QA Investigation Results

Pennsylvania Department of Health
CIRCLE OF HOPE HOMECARE, LLC
Health Inspection Results
CIRCLE OF HOPE HOMECARE, LLC
Health Inspection Results For:

This is the only survey for this facility

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on an unannounced, onsite home care agency state relicensure survey conducted on March 11, 2024, Circle of Hope Homecare, was found to be in compliance with requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.





Plan of Correction:




Initial Comments:


Based on an unannounced, onsite home care agency state relicensure survey conducted on March 11, 2024, Circle of Hope Homecare, 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 upon review of employee files (EFs) and interview with agency owner (EMP #1), it was determined agency failed to maintain documentation of interview, prior to hiring or rostering direct care workers for one (1) of five (5) EFs reviewed (EF# 2) and failed to maintain documentation of verification of two satisfactory references, prior to hiring or rostering direct care workers for four (4) of five (5) EFs reviewed. (EF# 1, EF# 2, EF# 3 and EF# 4)

Findings include:
Review of EFs conducted on April 11, 2024 at between approximately 12:45 p.m. and 2:00 p.m. revealed the following:
EF# 1, Date of Hire (DOH), 12/1/2023: No documentation of two references being verified prior to hiring or rostering direct care worker.

EF# 2, DOH, 2/21/2024: No documentation of conducted interview and no documentation of two references being verified prior to hiring or rostering direct care worker. Contained interview document dated 2/29/2024. No documentation of two references being verified prior to hiring or rostering direct care worker. Contained one reference document not dated.

EF# 3, DOH, 12/22/2023: No documentation of two references being verified prior to hiring or rostering direct care worker. Contained one reference dated 12/24/2023 and one reference document not dated.

EF# 4, DOH, 11/2/2023: No documentation of two references being verified prior to hiring or rostering direct care worker. Contained one reference dated 12/1/2023 and one reference document not dated.



An interview with the agency EMP #1 conducted on April 11, 2024 at approximately 2:45 p.m. confirmed the above findings.





Plan of Correction:

Circle of Hope Home Care Services will correct findings dealing with rostering a direct care worker by:
(1) Conducting a face-to-face interview with the individual and conduct an employee audit of all files to make sure no other individuals have been affected by the same deficient practice. (2) Obtaining not less than two satisfactory references for the individual by checking the prior audit checklist and policy change that will be used to ensure this error does not happen again. (3)A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other people not related to the individual that affirms the ability of the individual to provide home care services by a six-month review of all files to monitor that the deficient practice will not occur.
(4) In addition, as a twostep process The Administrator will audit all employees' files upon hiring and quarterly for missing face-to-face interviews, missing references, etc. to ensure ongoing compliance.



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) and interview with agency owner (EMP #1), it was determined agency failed to 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), not to exceed 12 months for three (3) of five (5) EFs reviewed. (EF# 1, EF# 2 and EF# 4)

Findings include:
Review of EFs conducted on April 11, 2024 at between approximately 12:45 p.m. and 2:00 p.m. revealed the following:
EF# 1, Date of Hire (DOH), 12/1/2023: No Federal criminal history record and a letter of determination obtained from the Department of Aging.

EF# 2, DOH, 2/21/2024: No Federal criminal history record and a letter of determination obtained from the Department of Aging.


EF# 4, DOH, 11/2/2023: No Federal criminal history record and a letter of determination obtained from the Department of Aging.



An interview with the agency EMP #1 conducted on April 11, 2024 at approximately 2:45 p.m. confirmed the above findings.




Plan of Correction:

Plan of Correction for Compliance with PA. 611.52 Circle of Hope Home Care will
1. Immediate Review and Action
- Conduct an immediate audit of all employee files to identify any additional instances of non-compliance.
- Obtain the missing federal criminal history records and letters of determination for all affected employees as required by .
1. Staff Training
- Implement mandatory training sessions for HR personnel on the requirements of PA. Code 15.144, emphasizing the importance of obtaining federal criminal history records and letters of determination from the Department of Aging.
1.Policy Revision
- Revise current hiring policies to include clear steps for obtaining and documenting federal criminal history records and letters of determination.
- Ensure that the policy reflects the procedure outlined in Pa code 611.52. including the submission of the FBI fingerprint card and associated fees1.
1.Monitoring and Auditing
- Establish a regular schedule for auditing employee files to ensure ongoing compliance with PA.611.52.
- Designate a compliance officer to oversee the implementation of the revised policies and training programs.
1.Documentation and Reporting
- Document all actions taken to correct the non-compliance issue, including dates of training sessions, policy revisions, and audits.
- Prepare a report detailing the plan of correction and submit it to the relevant regulatory body.
1.Preventive Measures
- Introduce a checklist for HR personnel to use during the hiring process to prevent future oversights.




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 upon review of employee files (EFs) and interview with agency owner (EMP #1), it was determined agency failed to maintain documentation of proof of residency for three (3) of five (5) EFs reviewed. (EF# 1, EF# 2 and EF# 4)

Findings include:
Review of EFs conducted on April 11, 2024 at between approximately 12:45 p.m. and 2:00 p.m. revealed the following:
EF# 1, Date of Hire (DOH), 12/1/2023: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. No evidence of Federal Bureau of Investigation (FBI) clearance not to exceed 12 months. Contained Pa. Identification Card issued: 1/13/2023-7/31/2023.
EF# 2, DOH, 2/21/2024: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. No evidence of Federal Bureau of Investigation (FBI) clearance not to exceed 12 months. Contained Pa. Identification Card issued: 1/23/2023-3/31/2027.

EF# 4, DOH, 11/2/2023: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. No evidence of Federal Bureau of Investigation (FBI) clearance not to exceed 12 months. Contained Pa. Identification Card issued: 9/9/2022-9/30/2026.


An interview with the agency EMP #1 conducted on April 11, 2024 at approximately 2:45 p.m. confirmed the above findings.




Plan of Correction:

Circle of Hope Homecare will require All applicants to furnish proof of residency by submitting 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
The Administrator will audit all employee records by 5/10/2024 for compliance with proof of residency. If an employee is missing the proper documentation to show proof, the employee will be required to obtain an F.B.I. background check.
To ensure ongoing compliance, all files will be audited quarterly by the Administrator.



611.55(a) LICENSURE
Competency Requirements

Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.

Observations:


Based upon review of employee files (EFs) and interview with agency owner (EMP #1), it was determined agency failed to demonstrate initial competency, prior to assigning or referring a direct care worker to provide services to a consumer, containing all required topics for two (2) of five (5) EFs reviewed. (EF# 2 and EF# 3)

Findings include:
Review of EFs conducted on April 11, 2024 at between approximately 12:45 p.m. and 2:00 p.m. revealed the following:

EF# 2, Date of Hire (DOH), 2/21/2024: No documentation provided initial competency containing all required topics completed prior to assigning or referring a direct care worker to provide services to a consumer.

EF# 3, DOH, 12/22/2023: No documentation provided initial competency containing all required topics completed prior to assigning or referring a direct care worker to provide services to a consumer.

An interview with the agency EMP #1 conducted on April 11, 2024 at approximately 2:45 p.m. confirmed the above findings.




Plan of Correction:

Circle of Hope Home Care Services will correct findings dealing with competency requirements by 6/10/2024.
And will ensure that all direct care workers have done one of the following: (1) Demonstrated competency by passing a prior to hire competency examination developed by the home care agency or home care registry which meets the requirements of subsection. Pa 611.55 (b) (c).
(2) standard score of 85% or hire must be met as a qualifying score to pass competency examination. Test will be scored in red on each employee exam.
(3) An audit with complete checklist will be conducted of each all employees files to make sure no other individuals
have been affected by the same deficient practice.



611.56(a) LICENSURE
Health Screening

Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.

Observations:


Based upon review of employee files (EFs) and interview with agency owner (EMP #1), it was determined agency failed to ensure each direct care worker and other staff or contractors with direct consumer contact, prior to consumer contact, were screened for and are free from active mycobacterium tuberculosis using a two-step tuberculin skin test or a single blood assay to test for infection with tuberculosis for three (3) of five (5) EFs reviewed (EF# 1, EF# 2 and EF# 5) and failed to ensure an individual TB risk assessment upon hire for five (5) of five (5) EFs reviewed (EF# 1, EF# 2, EF# 3, EF #4 and EF# 5)

Findings include:
The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. HCWs with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. (CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.)
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).

Review of EFs conducted on April 11, 2024 at between approximately 12:45 p.m. and 2:00 p.m. revealed the following:

EF# 1, Date of Hire (DOH), 12/1/2023: No documentation of an initial tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB); and of an individual TB risk assessment upon hire. Contained one TST conducted on 6/21/2022.

EF# 2, DOH, 2/21/2024: No documentation of an initial tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB); and of an individual TB risk assessment upon hire. Contained one TST conducted on 1/8/2024.

EF# 3, DOH, 12/22/2023: No documentation of an individual TB risk assessment upon hire.

EF# 4, DOH, 11/2/2023: No documentation of an individual TB risk assessment upon hire.

EF# 5, DOH, 12/25/2023: No documentation of an initial tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB); and of an individual TB risk assessment upon hire. Contained one TST conducted on 3/6/2023.

An interview with the agency EMP #1 conducted on April 11, 2024 at approximately 2:45 p.m. confirmed the above findings.




Plan of Correction:

Circle of Hope Home Care services will correct findings dealing with mycobacterium tuberculosis using a two-step tuberculin skin test or a single blood test for infection with tuberculosis
(3) of five EF's reviewed. EF#1, EF#2, EF#3 EF#4 and EF#5.
1. Circle of Hope Home Care will create and implement a new and separate checklist that will monitor and check all prior health screenings are complete and to ensure the Pa. 611.56, is in accordance with each employee.
2.Each employee /staff member will prior to consumer contact be provided by conducting and audit of entire employee files to make sure no other individuals have been affected by the same deficient practice.
(3) The agency will implement policy change that will be used to ensure deficient practice does not occur on documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.
(4) The screening shall be done according to the CDC guidelines and checked every quarter to monitor that the deficient practice will not occur.




611.57(a) LICENSURE
Consumer Rights

Name - Component - 00
(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

Observations:


Based upon review of consumer files (CFs) and interview with agency owner (EMP #1), it was determined agency failed to provide documentation of consumer being aware of having at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services for five (5) of five (5) CFs reviewed. (CF # 1, CF# 2, CF# 3, CF# 4 and CF# 5).
Findings include:
Review of CFs conducted on April 11, 2024 at between approximately 11:30 a.m. and 12:30 p.m. revealed the following:
CF# 1, Start of Service (SOS), 11/14/2023: No documentation of consumer being notified of having at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services.
CF# 2, SOS, 11/30/2023: No documentation of consumer being notified of having at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services.

CF# 3, SOS, 2/12/2024: No documentation of consumer being notified of having at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services.

CF# 4, SOS, 3/4/2024: No documentation of consumer being notified of having at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services.

CF# 5, SOS, 9/16/2023: No documentation of consumer being notified of having at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services.


An interview with the agency EMP #1 conducted on April 11, 2024 at approximately 2:45 p.m. confirmed the above findings.






Plan of Correction:

Plan of Correction:
Based on the findings, all new and future participants will receive the agency policy stating
"It is the Policy of Circle of Hope Home Care Services that a participant will receive at least ten (10) calendar days advance written notice of the intent of the home care agency to terminate services and that less than ten (10) days advance written notice may be provided in the event the consumer has failed to pay for services despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk. By your signature below, you agree that you read and understand the agency policy on termination of services.
To ensure compliance after reading the document, the participant/POA and a member of the Administrator team must sign off on the policy. The document will be kept in the participant file and a copy will be given to the participant as part of the welcome package.



611.57(b) LICENSURE
Prohibitions

Name - Component - 00
(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

Observations:


Based upon review of consumer files (CFs) and interview with agency owner (EMP #1), it was determined agency failed to inform the consumer that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry for five (5) of five (5) CFs reviewed. (CF # 1, CF# 2, CF# 3, CF# 4 and CF# 5) and failed to inform the consumer that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer for five (5) of five (5) CFs reviewed. (CF # 1, CF# 2, CF# 3, CF# 4 and CF# 5)
Findings include:
Review of CFs conducted on April 11, 2024 at between approximately 11:30 a.m. and 12:30 p.m. revealed the following:
CF# 1, Start of Service (SOS), 11/14/2023: No documentation of consumer notification that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry and no documentation of consumer notification that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer.
CF# 2, SOS, 11/30/2023: No documentation of consumer notification that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry and no documentation of consumer notification that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer.

CF# 3, SOS, 2/12/2024: No documentation of consumer notification that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry and no documentation of consumer notification that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer.

CF# 4, SOS, 3/4/2024: No documentation of consumer notification that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry and no documentation of consumer notification that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer.

CF# 5, SOS, 9/16/2023: No documentation of consumer notification that the home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry and no documentation of consumer notification that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer.


An interview with the agency EMP #1 conducted on April 11, 2024 at approximately 2:45 p.m. confirmed the above findings.






Plan of Correction:

Circle of Hope Home Care will address the following changes to CF files. There will be a paragraph added to CF Contract and Rights of responsibility to include the Home Care agency cannot require consumer to endorse checks and assume power of attorney or guardianship over the consumer. As deficiency seen in CF 1, 2, 3, 4, 5, all files will be immediately audited and corrected with new paperwork added to show the update.
(1) Administrator will conduct audit of CF deficient files and then of all other files to make sure no individuals have been affected by the same deficient practice.
(2) Administrator will implement an in-service day to go over all changes in the CF to make employees aware of the new additions to contract and right and responsibilities to ensure deficient practice does not recur.
(3) The agency administrator will conduct an immediate review once all changes have been added to CF and then 10% of pool of records to monitor that all files have been resigned by consumer and administrator every quarter, so this error does not recur.


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 consumer files (CFs) and interview with agency owner (EMP #1), it was determined agency failed to provide, prior to the commencement of services, to the consumer the identity of the direct care worker who will provide the services to five (5) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5); failed to provide a listing of the available home care services that will be provided to the consumer by the direct care worker for five (5) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5); failed to provide the hours when those services will be provided for five (5) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5); failed to provide the fees and total costs for those services on an hourly or weekly basis for five (5) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5); failed to provide 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 for five (5) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5); failed to provide the Departments complaint Hot Line phone number for five (5) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5); failed to provide the telephone number of the Ombudsman Program located with the local Area Agency on Aging for five (5) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5); failed to provide the hiring and competency requirements applicable to direct care workers employed by the home care agency for five (5) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5); and failed to provide 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 for five (5) of five (5) CFs reviewed (CF# 1, CF# 2, CF# 3, CF# 4 and CF# 5)

Findings include:
Review of CFs conducted on April 11, 2024 at between approximately 11:30 a.m. and 12:30 p.m. revealed the following:
CF# 1, Start of Service (SOS), 11/14/2023: No documentation of the identity of direct care worker being provided to consumer; of providing a listing of the available home care services that will be provided to the consumer by the direct care worker; of providing the hours when those services will be provided; of providing the fees and total costs for those services on an hourly or weekly basis; of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information about a particular home care agency or home care registry; of providing the consumer the Pa. Department of Health complaint Hot Line; of providing the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA); of providing the hiring and competency requirements applicable to direct care workers employed by the home care agency; and of providing 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

CF# 2, SOS, 11/30/2023: No documentation of the identity of direct care worker being provided to consumer; of providing a listing of the available home care services that will be provided to the consumer by the direct care worker; of providing the hours when those services will be provided; of providing the fees and total costs for those services on an hourly or weekly basis; of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information about a particular home care agency or home care registry; of providing the consumer the Pa. Department of Health complaint Hot Line; of providing the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA); of providing the hiring and competency requirements applicable to direct care workers employed by the home care agency; and of providing 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

CF# 3, SOS, 2/12/2024: No documentation of the identity of direct care worker being provided to consumer; of providing a listing of the available home care services that will be provided to the consumer by the direct care worker; of providing the hours when those services will be provided; of providing the fees and total costs for those services on an hourly or weekly basis; of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information about a particular home care agency or home care registry; of providing the consumer the Pa. Department of Health complaint Hot Line; of providing the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA); of providing the hiring and competency requirements applicable to direct care workers employed by the home care agency; and of providing 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

CF# 4, SOS, 3/4/2024: No documentation of the identity of direct care worker being provided to consumer; of providing a listing of the available home care services that will be provided to the consumer by the direct care worker; of providing the hours when those services will be provided; of providing the fees and total costs for those services on an hourly or weekly basis; of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information about a particular home care agency or home care registry; of providing the consumer the Pa. Department of Health complaint Hot Line; of providing the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA); of providing the hiring and competency requirements applicable to direct care workers employed by the home care agency; and of providing 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

CF# 5, SOS, 9/16/2023: No documentation of the identity of direct care worker being provided to consumer; of providing a listing of the available home care services that will be provided to the consumer by the direct care worker; of providing the hours when those services will be provided; of providing the fees and total costs for those services on an hourly or weekly basis; of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information about a particular home care agency or home care registry; of providing the consumer the Pa. Department of Health complaint Hot Line; of providing the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA); of providing the hiring and competency requirements applicable to direct care workers employed by the home care agency; and of providing 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


An interview with the agency EMP #1 conducted on April 11, 2024 at approximately 2:45 p.m. confirmed the above findings.




Plan of Correction:

Circle of Hope Home Care will carefully review all consumer rights of responsibility forms and correct to include a list of home care services, hours, cost and fees weekly and hourly fees, in all found deficient files CF, 1,2,3,4,5.
as seen in CF's there has a been a line added to include Direct Care worker name/ identity on consumer contract.
(2) will conduct an audit of entire consumer files to make sure no other individuals have been affected by the same deficient practice.
(3) administrator will implement policy change and provide an in service to reflect all new additions added to CF contracts and rights of responsibility. In addition, an administrator will audit all files immediately and then every quarter to monitor that the changes has been added to all files and that the deficient practice will not occur.




611.57(d) LICENSURE
Documentation

Name - Component - 00
(d) The home care agency or home care registry shall maintain documentation on file at the agency or registry of compliance with the requirements of this section which shall be available for Department inspection.

Observations:


Based on review of regulation and interview with agency owner (EMP #1), it was determined the agency failed to maintain documentation on file at the agency of compliance with requirements of this section which shall be available for Department inspection for one (1) of one (2) interviews conducted. (Interview #1)
Findings include:
Interview #1 conducted on April 11, 2024 approximately 12:35 p.m. revealed the following:

Surveyor asked EMP# 1 for consumer files and documentation. EMP# 1 was not able to provide any documents for consumer file # 3 and consumer file # 4. Surveyor asked EMP# 1 where consumer file # 3 and consumer file # 4 were located, EMP# 1 replied, "They are at the old office location. I am in the process of bringing them here."

No consumer files and documentation were provided for consumer file # 3 and consumer file # 4.


An interview with the agency EMP #1 conducted on April 11, 2024 at approximately 2:45 p.m. confirmed the above findings.





Plan of Correction:

Circle of Hope Home Care services will correct findings dealing with consumer files.
1. Identify the position of who will be responsible for such monitoring and what files need to be in place and on site at all times. Such person will retain to measure substantiate the monitoring performed and frequency of monitoring of all files.
2. Pa 611.57 (d) Circle of Hope Home Care will maintain documentation on file at the agency location, with quarterly monitoring to make sure all files are on the premises at all times.



Initial Comments:

Based on an unannounced, onsite home care agency state relicensure survey conducted on March 11, 2024, Circle of Hope Homecare, was found not to be in compliance with requirements of 35 P. S.448.809 (b).



Plan of Correction:




35 P. S. 448.809b LICENSURE
Photo Id Reg

Name - Component - 00
Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.


(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.



Observations:


Based upon review of ID regulation and an interview agency owner (EMP #1), it was determined agency failed to provide Identification Badges (ID) and format ID badges per regulation for nine (9) of nine (9) Direct Care Workers (DCW). (DCW#1-9).

Findings included:

Review of photo ID badges conducted on March 11, 2024 at approximately 11:00 a.m. revealed the following:

Review of ID badge revealed employee's title, 'Direct Care Worker' was 1/4 inch instead of the required 1/2 inch size and was not as close as practicable to the bottom edge of the badge.

An interview with the agency EMP #1 conducted on March 11, 2024 at approximately 2:45 p.m. confirmed the above findings.





Plan of Correction:

Circle of Hope Home Care will correct findings dealing with size of Font in Identification Badge (ID)for all (9) employees by:
1. correction font size from 1/4 to 1/2 inch as required by 28 Pa. Code ch. 53.
2. Font size of 36 in microsoft which is the database used to create all (ID) for Circle of Hope Home Care. is the correct 1/2 that meets requirements for all employees.
3. ALL TITLES for each badge will placed at the bottom of each badge close and practicable to the bottom edge of each badge as regarding Section 809b chages which took place on June 1, 2015.