QA Investigation Results

Pennsylvania Department of Health
CAREBUILDERS AT HOME, INC.
Health Inspection Results
CAREBUILDERS AT HOME, INC.
Health Inspection Results For:


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Initial Comments:


Based on the findings of an offsite complaint investigation completed on March 29, 2021, Carebuilders at Home, Inc. was found not to be in compliance with the requirements of 28 PA Code, 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 reviews of consumer record (CR), agency submissions to the Deprtment of Health (DOH) Event Reporting System (ERS), and staff (EMP) interview, it was determined the agency failed to notify the Department in writing of a known situation which could seriously compromise quality assurance or patient safety, the reason for its occurrence, and the steps taken to rectify the situation for one (1) consumer record reviewed (CR1).

Findings included:

Review of agency communication note documentation on 3/29/2021 revealed the following:
03/09/2021 2:26 pm by [Agency manager, EMP1)
"...APS (Adult Protective Services), went to see [CR1] this week- allegations of emotional abuse, caregiver neglect, leaving (him/her) in bed without care...went over the schedule, explained struggles with location, bus line, people not wanting to return...Will...call back if...has any other questions...."

Pre-survey preparation conducted 3/22/2021 included review of DOH Event Reporting system submissions by agency. There were no events entered into the system by the agency after 1/27/2021 (last event entered) detailing the agency situation/occurrence related to allegations of emotional abuse and caregiver neglect as documented by agency EMP1 on 3/9/2021.

Exit conference was conducted via telephone on 3/29/2021 at approximately 1:40 PM with agency manager (EMP1). Above findings were reviewed.






Plan of Correction:

The Manager of Operations took the call from Adult Protective Services (APS). In the process of following up on the APS report, the Agency failed to report the incident to the Department of Health (DOH). This failure was simply an oversight; we are aware that it is a requirement and a reportable event.
The staff will be required to complete a Mandatory Abuse Reporting Training Course through the Pennsylvania Department of Aging Learning Management System by May 7, 2021.
The event was reported on ERS on 4/5/2021.
To assure the solutions are sustained in the future, Reportable Events will be an included topic of review in our weekly staff meetings in direct questions. Examples would be: Did anyone report abuse or neglect of any kind? Did anyone report theft of any kind? Has there been a service interruption for any reason? Reportable Events will further be reviewed monthly by the Manager of Operations with the Agency Director of Clinical/QI.


Initial Comments:


Based on the findings of an offsite complaint investigation completed on March 29, 2021, Carebuilders at Home, Inc. 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 record (CR), agency documentation, consumer service agreement, and staff interview, the agency failed to ensure consumer received services with reasonable accommodation of individual needs and preferences for one (1) consumer record reviewed (CR1).

Findings Included:

Review of CR1 on 3/25/2021 revealed agency service agreement executed between agency and CR1 on 11/15/2018. Hours, 23 hours weekly Monday-Friday, flexible, 10 AM to 2 PM or 3 PM (agency documented as current hours of service effective 3/23/2020). Service agreement contained the following: "...SERVICE AGREEMENT ... CONSUMER RIGHTS ...Our consumers have the right of access to accurate and easy-to-understand information, to be informed about plan of service, to actively participate in the planning process, and to receive services with reasonable accommodation of individual needs and preferences....FUNCTIONAL LIMITATIONS ...Bedbound unless gets into chair ... " Review of 2/1/2021 through 3/19/2021 DCW (direct care worker) schedule and as documented on HHA exchange calendar (Managed Care Organization electronic DCW time record) revealed the following:
2/1/2021, 2:00 PM - 3:00 PM, 1 hour
2/2/2021, 7:30 AM - 8:30 AM, 1 hour
2/3/2021, 11:00 AM - 1:00 PM, 2 hours
2/4/2021, 10:00 AM - 3:00 PM, 5 hours
2/5/2021, 10:00 AM - 3:00 PM, 5 hours
Week of 2/6/2021 to 2/12/2021, 14 hours 15 minutes total:
2/8/2021, 10:00 AM - 3:00 PM, 5 hours
2/9/2021, Missed Visit
2/10/2021, 11:00 AM - 4:00 PM, 5 hours
2/11/2021, 10:45 - 3:00 PM, 4 hours 15 minutes
2/12/2021, Missed Visit
Week of 2/13/2021 to 2/19/2021, 5 hours total:
2/15/2021, 2/16/2021, 2/17/2021, Missed Visits
2/18/2021, 12:00 PM - 5:00 PM, 5 hours
2/19/2021, Missed Visit
Week of 2/20/2021 to 2/26/2021, 9 hours 15 minutes total:
2/22/2021, 9:30 AM - 3:00 PM, 5 hours, 30 minutes
2/23/2021, 8:15 AM - 9:00 AM, 45 minutes
2/24/2021, 11:00 AM - 2:00 PM, 3 hours
2/25/2021, 2/26/2021, Missed visits
Week of 2/27/2021 to 3/5/2021, 1 hour 30 minutes total:
3/1/2021, Missed Visit
3/2/2021, 8:15 - 9:00 AM, 45 minutes
3/3/2021, 3/4/2021, Missed visits
3/5/2021, 9:15 AM - 10:00 AM, 45 minutes
Week of 3/6/2021 to 3/12/2021, 45 minutes total:
3/8/2021, 3/9/2021, 3/10/2021, Missed Visits
3/11/2021, 8:30 AM - 9:15 AM, 45 minutes
3/12/2021, Missed Visit
Week of 3/13/2021 to 3/19/2021, no hours documented:
3/15/2021, missed Visit
3/16/2021, no documentation, blank
3/17/2021, 3/18/2021, Missed Visits
3/19/2021, no documentation, blank
CR1 HHA exchange Member General Notes for CR1 from 2/1/2021 to 3/19/2021 revealed the following:
"...Created Date 3/17/2021...Note...2/9/2021; caregiver called off-participant is aware-cancel shift, other agency is there..."
"...Created Date 3/17/2021...Note...2/12/2021; caregiver called off-participant is aware-denies back-up plan, left a message with SC..."
"...Created Date 3/17/2021...Note...2/15/2021; caregiver called off due to weather-participant is aware-denies back-up plan, left a message with SC (service coordinator) ... "
"...Created Date 3/17/2021...Note...2/16/2021; caregiver called off-participant is aware-cancel shift, does not want a replacement..."
"...Created Date 3/17/2021...Note...2/17/2021; unable to find coverage-participant is aware-denies back-up plan, left a message with SC..."
"...Created Date 3/17/2021 ...Note ...2/19/2021; unable to find coverage-participant is aware-denies back-up plan, left a message with SC ... "
"...Created Date 3/17/2021...Note...2/25/2021; unable to find coverage-participant is aware-denies back-up plan, left a message with SC..."
"...Created Date 3/17/2021...Note...2/26/2021; caregiver called off-participant is aware-denies back-up plan, left a message with SC..."
"...Created Date 3/17/2021...Note...3/1/2021; unable to find coverage-participant is aware-denies back-up plan, left a message with SC..."
"...Created Date 3/17/2021...Note...3/3/2021; unable to find coverage-participant is aware-denies back-up plan, left a message with SC..."
"...Created Date 3/17/2021...Note...3/4/2021; unable to find coverage-participant is aware-denies back-up plan, left a message with SC..."
"...Created Date 3/17/2021...Note...3/8/2021; unable to find coverage-participant is aware-denies back-up plan, left a message with SC..."
"...Created Date 3/17/2021...Note...3/9/2021; unable to find coverage-participant is aware-denies back-up plan, left a message with SC..."
"...Created Date 3/17/2021...Note...3/10/2021; unable to find coverage-participant is aware-denies back-up plan, left a message with SC..."
"...Created Date 3/17/2021...Note...3/15/2021; unable to find coverage-participant and SC aware-denies back-up plan..."
"...Created Date 3/17/2021...Note...3/12/2021; unable to find coverage-participant is aware-denies back-up plan, left a message with SC..."
"...Created date 3/17/2021...Note...3/17/2021; unable to cover. Informed client. Denies back-up plan. SC made aware..."
"...Created Date 3/18/2021...Note...3/18/2021; Unable to find coverage-Participant made aware-Participant using the other agency..."
There was no documented evidence identified of agency providing a resolution with consumer CR1 for above missed visits/shifts nor was there evidence identified that agency provided timely resolution with consumer CR1 service coordination for above missed visits/shifts.

Exit conference was conducted via telephone on 3/29/2021 at approximately 1:40 PM with agency manager (EMP1). Above findings were reviewed.










Plan of Correction:

Discontinuation of Service Letter was provided to the Consumer on 3/25/2021, stating that the Agency was unable to assign a qualified caregiver and it was in the Agency's and Consumers mutual best interest to discontinue services. Assistance was offered to the Consumer in their transition to refer them to a partner agency of the Agency. The Agency's Client Care Coordinator made visits and phone calls to the Consumer during the ten (10) days after the Discontinuation of Services Letter was provided to assure the Consumers well-being.
The Manager of Operations spoke with the Consumer on 4/6/2021 to follow up on whether they wanted or needed assistance with the transition. The Consumer stated that their Service Coordinator found an agency for the hours we were previously providing. The Consumer could not pronounce the name of the new agency and could not remember the new agency's start date. The Manager of Operations asked if there was anything else the Agency could do for them in the meantime, and the Consumer stated that they would like the Agency to stay in touch in the event the Agency finds a suitable caregiver. The Manager of Operations left a message and emailed the Service Coordinator on 4/6/2021 to inquire about the new agency.
To assure the solutions are sustained in the future, the Manager of Operations will review all current consumer records, including Service Agreements/Plans, Service Coordinators contact information, Back-Up Plan's and/or Family Member Contact Information, and Consumer's contact information, and verify that they are accurate and up to date. This process will be completed by 5/7/2021. Any changes made or that need to be made to a Consumers records will be reviewed in the Agency's weekly staff meeting.
Missed visits/shifts will continue to be documented in HHA Exchange, the Agency's Software System, with the Service Coordinator, and with the Consumers and their Family Members containing specific documentation of who, what, when, where, why, and how. A review of care hours will be implemented into the Agency's weekly staff meeting to better manage Consumer shifts, to prevent missed visits/shifts, and to provide timely resolutions with the Consumer and their Service Coordinator. Agency will add specific language to the Service Agreement that will allow for ongoing changes to the schedule as agreed to by both parties- this agreement will be executed by Addendum to the current Agreement.
The Agency will also implement a reevaluation process after more than 5 caregivers have asked not to return to the Consumer or the Consumer has asked for more than 5 caregivers not to return. The reevaluation process will address any issues and/or concerns, will involve the Agency's Client Care Coordinator, the Consumer, and the Consumers Service Coordinator, and will allow the Agency to put a remediation plan in place. The Manager of Operations also reviewed and reiterated the importance of documentation and documentation requirement during the 4/1/2021 weekly staff meeting.