QA Investigation Results

Pennsylvania Department of Health
CARING FAMILY HOME CARE LLC
Health Inspection Results
CARING FAMILY HOME CARE LLC
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 unannounced onsite state re-licensure survey conducted June 3, 2021, Caring Family Home Care, LLC., was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health facilities, Subpart G. Chapter 601.



Plan of Correction:




601.21(e) REQUIREMENT
SUPERVISING PHYS OR REGISTERED NURSE

Name - Component - 00
601.21(e) Supervising Physician or
Registered Nurse. The skilled nursing
and other therapeutic services
provided are under the supervision and
direction of a physician or a
registered nurse (with at least one
year of nursing experience). This
person or similarly qualified
alternate, is available at all times
during operating hours and
participates in all activities
relevant to the professional services
provided, including the development of
qualifications and assignment of
personnel.

Observations:




Based on review of personnel files (PF), interview with the Administrator and a review of agency documentation, it was determined the agency failed to ensure a qualified person was available at all times during operating hours to act in the absence of the Supervising Nurse.

Findings include:

A review of the Governing Body minutes was conducted on June 3, 2021 at approximately 11:00 am which revealed meeting held on March 1, 2021 that stated, "RN (PF #1) resigned from DON position effective 3/1/2021."

In interviewing adminstrator it was stated that PF #1 is only RN still employed with agency but functions now as a "supervising nurse" not a "director of nursing." Administrator showed surveyor the current job description of "supervising nurse" who reports to "Director of Nursing" for PF #1. Administrator unable to verify that PF#1 is available 24/7 but stated should be available if needed. PF #1 file did not contain job description for "Alternate Director of Nursing." The Administrator confirmed that there is no alternate supervising nurse currently employed with the agency.

























Plan of Correction:

The company is hiring a new DON and supervisory RN/alternative DON. Both employees will be oriented. Responsible party is Administrator.


601.21(f) REQUIREMENT
PERSONNEL POLICIES

Name - Component - 00
601.21(f) Personnel Policies.
Personnel practices and patient care
are supported by appropriate, written
personnel policies. Personnel records
include qualifications, licensure,
performance evaluations, health
examinations, documentation of
orientation provided, and job
descriptions, and are kept current.

Observations:




Based on a review of personnel files (PFs), review of policies and procedures, and an interview with the Administrator, the agency did not conduct an annual performance evaluation for one (1) out of five (5) PFs reviewed (PFs #1) the agency did not conduct initial competency for one (1) out of five (5) PFs reviewed. (PFs #1).


Findings include:

Review of Policy occurred on June 3, 2021 at approximately 1:00 P.M:


Policy titled, "Agency Supervision" stated, "The Administrator is authorized to organize and direct the agency's on-going functions. The Administrator's duties shall be to...complete staff performance evaluations in accordance with organizational policy..."

Policy titled, "Personnel policies and records" stated, "personnel records shall contain...for direct care staff, skills competencies checklist...annual performance evaluations..."


A review of the personnel files was conducted on June 3, 2021 between approximately 10:00 A. M. to 11:30 A.M.

PF#1, Date of Hire (DOH): 1/1/19, File did not contain documentation that initial competency testing was performed prior to employment. File revealed no annual performance evaluation conducted in 2020.

Interview with the Administrator on June 3, 2021 at approximately 3:00 PM confirmed the above findings.


















Plan of Correction:

Upon hiring all new employees will complete initial competency evaluation. The annual performance review will be conducted on annual bases for all employees. All required documentation will be filed with a personal record. Quarterly audit will be completed by Administrator and DON to ensure compliance. Responsible party is Administrator.


601.21(h) REQUIREMENT
COORDINATION OF PATIENT SERVICES

Name - Component - 00
601.21(h) Coordination of Patient
Services. All personnel providing
services maintain liason to assure
that their efforts effectively
complement one another and support the
objectives outlined in the plan of
treatment. (i) The clinical record
or minutes of case conferences
establish that effective interchange,
reporting, and coordinated patient
evaluation does occur. (ii) A
written summary report for each
patient is sent to the attending
physician at least every 60 days.

Observations:


Based on a review of clinical records and policy and procedures and interview with the Administrator, it was determined that the agency failed to ensure that a written summary report was completed and sent to the attending physician at least every 60 days for three (3) of three (7) clinical records (CR) with multiple certifications reviewed (CR# 1, 3 & 4).

Findings include:

Review of agency policy occurred on 6/3/21 at approximately 1 PM.

Policy titled, "Care plan" stated, "The patient care plan shall be updated as often as the patient's condition indicates but at least every sixty (60) days."

Policy titled, "Physician's Plan of Treatment" stated, "A physician prepares a plan of treatment and it is made available to the agency...Reports are made every sixty (60) days for patients receiving skilled or unskilled services..."

Review of clinical records on 6/3/21 at approximatley 1:30 PM revealed:


CR #1. SOC: 3/12/21. revealed no documentation of a written summary report sent to the physician every 60 days.

CR# 3. SOC: 3/1/21. revealed no documentation of a written summary report sent to the physician every 60 days.

CR #4. SOC: 8/16/20. revealed no documentation of a written summary report sent to the physician every 60 days.

Interview conducted on 6/3/21 at approximately 3:00 PM with administrator who confirmed the above findings.








Plan of Correction:

The company RN will be completing writing summary reports as needed or at least every 60 days for each patient and send it to the physician for the review. The quarterly audit will be completed to ensure compliance. Responsible party is Administrator.


601.31(b) REQUIREMENT
PLAN OF TREATMENT

Name - Component - 00
601.31(b) Plan of Treatment. The
plan of treatment developed in
consultation with the agency staff
covers all pertinent diagnoses,
including:
(i) mental status,
(ii) types of services and equipment
required,
(iii) frequency of visits,
(iv) prognosis,
(v) rehabilitation potential,
(vi) functional limitations,
(vii) activities permitted,
(viii) nutritional requirements,
(ix) medications and treatments,
(x) any safety measures to protect
against injury,
(xi) instructions for timely
discharge or referral, and
(xii) any other appropriate items.
(Examples: Laboratory procedures and
any contra-indications or
precautions to be observed).

If a physician refers a patient under
a plan of treatment which cannot be
completed until after an evaluation
visit, the physician is consulted to
approve additions or modifications to
the original plan.

Orders for therapy services include
the specific procedures and modalities
to be used and the amount, frequency,
and duration.
The therapist and other agency
personnel participate in developing
the plan of treatment.

Observations:


Based upon clinical record review, agency policy review, and an interview with the Director of Nursing, it was determined the agency failed to ensure a visit duration/frequency was listed on the Plan of Care for three (4) out of four (4) clinical records reviewed (CR #1, 3, & 4). The agency failed to provide services according to the plan of care for one (1) out of four (7) clinical records reviewed. (CR # 2).

Findings include:

Agency policy titled "Physician's Plan of treatment" reviewed on 6/3/21 at approximately 2PM and stated, "A physician's plan of treatment...must include...Frequencies of visits needed, specific orders and frequency of visits...Any changes in the physician's plan of treatment shall be made in writing and signed and dated by the physician or by the registered nurse...Physician orders are renewed more frequently when the physician changes orders or treatment.."


Clinical records were reviewed on 6/3/21 at approximately 1:00 PM, revealing the following:

CR#1 (Start of Care: 3/12/21) revealed a "Home Health Certification and Plan of Care" for the certification period from 3/12/21 to 5/10/21. Home Health aides ordered for 21 hours weekly . There was no treatment duration listed on the Home Health Certification and Plan of Care.

CR#2. Start of Care: 1/25/19 (patient discharged on 2/28/19),Certification Period 1/25/19 to 3/25/19...Orders for Skilled Nursing (SN) for 1 visit once per week for 1 week then 2 visits once a week for 2 weeks. Additional verbal order of "2 visits per week for 2 weeks then 1 visit per week for 1 week" was written on 2/7/19. Review of SN visits revealed the following: Visits conducted on 2/24/21 and 2/28/21 without an additional order. There was no documented evidence of physician notification and/or physician order to revise the plan of care for the aforementioned additional SN visits conducted.

CR#3 (Start of Care: 3/1/21) revealed a "Home Health Certification and Plan of Care" for the certification period from 3/1/21 to 4/29/21. Home Health aides ordered for 56 hours weekly. There was no treatment duration listed on the Home Health Certification and Plan of Care.

CR #4 (Start of Care: 8/16/20), revealed a "Home Health Certification and Plan of Care" for the certification period from 8/16/20 to 10/14/20. Home Health aides ordered for 56 hours weekly. There was no treatment duration. listed on the Home Health Certification and Plan of Care.


An interview the Administrator on 6/3/21 at approximately 3:00 PM confirmed the above findings.



























































Plan of Correction:

All plan of care will include frequency and duration of services provided for every patient. Any changes in patient care ordered by physician will be recorded, dated, and implemented in the patient plan of care. The quarterly audit will be completed to ensure compliance. Responsible party is DON/Administrator.


601.31(c) REQUIREMENT
PERIODIC REVIEW OF PLAN OF TREATMENT

Name - Component - 00
601.31(c) Periodic Review of Plan of
Treatment. The total plan of
treatment is reviewed by the attending
physician and agency personnel as
often as the severity of the patient's
condition requires, but at least once
every 60 days. Agency professional
staff promptly alert the physician to
any changes that suggest a need to
alter the plan of treatment

Observations:


Based on a review of clinical records and policy and procedures and interview with the Administrator, it was determined that the agency failed to ensure the total plan of treatment is reviewed by the attending physician and agency personnel as often as the severity of the patient's condition requires, but at least once every 60 days for three (3) of three (7) clinical records (CR) with multiple certifications reviewed (CR# 1, 3 & 4).

Findings include:

Review of agency policy occurred on 6/3/21 at approximately 1 PM.

Policy titled, "Care plan" stated, "The patient care plan shall be updated as often as the patient's condition indicates but at least every sixty (60) days."

Policy titled, "Physician's Plan of Treatment" stated, "A physician prepares a plan of treatment and it is made available to the agency...Reports are made every sixty (60) days for patients receiving skilled or unskilled services..."

Review of clinical records on 6/3/21 at approximatley 1:30 PM revealed:


CR #1. SOC: 3/12/21. revealed no documentation of a written summary report sent to the physician every 60 days.

CR# 3. SOC: 3/1/21. revealed no documentation of a written summary report sent to the physician every 60 days.

CR #4. SOC: 8/16/20. revealed no documentation of a written summary report sent to the physician every 60 days.

Interview conducted on 6/3/21 at approximately 3:00 PM with administrator who confirmed the above findings.
















Plan of Correction:

The company RN will perform, and review plan of cares as often as patient conditions required but at least every 60 days. The plan of care will be sent to the attending physician for review as often as patient conditions required but at least every 60 days. The quarterly audit will be completed to ensure compliance. Responsible party is Administrator.


601.32(b) REQUIREMENT
DUTIES OF THE REGISTERED NURSE

Name - Component - 00
601.32(b) Duties of the Registered
Nurse. The registered nurse:
(i) makes the initial evaluation
visit,
(ii) regularly reevaluates the
patient's nursing needs,
(iii) initiates the plan of treatment
and necessary revisions,
(iv) provides those services
requiring substantial specialized
nursing skill,
(v) initiates appropriate
preventive and rehabilitative nursing
procedures,
(vi) prepares clinical and progress
notes,
(vii) coordinates services, and
(viii) informs the physician and other
personnel of changes in the patient's
condition and needs, counsels the
patient and family in meeting nursing
and related needs, participates in
inservice programs, and supervises and
teaches other nursing personnel.

Observations:


Based on clinical record review, review of agency policy, and an interview with the administrator, the agency failed to ensure a registered nurse to make the initial evaluation assessment for three (3) of four (4) clinical records reviewed (CR #1, 3 & 4).

Findings include:

Review of agency policy, "Care Plan" on 6/3/21 at approximately 2:00 P.M. stated "A Care plan us started upon initial of services by the RN, based upon the plan of treatment and as assessment of the patient's needs, resources, family and environment...The initial assessment is made by a registered nurse.."


Review of Clinical record took place on 6/3/21 at approximately 1PM:

CR #1 (Start of Care: 3/12/21) There was no documentation of an initial RN initial assessment.

CR #3 (Start of Care: 3/1/21) There was no documentation of an initial RN initial assessment.

CR #4 (Start of Care: 8/16/20) There was no documentation of an initial RN initial assessment.

An interview with the administrator on 6/3/21 at approximately 3:00 pm confirmed the above findings.



































Plan of Correction:

The company RN will make and documented initial evaluation assessment for every new client during the admission process. The quarterly audit will be completed to ensure compliance. Responsible party Administrator/DON.


Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted on June 3, 2021, Caring Family Home Care, 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 unannounced state re-licensure survey conducted on June 3, 2021, Caring Family Home Care, LLC., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: