Initial Comments:
Based on the findings of an off site unannounced state relicensure survey completed April 20, 2023, Public Choice Homecare 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 off site unannounced state relicensure survey completed April 20, 2023, Public Choice Homecare 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:
611.51(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 employee files, and interview with the Administrator, it was determined that the agency failed to conduct a face-to-face interview with the individual, and to obtain two verifiable references that affirms the ability of a Direct Care Worker, (DCW) to provide home care services for five, (5), of five, (5) employee files reviewed. (DCW # 1, 2, 3, 4 and 5).
Findings include:
1. Review of personnel files on April 20, 2023, at approximately 11:00 a.m. revealed that DCW #1 was hired on August 6, 2022. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.
2. Review of personnel files on April 20, 2023, at approximately 11:10 a.m. revealed that DCW #2 was hired on February 17, 2022. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.
3. Review of personnel files on April 20, 2023, at approximately 11:20 a.m. revealed that DCW #3 was hired on October 1, 2019 . There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.
4. Review of personnel files on April 20, 2023, at approximately 11:30 a.m. revealed that DCW #4 was hired on March 6, 2021. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.
5. Review of personnel files on April 20, 2023, at approximately 11:40 a.m. revealed that DCW #5 was hired on December 22, 2016. There was no documented evidence that a face-to-face interview had been conducted, or that two verifiable references were obtained by the facility.
An interview with the Administrator on April 21, 2023, at 2:00 p.m., confirmed that the agency failed to document a face-to-face interview, and two verifiable references for each DCW employed at the agency.
Plan of Correction:The review showed the Agency did and does perform face to face interviews and reference checks for employees, but the did not conduct a face-to-face interview or a reference check for employees' personnel #'s (1, 2, 3, 4 and 5) as required by 611.51(a).
To correct this error on May 10, 2023; the Admin conducted face to face interviews along with contacting the refences for employees' personnel #'s (1, 2, 3, 4 and 5).
To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP"). This Policy will ensure all new hiring requirements of 11.51(a), have been met before a new employee can provide service consumers.
EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation.
By June 1, 2023; with the EPIP implementation, all employee Personnel file's including file #'s (1, 2, 3, 4 and 5), will have all required documents as directed by 611.51(a). All deficiencies under Citation 0210 have been addressed.
611.52(b) LICENSURE
State Police Criminal History Record
Name - Component - 00
If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.
Observations:
Based on review of personnel files, agency policy and interview with the Administrator, it was determined that the agency failed to complete background checks through the Pennsylvania Access To Criminal History, (PATCH), program at the time of application, or within one (1) year immediately preceding the date of application for three, (3), of five, (5), Direct Care Workers, (DCW), reviewed. (DCW # 1, 2, and 5)
Findings include:
On April 20, 2023 a review of the agency policy Titled, "Public Health Home Care," Subtitled, "(J) Individuals Currently Employed or Rostered," revealed that, "A direct care worker and each member of the agency or registry office staff who is employed by or rostered by a home care agency or home care registry as of December 12, 2009, shall obtain and submit a State Police criminal history record or Department of Aging letter of determination, as applicable, to the home care agency or home care registry by April 12, 2010......"
1. Review of personnel files on April 20, 2023, at approximately 11:00 a.m. revealed that DCW #1 was hired on August 6, 2022. There was no documented evidence that a criminal history report was obtained through PATCH, at time of employment.
2. Review of personnel files on April 20, 2023, at approximately 11:10 a.m. revealed that DCW #2 was hired on February 17, 2022. There was no documented evidence that a criminal history report was obtained through PATCH, at time of employment.
3. Review of personnel files on April 20, 2023, at approximately 11:40 a.m. revealed that DCW #5 was hired on December 22, 2016. There was no documented evidence that a criminal history report was obtained through PATCH, at time of employment.
In an interview with the Administrator on April 21, 2023, at approximately 2:00 p.m., it was confirmed that the agency had failed to conduct a criminal history report through PATCH, at time of employment, or within 1 year immediately preceding the date of an employee's application.
Plan of Correction:To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files including and specifically Personnel file #'s (1, 2 and 5), as directed by Citation 0310.
The review showed the Agency does obtain proof of Pennsylvania (PA) residency for employees, but did not provide documentation for employees' personnel #'s (1, 2 and 5) as required by 611.51(a).
To correct this error as of May 11, 2023; the Admin begin obtaining the required criminal background and related report documentation for employees' personnel #'s (1, 2 and 5).
To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP"). This Policy will ensure all new hiring requirements of 11.51(a), have been met before a new employee can provide service consumers.
EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation.
As of June 1, 2023; with the EPIP implementation, all employee Personnel file's including file #'s (1, 2 and 5), will have all required documents as directed by 611.51(a). All deficiencies under Citation 0310 have been addressed.
Initial Comments:
Based on the findings of an off site unannounced state relicensure survey completed April 20, 2023, Public Choice Homecare LLC, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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