Initial Comments:
Based on the findings of an onsite unannounced relicensure survey completed December 14, 2022, Empower Grace Home Care 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 relicensure survey completed December 14, 2022, Empower Grace Home Care 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(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 on review of personnel files, and interview with the Administrative Staff, it was determined that the agency failed to maintain an initial competency training program for three (3) of five (5) Direct Care Worker's, (DCW), personnel files reviewed. (DCW #2, 3, and 5).
Findings include:
1. A review of the agency personnel files conducted on December 14, 2022, at approximately 11:10 a.m., revealed that DCW #2 was hired on February 16, 2022. There was no evidence or documentation that an initial competency had been conducted at the time of hire.
2. A review of the agency personnel files conducted on December 14, 2022, at approximately 11:30 a.m., revealed that DCW #3 was hired on August 25, 2022. There was no evidence or documentation that an initial competency had been conducted at the time of hire.
3. A review of the agency personnel files conducted on December 14, 2022, at approximately 11:50 a.m., revealed that DCW #5 was hired on July 11, 2022. There was no evidence or documentation that an initial competency had been conducted at the time of hire.
Interview on December 14, 2022, at approximately 2:30 p.m., with the Administrative staff confirmed that an initial competency had not been conducted at the time of hire.
Plan of Correction:In reference to the observation on behalf of the competency training program, we have scheduled a two-day onsite training for every Direct Care Worker who has not conducted the program.
The date the training will be held are 27&28 December 2022. Every Direct care worker has been informed of the mandatory training program that has been established.
Set forward each Direct care worker that applies for the position will be provided the training before getting hired.
In accordance with the direct care workers that were hired and the certificate was not in the records, we apologize due that there were transferred.
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, and interview with the Administrative Staff, it was determined that the agency failed to conduct a competency at least once per year after initial the competency was established for one (1) of five (5) Direct Care Worker's, (DCW), personnel files reviewed. (DCW # 5).
Findings include:
3. A review of the agency personnel files conducted on December 14, 2022, at approximately 11:50 a.m., revealed that DCW #5 was hired on July 11, 2022. DCW #5 had a Personal Care Aide Certificate dated August 30, 2016. There was no evidence or documentation that an initial, or annual competency had been conducted since the date of hire.
Interview on March 6, 2017, at approximately 2:30 p.m., with the Administrative staff confirmed that the agency did not conduct any competencies since the time of hire.
Plan of Correction:In accordance with observation in the review, the company has made the following correction in providing the competency training program to each Direct care worker on the date they are hired.
Also, each file will be updated every three months to verify that all documents be on a date.
The Direct Care worker has provided the updated documentation required and the file has been updated.
Initial Comments:
Based on the findings of an onsite unannounced relicensure survey completed December 14, 2022, Empower Grace Home Care LLC, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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