Initial Comments:
Based on the findings of an off-site unannounced home care agency complaint investigation survey conducted January 30, 2024 through February 2, 2024, Penncares, was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. 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), personnel files (PF), agency complaint log and interview with agency program manager, the agency failed to ensure the consumer received services as agreed upon for three (3) of three (3) consumer files (CF # 1-CF # 3)
Findings:
Review of Consumer Files (CF) on 2/1/24 from 10:00 AM-1:00 PM revealed the following:
Review of CF # 1 missed shifts revealed: CF# 1 had six (6) missed shifts from 11/22/23-12/1/23. Four (4) out of the six (6) were due to client being in hospital. The other two (2) agency was unable to staff, provider cancelled both times, client ' s back-up plan was put in place. CF # 1 missed fourteen (14) hours of care during this period with ten (10) out of the fourteen (14) hours being due to client hospitalization and four (4) hours being due to agency unable to staff.
Review of CF # 2: SOC:2/20/23; authorized for thirty-five (35) hours per week with participant ' s requested hours being Sunday-Saturday from 9:00 AM-2:00 PM. Client had a total of twelve (12) missed shifts from 11/4/23-12/23/23. Four (4) shifts were missed due to agency being unable to staff for a total of seventeen and a half (17.5) hours. CF#2 did have a back-up plan listed.
Review of CF # 3: SOC:12/3/20; was authorized for ten (10) hours of services per day from 8:00 AM-6:00 PM until 11/30/23 when client ' s hours were increased to fourteen (14) hours per day from 8:00 AM-10:00 PM. Client had a total of forty-six (46) missed shifts from 11/4/23-12/31/23. Nine (9) of the missed shifts for a total of twenty-seven and a half (27.5) hours due to agency being unable to staff. The agency missed five and a half (5.5) hours in November. The agency missed twenty-two (22) hours in December. CF # 3 did not have a back-up plan noted which was confirmed with the agency program manager.
CF # 3 should have received a total of two hundred and eighty (280) hours for the month of November and client received two hundred seventy-one and a half (271.5) hours. Client should have received a total of three hundred and ninety-two (392) hours for the month of December and client received two hundred twenty-four and three quarters (224.75) hours for the month.
An email received from the program manager on 2/2/24 at 1:50 PM confirmed the above findings.
Plan of Correction:Per interviewer and review of CF#1-CF#3, Agency failed to ensure the consumer received services as agreed upon for 3 of 3 consumer files. For CF#1-CF#3 the failure to provide services as agreed upon was documented by missed shifts and are for dates in the past and there is no way to correct the specific finding. As noted by the interviewer, CF#1 and CF#2 had back-up plans put in place. CF# 3 did not have a back-up plan. To avoid this deficiency in the future, Agency will revise the forms that are signed by consumer at initial intake. These intake forms currently include a participant rights form (which requires signature) and a Participant Safety Rules and Standard Operating Procedures form (does not require signature). These forms will be revised to include the requirement to have back-up care when/if the agency is not able to fill a shift for various reasons including call offs, caregiver shortages, inclement weather, etc. This form will be required to be signed by the consumer. The Assistant Executive Director will review intake forms to verify the completeness of these signatures. In addition, the In-Home Program Manager will audit missed shifts to determine agency documented steps to fill missed shift and ensure back plans were put in place. This corrective action plan will be implemented by March 20, 2024.
|