QA Investigation Results

Pennsylvania Department of Health
AGING IN PLACE SERVICES
Health Inspection Results
AGING IN PLACE SERVICES
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite unannounced relicensure survey completed 9/12/2018, Aging In Place Services 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 onsite unannounced state relicensure survey completed 9/12/2018, Aging In Place Services 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:




611.52(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 a review of policy, personnel files (PFs) and staff (EMP) interview it was determined the agency failed to show proof of residency in this Commonwealth for the 2 years preceding the date of hire (DOH) for two (2) of six (6) PFs reviewed (PF3 and PF6).

Findings included:

A review of the agency policies on 9/12/2018 at approximately 10:56 AM revealed, Policy "CRIMINAL BACKGROUND CHECKS REFERENCE #102AP...PURPOSE...To provide an increased level of safety, thereby reducing risk for patients and employees ...POLICY...(agency) performs criminal background checks on all employee or office staff and owners if pertinent. PROCEDURE: Applicants living in Pennsylvania for more than 2 years, will have background checks through the Pennsylvania State Police...Applicants living in Pennsylvania for less than 2 years, will have background checks through the Federal Bureau of Investigation. The report must be obtained through the Department of Aging letter of determination based on an FBI check..."

A review of the PF conducted on 9/12/2018 at approximately 2:35 PM to 3:40 PM revealed the following:

PF #3 date of hire (DOH) 4/10/2017, there was a Pennsylvania driver's license with an issue date of 1/17/2017. A certificate of voter registration form "Valid 10 days after: 11/26/2013 or upon receipt by the voter." There was no additional documentation in PF to confirm the agency verified proof of residency in this Commonwealth for two (2) years immediately preceding the date of hire.

PF #6 date of hire (DOH) 9/21/2017, there was a Pennsylvania driver's license with an issue date of 7/6/2016. An additional document was in the PF, a certification of birth with a "Date Filed: JULY 16, 1981." There was no additional documentation in PF to confirm the agency verified proof of residency in this Commonwealth for two (2) years immediately preceding the date of hire.

An exit interview with the chief executive office, vice president of community services, administrator of long term care and human resource representative on 9/13/2018 at approximately 3:40 PM confirmed the above findings.








Plan of Correction:

Director of Human Resources created a checklist sticker for the front of every pre hire paperwork folder. Human Resources Assistant will use the stickers as an audit to ensure that proof of residency is received prior to date of hire. Stickers were created on 9/12/2018

Re-education of all staff in human resources in regards to the need for proof of residency, what qualifies as proof of residency, and the process of using the checklist sticker was completed on 9/12/2018

Human Resources Assistant will request for proof of residency for the staff that did not have information in their in their records will be completed by 9/28/2018

Director of Human Resources will conduct an audit monthly for three months and then quarterly for three quarters.


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 review of the agency welcome packet, consumer records (CR), and staff (EMP) interview, the agency failed to ensure consumers received services with reasonable accommodation of individual needs and preferences for three (3) of ten (10) CR reviewed (CR4, CR5 and CR6)

Findings Included:

A review of the agency welcome packet conducted on 9/12/2018 at approximately 10:45 AM revealed, "CLIENT RIGHTS AND RESPONSIBILITIES...As a Client of (agency), you have the right to: Be informed of your rights at the time of admission and before the initiation of services, and on an ongoing basis as necessary. Be involved in decisions about the service planning process and to receive services with reasonable accommodation of individual needs and preferences...Be informed of the list of services that will be provided, your direct care worker's identity, the hours when the services will be provided...Be advised of any change in the services plan before the change is made..."

Review of CR4, start of care date 2/5/2016, on 9/12/2018 at approximately 1:25 PM revealed, a "DIRECT CARE WORKER SERVICE PLAN/REPORT" with a "Date Plan Revised 01/11/18" that listed the "Service Dates/Hours 1 -2 hours 4 days a week." A review of the consumers schedule between 8/5/2018 and 8/25/2018 revealed services were provided 6 days a week. There was no documentation within CR4 to confirm that the agency confirmed or notified the consumer of the change in the days that services would be was provided.

Review of CR5, start of care date 10/19/2015, on 9/12/2018 at approximately 1:20 PM revealed, a "DIRECT CARE WORKER SERVICE PLAN/REPORT " with a "Date Plan Revised 01/17/18" that listed the "Service Dates/Hours 2 hours VA-Homemaker weekly." A review of the schedule from 8/1/2018 and 8/31/2018 was conducted. There was no documentation within CR5 to confirm that the agency confirmed or notified the consumer of the days that services would be provided.

Review of CR6, start of care date 9/14/2017, on 9/12/2018 at approximately 1:30 PM revealed, a "DIRECT CARE WORKER SERVICE PLAN/REPORT" with a "Service Dates/Hours 2 hours HM and 2 hours HHA per week." that listed the "Service Dates/Hours 2 hours VA-Homemaker weekly." A review of the schedule from 8/5/2018 and 8/31/2018 revealed services provided four (4) days a week. There was no documentation within CR5 to confirm that the agency confirmed or notified the consumer of the days that services would be provided.

An exit interview with the chief executive office, vice president of community services, administrator of long term care and human resource representative on 9/13/2018 at approximately 3:40 PM confirmed the above findings.






Plan of Correction:

Education to all staff that when they start services or changes are made to update the service plan and/or complete change in client's schedule form will be completed 10/05/2018.

Audit and update all service plans to ensure that agreed upon days and times for services are on all service plans will be completed by Vice President of Community Services or by designee by 10/26/2018.

Audit all new consumers service plans for next three months and then quarterly for next year by Vice President of Community Services or by designee.


Initial Comments:


Based on the findings of an onsite unannounced relicensure survey completed 9/12/2018, Aging In Place Services was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: