QA Investigation Results

Pennsylvania Department of Health
ANGELS ON CALL
Health Inspection Results
ANGELS ON CALL
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Initial Comments:

Based on the findings of an unannounced onsite state re-licensure survey conducted on November 28, 2022, Angels On Call Lebanon, 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 unannounced onsite state re-licensure home care agency survey conducted on November 28, 2022, Angels On Call Lebanon was found 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 a review of employee files (EFs), policy and procedure document, and interview with the agency Compliance Specialist, the agency failed to obtain two satisfactory references prior to consumer assignment for two (2) of ten (10) EFs reviewed (EF#9-10).

Findings include:

Review of EFs was conducted on November 28, 2022 at approximately 10:00 AM. Employee date of hire (doh) is listed below.

EF#9 doh 7/2/21, two satisfactory references were obtained on 7/20/2021; and first consumer assignment began 7/17/2021.

EF#10 doh 3/3/2021, no documentation of two satisfactory references found; and first consumer assignment began 3/15/2021. After a 2021 internal audit, two satisfactory references were obtained on 12/7/2021 and 2/9/2022.

Reviewed agency policy and procedure "Pre-employment Background Checks Review of the Federal & State Exclusionary Lists" on November 28, 2022 at approximately 10:30 AM.
Procedure requires "As a condition of employment, successful candidates shall undergo background checks, which include, but are not limited to the following: Item 5 i Personal/Professional Reference Verification."

Interview conducted on November 28, 2022 at approximately 10:30 AM with agency Compliance Specialist confirmed the above findings.


















Plan of Correction:

References

Agency has a policy which is consistent with the regulation to ensure two reference checks are completed prior to Date of Hire.

1.By 12/28/2022, Compliance Specialist will retrain office staff on above mentioned policy, that is consistent with regulation, to ensure that two satisfactory reference checks are received on all new employees prior to Date of Hire.

2.In order to ensure future records, contain the required references, beginning 12/29/2022, office coordinator will utilize the Applicant Tracking System (ATS) check box to ensure each new hire has the 2 references marked off prior to start date.

3.Starting 12/15/2022, the Compliance Specialist and/or team member will review each new hire's documents to ensure the references have been completed prior to Date of Hire.

4.By 1/2/2023 the Compliance Specialist and/or team member will initiate a two-month audit process for all new hired employees to ensure 2 satisfactory references are obtained prior to consumer assignment. Audit results will be held by the Compliance Specialist.



611.52(a) LICENSURE
Criminal Background Checks

Name - Component - 00
The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.

Observations:

Based upon review of employee files (EFs), agency policy and procedure document, and interviews with agency Compliance Specialist, the agency failed to obtain a Pennsylvania (PA) State Police criminal history record (PATCH) at the time of application or within 1 year immediately preceding the date of application for two (2) of ten (10) EFs (EF#7, #10).


Findings Include:


Review of EFs conducted on November 28, 2022 at approximately 10:30 AM. Date of Hire (doh) is listed below.

EF#7 doh 1/20/2021, no PATCH obtained on hire; PATCH obtained 2/22/2021; first assigned consumer shift on 2/11/21.

EF#10 doh 3/3/2021, no PATCH obtained on hire; PATCH obtained 12/7/2021; first assigned consumer shift on 3/15/2021.

Reviewed agency's policy and procedure "Pre-employment Background Checks Review of the Federal & State Exclusionary Lists" on November 28, 2022 at approximately 10:30 AM.
Procedure requires "pre-employment Background checks must be completed and the results verified before any candidate recieves an offer of employment. (Item #3).

Interview conducted on November 28, 2022 at approximately 10:30 AM with agency Compliance Specialist. She stated: "Pre-employment criminal background verifications of candidates are made prior to final employment decision. These late PATCH verifications were done due to internal agency audit findings for 2021 employees."

Interview conducted on November 28, 2022 at approximately 1:30 PM with agency Compliance Specialist confirmed the above findings.











Plan of Correction:

Plan of Correction:

Criminal History Report
Agency has a policy which is consistent with the regulation to ensure Criminal History Reports are completed on day one, Date of Hire.

1.By 12/28/2022Compliance Specialist will retrain office staff on above mentioned policy, that is consistent with regulation, to ensure that a Criminal History Report is completed for all new employees on Date of Hire.

2. Every Orientation day, the Office Coordinator will run the Criminal History Report on day of orientation for new hires, and will mark the Applicant Tracking System (ATS) when completed to ensure all requirements are met at the time of onboarding, prior to being placed on shift with consumer.

3. By 1/2/2023 the Compliance Specialist and/or team member will initiate a two-month aduit process for all new hired employees to ensure PA State criminal background reports are obtained prior to consumer assignment. Audit results will be held by the Compliance Specialist.




611.52(c) LICENSURE
Federal Criminal History Record

Name - Component - 00
If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code 15.144(b) (relating to procedure).

Observations:

Based upon review of employee files (EFs), agency policy and procedure document, and an interviews with the the agency Compliance Specialist, the agency failed to obtain a federal criminal history record and a letter of determination from the Pennsylvania (PA) Department of Aging for one (1) out of ten (10) EFs (EF#10).

Findings include:

A review of EFs was conducted on November 28, 2022 at approximately 10:30 AM. Employee date of hire (doh) is listed below.

EF#10 doh 3/3/2021, no documentation of onhire Federal criminal history record. PA driver's license issue date 4/22/2020 with expiration 4/21/2024 observed; first consumer assignment was 3/15/2021; and late Federal criminal history record was obtained 2/19/2022.

Reviewed agency policy and procedure "Pre-employment Background Checks Review of the Federal & State Exclusionary Lists" on November 28, 2022 at approximately 10:30 AM.
Procedure requires "pre-employment Background checks must be completed and the results verified before any candidate recieves an offer of employment. (Item #3 and #5(i)).

Interview conducted on November 28, 2022 at approximately 10:30 AM with agency Compliance Specialist. She stated: "Pre-employment criminal background verifications of candidates are made prior to final employment decision. This late Federal criminal background verification was obtained due to internal agency audit finding for 2021 employees."

Interview conducted on November 28, 2022 at approximately 11:00 AM with agency Compliance Specialist confirmed the above finding.









Plan of Correction:

FBI for Residency

Agency has a policy which is consistent with the regulation to ensure FBI checks are completed when unable to prove residency.

1.By 12/28/2022, Compliance Specialist will retrain office staff on the above mentioned policy, that is consistent with regulation, to ensure staff are aware of what documents are acceptable to prove residency.

2.If residency cannot be proven by said documents, by 12/30/2022, the employee will be scheduled for a Department of Aging FBI background check.

3. By 12/30/2022 documents will be requested of EF#10 to submit showing residency, if no documents can be found, EF#10 will be scheduled for a FBI appointment, at the earliest available appointment.

4.Starting 12/29/2022, The Office Manager and/or the Regional Manager will be responsible for reviewing all onboarding information, upon Date of Hire, to determine if proof of residency exists or if the new employee needs to be sent for an FBI background check through the Department of Aging. Proof of residency will be tracked on the ATS tracking system to ensure all requirements are met at the time of onboarding.

5. By 1/2/2023 the Compliance Specialist and/or team member will initiate a two-month audit process for all new hired employees to ensure appropriate criminal background reports are obtained prior to consumer assignment. Audit results will be held by the Compliance Specialist.



611.52(d) LICENSURE
Proof of Residency

Name - Component - 00
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 employee files (EFs) and interview with agency Compliance Specialist, the agency failed to require direct care workers to furnish Pennsylvania (PA) proof of residency for two years prior to date of hire 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
for one (1) of ten (10) EFs reviewed (EF#10).

Findings Included:

Review of EFs completed on November 28, 2022 at approximately 11:00 AM. Date of hire (doh) is listed below:

EF#10 doh 3/3/2021, revealed PA driver's license issued 4/22/2020 with expiration date 4/21/2024.

Interview conducted on Novemeber 28, 2022 at approximately 11:30 AM with agency Compliance Specialist confirmed the above finding.







Plan of Correction:

Agency has a policy which is consistent with the regulation to ensure FBI checks are completed when unable to prove residency.

1.By 12/28/2022, Compliance Specialist will retrain office staff on the above mentioned policy, that is consistent with regulation, to ensure staff are aware of what documents are acceptable to prove residency. If residency cannot be proven by said documents, the employee will be scheduled for a Department of Aging FBI background check.

2.Starting 12/29/2022, the Office Manager and/or the Regional Manager will be responsible for reviewing all onboarding information, upon Date of Hire, to determine if proof of residency exists or if the new employee needs to be sent for an FBI background check through the Department of Aging. Proof of residency will be tracked on the Applicant Tracking System (ATS) tracking
system to ensure all requirements are met at the time of onboarding.

3.By 12/29/2022 the Office Coordinator will request documents of EF#10 to submit showing residency, if no documents can be found, EF#10 will be scheduled for a FBI appointment.

4. By 1/2/2023 the Compliance Specialist and/or team member will initiate a two-month audit process for all new hired employees to ensure appropriate proof of PA residency is obtained prior to consumer assignment. Audit results will be held by the Compliance Specialist.



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 employee files (EFs) and interview with agency Compliance Specialist, the agency failed to complete and document individual Direct Care Worker (DCW) annual competency test in three (3) out of ten (10) EFs (EF#5-6, EF#10).

Findings Include:

A review of EFs conducted on November 28, 2022, at approximately 11:00 AM. Employee date of hire (doh) is listed below.

EF#5 doh 8/17/2021, no documentation of completed annual DCW competency test for 2022.

EF#6 doh 4/1/2021, no documentation of completed annual DCW competency test for 2022.

EF#10 doh 3/3/2021, no documentation of completed annual DCW competency test for
2022.

An interview conducted on November 28, 2022, at approximately 11:00 AM with agency Compliance Specialist confirmed the above findings.










Plan of Correction:

Annual Competency

Agency has a policy which is consistent with the regulation to ensure Annual Competency documents are completed.

1.By 12/28/2022, Compliance Specialist will retrain office staff on above mentioned policy that is consistent with regulation to ensure the Annual Competency documents are completed and contained within the staff's personnel file.

2.Starting 12/29/2022 the Field Service Coordinator and/or Regional Manager will be responsible for all Annual Evaluation and documents, including the Annual Competency training, and ensuring all training documents are contained within the personnel file of each employee.

3.By 1/20/2023 the Field Service Coordinator will contact and complete Annual Competencies for EF#5, EF#6 and EF#10.



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 on review of consumer files (CFs), the consumer admission packet, and an interview with the agency Compliance Specialist, the agency failed to provide the consumer, prior to commencement of services, documentation of listed services hours per week in one (1) out of ten (10) CFs (CF#2); incomplete Direct Care Worker (DCW) disclosure tax status form in two (2) out ten (10) CFs (CF#1-2); and incomplete Consumer Notice Acknowledgement form in one (1) out of ten (10) CFs (CF#1).

Findings include:

A review of CFs was conducted on November 28, 2022 at approximately 12:45 PM. Start of Care date (soc) is listed below.

CF#1 soc 3/3/2022, DCW disclosure tax status document is missing agency signature, date, and identification if DCW is an agency employee or contracted staff; and Consumer Notice Acknowledgement form is missing agency signature and date.

CF#2 soc 11/11/2020, DCW disclosure tax status document is missing item #3 information regarding agency liability insurance coverage as usually indicated by agency staff member; identification if DCW is an agency employee or contracted staff (item #2); and no documentation for scheduled hours for service.

An interview conducted on November 28, 2022 at approximately 12:45 PM with agency Compliance Specialist confirmed the above findings.










Plan of Correction:

Start of Care Information to Consumer

Agency has two policies which directs intake staff to provide specific information to the consumer prior to completed enrollment.

1.By 12/28/2022, Compliance Specialist, will retrain office staff on the above two agency consumer information policies consistent with regulation to ensure the client and/or client's family is aware of the caregiver name who will be providing services, date, hours to be provided, and completion of the Direct Care Worker disclosure form
Agency refers to this as the Start Of Care Note Review of the Memo and contents of memo, provided to offices on July 2, 2018, by corporate staff, will be provided at the retraining.

2.Starting 12/29/2022, the Scheduling Coordinator and/or Regional Manager will be responsible for making the Start of Care call and note in the electronic medical records system.

3.Starting 12/29/2022, the Compliance Specialist and/or team member will review client file in the electronic medical records system, when service begins, to ensure Start Of Care call and note have been completed.

4. By 1/2/2023, the Compliance Specialist and/or team member will initiate a two-month audit process for all new hired employees to all required information is provided to the consumer during enrollment process. Audit results will be reviewed by the Compliance Specialist.

5. By 1/20/2023, the Field Service Coordinator/Intake Specialist will meet with CF#1 and CF#2 missing documents or needed updates will be reviewed with both clients and signed off in the appropriate boxes and placed in their files.



Initial Comments:

Based on the findings of an unannounced onsite state re-licensure survey completed on November 28, 2022, Angels On Call Lebanon was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: