QA Investigation Results

Pennsylvania Department of Health
CAMBRIDGE HOME HEALTH CARE, INC./PRIVATE
Health Inspection Results
CAMBRIDGE HOME HEALTH CARE, INC./PRIVATE
Health Inspection Results For:


There are  8 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 onsite unannounced state license survey completed October 18, 2022, Cambridge Home Health Care, Inc./private was found not to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.



Plan of Correction:




51.3 (f) LICENSURE
NOTIFICATION

Name - Component - 00
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.

Observations:

Based on review of agency incident reports, the Department's event reporting system (ERS) and its manual, and staff (EMP) interview, the agency failed to report incidents that could seriously compromise quality assurance or patient safety. The agency failed to report an instance misappropriation of consumer property.

Findings included:

Per the Department's ERS Manual, "PA Department of Health (PA-DOH) Event Notification Internet Site Overview - Facilities ... Purpose: To provide a system to enter events per 28 PA Code - 51.3 that is readily available to all appropriate PA-DOH facilities, a simple process to insure consistent data entry and submission, and a source for quick and meaningful feedback on event notification submissions. All facilities are required to submit notification of events as defined in 28 Pa Code Chapter 51 to the Department of Health within 24 hours of occurrence or discovery. The Electronic Event Reporting System is the mechanism the Department will use to meet this regulatory requirement. ... The following is a list of all Categories that should be submitted: ... Misappropriation of Patient/Resident Property."

Review of "Incident Report Summary" on October 17, 2022, at 12 p.m. showed, "Event Date 4-29-2022 ... Entered Date 5-3-2022 ... Client stated that his wallet is missing containing $828.83 dollars. Through [sic] search of clients home and apartment building did not produce the wallet. Client feels it was stolen. Police and adult protective services notified."

Interview with EMP1 on October 17, 2022, at 1 p.m. confirmed findings and he/she wasn't sure if the event was submitted to ERS.

Review of ERS on October 18, 2022, at 2 p.m. did not show any events submitted by agency. The review period was 4/28/2022 to 5/3/2022.





Plan of Correction:

In order to prevent reoccurrence of the deficient practice, the Executive Director will be responsible for ensuring the monitoring and oversight of all incident/occurrence follow-up in accordance with 28 PA Code 51.

The Executive Director or trained designee is responsible for all communication and follow-up with the Department regarding any identified incidents or occurrences within 24 hours that could seriously compromise quality assurance or patient safety. The Executive Director will complete all required steps in the incident management process in accordance with PA regulations. All follow-up requests will be directed to the Executive Director and State Director for immediate attention, timely follow-up, and response.
Documentation will be maintained in the Incident Log Binder by the Executive Director.

The Executive Director will review the Incident Report Binder weekly to ensure documentation reflects adherence to PA requirements and effectiveness of staff education.

The Executive Director or designee will audit the Incident Log Binder monthly to ensure 100% of all reportable occurrences have been completed, reported, and responded to timely with appropriate follow-up as needed according to the individual needs of each incident. Any areas of non-compliance will be resolved immediately and reported to the State Director.

Audits will continue for 3 months and until 100% compliance has been met for 2 consecutive months.

Findings will be reported to the agency's Performance Improvement Team and substantiation of successful completion of the plan of correction will be included in the agency's quarterly performance improvement summary.






51.13 (b) LICENSURE
CIVIL RIGHTS COMPLIANCE RECORDS

Name - Component - 00
51.13. Civil rights compliance records

(b) Copies of the health care facility's nondiscriminatory policy shall be posted in locations accessible to the facility's staff and the general public.

Observations:
Based on observation, review of agency's file, and staff (EMP) interview, the agency failed to post its nondiscriminatory policy in an area accessible to staff and the general public.

Findings include:

Review of agency's file maintained by the Department on October 17, 2022, at 10:30 a.m. concerning civil rights requirements showed how agency was to post its non-discriminatory policy, "the non-discrimination policy is posted in the break room of the Agency."

Observation of agency office space on October 17, 2022, at 10:35 a.m. revealed the agency's nondiscriminatory policy was not posted.

Interview with EMP1 on October 12, 2022, at 1 p.m. confirmed findings.



Plan of Correction:

The Executive Director will be educated on 28 PA Code 51.13 and policy 1.010 HCBS Patient Non-Discrimination. With a focus on posting the policy accessible to staff and the general public. Education to be completed by 11/15/22.

The Executive Director has placed a copy of policy 1.010 HCBS Patient Non-Discrimination on a bulletin board in the break room visible to all staff and general public.

In order to prevent reoccurrence of the deficient practice.

The Executive Director will be responsible for the monitoring and maintenance of the posted policy 1.010 HCBS Patient Non-Discrimination on a regular basis.

At any time, the policy is missing or no longer in good condition the Executive Director will immediately replace the posting.





Initial Comments:

Based on the findings of an onsite unannounced state license survey completed October 18, 2022, Cambridge Home Health Care, Inc./private 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:




611.51(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 review of direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to obtain references and criminal history report prior to hire for six (6) of six (6) direct care worker personnel files reviewed (PF1-PF6).

Findings included:

Review of personnel files was conducted on October 17, 2022, at 8:30 a.m.

PF1 was hired on 9/12/2022. PF1 contained no references obtained prior to hire.

PF2 was hired on 7/27/2022. PF2 did not have an interview or references obtained prior to hire.

PF3 was hired on 9/15/2022. PF3 contained no references obtained prior to hire.

PF4 was hired on 12/21/21. PF4 contained two references dated 12/23/2021 (not prior to hire).

PF5 was hired on 4/8/2021. PF5 did not have a criminal history report or references obtained prior to hire (two dated 4/13/2021 and not prior to hire).

PF6 was hired on 4/13/2021. PF6 contained no references obtained and a criminal history report from 4/14/2021 (not prior to hire).

Interview with EMP1 on October 17, 2022, at 11 a.m. confirmed above findings.




Plan of Correction:

In order to prevent reoccurrence of the deficient practice, the Executive Director is responsible for ensuring all pre-hiring requirements have been verified and documented prior to any employee being scheduled for onboarding/orientation.

The Case Coordinator will review the employee's application, complete an interview, process reference checks and criminal history verification for completion before confirming employment and prior to scheduling the employee for orientation.
The Case Coordinator will report any issue with obtaining all required information for any applicant eligible for hire to the Executive Director for guidance on resolution.

The Executive Director or designee will review all applicant records eligible for hire to ensure evidence of all pre-hiring requirements and provide approval for scheduling of orientation. Any employee found to have not successfully met all the requirements will not be scheduled for orientation until requirements have been met.

The Executive Director or designee will audit the records of all new hires monthly to ensure evidence of all pre-hiring requirements. Audits will continue for 3 months and until 95% compliance is met for 2 consecutive months.

Findings will be reported to the agency's Performance Improvement Team and substantiation of successful completion of the plan of correction will be included in the agency's quarterly performance improvement summary.





611.51(b) LICENSURE
Direct Care Worker Files

Name - Component - 00
Files for direct care workers employed or rostered shall include documentation of the date of the face-to-face interview with the individual and of references obtained. Direct Care Worker files also shall include other information as required by 611.52, 611.53, if applicable, 611.54, 611.55 and 611.56 (relating to criminal background checks, child abuse clearance, provisional hiring, competency requirements; and health evaluations).

Observations:


Based on review of direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to ensure direct care worker (DCW) files included documentation as required by 611.55 (relating to competency requirements) for six (6) of six (6) direct care worker files (PF1-PF6).

Findings included:

Review of personnel files was conducted on October 17, 2022, at 8:30 a.m.

PF1 was hired on 9/12/2022 and began providing services to consumers the same day.

PF2 was hired on 7/27/2022 and began providing services to consumers on 8/9/2022.

PF3 was hired on 9/15/2022 and began providing services to consumers on 10/11/2022.

PF4 was hired on 12/21/21 and began providing services to consumers on 12/21/21.

PF5 was hired on 4/8/2021 and began providing services to consumers on 4/10/2021.

PF6 was hired on 4/13/2021 and began providing services to consumers on 4/21/2021.

Interview with EMP1 on October 17, 2022, at 11 a.m. confirmed above findings and he/she was unable to locate training documents in the personnel files at the time of onsite survey. Surveyor requested EMP1 email evidence of completed training by 4 p.m. on October 17, 2022.





Plan of Correction:

In order to prevent reoccurrence of the deficient practice, all direct care workers will complete a competency assessment on hire which consists of mandatory orientation training topics. Written and return demonstration, by the aide to an RN. The aide and the RN will accurately complete, sign and date both documents of evidence.

The Case Coordinator or designee will track and monitor for completion prior to the aide providing direct care to an individual. The Case Coordinator or designee will notify the Executive Director of any employee who is non-compliant and follow up for guidance on resolution.

Any DCW found to not have evidence of successfully completing the required competency assessment will be removed from the schedule until successful completion.

The Executive Director or designee will audit all new hire records each month to ensure that the competency evaluations have been reviewed and successfully completed prior to case assignment. Audits will continue for 3 months and until 95% compliance is met for 2 consecutive months.

Findings will be reported to the agency's Performance Improvement Team and substantiation of successful completion of the plan of correction will be included in the agency's quarterly performance improvement summary.




611.55(a) LICENSURE
Compentency 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 review of direct care worker personnel files (PF), email, and staff (EMP) interview, the agency failed to ensure the direct care worker (DCW) had successfully completed a training program that met the requirements of subsection (b) and (c) prior to being assigned to a consumer for six (6) of six (6) personnel files reviewed (PF1-PF6).

Findings included:

Review of personnel files was conducted on October 17, 2022, at 8:30 a.m.

PF1 was hired on 9/12/2022 and began providing services to consumers the same day.

PF2 was hired on 7/27/2022 and began providing services to consumers on 8/9/2022.

PF3 was hired on 9/15/2022 and began providing services to consumers on 10/11/2022.

PF4 was hired on 12/21/21 and began providing services to consumers on 12/21/21.

PF5 was hired on 4/8/2021 and began providing services to consumers on 4/10/2021.

PF6 was hired on 4/13/2021 and began providing services to consumers on 4/21/2021.

Interview with EMP1 on October 17, 2022, at 11 a.m. confirmed above findings and he/she was unable to locate training documents in the personnel files at the time of onsite survey. Surveyor requested EMP1 email evidence of completed training by 4 p.m. on October 17, 2022.

Review of email from EMP1 on October 18, 2022, at 10:00 a.m. showed an example of direct care worker test, "iTRAIN Aide Competency Test (Answer Key) COMPETENCY TEST," and "NON-SKILLED CLIENT PERSONAL CARE ASSESSMENT." The latter is a skill check list to be completed by the RN who would observe if DCW was competent in providing personal care services such as assisting with ambulation, oral hygiene, shaving and grooming. At the time of onsite survey, PF1-PF6 did not contain a completed "NON-SKILLED CLIENT PERSONAL CARE ASSESSMENT" completed prior to providing services to consumers.

A further review of emails from EMP1 on October 18, 2022, at 10:42 a.m. showed "Orientation Checklist: Assignments & Completion by Person" for PF1-PF6

PF1 has not yet completed the "Aide Competency Test"-- working with consumers on 9/12/2022.

PF2 did not complete the "Aide Competency Test" until 8/21/2022-- working with consumers on 8/9/2022.

PF3 has not yet completed the "Aide Competency Test"-- working with consumers on 9/15/2022

PF4 has not yet completed the "Aide Competency Test"-- working with consumers on 12/21/21.

PF5 has not yet completed the "Aide Competency Test"-- working with consumers on 4/8/2021.

PF6 did not complete the "Aide Competency Test" until 11/9/2021-- working with consumers on 4/21/2021.














Plan of Correction:

In order to prevent reoccurrence of this deficient practice, the Case Coordinator will verify successful completion of the agency's training program (as required per 611.55 (a)) prior to assigning a DCW to provide care.

The Executive Director or designee will review each DCW (new hire) record (hired within the month) monthly to verify compliance. Any DCW found to not have evidence of successfully completing the required training program will be removed from the schedule until training is successfully completed.

The Executive Director will notify the State Director of any occurrence of non-compliance upon discovery.

The Executive Director or designee will review 100% of each new hire DCW personnel records each month to ensure successful completion of a training program that meets the requirement 611.55 (b) and (c), prior to being assigned to provide care. Reviews will continue for 3 months and until 95% compliance has been met for 2 consecutive months.

Findings will be reported to the agency's Performance Improvement Team and substantiation of successful completion of the plan of correction will be included in the agency's quarterly performance improvement summary.



611.55(b) LICENSURE
Competency Requirements

Name - Component - 00
A competency examination or training program developed by an agency or registry for a direct care worker shall address, at a minimum, the following subject areas: 1. Confidentiality; 2. Consumer control and the independent living philosophy; 3. Instrumental activities of daily living; 4. Recoginizing changes in the consumer that need to be addressed; 5. Basic infection control; 6. Universal precautions; 7. Handling of emergencies; 8. Documentation; 9. Recognizing and reporting abuse or neglect; and 10. Dealing with difficult behaviors.

Observations:


Based on review of direct care worker personnel files (PF), email, and staff (EMP) interview, the agency failed to develop a competency program, and ensure it was administered to six (6) of six (6) six direct care workers prior to providing services to consumers (PF1-PF6).

Findings included:

Review of personnel files was conducted on October 17, 2022, at 8:30 a.m.

PF1 was hired on 9/12/2022 and providing services to consumers the same day with no competency completed.

PF2 was hired on 7/27/2022 and providing services to consumers on 8/9/2022 with no competency completed.

PF3 was hired on 9/15/2022 and providing services to consumers on 10/11/2022 with no competency completed.

PF4 was hired on 12/21/21 and providing services to consumers on 12/21/21 with no competency completed.

PF5 was hired on 4/8/2021 and providing services to consumers on 4/10/2021 with no competency completed.

PF6 was hired on 4/13/2021 and providing services to consumers on 4/21/2021 with no competency completed.

Interview with EMP1 on October 17, 2022, at 11 a.m. confirmed above findings and he/she was unable to locate training documents in the personnel files at the time of onsite survey. Surveyor requested EMP1 email evidence of completed training by 4 p.m. on October 17, 2022.

Review of email from EMP1 on October 18, 2022, at 10:00 a.m. showed an example of direct care worker test, "iTRAIN Aide Competency Test (Answer Key) COMPETENCY TEST." The test did not cover the required topics of confidentiality, consumer control and the independent living philosophy, documentation, and dealing with difficult behaviors.





Plan of Correction:

In order to prevent reoccurrence of this deficient practice, the Executive Director or Case Coordinator will review each direct care employee's personnel file for evidence of training that included all required subject areas prior to being assigned to provide care.

The Executive Director or designee will review each DCW (new hire) record (hired within the month) monthly to verify compliance. Any DCW found to not have evidence of successfully completing the required training program (including all required training topics) will be removed from the schedule until training is successfully completed.

The Executive Director will notify the State Director of any occurrence of non-compliance upon discovery.

The agency Executive Director or designee will audit 100% of DCW new hire personnel records monthly to ensure evidence of training to include all required subject areas is available in each direct care employee's personnel file. Audits will continue for 2 months and until 95% compliance has been met for 2 consecutive months.

Findings will be reported to the agency's Performance Improvement Team and substantiation of successful completion of the plan of correction will be included in the agency's quarterly performance improvement summary.



611.56(a) LICENSURE
Health Screening

Name - Component - 00
The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.

Observations:


Based on a review of CDC (Center for Disease Control and Prevention) guidelines, direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to ensure each direct care worker was screened for mycobacterium tuberculosis (TB) in accordance with CDC guidelines for four (4) of six (6) personnel files (PF1-PF2, PF4, & PF6).

Finding included:

According to CDC guidelines "Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment." Retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6819-H.pdf

Findings included:

Review of personnel files was conducted on October 17, 2022, at 8:30 a.m.

PF1 was hired on 9/12/2022 and providing services to consumers the same day. PF1 contained no symptom screen and no individual risk assessment.

PF2 was hired on 7/27/2022 and providing services to consumers on 8/9/2022. PF2 contained an undated risk assessment and no symptom screen

PF4 was hired on 12/21/21 and providing services to consumers on 12/21/21. PF4 contained no symptom screen and no individual risk assessment.

PF6 was hired on 4/13/2021 and providing services to consumers on 4/21/2021. PF6 contained no symptom screen and no individual risk assessment.

Interview with EMP1 on October 12, 2022, at 1 p.m. confirmed above findings.




Plan of Correction:

In order to prevent reoccurrence of this deficient practice, the Executive Director or Case Coordinator will review each direct care employee's personnel record for evidence of TB screening in accordance with the CDC guidelines prior to scheduling and rostering a direct care worker to provide care.

The Executive Director or designee will review each DCW (new hire) record (hired within the month) monthly to verify compliance. Any DCW found to not have TB screening per CDC guidelines will be removed from the schedule until training is successfully completed.


The Executive Director or designee will audit 100% of new hire personnel records monthly to ensure evidence of TB screening in accordance with CDC guidelines. Audits will continue for 3 months and until 95% compliance has been met for 2 consecutive months.

Findings will be reported to the agency's Performance Improvement Team and substantiation of successful completion of the plan of correction will be included in the agency's quarterly performance improvement summary.





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 (CR), information packet given to consumers, and staff (EMP) interview, the agency failed to provide the consumer with required information in a format that was easily read and understood prior to commencement of services for six (6) of six (6) consumer files reviewed (CR1-CR6).

Findings included:

Review of consumer files was conducted on October 17, 2022, at 11 a.m.

CR1 signed their service agreement on 8/28/2020 and services commenced 8/30/2020. CR1's service agreement did not show a listing of the available home care services that would be provided to the consumer by the direct care worker and the identity of the direct care worker who would provide the services.

CR2 signed their service agreement on 7/8/2022 and services commenced on 7/24/2022. CR2's service agreement did not show a listing of the available home care services that would be provided to the consumer by the direct care worker and the identity of the direct care worker who would provide the services nor whether agency maintained general and professional liability insurance covering the direct care worker.

CR3 signed their service agreement on 9/11/2021 and services commenced on 9/24/2021. CR3's service agreement did not show a listing of the available home care services that would be provided to the consumer by the direct care worker and the identity of the direct care worker who would provide the services nor whether agency maintained general and professional liability insurance covering the direct care worker.

CR4 signed their service agreement on 7/21/2021 and services commenced on 8/3/2021. CR4's service agreement did not show a listing of the available home care services that would be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services nor whether the agency maintained general and professional liability insurance covering the direct care worker.

CR5 signed their service agreement on 3/17/2021 and services commenced on 4/5/2021. CR5's service agreement did not show a listing of the available home care services that would be provided to the consumer by the direct care worker and the identity of the direct care worker who would provide the services nor whether agency maintained general and professional liability insurance covering the direct care worker.

CR6 signed their service agreement on 12/31/2021 and services commenced on 1/12/2022. CR6's service agreement did not show a listing of the available home care services that would be provided to the consumer by the direct care worker and the identity of the direct care worker who would provide the services nor whether agency maintained general and professional liability insurance covering the direct care worker.

Interview with EMP1 on October 17, 2022, at 1 p.m. confirmed above findings.




Plan of Correction:

In order to prevent reoccurrence of this deficient practice, the Executive Director or designee will review all new client records monthly to ensure evidence of a client information booklet (that meets the requirements of 611.57 (c)) has been provided before the commencement of services.

Any client record found to not include evidence that all required information has been provided to the client will be corrected within 7 days of discovery.

The Executive Director
or designee will review all new client admission records each month to ensure the evidence that a client information booklet has been provided to each client before the commencement of services. Reviews will continue for 3 months and until 95% compliance has been met for 2 consecutive months.

Findings will be reported to the agency's Performance Improvement Team and substantiation of successful completion of the plan of correction will be included in the agency's quarterly performance improvement summary.



Initial Comments:

Based on the findings of an onsite unannounced state license survey completed October 18, 2022, Cambridge Home Health Care, Inc./private was found to be in compliance with the requirement of 35 P.S. 448.809 (b).




Plan of Correction: