Initial Comments:
Based on the findings of an onsite State Re-Licensure Survey conducted on February 14, 2024, MCP Homecare Solutions, LLC 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 Re-Licensure Survey conducted on February 14, 2024, MCP Homecare Solutions 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:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
Name - Component - 00
Prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. (3) Require the individual to submit a criminal history report, in accordance with the requirements of § 611.52 (relating to criminal background checks), and a ChildLine verification, if applicable, in accordance with the requirements of § 611.53 (relating to child abuse clearance).
Observations:
Based on a review of personnel files (PF) and an interview with the administrator, prior to hiring a direct care worker (DCW), the agency did not (1) Conduct a face-to-face interview with the individual for one (1) of seven (7) PF's reviewed: PF# 6; (2) Did not obtain not less than two satisfactory, non-family member references for the individuals for two (2) of seven (7) PF's reviewed: PF#2 and PF#7; and (3) Did not require the individual to submit a criminal history report, in accordance with the requirements of 611.52 (relating to criminal background checks) for one (1) of seven (7) PF's reviewed: PF#2.
Findings include:
A review of PF's was conducted on February 14, 2024 starting at approximately 10:05 AM. The date of hire (DOH) is indicated below:
PF#2 DOH 07/07/2022 did not contain evidence that prior to hiring the DCW, two non-family member references were obtained. One (1) of the two (2) references present in the PF was from a family member (sister of the DCW). The Pennsylvania Access to Criminal History (PATCH) report was obtained on 08/03/2022, approximately one (1) month after the DOH.
PF#6 DOH 01/17/2022 did not contain evidence that prior to hiring the DCW, an interview was conducted.
PF#7 DOH 06/03/2022 did not contain evidence that prior to hiring the DCW, references were obtained. There were no references in the PF.
An interview conducted with the administrator on February 14, 2024 starting at 12;10 PM confirmed the above findings.
Plan of Correction:1. By the Department of Health state regulations 611.51 (a) Licensure Hiring or Rostering Prerequisites: The following Plan of Corrections was rectified for PF#2; another reference was submitted by a non-family member and the reference will be placed in the employee personnel file.
2. The agency implemented a new Document Collection and workflow intake system to enhance the accuracy and efficiency of obtaining and managing documents. By implementing this new system, our agency aims to enhance its document management practices, potentially leading to reduced errors, and remain in compliance with Department of Health state regulations. All other personnel files were reviewed and some were found to be lacking the correct reference checks. All reference checks will be obtained by the Chief Executive Officer and placed in the personnel file.
3. A Quarterly examination will ensure data integrity and compliance with Department of Health state regulations 611.51 (a) regulations.
4. The Chief Executive Officer will oversee the files to ensure accuracy and then place them in the personnel files.
5. The Plan of Correction completion date will occur on or before 04/14/2024 @11:59pm.
1. By Department of Health state regulations 611.51 (a) Licensure Hiring or Rostering Prerequisites: The following Plan of Corrections were rectified for PF#6; a current Face-to-Face interview will be conducted and placed in the employee personnel file.
2. The agency implemented a new Document Collection and workflow intake system to enhance the accuracy and efficiency of obtaining and managing documents. By implementing this new system, our agency aims to enhance its document management practices, potentially leading to reduced errors, and remain in compliance with Department of Health state regulations. All other personnel files were reviewed and some were found to be lacking the correct reference checks. All reference checks will be obtained by the administrator and placed in the personnel file.
3. A Quarterly examination will ensure data integrity and compliance with the Department of Health state regulations 611.51 (a) regulations.
4. The Chief Executive Officer will oversee the files to ensure their accuracy and then place them in the personnel files.
5. The Plan of Correction completion date will occur on or before 04/14/2024 @11:59pm.
1. By Department of Health state regulations 611.51 (a) Licensure Hiring or Rostering Prerequisites: Upon our observation for PF#7; Personal File there is evidence of two non–relative references. A copy of the initial application will be submitted.
2. The agency implemented a new Document Collection and workflow intake system to enhance the accuracy and efficiency of obtaining and managing documents. By implementing this new system, our agency aims to enhance its document management practices, potentially leading to reduced errors, and remain in compliance with Department of Health state regulations. All other personnel files were reviewed and some were found to be lacking the correct reference checks. All reference checks will be obtained by the administrator and placed in the personnel file.
3. A quarterly examination will ensure data integrity and compliance with the Department of Health state regulations 611.51 (a) regulations.
4. The Chief Executive Officer will oversee the files to ensure their accuracy and then place them in their personnel files.
5. The Plan of Correction completion date is 04/14/2024 @11:59pm.
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 review of personnel files (PF) and an interview with the administrator, the agency failed to document proof of Pennsylvania (PA) residency for two (2) consecutive years immediately preceding date of hire 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 for three (3) of seven (7) PF's reviewed: PF#1, PF#2, and PF#7.
Findings include:
A review of personnel files was conducted on February 14, 2024 starting at approximately 10:05 AM. The date of hire (DOH) is indicated below.
PF#1 DOH 05/17/2023 contained a Pennsylvania Driver's license issued on 09/08/2022. There was no proof of Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire from 05/17/2021 to 05/17/2023.
PF#2 DOH 07/07/2022 contained a Pennsylvania Driver's license issued on 03/16/2021. There was no proof of Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire from 07/07/2020 to 07/07/2022.
PF#7 DOH 06/03/2022 contained a Pennsylvania Driver's license issued on 05/11/2021. There was no proof of Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire from 06/03/2020 to 06/03/2022.
An interview conducted with the administrator on February 14, 2024 starting at 12:10 PM confirmed the above findings.
Plan of Correction:0330
1. By Department of Health state regulations 611.52: PF#1; will acquire the Proof of Residency documentation to meet the regulatory requirements set by the Department of Health.
2. The agency implemented a new Document Collection and workflow intake system to enhance the accuracy and efficiency of obtaining and managing documents. By implementing this new system, our agency aims to enhance its document management practices, potentially leading to reduced errors, and remain in compliance with Department of Health state regulations. All other personnel files were reviewed and some were found to be lacking the correct reference checks. All reference checks will be obtained by the administrator and placed in the personnel file.
3. A quarterly examination will ensure data integrity and compliance with Department of Health state regulations 611.51 (a) regulations.
4. The Chief Executive Officer will oversee the files to ensure their accuracy and place them in their personnel file.
5. The Plan of Correction completion date will occur on or before 04/14/2044@ at 11:59 pm.
1. By Department of Health state regulations 611.52: PF#2; will acquire Proof of Residency documentation to meet the regulatory requirements set by the Department of Health.
2. The agency implemented a new Document Collection and workflow intake system to enhance the accuracy and efficiency of obtaining and managing documents. By implementing this new system, our agency aims to enhance its document management practices, potentially leading to reduced errors, and remain in compliance with Department of Health state regulations. All other personnel files were reviewed and some were found to be lacking the correct reference checks. All reference checks will be obtained by the administrator and placed in the personnel file.
3. A quarterly examination will ensure data integrity and compliance with Department of Health state regulations 611.51 (a) regulations.
4. The Chief Executive Officer will oversee the files to ensure their accuracy and place them in their personnel file.
5. The Plan of Correction completion date will occur on or before 04/14/2044@ at 11:59 pm.
1. By Department of Health state regulations 611.52: PF#7; will acquire Proof of Residency documentation to meet the regulatory requirements set by the Department of Health.
2. The agency implemented a new Document Collection and workflow intake system to enhance the accuracy and efficiency of obtaining and managing documents. By implementing this new system, our agency aims to enhance its document management practices, potentially leading to reduced errors, and remain in compliance with Department of Health state regulations. All other personnel files were reviewed and some were found to be lacking the correct reference checks. All reference checks will be obtained by the administrator and placed in the personnel file.
3. A quarterly examination will ensure data integrity and compliance with Department of Health state regulations 611.51 (a) regulations.
4. The Chief Executive Officer will oversee the files to ensure their accuracy and place them in their personnel file.
5. The Plan of Correction completion date will occur on or before 04/14/2044@ 11:59pm.
611.55(a) LICENSURE
Competency Requirements
Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.
Observations:
Based on a review of direct care worker personnel files (PF) and an interview with the administrator, the home care agency failed to ensure that the direct care worker completed one of the following initial competency requirements prior to assigning a direct care worker to provide services to a consumer: (1) Obtained a valid nurse's license in this Commonwealth; (2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c). (3) Has successfully completed one of the following: (i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c). (ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services). (iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us. (iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency's or registry's participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers. (v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department's website. Two (2) of seven (7) PF's did not meet the requirement: PF#5 and PF#7.
A review of PF's was conducted on February 14, 2024 starting at 10:05 AM. The date of hire (DOH) is indicated below:
PF#5 DOH 09/19/2023 contained an initial competency exam that was dated 12/08/2021, approximately two (2) years prior to the date of hire. There was no evidence that a competency exam or training occurred at the time of hire.
PF#7 DOH 06/03/2022 contained an initial competency exam that was dated 10/15/2020, approximately eighteen (18) months prior to the date of hire. There was no evidence that a competency exam or training occurred at the time of hire.
An interview conducted with the administrator on February 14, 2024 starting at 12:10 PM confirmed the above findings.
Plan of Correction:0600
1. Upon our observation of PF#5; competency requirements there is evidence of documentation of the initial orientation training. The agency maintains a separate binder for orientation training.
2. The agency implemented a new Document Collection and workflow intake system to enhance the accuracy and efficiency of obtaining and managing documents. By implementing this new system, our agency aims to enhance its document management practices, potentially leading to reduced errors, and remain in compliance with Department of Health state regulations. All other personnel files were reviewed and some were found to be lacking the correct reference checks. All reference checks will be obtained by the administrator and placed in the personnel file.
3. A quarterly examination will ensure data integrity and compliance with the Department of Health regulations 611.55 (a) Licensure.
4. The Chief Executive Officer will oversee the files to ensure their accuracy and then place them in their personnel file.
5. The Plan of Correction completion date will occur on or before 04/14/2044@ 11:59 pm.
1. Upon our observation of PF#7; competency requirements there is documentation of the initial orientation training. The agency maintains a separate binder for orientation training.
2. The agency maintains a separate binder for orientation training. The agency implemented a new Document Collection and workflow intake system to enhance the accuracy and efficiency of obtaining and managing documents. By implementing this new system, our agency aims to enhance its document management practices, potentially leading to reduced errors, and remain in compliance with Department of Health state regulations. All other personnel files were reviewed and some were found to be lacking the correct reference checks. All reference checks will be obtained by the administrator and placed in the personnel file.
3. A quarterly examination will ensure data integrity and compliance with the Department of Health regulations 611.55 (a) Licensure.
4. The Chief Executive Officer will oversee the files to ensure their accuracy and then place them in their personnel file.
5. The Plan of Correction completion date will occur on or before 04/14/2044@ 11:59 pm.
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 files (PF) and an interview with the administrator, the agency did not show evidence that a competency review occurred at least once per year for four (4) of seven (7) PF's reviewed: PF#2, PF#3, PF#4, and PF#6.
Findings include:
A review of PF's was conducted on February 14, 2024 starting at approximately 10:05 AM. The date of hire (DOH) is indicated below:
PF#2 DOH 07/07/2022 did not contain evidence that an annual competency review occurred in 2023.
PF#3 DOH 02/12/2022 did not contain evidence that an annual competency review occurred in 2023.
PF#4 DOH 11/14/2022 did not contain evidence that an annual competency review occurred in 2023.
PF#6 DOH 01/17/2022 did not contain evidence that an annual competency review occurred in 2023.
An interview conducted with the administrator on February 14, 2024 starting at 12:10 PM confirmed the above findings.
Plan of Correction:0621
1. Upon our observation of PF#2, PF#3, PF#4, and PF#6; an annual competency review is maintained in a separate binder.
2. The agency implemented a new Document Collection and workflow intake system to enhance the accuracy and efficiency of obtaining and managing documents. By implementing this new system, our agency aims to enhance its document management practices, potentially leading to reduced errors, and remain in compliance with Department of Health state regulations. All other personnel files were reviewed and some were found to be lacking the correct reference checks. All reference checks will be obtained by the administrator and placed in the personnel file.
3. Annual competency reviews will be reviewed to ensure compliance with the Department of Health state regulations. Completed documentation will be placed in the employee personnel file to ensure compliance and serve as a record of training completion.
4. The Chief Executive Officer will oversee the files to ensure their accuracy and then place them in their personnel file.
5. The Plan of Correction completion date will occur on or before 04/14/2044@ 11:59 pm.
611.56(a) LICENSURE
Health Screening
Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.
Observations:
Based on a review of personnel files (PF), the Centers for Disease Control and Prevention (CDC) guidelines, and an interview with the administrator, the home care agency (HCA) did not provide documentation that a direct care worker (DCW), upon hire, was screened for and free from active mycobacterium tuberculosis for six (6) of seven (7) PF's reviewed: PF#1, PF#2, PF#3, PF#4, PF#6 and PF#7, did not provide documentation of a tuberculosis (TB) symptom screen questionnaire and TB risk assessment completed upon hire for six (6) of seven (7) PF's reviewed: PF#1, PF#2, PF#3, PF#4, PF#6, and PF#7, and did not provide documentation of annual TB education for five (5) of seven (7) PF's reviewed: PF#2, PF#3, PF#4, PF#6, and PF#7.
Findings include:
The Centers for Disease Control and Prevention (CDC) and the National TB Controllers Association released updated recommendations for Tuberculosis (TB) screening, testing, and treatment of health care personnel on May 17, 2019. These recommendations update the health care personnel screening and testing section of the 2005 CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings. All health care personnel should be screened for TB upon hire (i.e., preplacement). TB screening is a process that includes: a baseline individual TB risk assessment, a TB symptom evaluation, and a TB test (e.g., a TB single blood assay test or a two-step tuberculin skin test (TST), and additional evaluation for TB disease as needed. Health care personnel with a positive TB test result should receive a symptom evaluation and a chest x-ray to rule out TB disease. Additional workup may be needed based on those results. All health care personnel should receive TB education annually. TB education should include information on TB risk factors, the signs and symptoms of TB disease, and TB infection control policies and procedures. (CDC/MMWR/May 17, 2019/Vol.68/No.19).
A review of PF's was conducted on February 14, 2024 starting at approximately 10:05 AM. The date of hire (DOH) is indicated below.
PF#1 DOH 05/17/2023 contained a one-step TST administered on 05/13/2023. There was no evidence of completion of the second-step TST and no evidence that a TB symptom screen questionnaire and TB risk assessment were completed upon hire.
PF#2 DOH 07/07/2022 contained a one-step TST administered on 07/01/2022. The second-step TST was completed on 09/14/2023, fourteen (14) months after completion of the first step TST. There was no evidence of completion of a TB symptom screen questionnaire and TB risk assessment were completed upon hire and there was no evidence of annual TB infection control education in 2023.
PF#3 DOH 02/12/2022 contained a one-step TST administered on 03/07/2022, approximately one (1) month after the DOH. There was no evidence of completion of the second-step TST, no evidence that a TB symptom screen questionnaire and TB risk assessment were completed upon hire, nor evidence of annual TB infection control education in 2023.
PF#4 DOH 11/14/2022 contained a one-step TST administered on 11/16/2022. There was no evidence of completion of the second-step TST, no evidence that a TB symptom screen questionnaire and TB risk assessment were completed upon hire, nor evidence of annual TB infection control education in 2023.
PF#6 DOH 01/17/2022 contained a one-step TST administered on 05/12/2021. There was no evidence of completion of the second-step TST, no evidence that a TB symptom screen questionnaire and TB risk assessment were completed upon hire, nor evidence of annual TB infection control education in 2023.
PF#7 DOH 06/03/2022 contained a QuantiFERON blood assay (blood test for TB) obtained on 01/23/2024, nineteen (19) months after the DOH. There was no evidence that a TB symptom screen questionnaire and TB risk assessment were completed upon hire, nor evidence of annual TB infection control education in 2023.
An interview conducted with the administrator on February 14, 2024 starting at 12:10 PM confirmed the above findings,
Plan of Correction:0700
1. By Department of Health state regulations 611.56 Licensure (Health Screening). The following Plan of Correction for PF#1, PF#3, PF#4, and PF#6; is required to complete the 2nd Step Tuberculin skin test (TST) immediately. A Tuberculosis symptom screen questionnaire and Tuberculosis (TB) Risk Assessment will be completed as required.
2. The agency implemented a new Document Collection and workflow intake system to enhance the accuracy and efficiency of obtaining and managing documents. By implementing this new system, our agency aims to enhance its document management practices, potentially leading to reduced errors, and remain in compliance. All other personnel files were reviewed and some were found to be lacking the correct reference checks. All reference checks will be obtained by the Chief Executive Officer and placed in the personnel file.
3. Initial Hiring and Annual reviews for Tuberculosis (TB) documentation will be conducted to ensure compliance with the Department of Health state regulations. In addition, a Tuberculosis (TB) symptom screening questionnaire and the Tuberculosis (TB) Risk Assessment will be completed upon hiring. Completed documentation will be placed in the employee personnel file to ensure compliance.
4. The Chief Executive Officer will oversee the files to ensure their accuracy by conducting a quarterly and annual review of the Tuberculosis (TB) health screening process. In addition, an annual review of educational training will also be conducted to remain in compliance.
5. The Plan of Correction completion date will occur on or before 04/14/2044@ at 11:59 pm.
1. By Department of Health state regulations 611.56 Licensure (Health Screening). The following Plan of Correction for PF#7; is required to complete a Tuberculosis (TB) sympton screen questionnaire and Tuberculosis (TB) risk assessment. Completed documentation will be placed in the employee's file.
2. Annual reviews will be conducted to ensure compliance with the Department of Health state regulations. A Tuberculosis (TB) Symptom Screen Questionnaire and a Tuberculosis (TB) Risk Assessment will be completed upon hire. In addition, annual educational requirements will also be completed and placed in the employee personnel file to ensure compliance and serve as a record of training completion. All other personnel files were reviewed and some were found to lack the Tuberculosis (TB) health screening documentation. All reference checks will be obtained by the Chief Executive Officer and placed in the personnel file.
3. Initial Hiring and Annual reviews for Tuberculosis (TB) screening documentation will be conducted to ensure compliance with the Department of Health state regulations. In addition, a Tuberculosis (TB) symptom screen questionnaire and a TB Risk Assessment will be completed upon hiring. Completed documentation will be placed in the employee personnel file to ensure compliance.
4. The Chief Executive Officer will oversee the files to ensure their accuracy by conducting a quarterly and annual review of the Tuberculosis (TB) health screening process. In addition, an annual review of educational training will also be conducted to remain in compliance.
5. The Plan of Correction completion date will occur on or before 04/14/2044@ at 11:59 pm.
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 files (CF) and an interview with the administrator, the agency failed to provide the following information to the consumer, the consumer's legal representative, or a responsible family member prior to the start of services: the identity of the DCW providing the services for two (2) of five (5) CF's reviewed: CF#1 and CF#5; the hours when the services were to be provided for three (3) of five (5) CF's reviewed: CF#1, CF#2, and CF#3; the telephone number of who to contact at the Department for information about the agency's compliance and licensure for five (5) of five (5) CF's reviewed: CF#1, CF#2, CF#3, CF#4, and CF#5; the hiring and competency requirements applicable to direct care workers (DCW) employed by the home care agency (HCA) for five (5) of five (5) CF's reviewed; and a disclosure addressing the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency for five (5) of five (5) CF's reviewed: CF#1, CF#2, CF#3, CF#4 and CF#5.
Findings include:
A review of CF's was conducted on February 14, 2024 starting at 9:18 AM. The start of care (SOC) is indicated below.
CF#1 SOC 03/10/2023 did not contain evidence that the consumer, the consumer's legal representation or a responsible family member, prior to the start of services, received information regarding the identify of the DCW who would be providing the services, the hours when the services were to be provided, the Department contact/phone number for information concerning the agency's compliance and licensure, and the hiring and competency requirments applicable to DCW employed by the HCA. The section of the disclosure form intended to address the tax and insurance obligations and other responsibilities of the consumer and the home care agency was not completed.
CF#2 SOC 08/16/2022 did not contain evidence that the consumer, the consumer's legal representation or a responsible family member, prior to the start of services, received information regarding the hours when the services were to be provided, the Department contact/phone number for information concerning the agency's compliance and licensure, and the hiring and competency requirments applicable to DCW employed by the HCA. The section of the disclosure form intended to address the tax and insurance obligations and other responsibilities of the consumer and the home care agency was not completed.
CF#3 SOC 11/14/2022 did not contain evidence that the consumer, the consumer's legal representation or a responsible family member, prior to the start of services, received information regarding the hours when the services were to be provided, the Department contact/phone number for information concerning the agency's compliance and licensure, and the hiring and competency requirments applicable to DCW employed by the HCA. The section of the disclosure form intended to address the tax and insurance obligations and other responsibilities of the consumer and the home care agency was not completed.
CF#4 SOC 05/17/2023 did not contain evidence that the consumer, the consumer's legal representation or a responsible family member, prior to the start of services, received information regarding the Department contact/phone number for information concerning the agency's compliance and licensure, and the hiring and competency requirments applicable to DCW employed by the HCA. The section of the disclosure form intended to address the tax and insurance obligations and other responsibilities of the consumer and the home care agency was not completed.
CF#5 SOC 01/27/2024 did not contain evidence that the consumer, the consumer's legal representation or a responsible family member, prior to the start of services, received information regarding the identify of the DCW who would be providing the services, the Department contact/phone number for information concerning the agency's compliance and licensure, and the hiring and competency requirments applicable to DCW employed by the HCA. The section of the disclosure form intended to address the tax and insurance obligations and other responsibilities of the consumer and the home care agency was not completed.
An interview conducted with the administrator on February 14, 2024 starting at 12:10 PM confirmed the above findings.
Plan of Correction:0820
1. By Department of Health 611.57(c) Licensure Information to be Provided for CF#1, CF#2, CF#3, CF#4, and CF#5; the agency intake personnel will conduct a home visit to facilitate the completion of the Participant Services Rendered, Consumer Notice of Direct Care Worker Status, and the Participant Protection Notice and any other missing documentation. necessary for the consumer's start of care chart and the documentation will be placed in the consumer's chart.
2. The agency currently has an intake process system for the consumer's Start of Care (SOC) process. The Chief Executive Officer will supervise the required documentation and ensure it is placed in the consumer's chart. All other consumer charts were reviewed and some were found to be lacking the correct documentation. All consumer documentation will be supervised by the Chief Executive Officer and then placed in the consumer's chart.
3. A quarterly and annual inspection of the consumer's chart will be examined to ensure the proper documentation is correct and up-to-date according to Department of Health state regulations. This periodic review is essential for maintaining compliance with regulations and ensuring the accuracy and completeness of consumer records. If there are any discrepancies or missing documentation found during these examinations, appropriate actions will be taken to rectify the situation promptly.
4. The Chief Executive Officer will inspect consumer files to ensure their accuracy and then place them in the consumer's chart.
5. The Plan of Correction completion date is on or before 04/14/2024 @11:59pm.
Initial Comments:
Based on the findings of an onsite State Re-Licensure Survey conducted on February 14, 2024, MCP Homecare Solutions, LLC was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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