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PRINTED: 08/17/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING: ______________________

C
060328 B. WING _____________________________
08/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1304 WOODSIDE DRIVE


HALIKIERRA HOME CARE
GREENSBORO, NC 27405
(X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

G 409 .0904(B) INSPECTIONS G 409

10A-13J .0904 (b) Any organization


subject to licensure which presents
itself to the public as a home care
agency, which does not hold a license,
and is or may be in violation of Rule
.0902 of this Section and G.S.
131E-138 shall be subject to
inspections at any time by authorized
representatives of the Department.

This Rule is not met as evidenced by:


Based on review of Division of Health Service
Regulation (DHSR) file, agency website and
administrative staff interview, the agency
presented itself to the public as having five
additional agency locations.

Findings included:

Review of the DHSR files on 07/26/18 showed


the Agency Owner had only 2 (two) licensed sites.
Site #1 HC 3367 is located at 1304 Woodside
Drive, Greensboro, NC and Site #2 HC 4510 is
located at 910 E. Ash Street Suite A, Goldsboro,
NC.

Review of the Agency web page on 07/26/18 at


http://halikierrahomecare.com/contact-us/
revealed an advertisement that read, "...Proudly
serving North Carolina Raleigh Location 5300 Six
Forks Rd Suite 213 Raleigh, NC 27609 (888)
243-1319; Greensboro Location 1304 Woodside
Drive, Greensboro, NC; Charlotte Location 1914
J N Pease Place Charlotte, NC 28262 (888)
243-1319; Henderson Location 624 Corbbit Rd.
Henderson, NC 27536 (252) 430-7101;
Division of Health Service Regulation
LABORATORY D RECTOR'S OR PROV DER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM 6899


BY9I11 If continuation sheet 1 of 18
PRINTED: 08/17/2018
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING: ______________________

C
060328 B. WING _____________________________
08/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE

1304 WOODSIDE DRIVE


HALIKIERRA HOME CARE
GREENSBORO, NC 27405
(X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

G 409 Continued From page 1 G 409

Statesville Location 111 S. Center St. Apt. 104


Statesville, NC 28677 (704) 500-1830; Reidsville
Location 1235 S. Scales St. Reidsville, NC
27320 (336) 637-8129; and Goldsboro Location
910 E. Ash Street Suite A, Goldsboro, NC (919)
734-3363.

Review revealed the Raleigh, Charlotte,


Henderson, Statesville, and Reidsville locations
are unlicensed sites.

On 07/31/18 at 2:31 p.m. the Agency Owner was


informed that Cease and Desist letters for all the
unlicensed locations presented on the agency's
website will be mailed via certified mail to the
agency mailing address at 1316 Laneridge Ct.
Raleigh, NC 27603.

The Agency Owner/Director verbalized


understanding and stated, "I'm shutting all of that
down."

On 08/06/18 Cease and Desist letters were


mailed to the Agency Owner at 1316 Laneridge
Ct. Raleigh, NC via certified mail for all of the
unlicensed locations advertised on the agency
website.

G 416 .0906(A) COMPLIANCE WITH LAWS G 416

10A NCAC 13J .0906 COMPLIANCE WITH


LAWS
(a) The agency shall be in compliance with all
applicable federal, state, and local laws, rules,

Division of Health Service Regulation


STATE FORM 6899
BY9I11 If continuation sheet 2 of 18
PRINTED: 08/17/2018
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING: ______________________

C
060328 B. WING _____________________________
08/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE

1304 WOODSIDE DRIVE


HALIKIERRA HOME CARE
GREENSBORO, NC 27405
(X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

G 416 Continued From page 2 G 416

and regulations including Title XI Part A Section


1128B of the Social Security Act - Criminal
penalties for acts involving Federal health care
programs. A failure to comply with Federal law
may subject the agency to civil or criminal
penalties as set forth in 42 U.S.C. §1320a-7a -
Making or causing to be made false statements
or representations - and 42 U.S.C. §1320a-7b -
Illegal remunerations.
.

This Rule is not met as evidenced by:


Based on the review of the agency complaint log
and administrative interviews, the agency failed to
report an allegation of theft to the Health Care
Personnel Registry (HCPR) within 24 hours and
submit a detailed investigation report, including
investigative documents collected, within 5
working days of becoming aware of the alleged
incident for 1 of 1 client with such an allegation
(#6).

The findings included:

Review of the G.S.131E-256 (g) Health Care


Personnel Registry investigation process and
reporting requirements revealed, "...Health care
facilities shall ensure that the Department is
notified of all allegations against health care
personnel, including injuries of unknown source,
which appear to be related to any act listed in
subdivision (a)(1) of this section. Facilities must
have evidence that all alleged acts are
investigated and must make every effort to
protect residents from harm while the
investigation is in progress. The results of all
investigations must be reported to the
Division of Health Service Regulation
STATE FORM 6899
BY9I11 If continuation sheet 3 of 18
PRINTED: 08/17/2018
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING: ______________________

C
060328 B. WING _____________________________
08/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE

1304 WOODSIDE DRIVE


HALIKIERRA HOME CARE
GREENSBORO, NC 27405
(X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

G 416 Continued From page 3 G 416

Department within five working days of the initial


notification to the Department..."

Review of the agency policy and procedure


manual revealed no policy governing reporting to
the Health Care Personnel Registry.

1. Review of the agency complaint log on


07/24/18 revealed a complaint dated 5/29/18 that
read, "...(Family Member) of Client #6 accused
Employee #4 of stealing jewelry..." Further review
of the complaint log revealed the allegation of
theft was not reported to the HCPR within 24
hours of notification nor were the detailed
investigation report and investigative documents
submitted within 5 working days to the HCPR.

Interview with the Agency Manager on 07/24/18 at


12:50 p.m. confirmed that the allegation of theft
was not reported to HCPR within 24 hours and
the agency did not submit a detailed investigation
report within 5 working days of becoming aware
of the alleged incident. The Agency Manager
states, "...we sent the report but they did not get
it...we did not know they did not get it..." The
agency could not produce any documentation that
showed the report of theft had been submitted to
the HCPR within 24 hours and the agency did not
submit a detailed investigation report within 5
working days of becoming aware of the alleged
incident.

Interview with an Employee with the HCPR on


7/24/18 at 2:09 p.m. revealed, "...the 24 hour
report came in from this agency on 06/08/18 at
1:59 p.m...the 5 day working report was received
on 07/18/18 at 4:10 p.m..."
Division of Health Service Regulation
STATE FORM 6899
BY9I11 If continuation sheet 4 of 18
PRINTED: 08/17/2018
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING: ______________________

C
060328 B. WING _____________________________
08/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE

1304 WOODSIDE DRIVE


HALIKIERRA HOME CARE
GREENSBORO, NC 27405
(X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

G 416 Continued From page 4 G 416

Interview with the Agency Nurse and Agency


Owner on 07/31/18 at 3:04 p.m. confirmed the
allegation of theft was not reported to HCPR
within 24 hours and the agency did not submit a
detailed investigation within 5 working days of
becoming aware of the alleged incident.

G 425 .1001(A) AGENCY MANAGEMENT & G 425


SUPERVISION

10A-13J .1001 (a) The governing body or


its designee shall establish and
implement written policies governing
agency operation. Such policies shall
be available for inspection by the
Department. The policies shall
include, at a minimum:
(1) a description of the scope of
services offered;
(2) admission and discharge policies;
(3) supervision of personnel;
(4) development of, and updates to,
the plan of care;
(5) management of emergency care
situations in the home;
(6) time frame for completion and
return of service records to the
agency;
(7) personnel qualifications;
(8) an organizational chart
(9) program evaluation;
(10) empLoyee and client
confidentiality; and
(11) coordination of and referral to
and from other community agencies and
resources.

Division of Health Service Regulation


STATE FORM 6899
BY9I11 If continuation sheet 5 of 18
PRINTED: 08/17/2018
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING: ______________________

C
060328 B. WING _____________________________
08/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1304 WOODSIDE DRIVE


HALIKIERRA HOME CARE
GREENSBORO, NC 27405
(X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

G 425 Continued From page 5 G 425

This Rule is not met as evidenced by:


Based on the agency 2018 home care license
renewal application, policy and procedure review,
client record review, personnel record review, and
staff interviews the agency failed to provide
services within the scope of services as defined
by the home care license and agency policy for 1
of 1 Client (#2).

Findings included:

Review of the agency 2018 License Renewal


Application for Home Care, Nursing Pool, and
Hospice on 7/31/18 revealed the agency is
licensed to provide In-Home Aide services and
Companion, Sitter Respite services which do not
include medication administration.

Review of agency Medications-Unlicensed


Personnel policy dated 09/01/11 on 07/31/18
revealed unlicensed personnel may assist a client
with self-administration of medication but will not
administer any medications to client...No
unlicensed Assistive Personnel, Nurse Aides, or
In-Home Aide is allowed to administer any type of
medication.

Record review for Client #2 on 07/30/18 revealed


a start of care date of /18 with diagnoses
including and Review of the
written instructions by the RN dated 05/18/18
revealed Client #2 required hands on assistance
with bathing, dressing, eating, blood glucose
monitoring, and help identifying medications
Sunday thru Saturday.
Division of Health Service Regulation
STATE FORM 6899
BY9I11 If continuation sheet 6 of 18
PRINTED: 08/17/2018
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING: ______________________

C
060328 B. WING _____________________________
08/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE

1304 WOODSIDE DRIVE


HALIKIERRA HOME CARE
GREENSBORO, NC 27405
(X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

G 466 Continued From page 7 G 466

accordance with the client's plan of care.


Agencies participating in the Home and
Community Care Block Grant or Social Services
Block Grant through the Division of Aging and
Adult Services shall comply, for those clients, with
the in-home aide service level rules contained in
10A NCAC 06A and 10A NCAC 06X which are
hereby incorporated by reference with all
subsequent amendments. All other agencies
providing in-home aide services shall comply with
the provisions in Paragraphs (b) and (c) of this
Rule.
.

This Rule is not met as evidenced by:


Based on the agency policy and procedure
review, client record review, and staff interview,
the agency failed to provide care such as bathing,
dressing, toileting, and eating according to the
plan of care for 4 of 7 clients that did not receive
services even though documentation showed
care was provided (#1, 4, 5, & 7).

Findings included:

Review of the agency "Scope of Service" policy


dated 07/27/17 on 07/31/18 revealed ...(Agency)
provides In-Home Aide services ...in accordance
with a plan of care developed by a Registered
Nurse ...In-home Aides follow instructions for
client care written by the Registered Nurse for
services to be provided.

Division of Health Service Regulation


STATE FORM 6899
BY9I11 If continuation sheet 8 of 18
PRINTED: 08/17/2018
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING: ______________________

C
060328 B. WING _____________________________
08/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1304 WOODSIDE DRIVE


HALIKIERRA HOME CARE
GREENSBORO, NC 27405
(X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

G 466 Continued From page 10 G 466

and it is not me..."

3. Record review for Client #5 on 07/30/18


revealed a start of care date of /18 with
diagnoses including , and
. Review of the record revealed an
authorization dated 05/18/18 for Personal Care
Services at 54 hours per month, Sunday -
Saturday. Client #5 required hands on assistance
with bathing, dressing, and eating, Monday -
Sunday. Client #5 received services from 9:00
a.m. - 11:00 a.m. Monday - Friday; and 9:00 a.m.
- 10:00 a.m. on Saturday and Sunday. Review of
the in-home aide time sheets revealed personal
care was provided from 9:00 a.m. - 11:00 a.m.
Monday - Friday; and 9:00 a.m. - 10:00 a.m. on
Saturday and Sunday by Employee #3, from
05/19/18 - 07/22/18.

Interviews were attempted with Client #5 on


07/30/18 at 3:02 p.m. and on 07/31/18 at 11:58
a.m. but Client #5 was unavailable.

Interview with Employee #3 on 07/31//18 at 4:05


p.m. revealed, "...I know I documented I was
working for Client #5 at the same time I was
working for Client #4...I thought we could not
deviate from the service plan that's why I did it
that way...I don't know what time I went to Client
#5 but I know got the care..."

Phone call from Employee #3 on 07/31/18 at 8:40


p.m. revealed, "I have thought about the answers
I gave you...I was going to take the fall for the
agency...I did not work those patients and I did
Division of Health Service Regulation
STATE FORM 6899
BY9I11 If continuation sheet 11 of 18
PRINTED: 08/17/2018
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING: ______________________

C
060328 B. WING _____________________________
08/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE

1304 WOODSIDE DRIVE


HALIKIERRA HOME CARE
GREENSBORO, NC 27405
(X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

G 466 Continued From page 12 G 466

p.m. revealed, "...I have thought about the


answers I gave you...I was going to take the fall
for the agency...I did not work those patients and
I did not sign those times sheets...that is not my
signature...someone is signing those timesheets
and it is not me..."

Interview with the Agency Owner/Director, Agency


Manager, and RN Supervisor on 07/31/18
confirmed that care was not provided for Client
#1, 4, 5, and 7. No further explanation was
provided.

G 503 .1402(A) CONTENT OF RECORD G 503

10A-13J .1402 (a) If the agency is


providing services to a client which
do not require a physician's order,
the service record shall contain the
following information at a minimum:
(1) Admission data:
(A) identification data such as name,
address, telephone number, date of
birth, sex, marital status, social
security number; all information
essential to the identification of the
client; and a copy of the signed
client's right's form or documentation
of its delivery;
(B) names of next of kin or legal
guardian;
(C) names of other family members;
(D) source of referral; and
(E) assessment of home environment.
(2) Service data:
(A) initial assessments by appropriate
professional of the client's
functional status in the areas of

Division of Health Service Regulation


STATE FORM 6899
BY9I11 If continuation sheet 13 of 18
PRINTED: 08/17/2018
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING: ______________________

C
060328 B. WING _____________________________
08/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE

1304 WOODSIDE DRIVE


HALIKIERRA HOME CARE
GREENSBORO, NC 27405
(X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

G 503 Continued From page 13 G 503

social, mental, physical health,


environmental, economic, activities of
daily living and instrumental
activities of daily living;
(B) identification of problems, the
establishment of goals and proposed
intervention and indication of the
client's understanding of and approval
for services to be provided. If the
client is not competent to understand
the treatment plan, the approval of
the client's responsible party shall
be recorded;
(C) a record of all services provided,
directly and by contract, with entries
dated and signed by the individual
providing the service. Records shall
include dates and times of services
provision;
(D) discharge summary which includes
an overall summary of services
provided by the agency and the date
and reason for discharge. When a
specific service to a client is
terminated and other services
continue, there shall be documentation
of the date and reason for terminating
the specific service; and
(E) evidence of coordination of
services when the client is receiving
more than one home care service.

This Rule is not met as evidenced by:


Based on review of agency policy and
procedures, medical record reviews and staff
interview, the agency did not have records of
service provision for 1 of 1 closed records
Division of Health Service Regulation
STATE FORM 6899
BY9I11 If continuation sheet 14 of 18
PRINTED: 08/17/2018
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING: ______________________

C
060328 B. WING _____________________________
08/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE

1304 WOODSIDE DRIVE


HALIKIERRA HOME CARE
GREENSBORO, NC 27405
(X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

G 512 Continued From page 15 G 512

G 512 .1003(F) Personnel G 512

f) Personnel records shall be established and


maintained for each home care employee. When
requested, the records shall be available on the
agency premises for inspection by the
Department. These records shall be maintained
for at least one year after termination from
agency employment. The records shall include
the following:
(1) an application or resume which lists
education, training and previous employment that
can be verified, including job title;
(2) a job description with record of
acknowledgment by the employee;
(3) reference checks or verification of previous
employment;
(4) records of tuberculosis screening for
employees for whom the test is necessary as
described in Paragraph (a) of this Rule;
(5) documentation of Hepatitis B immunization or
declination for hands-on care employees in
accordance with the agency's exposure control
plan;
(6) airborne and bloodborne pathogen training for
hands on care employees, including annual
updates, in compliance with 29 CFR 1910 and in
accordance with the agency's exposure control
plan;
(7) performance evaluations according to agency
policy and at least annually. These evaluations
may be confidential pursuant to Rule .0905 of this
Subchapter;
(8) verification of employees' credentials as
applicable; and
(9) records of the verification of competencies by
agency supervisory personnel of all skills required
of home care services personnel to carry out
client care tasks to which the employee is

Division of Health Service Regulation


STATE FORM 6899
BY9I11 If continuation sheet 16 of 18
PRINTED: 08/17/2018
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING: ______________________

C
060328 B. WING _____________________________
08/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE

1304 WOODSIDE DRIVE


HALIKIERRA HOME CARE
GREENSBORO, NC 27405
(X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

G 512 Continued From page 16 G 512

assigned. The method of verification shall be


defined in agency policy.

This Rule is not met as evidenced by:


Based on agency policy and procedure review,
personnel record reviews, and staff interview, the
agency did not have (a) verification of references
for 3 of 7 employee records reviewed (#1, 3, & 5);
(b) verification of competencies for 4 of 6
employee records reviewed (#2, 3, 6, & 13); and
(c) job descriptions for 3 of 7 employee records
reviewed (#2, 5, & 13).

Findings included:

Review of the agency policy "Personnel Files"


dated 09/01/11 showed the Agency personnel
files contain past and current information as
follows: a job description...reference check or
verification of previous employment...records of
the verification of competencies by supervisory
personnel to carry out client care tasks to which
the employee is assigned.

1). Review of the personnel records for


Employee's #1, 3, and 5 on 07/30/18 revealed no
verification of references; review of the personnel
records for Employee's #2, 3, 6, and 13 on
07/30/18 revealed no verification of
competencies; and review of the personnel
records for Employee's #2, 5, and 13 on 07/30/18
revealed no job descriptions.

Division of Health Service Regulation


STATE FORM 6899
BY9I11 If continuation sheet 17 of 18
PRINTED: 08/17/2018
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING: ______________________

C
060328 B. WING _____________________________
08/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE

1304 WOODSIDE DRIVE


HALIKIERRA HOME CARE
GREENSBORO, NC 27405
(X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

G 512 Continued From page 17 G 512

a) Employee #1, a Personal Care Aide (PCA),


had a hire date of 09/19/16;
b) Employee #2, a PCA, had a hire date of
5/21/18.
c) Employee #3, a PCA, had a hire date of
09/18/17;
d) Employee #5, a Nurse Aide (NA), had a hire
date of 12/21/17;
e) Employee #6, a PCA, had a hire date of
5/21/18; and
f) Employee #13, a PCA, had a hire date of
02/27/17.

An interview with the Agency Owner, Agency


Manager, and Agency RN Supervisor on 07/31/18
at 3:28 p.m. confirmed the personnel files were
incomplete. No further explanation was given as
to why the personnel files were incomplete.

Division of Health Service Regulation


STATE FORM 6899
BY9I11 If continuation sheet 18 of 18