QA Investigation Results

Pennsylvania Department of Health
EXCEL HOME CARE
Health Inspection Results
EXCEL HOME CARE
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 May 20, 2019, Excel Home Care was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, and Subpart A





Plan of Correction:




51.3 (g)(1-14) LICENSURE
NOTIFICATION

Name - Component - 00
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.


Observations:

Based on review of agency incident and complaints and interview with the office manager, the agency failed to report or notify the Department in writing of an events that seriously compromised patient safety such as direct care giver (DCW) neglect and client exploitation for three (3) of three (3) events.

Finding:

The Health Care Facilities Act 35 P.S. 448.01-448.90b - The Department of
Health of the Commonwealth of Pennsylvania states
51.3 Notification
(f) If a health care facility is aware of a situation or the occurrence of an event at the facility which could seriously compromise quality assurance or patient safety, the facility shall immediately notify the Department in writing. The notification shall include sufficient detail and information to alert the Department as to the reason for its occurrence and the steps which the health care facility shall take to rectify the situation.
(g) For purposes of subsections (e)
and (f), events which seriously compromise quality assurance and patient safety include, but not limited to the following:
(6) Complaints of patient abuse, whether or not confirmed by the facility.


Review of agency incidents and complaints on May 20, 2019 at 1330 revealed:

Incident # 1 dated May 7, 2019 stated " The service coordinator reported that the consumer's Veterans Association social worker called " Stating the client disclosed to the service coordinator that the DCW is heavily drinking and the consumer is providing his own personal care DCW moved into consumer ' s home, consumer does not know why. Consumer also found the DCW passes out outside of his home. "

Service coordinator terminated the DCW for neglect and sent a report to Adult Protective Services (APS). " Agency could not continue to provide care per Service Coordinator due to the lack of DCE in the consumer ' s area. " The agency stated on the incident report that Adult Protective Services was contacted.

Incident # 2 dated March 28, 2019 stated, " Consumer ' s daughter called stating " the DCW wasn ' t showing up. Her schedule is from Monday through Saturday and the DCW doesn ' t come on Saturday ' s. Daughter stated the DCW is manipulating the consumer. Daughter stated " that the consumer was hospitalized for a week and the DCW didn ' t report it to the agency and the DCW was paid. Daughter stated the DCW makes the consumer pay for gas when they travel to appointments. " Service coordinator was made aware and APS was contacted. Care Coordinator will also do a pop-up visit today. "

Incident # 3 dated March 29, 2019 stated, " Consumer ' s daughter stated that the DCW refused to share agency information with the daughter. On March 29, 2019 at 0930 the agency coordinator went to the client ' s home and the DCW was not present for her shift 0900 to 1500. DCW worker was terminated for neglect and exploitation."

Interview with the office manager on May 20, 2019 at 1400 confirmed that above events were not reported to the Pennsylvania Department of Health via the Event Reporting System.


Review of agency incidents and complaints on May 20, 2019 at 1330 revealed that the incidents were reported to the Office of Long -Term Living (OLTL)incident reporting form was completed and sent to OLTL and APS was notified.

Review of PA Event Reporting System on May 20, 2019 at 0900 revealed no documentation of any incidents from this agency since November 30, 2018.

Agency failed to report events to the Pennsylvania Department of Health via the Event Reporting System.

This a repeat deficiency from licensure survey completed on November 26, 2018.







Plan of Correction:

Incident #1 ERS report filed 6-06-19 Event # 582484
Incident #2 ERS report filed 6-06-19 Event #582493
Incident #3 ERS report filed 6-06-19 Event # 582493

Agency will hold a compliance workshop to review all required reporting requirements with an emphasis on the ERS reporting requirements to stay compliant with 28 PA code 51.3. This workshop will be held on June 06, 2019.
All reports will be reviewed directly by quality management team to ensure that all required reporting has been satisfied. The quality management team will take direct responsibility for all reporting requirements and work with location to improve reporting processes.
The Compliance Officer will be responsible for facilitating the workshop and all training materials required. The location manager and staff will be under the direct supervision of the quality management team to ensure proper reporting.



Initial Comments:

Based on the findings of an on-site state licensure survey conducted on May 20, 2019, Excel Home Care was found not to be in compliance with the following requirement of Title 28 Health and Safety Part IV, Health Facilities, Subpart H. Chapter 611 Home Care Agencies and Home Care Registries




Plan of Correction:




611.57(d) LICENSURE
Documentation

Name - Component - 00
(d) The home care agency or home care registry shall maintain documentation on file at the agency or registry of compliance with the requirements of this section which shall be available for Department inspection.

Observations:

Based on review of agency documentation and consumer files, and interview with the office manager, the agency failed to ensure documentation that personal care was provided based on the agency's "Individualized Service Plan" and/or the "OLTL (Office of Long-Term Living) Service Authorization Form" for one (1) of five (5) consumer files. Consumer file # 1.

Findings:

Review of the consumer file # 1 on May 20, 2019 at 1300 revealed:

Excel ' s DCW Care Plan and Assignment dated October 23, 2018 listed shower or tub bath, oral care hair care, toileting.

Office of Long-Term Living dated March 8, 2019 details of current needs included bathing, dressing, toileting and incontinence care for March 16, 2019 to May 31, 2019/

Review of weekly time sheets and service log on May 20, 2019 from 1330 to 1430 revealed:

Start of care was October 29, 2018. Review of weekly time sheets and service log for October 29, 2018 through November 3, 2018. No documentation of bathing, hair care, dressing assistance, toileting and incontinent care.

Review of weekly time sheets and service log March 11, 2019 to March 16, 2017(Monday through Saturday). No documentation of bathing, hair care, dressing assistance, toileting and incontinent care.

Review of weekly time sheets and service log for March 18, 2019 to March 23, 2019 (Monday through Saturday). No documentation of bathing, hair care, dressing assistance, toileting and incontinent care.


Interview on May 20, 2019 at 1530 with the office manager confirmed there was no documentation in the agency files which provided evidence that home care services for personal care were provided as per the "Individualized Service Plan" and/or the "OLTL Service Authorization Form" for the above identified consumer.






Plan of Correction:

Agency will include review of care plans and individual service plans (ISP) as a component of the compliance training workshop to be held on site at the agency location.
Location manager and staff will be re-trained on the importance of adhering to the consumer's ISP. Quality management team will assist location staff with auditing consumer's established ISPs to ensure that care plans are being followed and consumers receive appropriate services.
All documentation will be kept in electronic format in the consumer's file.

Quality Management team is responsible for implementation and completion of care plan audit.

Results are to be reported to Compliance office and Regional Vice-President.



Initial Comments:

Based on the findings of an on-site state licensure complaint investigation survey conducted on May 20, 2019, Excel Home Care was found to be in compliance with the requirements of 35 P.S. 448.809(b)






Plan of Correction: