QA Investigation Results

Pennsylvania Department of Health
A VETERAN'S LOVE HOME CARE, LLC
Health Inspection Results
A VETERAN'S LOVE HOME CARE, LLC
Health Inspection Results For:

This is the only survey for this facility

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:

Based on the findings of an onsite State Re-Licensure Survey conducted on April 8, 2024, A Veteran's Love Home Care, 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 State Re-Licensure Survey conducted on April 8, 2024, A Veteran's Love home Care, 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 a review of direct care worker personnel files (PF) and an interview with the administrator, the agency failed to obtain not less than two (2) satisfactory references for the direct care workers. Five (5) of five (5) PF's did not meet the requirement: PF#1, PF#2, PF#3, PF#4, and PF#5.

Findings include:

A review of PF's was conducted on April 8, 2024 starting at 10:20 AM. The date of hire (DOH) is indicted below.

PF#1 DOH 12/31/2023 did not contain any reference checks.

PF#2 DOH 09/22/2022 did not contain any reference checks.

PF#3 DOH 01/31/2024 did not contain any reference checks.

PF#4 DOH 10/08/2023 did not contain any reference checks.

PF#5 DOH 10/23/2023 did not contain any reference checks.

An interview the administrator held on April 8, 2024 starting at 11:20 AM confirmed the above findings.






Plan of Correction:

For all personnel file 2 non-family member reference checks will be obtained and the references will be placed in the personnel files.

The agency will implement a checklist and practice of checking compliance to ensure that two satisfactory, non-family member reference checks have been obtained prior to the date of hire.

In order to confirm that the plan of correction is effective and sustained and that the corrective reference checks are obtained prior to rostering the direct care worker, personnel files will be checked on a monthly basis by the administrator.

The plan of correction will be fully implemented on 06/07/2024.


611.52(d) LICENSURE
Proof of Residency

Name - Component - 00
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 on review of direct care worker personnel files (PF) and an interview with the administrator, the agency failed to document proof of Pennsylvania (PA) 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 for two (2) of five (5) PF's reviewed: PF#3 and PF#5.

Findings include:

A review of PF's was conducted on April 8, 2024 starting at 10:20 AM. The date of hire (DOH) is indicated below.

PF#3 DOH 01/31/2024 contained a copy of a Pennsylvania (PA) Driver's License issued 12/06/2023. There was no verifiable documentation in the PF of PA residency for the two (2) consecutive years immediately preceding the DOH from 01/31/2022 to 01/31/2024. There was no documentation of a Federal criminal background check completed upon hire in the absence of establishing PA residency.

PF#5 DOH 10/23/2023 contained a copy of a Pennsylvania (PA) Driver's License issued 01/05/2024. There was no verifiable documentation in the PF of PA residency for the two (2) consecutive years immediately preceding the DOH from 0110/23/2021 to 10/23/2023. There was no documentation of a Federal criminal background check completed upon hire in the absence of establishing PA residency.

An interview conducted with the administrator on April 8, 2024 starting at 11:20 AM confirmed the above findings.




Plan of Correction:

For all personnel a FBI check will be conducted if there is no proof of PA residency for a minimum of 2 years prior to date of hire.

The agency will implement a checklist and practice of checking compliance to ensure that every direct care worker has lived in PA for at least 2 years or have an FBI check conducted, if proof cannot be provided.

In order to confirm that the plan of correction is effective and sustained and that the correct ID or verification are obtained prior to rostering or hiring the direct care worker, IDs will be checked for 2 year residency or FBI checked will be conducted and placed in file with personnel ID.

The plan of correction will be fully implemented on 06/07/2024.



611.55(c) LICENSURE
Competency Requirements

Name - Component - 00
A competency examination or training program developed by an agency or registry for a direct care worker who will provide personal care must address the following additional subject areas: 1. Bathing, shaving, grooming and dressing; 2. Hair, skin and mouth care; 3. Assistance with ambulation and transferring; 4. Meal preparation and feeding; 5. Toileting; 6. Assistance with self-administered medications.

Observations:

Based on a review of direct care worker personnel files (PF) and an interview with the administrator, the agency failed to administer a competency examination addressing 1. Bathing, shaving, grooming and dressing; 2. Hair, skin and mouth care; 3. Assistance with ambulation and transferring; 4. Meal preparation and feeding; 5. Toileting; 6. Assistance with self-administered medications for direct care workers who were providing personal care to consumers. Five (5) of five (5) PF's did not meet the requirement: PF#1, PF#2, PF#3, PF#4, and PF#5.

Findings include:

A review of PF's was conducted on April 8, 2024 starting at 10:20 AM. The date of hire (DOH) is indicated below.

PF#1 DOH 12/31/2023 contained a competency exam completed upon hire that did not include testing for the six (6) subject matter items associated with personal care. There was no other evidence that personal care training was offered by the agency. The direct care worker's duties were inclusive of personal care services to the consumer. The competency exam in the PF was not scored and did not contain information regarding the passing score established by the agency.

PF#2 DOH 09/22/2022 contained a competency exam completed upon hire that did not include testing for the six (6) subject matter items associated with personal care. There was no other evidence that personal care training was offered by the agency. The direct care worker's duties were inclusive of personal care services to the consumer. The competency exam in the PF was not scored and did not contain information regarding the passing score established by the agency. An annual competency examination completed 09/01/2023 contained the same issues as described above.

PF#3 DOH 01/31/2024 contained a competency exam completed upon hire that did not include testing for the six (6) subject matter items associated with personal care. There was no other evidence that personal care training was offered by the agency. The direct care worker's duties were inclusive of personal care services to the consumer. The competency exam in the PF was not scored and did not contain information regarding the passing score established by the agency.

PF#4 DOH 10/08/2023 contained a competency exam completed upon hire that did not include testing for the six (6) subject matter items associated with personal care. There was no other evidence that personal care training was offered by the agency. The direct care worker's duties were inclusive of personal care services to the consumer. The competency exam in the PF was not scored and did not contain information regarding the passing score established by the agency.

PF#5 DOH 10/23/2023 contained a competency exam completed upon hire that did not include testing for the six (6) subject matter items associated with personal care. There was no other evidence that personal care training was offered by the agency. The direct care worker's duties were inclusive of personal care services to the consumer. The competency exam in the PF was not scored and did not contain information regarding the passing score established by the agency.

An interview held with the administrator on April 8, 2024 starting at 11:20 AM confirmed the above findings.









Plan of Correction:

For PF 1, PF 2, PF 3, PF 4, and PF 5 a competency exam will be administered addressing the following topics 1. Bathing, shaving, grooming and dressing; 2. Hair, skin and mouth care; 3. Assistance with ambulation and transferring; 4. Meal preparation and feeding; 5. Toileting; 6. Assistance with self-administered medications for direct care workers who were providing personal care to consumers. As well as graded and received a passing score of 70% or higher.

The agency will implement a checklist and practice of checking compliance to ensure that every direct care worker has tested on 1. Bathing, shaving, grooming and dressing; 2. Hair, skin and mouth care; 3. Assistance with ambulation and transferring; 4. Meal preparation and feeding; 5. Toileting; 6. Assistance with self-administered medications for direct care workers who were providing personal care to consumers. As well as graded and received a passing score of 70% or higher.

In order to confirm that the plan of correction is effective and sustained and that all personnel is tested correctly and graded for accuracy the administrator will retest personnel and create a grading system, grade competency exams and place in all personnel file. The administrator will monitor files monthly.

The plan of correction will be fully implemented on 06/07/2024.



611.56(a) LICENSURE
Health Screening

Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.

Observations:

Based on a review of personnel files (PF), the Centers for Disease Control (CDC) guidelines and an interview with the administrator, the agency did not provide documentation that a direct care worker completed a baseline tuberculosis symptom screen questionnaire upon hire for five (5) of five (5) PF's: PF#1, PF#2, PF#3 PF#4, and PF#5.

Findings include:

In May 2019, the Centers for Disease Control (CDC) updated its recommendation for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should receive 1) baseline tuberculosis screening upon hire using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis; 2) Completion of a tuberculosis symptom questionnaire, and 3) Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease (CDC Guidelines for Preventing Transmission of Mycobacterium Tuberculosis in Health Care Settings, 2005. Morbidity and Mortality World Report 2005, RR-17) (http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf). *Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).

A review of PF's was conducted on April 8, 2024 starting at 10:20 AM. The date of hire (DOH) is indicated below.

PF#1 DOH 12/31/2023 did not contain evidence that a baseline tuberculosis (TB) symptom screen questionnaire was completed upon hire.

PF#2 DOH 09/22/2022 did not contain evidence that a baseline tuberculosis (TB) symptom screen questionnaire was completed upon hire.

PF#3 DOH 01/31/2024 did not contain evidence that a baseline tuberculosis (TB) symptom screen questionnaire was completed upon hire.

PF#4 DOH 10/08/2023 did not contain evidence that a baseline tuberculosis (TB) symptom screen questionnaire was completed upon hire.

PF#5 DOH 10/23/2023 did not contain evidence that a baseline tuberculosis (TB) symptom screen questionnaire was completed upon hire.

An interview held with the administrator on April 8, 2024 starting at 11:20 AM confirmed the above findings.





Plan of Correction:

For PF 1, PF 2, PF 3, PF 4, and PF 5 a baseline tuberculosis (TB) symptom screen questionnaire will be obtained and the questionnaire will be placed in the file.

The administrator will implement a checklist and practice of checking compliance to ensure that every direct care worker has completed a questionnaire prior to working with a consumer.

In order to confirm that the plan of correction is effective and sustained and that all personnel has answered and signed a baseline tuberculosis symptom screen, all personnel file will be audited by the agency administrator on a monthly basis.

The plan of correction will be fully implemented on 06/07/2024.



611.57(a) LICENSURE
Consumer Rights

Name - Component - 00
(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

Observations:

Based on a review of consumer files (CF) and an interview with the administrator, the home care agency (HCA) failed to provide evidence that the consumer was involved in the service planning process, and that the consumer received information regarding the requirements associated with termination of services by the HCA. Four (4) of five (5) CF's did not meet the requirement: CF#1 CF#2, CF#4, and CF#5.

Findings include:

A review of CF's was conducted on April 8, 2024 starting at 9:30 AM. The start of care (SOC) is indicated below.

CF#1 SOC 12/31/2023 contained a service agreement and a notice regarding the requirements associated with termination of services by the HCA, but neither the service agreement nor the information concerning termination of services by the HCA were signed by the consumer. The consumer signature line was blank and there was no other evidence that the consumer received the information.

CF#2 SOC 10/20/2023 contained a service agreement and a notice regarding the requirements associated with termination of services by the HCA, but neither the service agreement nor the information concerning termination of services by the HCA were signed by the consumer. The consumer signature line was blank and there was no other evidence that the consumer received the information.

CF#4 SOC 10/08/2023 contained a service agreement and a notice regarding the requirements associated with termination of services by the HCA, but neither the service agreement nor the information concerning termination of services by the HCA were signed by the consumer. The consumer signature line was blank and there was no other evidence that the consumer received the information.

CF#5 SOC 10/08/2023 contained a service agreement and a notice regarding the requirements associated with termination of services by the HCA, but neither the service agreement nor the information concerning termination of services by the HCA were signed by the consumer. The consumer signature line was blank and there was no other evidence that the consumer received the information.

An interview held with the administrator on April 8, 2024 starting at 11:20 AM confirmed the above findings.





Plan of Correction:

For CF 1, CF 2, CF 3, CF 4, and CF 5 will be instructed to sign the service agreement and the notice regarding the requirements associated with termination of services by the home care agency will be placed in the file.

The administrator will implement a checklist and practice of checking consumer files to ensure that there is proof that all consumers received service agreement and information concerning 10-day notice by having each consumer sign each agreement and placing it in the consumer file.

In order to confirm that the plan of correction is effective and sustained and that all consumers have received the agreement plan and 10-day termination notice, all consumer file will be audited by the agency administrator on a quarterly basis making sure all new consumers have signed the forms.

The plan of correction will be fully implemented on 06/07/2024.



611.57(b) LICENSURE
Prohibitions

Name - Component - 00
(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

Observations:

Based on a review of consumer files (CF) and an interview with the administrator, the home care agency (HCA) failed to provide evidence that the consumer received information regarding the prohibitions that no individual as a result of the individual's affiliation with a HCA may assume power of attorney or guardianship over a consumer utilizing the services of that HCA, and that the HCA may not require a consumer to endorse checks over to the HCA. Four (4) of five (5) CF's did not meet the requirement: CF#1 CF#2, CF#4, and CF#5.

Findings include:

A review of CF's was conducted on April 8, 2024 starting at 9:30 AM. The start of care (SOC) is indicated below.

CF#1 SOC 12/31/2023 contained information pertaining to the prohibitions that no individual as a result of the individual's affiliation with a HCA may assume power of attorney or guardianship over a consumer utilizing the services of that HCA, and that the HCA may not require a consumer to endorse checks over to the HCA, but the consumer signature line was blank and there was no other evidence that the consumer received the information.

CF#2 SOC 10/20/2023 contained information pertaining to the prohibitions that no individual as a result of the individual's affiliation with a HCA may assume power of attorney or guardianship over a consumer utilizing the services of that HCA, and that the HCA may not require a consumer to endorse checks over to the HCA, but the consumer signature line was blank and there was no other evidence that the consumer received the information.

CF#4 SOC 10/08/2023 contained information pertaining to the prohibitions that no individual as a result of the individual's affiliation with a HCA may assume power of attorney or guardianship over a consumer utilizing the services of that HCA, and that the HCA may not require a consumer to endorse checks over to the HCA, but the consumer signature line was blank and there was no other evidence that the consumer received the information.

CF#5 SOC 10/08/2023 contained information pertaining to the prohibitions that no individual as a result of the individual's affiliation with a HCA may assume power of attorney or guardianship over a consumer utilizing the services of that HCA, and that the HCA may not require a consumer to endorse checks over to the HCA, but the consumer signature line was blank and there was no other evidence that the consumer received the information.

An interview held with the administrator on April 8, 2024 starting at 11:20 AM confirmed the above findings.






Plan of Correction:

For CF 1, CF 2, CF 4, and CF 5 will be instructed to sign the agreement regarding prohibitions that no individual as a result of the individual's affiliation with our agency may assume power of attorney or guardianship over a consumer utilizing the services of our agency and that our agency may not require a consumer to endorse checks over to our agency.


The administrator will implement a checklist and practice of checking consumer files to ensure that there is proof that all consumers received the agreement regarding prohibitions that no individual as a result of the individual's affiliation with our agency may assume power of attorney or guardianship over a consumer utilizing the services of our agency and that our agency may not require a consumer to endorse checks over to our agency by having each consumer sign each agreement and placing it in the consumer file.


In order to confirm that the plan of correction is effective and sustained and that all consumers have received the agreement, all consumer file will be audited by the agency administrator on a quarterly basis making sure all new consumers have signed the forms.


The plan of correction will be fully implemented on 06/07/2024.




611.57(c) LICENSURE
Information to be Provided

Name - Component - 00
(c) Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.

Observations:

Based on a review of consumer files (CF) and an interview with the administrator, the home care agency (HCA) failed to provide evidence that the consumers received a listing of home care services to be provided for four (4) of five (5) CF's: CF#1, CF#2, CF#4, and CF#5; the identity of the direct care worker who would be providing the services for four (4) of five (5) CF's: CF#1, CF#2, CF#4, and CF#5; the hours when the services were to be provided for five (5) of five (5) CF's: CF#1, CF#2, CF#3, CF#4, and CF#5; who to contact at the Department regarding licensure and compliance information for five (5) of five (5) CF's: CF#1, CF#2, CF#3, CF#4, and CF#5; the department's complaint hot line telephone number the the telephone number of the local area agency on aging for five (5) of five (5) CF's reviewed: CF#1, CF#2, CF#3, CF#4, and CF#5; the hiring and competency requirements of the HCA for four (4) of five (5) CF's reviewed: CF#1, CF#2, CF#4, and CF#5; and a disclosure addressing the employment or independent contractor status of the direct care workers and the tax and insurance obligations of the consumer and the HCA for five (5) of five (5) CF's: CF#1, CF#2, CF#3, CF#4, and CF#5.

Findings include:

A review of CF's was conducted on April 8, 2024 starting at 9:30 AM. The start of care (SOC) is indicated below.

CF#1 SOC 12/31/2023 contained a form which included the list of the home care services to be provided, the identity of the direct care worker, and the hiring and competency requirements of the agency, but the consumer signature line on the form was blank and there was no other evidence that the consumer received the information. The hours of service were not provided to the consumer. The phone numbers for the department regarding licensure and compliance and the department's complaint hotline number contained in the CF and consumer welcome packet were incorrect phone numbers. The phone number to the local area agency on aging was not provided to the consumer. A disclosure statement was contained in the CF, but it only addressed the employment status of the direct care worker, and it was not signed by the consumer.

CF#2 SOC 10/20/2023 contained a form which included the list of the home care services to be provided, the identity of the direct care worker, and the hiring and competency requirements of the agency, but the consumer signature line on the form was blank and there was no other evidence that the consumer received the information. The hours of service were not provided to the consumer. The phone numbers for the department regarding licensure and compliance and the department's complaint hotline number contained in the CF and consumer welcome packet were incorrect phone numbers. The phone number to the local area agency on aging was not provided to the consumer. There was no disclosure form in the CF.

CF#3 SOC 09/19/2022 did not contain the hours when services were to be provided. The phone numbers for the department regarding licensure and compliance and the department's complaint hotline number contained in the CF and consumer welcome packet were incorrect phone numbers. The phone number to the local area agency on aging was not provided to the consumer. A disclosure statement was contained in the CF, but it only addressed the employment status of the direct care worker.

CF#4 SOC 10/08/2023 contained a form which included the list of the home care services to be provided, the identity of the direct care worker, and the hiring and competency requirements of the agency, but the consumer signature line on the form was blank and there was no other evidence that the consumer received the information. The hours of service were not provided to the consumer. The phone numbers for the department regarding licensure and compliance and the department's complaint hotline number contained in the CF and consumer welcome packet were incorrect phone numbers. The phone number to the local area agency on aging was not provided to the consumer. A disclosure statement was contained in the CF, but it only addressed the employment status of the direct care worker, and it was not signed by the consumer.

CF#5 SOC 10/08/2023 contained a form which included the list of the home care services to be provided, the identity of the direct care worker, and the hiring and competency requirements of the agency, but the consumer signature line on the form was blank and there was no other evidence that the consumer received the information. The hours of service were not provided to the consumer. The phone numbers for the department regarding licensure and compliance and the department's complaint hotline number contained in the CF and consumer welcome packet were incorrect phone numbers. The phone number to the local area agency on aging was not provided to the consumer. A disclosure statement was contained in the CF, but it only addressed the employment status of the direct care worker, and it was not signed by the consumer.

An interview held with the administrator on April 8, 2024 starting at 11:20 AM confirmed the above findings.







Plan of Correction:

For CF 1, CF 2, CF 4, and CF 5 will be instructed to sign the agreement list of the home care services to be provided, the identity of the direct care worker, and the hiring and competency requirements of the agency. The hours of the service will be provided to consumer with a signature line to be signed for proof of receipt. The phone numbers to the department regarding licensure and compliance and the departments complaint hotline number in the consumer's packet will be updated to correct phone numbers. The consumer will also receive the correct number for the local area on aging. All disclosure statements will be signed by all consumers.


The administrator will implement a checklist and practice of checking consumer files to ensure that there is proof that all consumers received the list of the home care services to be provided, the identity of the direct care worker, and the hiring and competency requirements of the agency. The hours of the service provided to consumer with a signature line to be signed for proof of receipt. The phone numbers to the department regarding licensure and compliance and the departments complaint hotline number in the consumer's packet and local area on aging with correct phone numbers by having each consumer sign each agreement and placing it in the consumer file.

In order to confirm that the plan of correction is effective and sustained and that all consumers have received the agreement, all consumer file will be audited by the agency administrator on a quarterly basis making sure all new consumers have signed the forms.

The plan of correction will be fully implemented on 06/07/2024.



Initial Comments:

Based on the findings of an onsite State Re-Licensure Survey conducted on April 8, 2024, A Veteran's Love Home Care, LLC was found not to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction:




35 P. S. 448.809b LICENSURE
Photo Id Reg

Name - Component - 00
Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.


(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.



Observations:

Based on an interview with the administrator, it was determined that the Agency failed to provide photo identification tags that would include the employee's name, title, picture, and the name of the Agency.

Findings include:

During discussion with the administrator on April 8, 2024 at approximately 9:45 AM, the administrator was asked if the Agency was using photo identification tags and to provide evidence of the use of photo identification tags. The Administrator stated that the Agency was not using photo identification tags at this time.

In an interview conducted with the Administrator on April 8, 2024 starting at 11:20 AM, the above findings were confirmed.





Plan of Correction:

For all employees a photo identification tag will be provided that would include the employee's name, title, picture, and the name of the agency.

The administrator will implement a checklist and practice of checking to ensure that all employees received a photo identification tag with the proper name, picture and title.

In order to confirm that the plan of correction is effective and sustained and that all employees have received an identification card, all employee files will be audited by the agency administrator on a quarterly basis making sure all new employees have gotten an identification card.

The plan of correction will be fully implemented on 06/07/2024.