This is the only survey for this facility

1. Immediate Actions:
The agency's administrators are reviewing all employee files to ensure that their background checks are run and in the file. Any caregiver file without background checks the agency will obtain at the time of the finding.
We will obtain background reports for staff members (PF#2, PF#4, and PF#6) who are missing recent checks and make sure they are processed promptly.
We will also search for any missing background check documentation due to an office incident and retrieve them if they were previously conducted within the acceptable time frame.
2. Preventive Measures:
We are updating our document management policies to include digital backups of all important documents, including criminal background checks, to prevent future loss due to physical damage.
Staff will undergo training on the importance of following state regulations regarding criminal background checks and the new documentation procedures by August 15, 2024.
Starting August 1, 2024, we will conduct monthly reviews of a sample of personnel files to ensure ongoing compliance with the background check requirements.
3. Accountability and Monitoring:
The office manager will oversee the implementation of this plan and provide the administrator with monthly progress reports.
4. Documentation:
We will carefully document all actions taken to address the identified deficiencies, including dates of background checks, details of training sessions, and findings from monthly audits.
5. Timeline for Correction:
Completion of background checks for flagged personnel by July 25, 2024.
Implementation of digital backup procedures by August 1, 2024.
Completion of staff training on new policies and procedures by August 15, 2024.
First monthly compliance audit: September 1, 2024, with ongoing monthly audits thereafter.

1. Immediate Action
The home care agency's administrator will contact PF#7 (the direct care worker in question) immediately to inform them of the requirement for a Federal Criminal History Report and the process of obtaining a letter of determination from the Department of Aging. This action will be taken no later than two (2) business days from the date of the discovery.
The administrator will also review all personnel files again to ensure that no other employee has been overlooked concerning this requirement.
2. Documentation and Verification
PF#7 will be instructed to obtain the necessary Federal Criminal History Record and the letter of determination as per 6 PA. Code § 15.144(b). He/she will be given a deadline of 30 days to comply with this requirement.
Upon receipt of the Federal Criminal History Record and the letter of determination, the administrator will document, sign, and date this action and promptly add it to PF#7's personnel file.
3. Compliance Training
Within 30 days, the home care agency will conduct a mandatory training session for all administrative staff involved in the hiring process. The training will cover state and federal requirements for background checks, focusing on the specific stipulations for employees who lack two years of Pennsylvania residency prior to their hire date. Attendance will be documented and filed, and refresher training will be scheduled annually.
4. Policy Revision
The home care agency will revise its hiring policies and procedures to include a detailed checklist for employment eligibility and background check requirements. This revised policy will underscore the importance of verifying Pennsylvania residency or, alternatively, obtaining a Federal Criminal History Report for those without such residency. The revised policy will be distributed to all staff, with a signoff sheet to confirm they have read and understood the new procedures.
5. Ongoing Monitoring
To prevent future lapses, a quarterly review of personnel files will be instituted. The purpose is to ensure all employees have the appropriate documentation on file, adhering to state and federal regulations. A report of these reviews will be made available to the administrator and kept on file for compliance tracking.

6. Responsibility and Accountability
The administrator will implement and oversee this correction plan.

1. Immediate Review:
Conduct an immediate review of all personnel files, prioritizing those identified in the observations (PF#1, PF#2, PF#3, PF#4, PF#6, and PF#7), to verify the residency documentation status. The administrator will extend this review to include all current personnel files to ensure full agency compliance.
2. Staff Notification:
Notify affected personnel (associated with PF#1, PF#2, PF#3, PF#4, PF#6, and PF#7) about the need to provide updated or missing PA residency documentation. Within 30 days, if employees are unable to submit the necessary documentation showing proof of residency, an F.B.I. background check will be required.
3. Documentation Collection:
The hiring manager will guide staff on the acceptable forms of proof of residency, as outlined (motor vehicle records, housing records, public utility records, local tax records, tax return documents, and employment records), and offer support in obtaining these, should they need assistance.
4. Records Update:
Upon receipt of the necessary documents, promptly update the personnel files.
If there are any discrepancies or issues with the documentation received, communicate with the respective staff member to rectify the issue promptly.
5. Ongoing Compliance Monitoring:
The administrator will implement a routine audit of all personnel files at regular intervals (e.g., semiannually) to ensure ongoing compliance with the proof of residency requirement.
The administrator will develop a checklist to be used during the hiring process and personnel file audits to guarantee all required documents, including proof of residency, are collected and filed appropriately.
6. Policy and Procedure Update:
Review and update existing policies and procedures regarding employee documentation and compliance requirements.
Include specific protocols for collecting, reviewing, and maintaining proof of PA residency documentation. Ensure that these processes are clearly articulated and accessible to all staff involved in the hiring and documentation maintenance processes.
7. Staff Training:
Conduct training sessions for administrative staff and managers to reinforce the importance of regulatory compliance, specifically focusing on proof of residency requirements.
Ensure all staff involved in the hiring process are fully aware of the documentation requirements and are equipped to communicate these effectively to new hires.

For the affected files, the administrator will ensure that any missing tuberculosis screenings are completed as per CDC guidelines. This includes any necessary follow-ups, such as chest x-rays, and updating the files with the completed screenings.
2. Verification of Compliance:
The administrator/ Human Resources will review all staff files to ensure compliance with CDC guidelines for TB screening. Any additional non-compliance discovered during this review will be promptly addressed.
Training and Education:
Caring with Integrity Administrator will implement annual training for all staff on the importance of TB screening, using clear language and emphasizing CDC guidelines and our own policies.
3. Monitoring and Compliance
We will establish a quarterly audit of staff files to ensure ongoing compliance with TB screening policies and implement a tracking system for TB screening due dates.
4. Communication:
We will communicate any policy changes and the importance of TB screening compliance to all staff through meetings and written updates.
Immediate actions for correction will be initiated within 1 week.
The review of all staff files and policy updates will be completed within 30 days.

1. Immediate Review and Update of Existing Disclosure Forms
The administrator will conduct immediate review of all active consumer files to ensure that disclosure forms are completed accurately and fully. Priority will be given to correcting the forms identified in the observations (CF#1, CF#2, CF#3, CF#4).
The hiring manager will review and update the forms to correctly indicate the DCW's employment status and clearly mention the respective tax and insurance obligations.
2. Staff Training
Organize mandatory training sessions for all administrative staff involved in the preparation and review of consumer files and disclosure forms. The training will cover
Detailed instructions on how to fill out the disclosure forms correctly.
Importance of accurately communicating the employment status of D.C.W.s and related tax and insurance information. This will be completed within 30 days of the findings.
3. Revision of the Consumer Onboarding Process
Revise the existing consumer onboarding process to include a step where the consumer, their legal representative, or responsible family member is verbally informed about the contents of the information packet and the significance of the disclosure concerning the employment status of the DCW.
Implement a double-check system in which the administrator reviews the completed disclosure form and information packet before they are handed over to the consumer.
4. Introduction of a Quality Assurance Protocol
The administrator will implement a Quality Assurance (QA) protocol to regularly audit consumer files and ensure compliance with information provision requirements, focusing on the accuracy and completeness of the disclosure forms.