Initial Comments:
Based on the findings of an onsite unannounced relicensure survey completed January 4, 2022, Medi-Home Healthcare Agency, 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 January 4, 2022, Medi-Home Healthcare Agency, 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:
611.57(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 upon review of the agency admission packet, consumer files, and interview with the Administrator, it was determined that the agency failed to identify information to the consumer, about Department's complaint Hot Line, and the telephone number of the Ombudsman Program located within each local Area Agency on Aging (AAA), for eleven 11, of eleven (11) consumer records (CR), reviewed. (CR #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11).
Findings include:
Review of the agency admission packet entitled, "Medi-Home Healthcare Agency," revealed no identified Pennsylvania Department of Health complaint Hot Line number, and no Ombudsman's number for each local county being served.
1. On January 4, 2022 at approximately 11:37 a.m., a review of CR #1 revealed a start of service on January 29, 2021. There was no documentation for the correct Department complaint Hot Line, and telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
2. On January 4, 2022 at approximately 11:45 a.m., a review of CR #2 revealed a start of service on October 1, 2020. There was no documentation for the correct Department complaint Hot Line, and telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
3. On January 4, 2022 at approximately 11:50 a.m., a review of CR #3 revealed a start of service on November 1, 2019. There was no documentation for the correct Department complaint Hot Line, and telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
4. On January 4, 2022 at approximately 11:55 a.m., a review of CR #4 revealed a start of service on January 1, 2019. There was no documentation for the correct Department complaint Hot Line, and telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
5. On January 4, 2022 at approximately 12:00 p.m., a review of CR #5 revealed a start of service on December 20, 2019. There was documentation for the correct Department complaint Hot Line, and no telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
6. On January 4, 2022 at approximately 12:05 p.m., a review of CR #6 revealed a start of service on March 16, 2021. There was no documentation for the correct Department complaint Hot Line, and telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
7. On January 4, 2022 at approximately 12:10 p.m., a review of CR #7 revealed a start of service on January 1, 2019. There was no documentation for the correct Department complaint Hot Line, and telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
8. On January 4, 2022 at approximately 12:15 p.m., a review of CR #8 revealed a start of service on June 19, 2019. There was documentation for the correct Department complaint Hot Line, and telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
9. On January 4, 2022 at approximately 12:20 p.m., a review of CR #9 revealed a start of service on September 4, 2019. There was no documentation for the correct Department complaint Hot Line, and telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
10. On January 4, 2022 at approximately 12:25 p.m., a review of CR #10 revealed a start of service on March 27, 2020. There was no documentation for the correct Department complaint Hot Line, and telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
11. On January 4, 2022 at approximately 12:30 p.m., a review of CR #11 revealed a start of service on September 3, 2021. There was no documentation for the correct Department complaint Hot Line, and telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
On January 4, 2022 at approximately 1:30 p.m., during an exit interview with the administrator, it was confirmed that documentation did not identify the Departments Hotline, and Consumers did not receive the Ombudsman's telephone numbers for each local area being served.
Plan of Correction:Contain elements detailing how the facility will correct the deficiency as it relates to the individual:
This agency will update this agency's participant handbook and admission packet with the correct information for the Department of Health Complaint Hotline to reflect:
Department of Health Complaint Hotline number: 1-800-254-5164 and include the Ombudsman's contact number for all the counties this agency is servicing. This will be given to all new participants moving forward and they will be instructed to keep this information in their home and nearby. The participant will sign an acknowledgement of receipt and it will be kept in the participants file for review.
Indicate how the facility will act to protect patient in a similar situation:
For all existing participants: All the participants will receive a call notifying them of the proper information to the department of health complaint hotline, and the number to the Ombudsman's office in their area.
A revised copy of this agency's participant handbook and Civil Rights will be mailed to the participants home, which will include the updated information to the department of health complaint hotline/local Ombudsman's contact information, and they will be instructed to keep this information close by in their home.
An acknowledgment of receipt form and a self-addressed/stamped envelope to be mailed back to this agency or given to the direct care worker for delivery to this office and then it will be filed in the participants file. AND
For all existing participants: All the participant will receive a call notifying them with the proper information to the department of health complaint hotline and the number to the Ombudsman's office in their area.
They will be given the option of having their direct care worker pick up a revised copy of this agency's participant handbook and Civil Rights which will include the updated information to the department of health complaint hotline/local Ombudsman's contact information, and they will be instructed to keep this information close by in the participant's home.
The handbook will be given to the direct care worker for delivery to the participant and the direct care worker will return the receipt of acknowledgment to this agency or mail it back to this agency in the self-addressed /stamped envelope provided by this agency.
Include measures the facility will take or the system s it will alter to ensure that the problem does not recur:
This agency will throw out all the old documents with the incorrect information, delete all copies of the old documents with the incorrect information from all the electronic files and update them with the new documentation.
Update all documents to include document dates at the bottom of each form to ensure we are using the correct and most updated information. Also, this agency will use the OLTL website and the department of health website as a resource to be sure we are providing our participants with the most recent updates required by the state of Pennsylvania and the department of health.
Indicate how it plans to monitor its performance to make sure that solutions are sustained
This agency will track all the calls made to the participants to provide the correct information by utilizing a spreadsheet, documentation in HHA exchange where a report will be conducted to identify the calls made /documented in HHA exchange.
This agency will track the return of each acknowledgement by utilizing a spreadsheet and notating the date received and filed in the participant's file. This agency will also utilize HHA exchange to record the receipt of the acknowledgement and utilize the reports available to keep track of them.
This agency will also conduct quarterly audits of our files to ensure that they are current, up to date and compliant with all state regulations. This will include a file check list that compliance team will verify each document inside the participant's and direct care worker's file. Each document will be reviewed for accuracy and the correct information.
Provide dates when corrective action will be completed:
This agency will have the infraction corrected by or on March 15, 2022.
Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed January 4, 2022, Medi-Home Healthcare Agency, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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