QA Investigation Results

Pennsylvania Department of Health
COMMUNITY CARE INC.
Health Inspection Results
COMMUNITY CARE INC.
Health Inspection Results For:


There are  4 surveys for this facility. Please select a date to view the survey results.

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 unannounced onsite State relicensure survey completed on May 9, 2019, Community Care Inc. was found not 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:




51.6 (a)(2) LICENSURE
IDENTIFICATION OF PERSONNEL

Name - Component - 00
51.6. Identification of personnel

(a) When working in a health care
facility and when clinically feasible,
the following individuals shall wear
an identification tag which displays
that person's name and professional
designation:
(2) Health care providers employed
by health care facilities.

Observations:


Based on observation and staff (EMP) interview it was determined the agency failed to ensure staff identification badges contained the title of the employee in block type as close as possible to the bottom edge of the badge in a one-half inch tall strip for eleven (11) of eleven (11) PF reviewed.

Findings Included:

Observation on 5/8/2019 at approximately 1:00 p.m. Surveyor observed EMP20 identification badge to have the name of the agency at the top of the badge, EMP20 photo, then name and job title below the photo with the agency address at the bottom of the badge.
Surveyor then asked "are all employee badges like yours" EMP20 replied "yes"

Interview completed on 5/9/2019 at approximately 1:00 p.m. with EMP18, EMP19, and EMP20 confirmed the findings.




Plan of Correction:

Badge templates will be corrected to contain the company name, photo, employee name, and job title. The Company name will be at the top of the badge. The picture will be in the middle of the badge. The employee name will be below the photo. An expiration date will be listed below the employee name so the employee is aware of when the badge photo needs updated. At the bottom of the badge, the employees job title will be placed in large block letters. All badges will be reprinted with current photos on updated template and mailed to the field employees. Office employee badges will also be updated to contain the correct template. Field employee badges will be updated again during 2020 early in-services for staff. Human Resources will print the new badges for all new staff. Staff will not be able to start without their newly issued badge. Human Resources will also be printing badges for current employees with non-expired photos.


51.13 (b) LICENSURE
CIVIL RIGHTS COMPLIANCE RECORDS

Name - Component - 00
51.13. Civil rights compliance records

(b) Copies of the health care facility's nondiscriminatory policy shall be posted in locations accessible to the facility's staff and the general public.

Observations:


Based on direct observation, and staff (EMP) interview, it was determined that the agency failed to post the agency's nondiscriminatory policy in an area accessible to staff and the general public as required in PA Code Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.

Findings Included:

During a tour of the agency office on 5/8/2019 at approximately 10:00 a.m. Surveyor observed that the agency failed to post the agency's nondiscriminatory policy in the area that was accessible to the general public and the staff.

Interview completed in 5/9/2019 at approximately 1:00 p.m. with EMP18, EMP19 and EMP20 confirmed the findings. EMP20 stated "we have that in the small room you were in yesterday." Surveyor stated "yes but that room is not a room that the general public would access."





Plan of Correction:

The agency nondiscriminatory policy will be placed on the wall next to the the agency license in the main area in which the general public would be more likely to be located.


Initial Comments:



Based on the findings of an unannounced State relicensure survey completed on May 9, 2019, Community Care, Inc, was found not to be in compliance with the requirements of 28 PA Code, Part IV, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.




Plan of Correction:




611.4(c) LICENSURE
Requirements for HCA and HCR

Name - Component - 00
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 observation, staff (EMP) interview and as specified in Health Care Facilities Act: 35 PS 448.809 (b) the agency failed to post the current license.

Findings Included:

Health Care Facilities Act 35 PS 448.809 (b) "Posting. -- The license shall at all times be posted in a conspicuous place on the provider's premises."

During a tour of the agency completed on 5/8/2019 at approximately 10:00 a.m. Surveyor observed the agency license hanging on the entry wall. It was dated to have expired 5/31/2018.

Interview completed on 5/9/2019 at approximately 1:00 p.m. with EMP18, EMP19, and EMP20 confirmed the findings.






Plan of Correction:

The current license will be hung on the entry wall within the office located in Washington, PA.


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), agency consumer handbook, and staff (EMP) interview it was determined the agency failed to ensure the consumer or the consumer's legal representative, prior to the commencement of services, was provided the following information: the identity of the direct care worker who will be providing the services, the services to be provided, the fees and total costs for those services, The Departments complaint Hot Line number, A disclosure addressing the employee status of the direct care worker providing services to the consumer for ten (10) of ten (10) CF reviewed. (CF1-CF10)

Findings Included:

Review of the "Patient and Family Handbook" completed on 5/8/2019 at approximately 10:25 a.m. revealed "the Department Hotline number 1-800-254-5164. Consumer Bill of Rights Effective Date: 6/1/2010 #6 Department of Health complaint Hotline (1-866-826-3644)"

CF's reviewed on 5/8/2019 between approximately 10:55 a.m. and 1:40 p.m. revealed:

CF1, signed service agreement dated 10/12/2016, Service agreement failed to contain the identity of the direct care worker (DCW) to provide the services, the services to be provided, and the correct number for the Department Hotline number. The Hotline number provided to the consumer was 866-826-3644.

CF2, signed service agreement dated 3/25/2019, Service agreement failed to contain the identity of the DCW to provide the services, the services to be provided, fees and total costs for those services, and the correct number for the Department Hotline number. The Hotline number provided to the consumer was 866-826-3644.

CF3, signed service agreement dated 7/20/2018, Service agreement failed to contain the services to be provided, fees and total costs for those services, and the disclosure addressing the employee status of the DCW.

CF4, signed service agreement dated 1/23/2018, Service agreement failed to contain the identity of the DCW to provide the services, the services to be provided, and the correct number for the Department Hotline number. The Hotline number provided to the consumer was 866-826-3644.

CF5, signed service agreement dated 9/23/2014, Service agreement failed to contain the correct number for the Department Hotline number. The Hotline number provided to the consumer was 866-826-3644.

CF6, signed service agreement dated 9/27/2013, Service agreement failed to contain the correct number for the Department Hotline number. The Hotline number provided to the consumer was 866-826-3644.

CF7, signed service agreement dated 4/10/2011, Service agreement failed to contain the correct number for the Department Hotline number and the disclosure addressing the employee status of the DCW. The Hotline number provided to the consumer was 866-826-3644.

CF8, signed service agreement dated 12/3/2014, Service agreement failed to contain the correct number for the Department Hotline number. The Hotline number provided to the consumer was 866-826-3644.

CF9, signed service agreement dated 12/3/2014, Service agreement failed to contain the correct number for the Department Hotline number. The Hotline number provided to the consumer was 866-826-3644.

CF10, signed service agreement dated 9/6/2013, Service agreement failed to contain the identity of the DCW and the correct number for the Department Hotline number. The Hotline number provided to the consumer was 866-826-3644.

Interview completed on 5/9/2019 at approximately 1:00 p.m. with EMP18, EMP19, and EMP20 confirmed the findings.










Plan of Correction:

The department of health hotline phone number is corrected on all paperwork given to, and signed by the consumer. A memo will be sent out to all current consumers advising of the hotline phone number. The updated phone number was placed on the Consumer Bill of Rights. An updated Consumer Bill of Rights will be mailed with each memo. The supervisory nurse will also bring a copy of the updated consumer bill of rights with the correct phone number. The admission packet will be reviewed with admitting nurses so they are aware that all pages are filled out correctly, and contain all of the needed information, including, but not limited to the name of the direct care worker providing staff, and the cost of the services (even if the cost is $0). Medical records will review the admission packets signed by the consumers prior to scanning into their files to check for completeness. Anything that is not completed, will be given back to the nurse, and may require a second visit to the consumers home to ensure that they have received all of the needed information for Community Care to provide care to them. All admitting RNs will be educated on what needs to be reviewed with consumers at start of care, as well as all documentation that needs to be completed and signed by both the consumer(of appointed rep), and RN. Chart reviews will be completed by the Direct of Nursing quarterly to ensure that all regulations are being followed. The Director of Nursing will be responsible for educating the admitting RNs, and will also continue to monitor all admissions for completeness, and correctness.


Initial Comments:



Based on the findings of an on site unannounced State relicensure survey completed on May 9, 2019, Community Care, Inc, 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
(1) The photo identification tag shall include a recent photograph of the employee, the employee's name, the employee's title and the name of the health care facility or employment agency.

(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) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.



Observations:


Based on observation and staff (EMP) interview it was determined the agency failed to ensure staff identification badges contained the title of the employee in block type as close as possible to the bottom edge of the badge in a one-half inch tall strip for eleven (11) of eleven (11) PF reviewed.

Findings Included:

Observation on 5/8/2019 at approximately 1:00 p.m. Surveyor observed EMP20 identification badge to have the name of the agency at the top of the badge, EMP20 photo, then name and job title below the photo with the agency address at the bottom of the badge.
Surveyor then asked "are all employee badges like yours" EMP20 replied "yes"

Interview completed on 5/9/2019 at approximately 1:00 p.m. with EMP18, EMP19, and EMP20 confirmed the findings.





Plan of Correction:

Badge templates will be corrected to contain the company name, photo, employee name, and job title. The Company name will be at the top of the badge. The picture will be in the middle of the badge. The employee name will be below the photo. An expiration date will be listed below the employee name so the employee is aware of when the badge photo needs updated. At the bottom of the badge, the employees job title will be placed in large block letters. All badges will be reprinted with current photos on updated template and mailed to the field employees. Office employee badges will also be updated to contain the correct template. Field employee badges will be updated again during 2020 early in-services for staff. Human Resources will print the new badges for all new staff. Staff will not be able to start without their newly issued badge. Human Resources will also be printing badges for current employees with non-expired photos.