Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on March 17, 2023, Serenity At Home Llc, 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 home care agency state re-licensure survey conducted on March 17, 2023, Serenity At Home Llc, 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 review of personnel files (PF) and interview with agency administrator, it was determined the agency failed to ensure that two (2) verifiable references were obtained prior to hiring each direct care worker for two (2) of six (6) files reviewed. (PF# 1 and 2)
Review of personnel files (PF) conducted on 3/17/23 from 10:20 PM-11:30 AM revealed the following:
PF # 1, date of hire DOH 10/18/22; had no documentation of two (2) references being verified.
PF # 2, DOH: 11/30/22; had no documentation of two (2) references being verified.
An interview with the agency administrator conducted on March 17, 2023 at approximately 11:50 AM confirmed the above findings.
Plan of Correction:PF #1 and #2 we will retrieve 2 verifiable references for their files. As we can not go back date it for the prior to hire date.
We will audit all remaining personnel files to ensure no other files were affected by this deficiency.
We have implemented a checklist, that will be audited by the office manager prior to date hired. The office manager will use this checklist to ensure that all signatures and forms are received prior to hire.
The office manager will be conducting audits on 25% of our files quarterly with the checklist to ensure no other files are affected by the same deficiency.
611.51(b) LICENSURE
Direct Care Worker Files
Name - Component - 00
Files for direct care workers employed or rostered shall include documentation of the date of the face-to-face interview with the individual and of references obtained. Direct Care Worker files also shall include other information as required by § 611.52, § 611.53, if applicable, § 611.54, § 611.55 and § 611.56 (relating to criminal background checks, child abuse clearance, provisional hiring, competency requirements; and health evaluations).
Observations:
Based on review of personnel files (PF) and interview with agency administrator, it was determined the agency failed to ensure that two (2) verifiable references were obtained prior to hiring each direct care worker for two (2) of six (6) files reviewed. (PF# 1 and 2); the agency failed to ensure completed documentation demonstrating each direct care worker had satisfactorily completed an initial competency exam containing ten (10) areas of care and an additional six (6) areas of personal care for four (4) of six (6) files reviewed. ( PF #2, # 4, # 5 and # 6)
Review of personnel files (PF) conducted on 3/17/23 from 10:20 PM-11:30 AM revealed the following:
PF # 1, date of hire DOH 10/18/22; had no documentation of two (2) references being verified.
PF # 2, DOH: 11/30/22; had no documentation of two (2) references being verified; contained no docmentation of a competency exam containing ten (10) areas of care and an additional six (6) areas of personal care upon hire.
PF # 4, DOH: 3/9/20; contained an incomplete written competency test containing all sixteen (16) areas required with no date or signature of the person that reviewed the test.
PF # 5, DOH: 9/16/21; contained an incomplete written competency test containing all sixteen (16) areas required with no date or signature of the person that reviewed the test.
PF # 6, DOH: 2/5/22; contained an incomplete written competency test containing all sixteen (16) areas required with no date or signature of the person that reviewed the test.
An interview with the agency administrator conducted on March 17, 2023 at approximately 11:50 AM confirmed the above findings.
Plan of Correction:PF #1 we will retrieve 2 satisfactory references.
PF #2 we will retrieve 2 satisfactory references, as well as a new competency exam containing all 10 areas of care and 6 areas of personal care upon hire.
PF #4 we will retrieve a new competency exam containing all 10 areas of care and 6 areas of personal care upon hire.
PF #5 we will retrieve a new competency exam containing all 10 areas of care and 6 areas of personal care upon hire.
PF #6 we will retrieve a new competency exam containing all 10 areas of care and 6 areas of personal care upon hire.
We will audit all remaining personnel files to ensure no other files were affected by this deficiency.
We have implemented a checklist, that will be audited by the office manager prior to date hired. The office manager will use this checklist to ensure that all signatures and forms are received prior to hire.
The office manager will be conducting audits on 25% of our files quarterly with the checklist to ensure no other files are affected by the same deficiency.
611.55(b) LICENSURE
Competency Requirements
Name - Component - 00
A competency examination or training program developed by an agency or registry for a direct care worker shall address, at a minimum, the following subject areas: 1. Confidentiality; 2. Consumer control and the independent living philosophy; 3. Instrumental activities of daily living; 4. Recoginizing changes in the consumer that need to be addressed; 5. Basic infection control; 6. Universal precautions; 7. Handling of emergencies; 8. Documentation; 9. Recognizing and reporting abuse or neglect; and 10. Dealing with difficult behaviors.
Observations:
Based on review of personnel files (PF) and interview with agency office manager, it was determined the agency failed to ensure completed documentation demonstrating each direct care worker had satisfactorily completed an initial competency exam containing ten (10) areas of care and an additional six (6) areas of personal care for four (4) of six (6) files reviewed. ( PF #2, # 4, # 5 and # 6)
Review of personnel files (PF) conducted on 3/17/23 from 10:20 PM-11:30 AM revealed the following:
PF # 2, DOH: 11/30/22; contained no docmentation of a competency exam containing ten (10) areas of care and an additional six (6) areas of personal care upon hire.
PF # 4, DOH: 3/9/20; contained an incomplete written competency test containing all sixteen (16) areas required with no date or signature of the person that reviewed the test.
PF # 5, DOH: 9/16/21; contained an incomplete written competency test containing all sixteen (16) areas required with no date or signature of the person that reviewed the test.
PF # 6, DOH: 2/5/22; contained an incomplete written competency test containing all sixteen (16) areas required with no date or signature of the person that reviewed the test.
An interview with the agency administrator conducted on March 17, 2023 at approximately 11:50 AM confirmed the above findings.
Plan of Correction:PF #2 we will conduct a new competency exam containing all 10 areas of care and 6 areas of personal care.
PF #4 we will conduct a new competency exam containing all 10 areas of care and 6 areas of personal care. The new exam was updated with date and signature area.
PF #5 we will conduct a new competency exam containing all 10 areas of care and 6 areas of personal care. The new exam was updated with date and signature area.
PF #6 we will conduct a new competency exam containing all 10 areas of care and 6 areas of personal care. The new exam was updated with date and signature area.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on March 17, 2023, Serenity At Home Llc, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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