QA Investigation Results

Pennsylvania Department of Health
ALLEGHENIES UNLIMITED CARE PROVIDERS
Health Inspection Results
ALLEGHENIES UNLIMITED CARE PROVIDERS
Health Inspection Results For:


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Initial Comments:



Based on the findings of an onsite unannounced state relicense survey completed 5/3/2024, Alleghenies Unlimited Care Providers Inc. 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 complaint tracker documents, review of the Event Reporting System (ERS) and staff (EMP) interviews the agency failed to notify the Department of Health in writing of an event that occurred in the consumer's home for one (1) of twenty-three (23) events submitted for 2023.

Findings include:

Review of the agency policy and employee handbook on 5/3/2024 at approximately 1:00 PM revealed, "PA Department of Health (PA-DOH) Event Notification Internet Site Overview - Facilities Effective March 9, 2021 ... The following is a list of all Categories that should be submitted ...Misappropriation of Patient/resident Property..."

Review of agency complaint tracker conducted on 5/2/2024 between approximately 11:10 AM revealed the following: Date of event 12/18/2023, consumer (name), subject: "Complaint of theft. Consumer missing $380 dollars from an envelope in her dresser drawer..."

During an interview with EMP5 on 5/2/2024 at approximately 2:30 PM the surveyor made EMP5 aware of the incident and notified EMP5 no ERS reports have been submitted from the agency since 2022. The surveyor confirmed EMP5 was aware of the ERS reporting requirements.

An interview with the director of service provision was conducted on 5/2/2024 at approximately 2:30 PM which confirmed the above findings.








Plan of Correction:

The event involving theft that went unreported on 12/19/2023 was submitted to DOH on 5/7/2024.
As of 5/20/2024, Service Provision revised the Critical Incident & Risk Management Policy to include DOH event reporting. The revised policy is now labeled "Critical Incident, Risk Management, and Event Reporting". There is a section specific to DOH Event Reporting that states a reportable event will be submitted to DOH in writing within 24 hours of the report being made. If the event occurs over the weekend, a report must be entered the Monday immediately after the incident occurred.
On 5/22/2024, this policy was reviewed and signed off on by all relevant office staff as proof that they were trained on the revised policy, and they understand the steps that must be taken. Moving forward, new office staff will be required to review and sign off on Service Provision's policy handbook which includes this revised policy.
This will be audited annually as the Policy Binder is updated.



Initial Comments:


Based on the findings of an onsite unannounced state relicensure survey completed 5/3/2024, Alleghenies Unlimited Care Providers Inc. 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(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 policy, personnel files (PF) and staff (EMP) interview, it was determined the agency failed to include documentation of the date references were obtained for one (1) of seven (7) reviewed (PF3).

Findings included:

Review of the agency policy and employee handbook on 5/3/2024 at approximately 1:00 PM revealed, "Employment References The Agency is also required to conduct employment reference checks on all applicants. The Agency reference checks follow state and federal regulations..."

PF#1 review was conducted on 5/2/2024 at approximately 12:35 PM, and the date of hire was (DOH) 9/26/2022. Two references were documented, but the reference dates could not be confirmed.

An interview with the director of service provision was conducted on 5/2/2024 at approximately 2:30 PM which confirmed the above findings.










Plan of Correction:

As of 5/20/2024, HR has updated the frequency of internal file audits to quarterly. This is to ensure all Direct Care Worker files are updated with the most recent employee information and are compliant with regulations. The HR Generalist and HR Assistant are responsible for auditing employee files.
A new standard operating procedure in regard to reference checks for new applicants has been created, and applicable administrative staff will be trained on this process bi-annually, and on an as-needed basis. The new procedure specifies the requirements for reference checks including what type (professional or personal), when and who it was collected by. Applicable administrative staff shall include HR staff, Marketing staff, Recruiting, and front desk personnel.



611.52(c) LICENSURE
Federal Criminal History Record

Name - Component - 00
If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code 15.144(b) (relating to procedure).

Observations:


Based on a review of the policy, personnel files (PF) and staff (EMP) interview, it was determined the agency failed to obtain a letter of determination from the Department of Aging for one (1) of one (1) PF's who were not confirmed a resident of Pennsylvania for the 2 years immediately preceding date of hire (PF). PF2.

Findings included:

Review of the agency policy and employee handbook on 5/3/2024 at approximately 1:00 PM revealed, " ...Background Checks Several background checks are required per state and federal regulations, including Older Adults Protective Service Act (OAPSA) Federal Bureau of Investigation background check. A Pennsylvania State Police criminal history background check must be obtained through the Pennsylvania State Police and Child Abuse Clearance obtained through the Childline and Abuse Registry at the Department of Child Welfare are required for all applicants and employees..."
Review of the agency policy and employee handbook on 5/3/2024 at approximately 1:00 PM revealed, "PROVISIONAL HIRE/RECORD KEEPING REQUIREMENTS ...RECORDKEEPING 1. (Agency) shall maintain files for all employees (direct care and administrative staff) that include copies of state police criminal history records or Department of Aging letters of determination regarding federal criminal history records. The files shall be available for any Department of Aging inspection or other auditing entity..."
A review of PF2 on 5/2/2024 at approximately 12:00 PM, date of hire (DOH) 9/26/2022 revealed: There was a Pennsylvania identification card with an issue date of 9/28/2022. Also, a Commonwealth of Pennsylvania Department of Health Certification of Birth with an issue date of 9/17/2004. A federal criminal history check was completed as of 10/20/2022 from the Pennsylvania Department of Human Services. No letter of determination from the Pennsylvania Department of Aging was available for review.

An interview with the director of service provision was conducted on 5/2/2024 at approximately 2:30 PM which confirmed the above findings.










Plan of Correction:

The agency completes several background checks on all employees of Alleghenies Unlimited Care Providers including a Pennsylvania State Police Criminal Record Check, FBI Fingerprint Clearance, Pennsylvania Child Abuse Clearance, Pennsylvania Department of Motor Vehicles Driver history, Social Security Verification, reference check and Medical Assistance Fraud check.
During the application and onboarding process, the applicant/employee completes background check authorization forms in accordance with all state and federal regulations, including the Older Adults Protective Services Act (OAPSA) and Act 73 relating to the Child Protective Services Law. As of 5/20/2024, current HR staff (HR Generalist and Assistant) shall be retrained bi-annually on state and federal regulations pertaining to background checks. All incoming HR staff shall be trained on these procedures during their first week.



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 a review of the agency policy, personnel files (PFs) and staff (EMP) interview it was determined the agency failed to show proof of residency in this Commonwealth for the 2 years preceding the date of hire (DOH) for one (1) of seven (7) PFs reviewed (PF2).

Findings included:

Review of the agency policy and employee handbook on 5/3/2024 at approximately 1:00 PM revealed, " ...Background Checks Several background checks are required per state and federal regulations, including Older Adults Protective Service Act (OAPSA) Federal Bureau of Investigation background check. A Pennsylvania State Police criminal history background check must be obtained through the Pennsylvania State Police and Child Abuse Clearance obtained through the Childline and Abuse Registry at the Department of Child Welfare are required for all applicants and employees. The Agency will request that an applicant furnish proof of residency through submission of any of the following documents: motor vehicle records, such as a valid driver ' s license or a State-issued identification, housing record, such as mortgage records or rent receipts, public utility records and receipts, such as electric bills, local tax records, a completed, signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it, employment records, including records of unemployment compensation ... "
A review of PF2 on 5/2/2024 at approximately 12:00 PM, date of hire (DOH) 9/26/2022 revealed: There was a Pennsylvania identification card with an issue date of 9/28/2022. Also a Commonwealth of Pennsylvania Department of Health Certification of Birth with an issue date of 9/17/2004. There was no additional documentation in PF to confirm the agency verified proof of residency in this Commonwealth for two (2) years immediately preceding the date of hire.

An interview with the director of service provision was conducted on 5/2/2024 at approximately 2:30 PM which confirmed the above findings.











Plan of Correction:

Applicants who have not worked or lived in the state of Pennsylvania for two (2) years must obtain an additional FBI background check as required for the Pennsylvania department of Aging under the Older Adults Protective Services Act (OAPSA).
As of 5/20/2024, the employee handbook has been updated to state this requirement under the "Background Check and Employment Reference Requirements". This section also states all employees shall submit an FBI background check and the original results within 30 days of initial hire and every subsequent five (5) year period thereafter.



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 a review of the agency policy, consumer records (CR) and staff (EMP) interview, the agency failed to involve the consumer in the service planning process and to receive services with reasonable accommodation of individual needs and preferences for five (5) of five (5) CR's reviewed (CR1 to CR5).

Findings included:

Review of the agency onboarding manual on 5/2/2024 at approximately 10:50 AM revealed, "Consumers' Rights and Responsibilities Consumer Rights A consumer receiving home care services provided by a Home Care Agency or through a Home Care Registry has rights including but not limited to the following: 1. To be involved in the services planning process and to receive with reasonable accommodations of individual needs and preferences, except where the health and safety of the direct care worker is at risk ...6. Consumers have the right to schedule services that meet their lifestyle as per Service Authorization Form..."

A review of CR1 on 5/2/2023 at approximately 1:15 PM revealed start of services 5/25/2023. Per the "Consumer Services Manual Hours of Service/Schedule" Hours were listed under the document section "Master Schedule-Week 1...Master Schedule-Week 2..." The hours listed under both weeks were two (2) hours Monday, Wednesday, Friday or Saturday. The surveyor could not confirm from the agency documentation that scheduled times were reviewed with the consumers or consumers representative for approval.

A review of CR2 on 5/2/2023 at approximately 1:30 PM revealed start of services 9/25/2023. Per the "Consumer Services Manual Hours of Service/Schedule" No hours were listed under the document section "Master Schedule-Week 1...Master Schedule-Week 2..." The surveyor could not confirm from the agency documentation that scheduled times were reviewed with the consumers or consumers representative for approval.

A review of CR3 on 5/2/2023 at approximately 1:40 PM revealed start of services 8/28/2023. Per the "Consumer Services Manual Hours of Service/Schedule" Hours were listed under the document section "Master Schedule-Week 1...Master Schedule-Week 2..." The hours listed under both weeks were 11:00 AM to 2:00 PM. The consumer's April 2024 scheduled was reviewed and the times and days did not match. The surveyor could not confirm from the agency documentation that scheduled times were reviewed with the consumers or consumers representative for approval.

A review of CR4 on 5/2/2023 at approximately 1:48 PM revealed start of services 10/21/2023. Per the "Consumer Services Manual Hours of Service/Schedule" Hours were listed under the document section "Master Schedule-Week 1." The hours listed were 10:00 AM to 5:00 PM Monday through Thursday, 10:00 AM to 6:00 PM on Fridays and 5:00 PM to 7:00 PM on Saturday and Sunday. The consumer's April 2024 scheduled was reviewed and the scheduled times did not match for Fridays, Saturday and Sunday. The surveyor could not confirm from the agency documentation that scheduled times were reviewed with the consumers or consumers representative for approval.

A review of CR5 on 5/2/2023 at approximately 1:45 PM revealed start of services 3/27/2024. Per the "Consumer Services Manual Hours of Service/Schedule" No hours were listed under the document section "Master Schedule-Week 1..Master Schedule-Week 2..." The surveyor could not confirm from the agency documentation that scheduled times or days were reviewed with the consumers or consumers representative for approval.

An interview with the director of service provision was conducted on 5/2/2024 at approximately 2:30 PM which confirmed the above findings.











Plan of Correction:

As of 5/20/2024, the Service Provision department adopted a "New Consumer Onboarding, Meet & Greet and Schedule Establishment" policy and procedure guideline to be followed by relevant Service Provision staff.
This policy outlines how a schedule will be established, reviewed and signed off on by the consumer prior to onset of services to ensure that they have been involved in the service planning process.
On 5/22/2024, this policy was reviewed and signed off on by relevant Service Provision staff as proof that they were trained on the policy and understand the new onboarding protocol. Moving forward, new office staff will be required to review and sign off on Service Provision's policy handbook which includes this new policy/procedure.
This will be audited annually as the policy binder is updated.



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 a review of consumer admission packet, consumer records (CR) and staff (EMP) interview, the agency failed to provide required information in writing to consumers/consumer representatives prior to the commencement of services for five (5) of five (5) CR's reviewed (CR 1 to CR5).

Findings included:

A review of CR1 on 5/2/2024 at approximately 1:15 PM, start of services 5/25/2023 revealed, No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The identity of the direct care worker who would provide services.
2. The hours when services would be provided.

A review of CR2 on 5/2/2024 at approximately 1:30 PM, start of services 9/25/2023 revealed, No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The identity of the direct care worker who would provide services.
2. The hours when services would be provided.

A review of CR3 on 5/2/2024 at approximately 1:40 PM, start of services 8/28/2023 revealed, No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The identity of the direct care worker who would provide services.

A review of CR4 on 5/2/2024 at approximately 1:45 PM, start of services 10/21/2023 revealed, No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The identity of the direct care worker who would provide services.

A review of CR5 on 5/2/2024 at approximately 1:45 PM, start of services 3/27/2024 revealed, No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The identity of the direct care worker who would provide services.
2. The hours when services would be provided.

An interview with the director of service provision was conducted on 5/2/2024 at approximately 2:30 PM which confirmed the above findings.









Plan of Correction:

As of 5/20/2024, the Service Provision department adopted a "New Consumer Onboarding, Meet & Greet and Schedule Establishment" policy and procedure guideline to be followed by relevant Service Provision staff.
This policy outlines how a Consumer Onboarding and staff meet and greet must take place and a schedule of services will be established, reviewed and signed off on by the consumer prior to onset of services to ensure that they have been involved in the service planning process.
On 5/22/2024, this policy was reviewed and signed off on by relevant Service Provision staff as proof that they were trained on the policy and understand the new onboarding protocol. Moving forward, new office staff will be required to review and sign off on Service Provision's policy handbook which includes this new policy/procedure.
This will be audited annually as the policy binder is updated.



Initial Comments:


Based on the findings of an onsite unannounced state relicense survey completed 5/3/2024, Alleghenies Unlimited Care Providers Inc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: