Inspection Reports for Trinity Family Services
2385 Ewing Chapel Rd, Dacula, GA 30019, GA, 30019
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Inspection Report
Routine
Deficiencies: 2
Apr 17, 2024
Visit Reason
The purpose of this visit was to conduct a periodic compliance survey on 4/17/2024.
Findings
Rule violations were cited related to incomplete personnel files and missing criminal background checks for staff. Specifically, two of three sampled staff did not have required fingerprint criminal background checks and incomplete personnel records were noted.
Severity Breakdown
D: 1
E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure staff hired after October 1, 2019 had required criminal background checks after 30 days of employment for 2 of 3 sampled staff. | D |
| Failed to maintain complete personnel records for 2 of 3 sampled employees, including missing 5 year employment history, emergency contact, and TB test or chest x-ray. | E |
Report Facts
Number of sampled staff with missing criminal background checks: 2
Number of sampled staff with incomplete personnel records: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant | Named in findings for missing criminal background check and incomplete personnel records |
| Staff C | Certified Nursing Assistant | Named in findings for missing criminal background check and incomplete personnel records |
| Staff A | Interviewed during exit conference; stated fingerprint appointments scheduled and agency will make corrections |
Inspection Report
Follow-Up
Deficiencies: 0
Jan 9, 2023
Visit Reason
The purpose of this visit was to conduct the follow-up to the 10-5-2022 compliance inspection.
Findings
No rule violation was cited as a result of this inspection.
Inspection Report
Original Licensing
Deficiencies: 14
Oct 5, 2022
Visit Reason
The purpose of this visit was to conduct the initial on-site compliance inspection of Trinity Family Services, LLC on October 5, 2022.
Findings
Multiple rule violations were cited including failure to maintain proper employee documentation, incomplete policies and procedures, missing service agreements and plans, inadequate documentation of personal care tasks, lack of supervisory reviews, and failure to maintain complaint and incident logs.
Severity Breakdown
SS= D: 13
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure unlicensed professionals maintained documentation as employees rather than independent contractors. | SS= D |
| Governing body failed to ensure development and implementation of required policies and procedures. | SS= D |
| Failed to establish policy and procedure to determine whether clients may be medically frail and/or medically compromised. | SS= D |
| Failed to ensure service agreements included all required elements for clients. | SS= D |
| Failed to document revisions to initial service agreements noting specific changes in services provided. | SS= D |
| Failed to ensure service plans were included and complete in client records. | SS= D |
| Failed to ensure documentation of personal care tasks actually performed for clients. | SS= D |
| Failed to document date and source of referral for clients. | SS= D |
| Failed to maintain complete personnel records for employees. | SS= D |
| Failed to maintain documentation of complaints and incidents including internal investigations and resolutions. | SS= D |
| Failed to ensure staff provided personal care services in accordance with client service plans. | SS= D |
| Failed to ensure supervisory review of services provided by staff was documented. | SS= D |
| Failed to conduct supervisory home visits including all required elements for clients. | SS= D |
| Failed to ensure documentation of personal care tasks and companion sitter tasks performed were incorporated in client files. | SS= D |
Report Facts
Clients sampled: 2
Employees sampled: 3
Frequency and duration of services: 7
Frequency and duration of services: 4
Missing task sheets: 8
Supervisory visit interval: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed during exit conference; acknowledged agency will make all changes | |
| Staff B | Employee providing personal care services; missing quarterly tax and wage report | |
| Staff C | Employee record reviewed; missing signed abuse statement and reporting client's progress/problems |
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