Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on January 2, 2025 and completed off site January 7, 2025, Aveanna Healthcare was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on January 2, 2025 and completed off site January 7, 2025, Aveanna Healthcare was found to 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 personnel files (PF) and an interview with agency administrator, the agency failed to retain within the direct care worker files, two verifiable satisfactory references for the individual, either written or verbal from an employer or other person not related to the individual, prior to hiring or rostering the individual for three (3) of the seven (7) PF's reviewed. (PF#1, PF#2, and PF#7)
Findings include:
Personnel file review conducted on January 2, 2025 from approximately 2:45pm to 4:30pm revealed the following:
PF #1, Date of hire (DOH) 3/4/21: Did not contain documentation of two (2) referrences before hire date.
PF#2, DOH 6/25/22: Did not contain documentation of two (2) referrences before hire date.
PF#7, DOH 6/24/22: Did not contain documentation of two (2) referrences before hire date.
An interview with the administrator on January 2, 2025 at approximately 4:30 pm confirmed the above findings.
Plan of Correction:Agency Response: Trevose location will review personnel files with missing required references and obtain information needed to complete files. Proper training has been provided for office staff on obtaining the required number of references from candidates before working a shift.
We plan to audit 100% of current employee files by 2/26 to ensure they do not have any missing documents. Also, all new hire files will be reviewed before they are listed as eligible to work. We will create a checklist to include all requirements for hire to guarantee the file is completed before working. We will also create a tracker of every file reviewed so we can keep track of what is needed and verify that needed documents do not get missed.
611.52(d) LICENSURE
Proof of Residency
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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 personnel files (PF) and an interview with the administrator, the agency did not provide documentation of proof of residency in order to obtain a criminal history record through submission of any 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 for one (1) of seven (7) PFs. PF#1.
Findings include:
Personnel file review conducted on January 2, 2025 from approximately 2:45pm to 4:30pm revealed the following:
PF #1, Date of hire (DOH) 3/4/21: Contained a Pennsylvania driver's license issued 7/3/20, which fails to ascertain PA residence of 2 or more years. No other documentation on file. No FBI check on file.
An interview with the administrator on January 2, 2025 at approximately 4:30pm confirmed the above findings.
Plan of Correction:Agency Response: Trevose location will review personnel files with missing required references and obtain information needed to complete files. Proper training has been provided for office staff on obtaining required proof of residency documents from candidates before working a shift.
We plan to audit 100% of current employee files by 2/26 to ensure they do not have any missing documents. Also, all new hire files will be reviewed before they are listed as eligible to work. We will create a checklist to include all requirements for hire to guarantee the file is completed before working. We will also create a tracker of every file reviewed so we can keep track of what is needed and verify that needed documents do not get missed.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on January 2, 2025 and completed off site January 7, 2025, Aveanna Healthcare was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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