Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed August 12, 2021, Compassionate Caretakers Home Care Agency 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 August 12, 2021, Compassionate Caretakers Home Care Agency 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
If the direct care worker has a nurse's license or other licensure or certification as a health professional, the individual's file shall include a copy of the current license or certification.
Observations:
Based on review of personnel files, for Direct Care Workers, (DCW), and interview with the Administrator, it was determined that the agency failed to maintain a copy of the current license or certification for the health professionals employed. This did not occur for three, (3), of ten (10) DCW's reviewed. (DCW #1, 2, and 4).
Findings include:
1. Review of personnel files on August 12, 2021, at approximately 11:15 a.m. revealed that DCW #1 a Certified Nurse Aide, (CNA), was hired on December 30, 2019. The certification expired on May 21, 2020. There was no current CNA certification in the DCW's
2. Review of personnel files on August 12, 2021, at approximately 11:30 a.m. revealed that DCW #2, a Registered Nurse, (RN), was hired on September 6, 2018. The RN license expired on April 30, 2021. There was no current RN license in the DCW's file.
4. Review of personnel files on August 12, 2021, at approximately 12:00 p.m. revealed that DCW #4, a CNA was hired on August 11, 2019. The certification expired on August 1, 2019. There was no current CNA certification in the DCW's file.
An interview with the Administrator on August 12, 2021 at approximately 2:25 p.m., confirmed that the agency had failed to maintain current licensure and certifications for health professionals.
Plan of Correction:DCW #1 Corrective plan
DCW #1 ON 8/16/2021 came in to the office and gave us her new and current certification which expires 5/21/2022
DCW #2 Corrective plan
The RN New and updated license was placed in RN's file on 8/13/2021 which currently expires 4/30/2022
DCW #4 Corrective Plan
On 8/17/2021 DCW #4 faxed her new and current certification which expires 11/11/2022
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, for Direct Care Workers, DCW), and interview with the Administrator, it was determined that the agency failed to conduct annual competency reviews for five (5) of ten (10) Direct Care Worker personnel files reviewed. (DCW #2, 3, 4, and 7).
Findings include:
2. Review of personnel files on August 12, 2021, at approximately 11:30 a.m. revealed that DCW #2 was hired on September 6, 2018. There was no evidence that an annual competency had been conducted for the year 2019.
3. Review of personnel files on August 12, 2021, at approximately 11:45 a.m. revealed that DCW #3 was hired on January 13, 2020. There was no evidence that an annual competency had been conducted for the year 2021.
4. Review of personnel files on August 12, 2021, at approximately 12:00 p.m. revealed that DCW #4 was hired on August 11, 2019. There was no evidence that an annual competency had been conducted for the year 2021.
5. Review of personnel files on August 12, 2021, at approximately 12:45 p.m. revealed that DCW #7 was hired on January 10, 2020. There was no evidence that an annual competency had been conducted for the year 2021.
An interview with the Administrator on August 12, 2021 at approximately 2:25 p.m., confirmed that the agency had failed to conduct annual competencies.
Plan of Correction:
DCW #2 Annual Competency written exam was completed and skills were demonstrated and observed in person at office on 8/13/21 both written and skills were passed.
DCW #3 Annual Competency written exam was completed and skills were demonstrated and observed in person at office on 8/16/21 both written and skills were passed.
DCW #4 Annual Competency written exam was completed and skills were demonstrated and observed in person at office on 8/19/21 both written and skills were passed.
DCW #7 Annual Competency written exam was completed and skills were demonstrated and observed in person at office on 8/17/21 both written and skills were passed.
Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed August 12, 2021, Compassionate Caretakers Home Care Agency LLC, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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