revealed that DCW #3 was hired on January 28, 2019. The personnel file for DCW #3 contained a competency on March 5, 2019. There was no evidence that an annual competency had been conducted for years 2020, or 2021.
2. A review of the agency personnel files conducted on June 23, 2021 at approximately 12:30 p.m., revealed that DCW #4 was hired on October 18, 2019. The personnel file for DCW #4 contained an incomplete competency multiple choice test, (no date). There was no evidence that an annual competency had been conducted for the year 2020.
3. A review of the agency personnel files conducted on June 23, 2021 at approximately 12:45 p.m., revealed that DCW #5 was hired on May 11, 2020. The personnel file for DCW #5 contained a incomplete competency multiple choice test, (no date). There was no evidence that an annual competency had been conducted for the year 2021.
4. A review of the agency personnel files conducted on June 23, 2021 at approximately 1:30 p.m., revealed that DCW #8 was hired on April 9, 2018. The personnel file for DCW #8 contained a competency exam for August 3, 2018, and March 19, 2019, There was no evidence that an annual competency had been conducted for years 2020, and 2021.
In an interview with the administrator on June 23, 2021, at approximately 2:30 p.m., it was confirmed that the agency failed to provide documented proof, (dates and scores), that the direct care workers had satisfactorily completed annual competency evaluations.
Plan of Correction:All caregivers will be directed to complete the PA Direct Care Worker Training annually http://services.dpw.state.pa.us/pch_comptest/
On completion, caregivers will submit the dated certificate of completion. If a Signature Home Care Annual Education module is needed for any reason, it will be completed online using Google Classroom which will grade and timestamp the test responses on submission and the caregiver will be issued a certificate.
Annual Education completion certificates will be uploaded to the current electronic records management system used by Signature Home Care, LLC as well as a printed copy kept in caregiver personnel file.
Jazmin Rodriguez and Constance Courduff will be responsible for monitoring this process.
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 upon review of the agency admission packet, Consumer files, and interview with the Administrator, it was determined that the agency failed to provide information to the Consumer, the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). for ten (10), of ten (10), Consumers Records (CR), reviewed. (CR #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10).
Findings include:
On June 23, 2021 at approximately 11:30 a.m. a review of the agency admission packet documents, revealed no telephone numbers to the Ombudsman Program located with the local Area Agency on Aging (AAA).
1. A review of CR #1, on June 23, 2021, at approximately 1:30 p.m., revealed a start of service on January 1, 2019. There was no evidence or documented information on the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
2. A review of CR #2, on June 23, 2021, at approximately 1:35 p.m., revealed a start of service on January 27, 2020. There was no evidence or documented information on the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
3. A review of CR #3, on June 23, 2021, at approximately 1:40 p.m., revealed a start of service on December 19, 2018. There was no evidence or documented information on the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
4. A review of CR #4, on June 23, 2021, at approximately 1:45 p.m., revealed a start of service on October 21, 2019. There was no evidence or documented information on the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
5. A review of CR #5, on June 23, 2021, at approximately 1:50 p.m., revealed a start of service on October 28, 2019. There was no evidence or documented information on the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
6. A review of CR #6, on June 23, 2021, at approximately 1:55 p.m., revealed a start of service on November 26, 2019. There was no evidence or documented information on the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
7. A review of CR #7, on June 23, 2021, at approximately 2:00 p.m., revealed a start of service on October 1, 2018. There was no evidence or documented information on the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
8. A review of CR #8, on June 23, 2021, at approximately 2:05 p.m., revealed a start of service on August 19, 2020. There was no evidence or documented information on the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
9. A review of CR #9, on June 23, 2021, at approximately 2:10 p.m., revealed a start of service on December 17, 2019. There was no evidence or documented information on the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
10. A review of CR #10, on June 23, 2021, at approximately 2:15 p.m., revealed a start of service on April 2, 2018. There was no evidence or documented information on the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
Interview with the Administrator on June 23, 2021, at approximately 2:30 p.m., confirmed the there was no documentation in the admission packet, the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
Plan of Correction:Consumer Welcome Packet was updated to include contact information for the following PA agencies:
Office of the State Long-Term Care Ombudsman
Pennsylvania Department of Aging
555 Walnut Street, 5th Floor
Harrisburg, PA 17101-1919
(717) 783-8975
Pennsylvania Department of Health
Bureau of Community Program Licensure and Certification
Division of Home Health
132 Kline Plaza, Suite A
Harrisburg, PA 17104-1579
(717) 783-8665
(717) 772-0232 (fax)
Pennsylvania Department of Health
Quality Assurance Complaint Hotline
1-800-254-5164
Philadelphia Corp. For Aging
642 N Broad St, Philadelphia, PA 19130
(215) 765-9040
Bucks County Corp. For Aging
30 E Oakland Ave, Doylestown, PA 18901
267-880-5700
Montgomery County Office of Senior Services
1430 DeKalb Street, 2nd Fl.
Norristown, PA 19404
(Enter bldg. from Fornance St.)
610- 278-3601
Protective Services Hotline :1-800-734-2020
PA Area Agency on Aging- Chester County
601 Westtown Rd, West Chester, PA 19382
(610) 344-6350
Delaware County COSA
1510 Chester Pike, Eddystone, PA 19022
(610) 490-1300
Initial Comments:
Based on the findings of an onsite unannounced relicensure survey completed June 23, 2021, Signature Home Care LLC, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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