QA Investigation Results

Pennsylvania Department of Health
CREDENCE HOME CARE AGENCY, INC.
Health Inspection Results
CREDENCE HOME CARE AGENCY, INC.
Health Inspection Results For:


There are  3 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 on-site state licensure survey conducted on August 15, 2017, Credence Home Care Agency, Inc. 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 licensure survey conducted on August 15, 2017, Credence Home Care Agency, Inc. 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:




611.57(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's consumer information packet, consumer records and an interview with the Administrator, the home care agency failed to ensure required consumer rights information for ten (10) of ten (10) consumer records reviewed. (Consumers record #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, & 10).

Findings include:

A review of consumer records was conducted on August 15, 2017 at approximately 10:30 AM through 11:45 AM revealed the following:

1. There was no documentation for consumer record # 1, start of care 09/16/2016, that the consumer had received information, 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.

2. There was no documentation for consumer record # 2, start of care 04/13/2017, that the consumer had received information, 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.

3. There was no documentation for consumer record # 3, start of care 08/30/2016, that the consumer had received information, 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.

4. There was no documentation for consumer record # 4, start of care 08/26/2015, that the consumer had received information, 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.

5. There was no documentation for consumer record # 5, start of care 08/04/2016, that the consumer had received information, 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.

6. There was no documentation for consumer record # 6, start of care 10/28/2014, that the consumer had received information, 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.

7. There was no documentation for consumer record # 7, start of care 01/22/2015, that the consumer had received information, 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.

8. There was no documentation for consumer record # 8, start of care 12/16/2016, that the consumer had received information, 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.

9. There was no documentation for consumer record # 9, start of care 03/03/2015, that the consumer had received information, 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.

10. There was no documentation for consumer record # 10, start of care 11/28/2016, that the consumer had received information, 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.


Interview with the Administrator on August 15, 2017 at approximately 12:25 PM confirmed that the written notice to the consumer was missing.


























Plan of Correction:

vOn Thursday, August 24th, 2017,the discussed the outcome of the State's unannounced licensing inspection conducted on August 15th, 2017 with the Agency's administrative staff.
The Administrator acknowledged three deficiencies identified by the Inspector and enjoined all administrative staff to strive for perfection and zero deficiencies during the next inspection. The Administrator reviewed the Agency's "Consumer Information Book". This booklet developed by the Agency was drawn from all Local, State and Federal regulations which the Agency is mandated to gives to Consumers and/or their Representatives during initial admission and reviewed periodically while they receive services from the agency. Among other rights and privileges for the Consumers and/or their Representatives included in this information booklet are the Consumer's rights "To receive at least 10 calendar days advance written notice of intent of the Credence Home Care Agency to terminate Services. Less than 10 calendar days 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 the health and welfare of the direct care worker is at risk".
In order to avoid a re-occurrence of this deficiency the Agency will bold and highlight the conditions and timelines for termination of services and ensure during initial admission that the consumer and/or their representative understands their right and privileges. The consumer or their representative will receive a copy of this information booklet and will acknowledge by signing and dating a declaration page that they received and that these rights and privileges were explained to them in a language they understood.
The Agency will retain and file a copy of the signed declaration page on the consumer file in the Agency's office. The Office Manager or a designee will review all Consumer admission files for completeness to ensure that all consumers have received and a signed a declaration page on file as proof of documentation.
In order to further avoid and capture a re-occurrence of this deficiency, the Office Manager will develop a monthly chart review template and will conduct a monthly chart review of all consumer charts for completeness including evidence and documentation that the consumer and/or his/her representative received and was properly instructed on his/her right to receive at least 10 calendar days of advance written notice before services could be terminated for failure to pay for their services or if the health and welfare of the direct care worker is at risk. Any errors or omissions identified during the chart review will be reported to the Director of Nursing for immediate action and remediation. The Agency will also include a questionnaire in the Agency's consumer on-going and annual satisfaction survey asking the consumer if the received at the time of initial admission and if it was explained to them in the language they understand their rights and privileges to receive at least 10 calendar days advance written notice before the agency could terminate their services for non-payment exceeding 14 days or if the health and welfare of the direct care worker is at risk. This survey questionnaire will be used as a key metric performance indicator in the agency's on-going and annual quality and assurance performance measures

The Director of Nursing (Patricia Ezike) will be responsible to monitor the continued implementation of this plan of correction. This plan of correction will be implemented no later than 60 days from August 15th, 2017


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 records and interview with the administrator, the agency failed to provide consumer information regarding the prohibition of assuming power of attorney or guardianship over a consumer utilizing the services of that home care agency or not requiring a consumer to endorse checks over to the home care agency for ten (10) of ten (10) consumer records reviewed (Consumer record #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, & 10,).

Findings include:


A review of consumer records was conducted on August 15, 2017 at approximately 10:30 AM through 11:45 AM revealed the following:

1. There was no documentation for consumer record # 1, start of care 09/16/2016, that consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks.

2. There was no documentation for consumer record # 2, start of care 04/13/2017, that consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks.

3. There was no documentation for consumer record # 3, start of care 08/30/2016, that consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks.

4. There was no documentation for consumer record # 4, start of care 08/26/2015, that consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks.

5. There was no documentation for consumer record # 5, start of care 08/04/2016, that consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks.

6. There was no documentation for consumer record # 6, start of care 10/28/2014, that consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks.

7. There was no documentation for consumer record # 7, start of care 01/22/2015, that consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks.

8. There was no documentation for consumer record # 8, start of care 12/16/2016, that consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks.

9. There was no documentation for consumer record # 9, start of care 03/03/2015, that consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks.

10. There was no documentation for consumer record # 10, start of care 11/28/2016, that consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks.


Interview with the administrator on August 15, 2017 at approximately 12:27 PM confirmed that the consumer records lacked the above mentioned information.




























Plan of Correction:

On Thursday, August 24th, 2017,the discussed the outcome of the State's unannounced licensing inspection conducted on August 15th, 2017 with the Agency's administrative staff.
The Administrator acknowledged three deficiencies identified by the Inspector and enjoined all administrative staff to strive for perfection and zero deficiencies during the next inspection. The Administrator reviewed the Agency's "Consumer Information Book". This booklet developed by the Agency was drawn from all Local, State and Federal regulations which the Agency is mandated to gives to Consumers and/or their Representatives during initial admission and reviewed periodically while they receive services from the agency includes; "No individual as a result of the individual's affiliation with Credence Home Care Agency may assume power of attorney or guardianship over a consumer utilizing the services of Credence Home Care Agency. Credence Home Care Agency may not require a consumer to endorse checks over to the Agency.
In order to avoid a re-occurrence of this deficiency the Agency will update by highlighting and bolding these regulations for emphasis and will have the consumer or his/her representative initial this provision on the Agency's consumer information booklet. The Agency staff during initial admission will ensure that the consumer and/or their representative understands these regulations. The consumer or their representative will receive a copy of this information booklet and will acknowledge by signing and dating a declaration page that they received and that these regulations were explained to them in a language they understood.
The Agency will retain and file a copy of the signed declaration page on the consumer file in the Agency's office. The Office Manager or a designee will review all Consumer admission files for completeness to ensure that all consumers have received and a signed a declaration page on file as proof of documentation.
In order to further avoid and capture a re-occurrence of this deficiency on time, the Office Manager will develop a monthly chart review template and will conduct a monthly chart review of all consumer charts for completeness including evidence and documentation that the consumer and/or his/her representative received and was properly instructed that "No individual as a result of the individual's affiliation with Credence Home Care Agency may assume power of Attorney or guardianship over them while receiving services from the agency and that no consumer receiving services from the agency should endorse checks to the agency". Any errors or omissions identified during the chart review will be reported to the Director of Nursing for immediate action and remediation. The Agency will also include a questionnaire in the Agency's consumer on-going and annual satisfaction survey asking the consumer if the received at the time of initial admission and if it was explained to them in the language they understand their rights and privileges refuse any individual as a result of their affiliation with the agency to assume power of attorney or guardianship over them and that not to endorse checks over to Credence Home Care Agency. This survey questionnaire will be used as a key metric performance indicator in the agency's on-going and annual quality and assurance performance measures.
The Director of Nursing (DON) will be responsible to monitor the continued implementation of this plan of correction. This plan of correction will be implemented no later than 60 days from August 15th, 2017.



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 review of consumer records and interview with the Administrator, it was determined the agency failed to ensure that the consumers received all the required information prior to the initiation of services for ten (10) of ten (10) consumer records (Consumer record #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, & 10 ) reviewed.

Findings include:


A review of consumer records was conducted on August 15, 2017 at approximately 10:30 AM through 11:45 AM revealed the following:


1. Review of consumer record #1, start of care 09/16/2016, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ).

2. Review of consumer record #2, start of care 04/13/2017, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ) .

3. Review of consumer record #3, start of care 08/30/2016, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ) .

4. Review of consumer record #4, start of care 08/26/2015, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ).

5. Review of consumer record #5, start of care 08/04/2016, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ) .

6. Review of consumer record #6, start of care 10/28/2014, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ).

7. Review of consumer record #7, start of care 01/22/2015, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ) .

8. Review of consumer record #8, start of care 12/16/2016, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ) .

9. Review of consumer record #9, start of care 03/03/2015, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ) .

10. Review of consumer record #10, start of care 11/28/2016, revealed that the consumer had not received the telephone number of the Ombudsman Program located with the local Area Agency on Aging ( AAA ) .


Interview with the Administrator on August 15, 2017 at approximately 12:30 PM confirmed that the consumer records lacked the above mentioned information.

























Plan of Correction:

On Thursday, August 24th, 2017,the discussed the outcome of the State's unannounced licensing inspection conducted on August 15th, 2017 with the Agency's administrative staff.
The Administrator acknowledged three deficiencies identified by the Inspector and enjoined all administrative staff to strive for perfection and zero deficiencies during the next inspection. The Administrator reviewed the Agency's "Consumer Information Book". This booklet developed by the Agency was drawn from all Local, State and Federal regulations which the Agency is mandated to gives to Consumers and/or their Representatives during initial admission and reviewed periodically while they receive services from the agency. Unfortunately the Agency omitted the information that includes the telephone numbers and websites of the Ombudsman Program located within Credence Home Care Agency service areas;

Bucks County
1-215-348-0510
www.buckscounty.org/

Chester County
Phone; 1-610-344-6350; 1-800-692-1100
www.chesco.org/aging

Delaware County
1-610-490-1300; 1-800-416-4504
www.delcosa.org

Philadelphia County

South, West or North Philadelphia;
Phone; 1-215-545-5728; 1-800-356-3606
Website; www.carie.org

Northeast or Northwest Philadelphia
Phone; 1-215-844-1829
Website; www.centerinthepark.org

Montgomery County
1-610-278-3601
www.montcopa.org/mcaas

Hotline 1-800-254-5164

The Agency has updated these information and has highlighted and bolded them for emphasis.

The consumer and/or his/her representative during initial admission will receive a copy of the Agency's consumer information booklet and will sign a declaration page to acknowledge that the consumers right and privileges have been explained to them in a language they understand The Agency will retain and file a copy of the signed declaration page on the consumer file in the Agency's office.
The Office Manager or a designee will review all Consumer admission files for completeness to ensure that all consumers have received and a signed a declaration page on file as proof of documentation.

In order to further avoid and capture a re-occurrence of this deficiency, the Office Manager will develop a monthly chart review template and will conduct a monthly chart review of all consumer charts for completeness including evidence and documentation that the consumer and/or his/her representative received the telephone number of the Ombudsman program located with their local Area Agency on Aging (AAA) in a written document form and also properly explained to them their rights and privileges to contact and report any grievances to their Ombudsman at anytime without incurring any reprisals from the agency. Any errors or omissions identified during the chart review will be reported to the Director of Nursing for immediate action and remediation. The Agency will also include questions in the Agency's consumer on-going and annual satisfaction survey questionaire asking the consumer and/or their representative if they received at the time of initial admission the telephone number of their local Ombudsman program in a written document form if their rights and privileges to contact their Ombudsman at any time without incurring any reprisals from the agency was explained to them in the language they understand. This survey questionnaire will be used as a key metric performance indicator in the agency's on-going and annual quality and assurance performance measures.
The Director of Nursing (DON) will be responsible to monitor the continued implementation of this plan of correction. This plan of correction will be implemented no later than 60 days from August 15th, 2017.



Initial Comments:

Based on the findings of an unannounced licensure survey conducted on August 15, 2017, Credence Home Care Agency, Inc.was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: