QA Investigation Results

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

This is the only survey for this facility

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 state licensure survey conducted on October 10, 2018, Ameribest Home Care Inc., was found to be in compliance with the following requirements of 28 PA Code, Part IV, Health Facilities, Subpart A, Chapter 51.












Plan of Correction:




Initial Comments:


Based on a findings of an unannounced state re-licensure survey conducted on October 10, 2018, Ameribest Home Care Inc., was found not to be in compliance with the following requirement of 28 Pa. Code, Part IV, Subpart H. Chapter 611, Home Care Agencies and Home Care Registries.










Plan of Correction:




611.51(b) LICENSURE
Direct Care Worker Files

Name - Component - 00
Files for direct care workers employed or rostered shall include documentation of the date of the face-to-face interview with the individual and of references obtained. Direct Care Worker files also shall include other information as required by 611.52, 611.53, if applicable, 611.54, 611.55 and 611.56 (relating to criminal background checks, child abuse clearance, provisional hiring, competency requirements; and health evaluations).

Observations:


Based on a review of direct care worker personnel files (PF), and an interview with the Office Manager, the agency failed to ensure that a face to face interview was obtained for potential employees, prior to employment for three (3) of nine (9) PF reviewed. (PF # 3, 5, and 8).

Findings Include:

1. A review of PF's was conducted on October 10, 2018, between approximately 10:00 A.M. and 12:00 P.M. revealed the following:

PF #3, date of hire 3/17/16, no documentation of a face to face interview, was contained within the file.

PF #5, date of hire 6/16/16, no documentation of a face to face interview, was contained within the file.

PF #8, date of hire 1/8/15, no documentation of a face to face interview, was contained within the file.

2. An interview was conducted with the Office Manager on October 10, 2018, at approximately 1:30 PM. The Office Manager confirmed the above findings.
















Plan of Correction:

Moving forward the Human Resource manager will add a checklist for new hires that addresses the face-to-face interview. When new employees are hired an HR associate will audit the full new hire package and ensure a face-to-face interview is conducted in conjunction with reference checks and other pertinent new hire instructions.
The HR manager will proceed to audit personnel files monthly and quarterly to ensure that all requirements are being met including the face-to-face interview. All documentation will be retained in a master personnel record for each employee. Administrator will oversee the HR department and conduct internal desk audits to ensure compliance is met.



611.55(e) LICENSURE
Competency Requirements

Name - Component - 00
The competency review must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction.

Observations:


Based on a review of personnel records of direct care workers, and an interview with the Office Manager, it was determined that the agency failed to provide documentation of an annual review for two (2) of nine (9) direct care workers. (Staff Members #4 and #7)

Findings include:

1. A review of the Agency's staff records was conducted on 10-10-18, between the hours of 10:00 AM and 12:00 PM. The following was noted:

Staff Member # 4, date of hire 6-6-16, contained no documentation of an annual review for 2017 and 2018.

Staff Member # 7, date of hire 4-10-17, contained no documentation of an annual review for 2018.

2. An interview was conducted with the Office Manager on 10-10-18, at approximately 1:30 PM. The Office Manager confirmed the above findings.


















Plan of Correction:

Moving forward the Human Resource manager will add a checklist for new hires that includes a checklist for competency checklists and annual reviews.
The Human Resources department will ensure adequate compliance with respect to documentation of an annual reviews 1 year after the new hire date. All documentation will be retained in a master personnel record for each employee. HR Manager and Director of Nursing will work in concert in establishing method of evaluations via field, lab and office interview observations.
Responsible Person: Human Resources Manager will monitor ongoing compliance by leveraging EMR software that tracks essential HR checkpoints including annual reviews. Administrator will oversee all departments. HR department will conduct an internal desk audit to ensure compliance in this area with a hard deadline of 12/24/2018.



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 consumer records (CR) and interview with the Office Manager, it was determined that the home care agency failed to ensure that the consumer rights included the following, "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 maybe 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," for ten (10) of ten (10) Consumer Records (CR) reviewed (CR # 1 through #10).

Findings include:

The following consumer records were reviewed between the hours of 10:00 AM through 12:00 PM, on 10-10-18.

1. A review of CR#1 revealed that there was no documentation to show that the consumer had received the following consumer rights 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. The client's start of service date was 6-18-15.

A review of CR#2 revealed that there was no documentation to show that the consumer had received the following consumer rights 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. The client's start of service date was 12-23-17.

A review of CR#3 revealed that there was no documentation to show that the consumer had received the following consumer rights 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. The client's start of service date was 6-13-15.

A review of CR#4 revealed that there was no documentation to show that the consumer had received the following consumer rights 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. The client's start of service date was 9-4-15.

A review of CR#5 revealed that there was no documentation to show that the consumer had received the following consumer rights 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. The client's start of service date was 6-30-16.

A review of CR#6 revealed that there was no documentation to show that the consumer had received the following consumer rights 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. The client's start of service date was 9-29-14.

A review of CR#7 revealed that there was no documentation to show that the consumer had received the following consumer rights 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. The client's start of service date was 1-13-16.

A review of CR#8 revealed that there was no documentation to show that the consumer had received the following consumer rights 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. The client's start of service date was 11-12-14.

A review of CR#9 revealed that there was no documentation to show that the consumer had received the following consumer rights 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. The client's start of service date was 5-5-15.

A review of CR#10 revealed that there was no documentation to show that the consumer had received the following consumer rights 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. The client's start of service date was 4-8-15.

3. An interview with the Office Manager was conducted on 10-10-18, at approximately 1:30 PM. The Office Manager confirmed the above findings.






















Plan of Correction:

Moving forward the QA manager will in-service a new addition to the patient booklet that includes language on consumer rights that includes the following, "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 maybe 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."
All supervisory nurses will be tasked with understanding the new requirement via in-service and sign the sign-in sheet. The QA manager will develop an addendum to distribute and mail out acknowledgment forms and the supervisory nurses will be responsible for giving direction and collecting attestation forms. All patients will be tracked through the EMR system.
The administrator will be monitoring the QA manager and ensure that compliance is being met with the requirement.



Initial Comments:


Based on the findings of an unannounced onsite licensure survey conducted October 10, 2018, Ameribest Home Care Inc., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).









Plan of Correction: