Initial Comments:
Based on the findings of an unannounced onsite State Re-licensure survey completed on February 5, 2025, Arcadia Home Care & Staffing 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 unannounced onsite State Re-licensure survey completed on February 5, 2025, Arcadia Home Care & Staffing was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.
Plan of Correction:
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 Files (CF) and employee (EMP) interview, the agency failed to provide services with reasonable accommodation for three (3) of five (5) CF reviewed (CF 2, 4, & 5).
Findings included:
Review of CFs on February 5, 2025, at approximately 11:30am revealed:
CF2, start of services (SOS) 8/9/24, time period reviewed 12/1/24-12/31/24. Authorization dated 8/16/24-12/31/24 authorized 33 hours of services weekly. Start of service paperwork signed by consumer stated 33 hours weekly staffed as Monday-Friday 10:00am-4:00pm and Saturday 10:00am-1:00pm. Review of service records revealed 0 hours staffed in timeframe reviewed. Ongoing documentation throughout the month revealed no available staff to cover shifts.
CF4, SOS 11/20/24, time period reviewed 12/1/24-12/31/24. Authorization dated 11/19/24-3/13/25 authorized 18 hours of services weekly. Start of service paperwork signed by consumer stated 15 hours weekly staffed as Tuesday, Thursday and Sunday from 1:00pm-6:00pm. Review of service records revealed 6 hours serviced on 12/1/24. hours staffed in timeframe reviewed. Ongoing documentation throughout the month revealed no available staff to cover shifts.
CF5, SOS 9/6/24, time period reviewed 12/1/24-12/31/24. Authorization dated 8/24/24-2/7/25 authorized 10 hours of services weekly. Start of service paperwork signed by consumer stated 4 hours weekly staffed as Wednesday 12:00pm-4:00pm. Review of service records revealed 0 hours staffed in timeframe reviewed. Ongoing documentation throughout the month revealed no available staff to cover shifts.
Exit interview on February 5, 2025, at approximately 3:00pm with State Director of agency confirmed findings.
Plan of Correction:Administrative Staff will be re-educated on the agency's Missed Visit Protocol as well as the agency's Daily Visit Verification process. This policy and process ensures that Administrative Staff are addressing client visit daily to verify care is being provided, and identifies the proper steps to take if care isn't being provided. The Office Coordinator will provide evidence to the State Director every week that the Daily Visit Verification process is being followed. The Office Coordinator will also be responsible for completing an incident report for Pattern of Missed Visits for any client that doesn't consistently receive their authorized care. The Incident Report will be sent to the client's Case Manager, and the agency will communicate with the client as to whether another agency may be a better fit for their care. These discussions and steps will be documented in the client's Coordination Notes in our agency's scheduling system.
The State Director will review all client records before 3.1.2025 to ensure all authorized hours are scheduled and/or provided to the client. The State Director and/or Agency Director will audit the client schedule once per month thereafter to ensure consistent and authorized care is provided. If it is discovered the client is consistently not receiving their authorized care, a customer service call will be made to the client, and the case will be reviewed for termination with at least a 10-day notice provided to the client and Case Manager.
The agency's Quality Assurance Manager will be conducting an internal audit of the branch files to ensure all policies, procedures, and regulations are being followed. The branch will receive detailed feedback with an outline on how to correct any issues discovered during the internal audit.
Initial Comments:
Based on the findings of an unannounced onsite State Re-licensure survey completed on February 5, 2025, Arcadia Home Care & Staffing was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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