Initial Comments:
Based on the findings of an onsite unannounced complaint survey completed on January 19, 2024, Divine Family Human Services Limited Liability Company, 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:
611.4(c) LICENSURE
Requirements for HCA and HCR
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Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.
Observations:
Based on surveyor observation, and agency administrator interview, the agency failed to maintain standards required by State authorities, specifically, the agency failed to be subject to an unannounced inspection by authorized representatives of the Department.
Per 35 P.S. 448.813, "...Authorization.--For the purpose of determining the suitability of the applicants and of the premises or for determining the adequacy of the care and treatment provided or the continuing conformity of the licensees to this act and to applicable local, State and Federal regulations, any authorized agent of the department may enter, visit and inspect the building, grounds, equipment and supplies of any health care facility licensed or requiring a license under this act and shall have full and free access to the records of the facility and to the patients and employees therein and their records, and shall have full opportunity to interview, inspect, and examine such patients and employees..."
Findings include:
A review of the agency website on 1/16/24, at approximately 8:00 a.m. in preparation for an unannounced onsite complaint survey investigation to be conducted on 1/17/24, revealed it did not contain office hours information.
On 1/18/24, at 9:06 a.m. while enroute to the survey, the Administrator was called and indicated that she does not have office personnel at this time, that she is out of town.
A phone interview on 1/19/23, at 9:26 a.m. the agency Administrator confirmed that the agency website did not contain posted hours, and that staff were not available for an unannounced onsite survey.
Plan of Correction:Divine Family Human Services will hire office personnel to be available for office hours.
611.52(d) LICENSURE
Proof of Residency
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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 of review of personnel files (PF), and interview with the agency Administrator the agency failed to ensure documentation showed the employee was a resident of the state for two (2) years immediately preceding the date of hire for one (1) of three (3) files reviewed (PF1).
Findings include:
Personnel file (PF) reviews conducted on 1/19/24 from aproximately 8:00 a.m. to 8:10 a.m. revealed:
PF1 Date of Hire (DOH), 11/2/23, Start of Service (SOS) 11/7/23, No documented evidence to verify proof of PA residency for the two years immediately preceding the date of hire. PF contained a PA identification card issued 3/9/22, a period of 20 months not two years.
Interview with the agency administrator on 1/19/24, at approximately 12:01 p.m. confirmed the above findings.
Plan of Correction:All employees files who are currently employed with Divine Family Human Services will be reviewed to ensure that all identifications received will have met the requirements required by the state. This task will be completed by 4/01/2024. In addition for newly hired employees, all identifications will be reviewed for the 2 yr requirement at the time of hire. Verification of this requirement will also be added to the quarterly audit of the employee files and reviewed by the HR manager. The HR manager will be trained on items accepted for the requirement and will be documented.
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