Initial Comments:
Based on the findings of an onsite unannounced complaint and relicesure survey conducted on 9/21/2017 and completed on 9/22/2017, Community Resources for Independence Inc. was found not to be in compliance with the requirements 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 a review of agency memorandum, a review of the Department's online Event Reporting System (ERS), and an interview with agency staff (EMP), the agency failed to notify the Department in writing of an event that could seriously compromise quality assurance or patient safety 9/13/0217.
Findings Include:
A review of the agency Department of Health Mandatory Incident Reporting memorandum on 9/21/2017 at approximately 9:50 AM revealed. Memorandum...Date: 2/22/2010, Subject: Department of Health Mandatory Incident Reporting...Mandatory Reporting under the Department of Health...is required to report events with is seriously compromise quality assurance of patient safety, including but not limited to, the following:...5. Transfer to a hospital as a result of injury or accidents.
A review of CR4 on 9/22/2017 at approximately 11:28 AM revealed: "Incident report...type of incident, went to hospital...Event Date 09/13/17, Event time 1:30 PM, Location of the incident, home...Description of the incident (WhoWhat When Where Why How): DCW6 came in, CR4 was sliding out of his chair I had pulled him up. His nurse came and he was having trouble eating, talking, and said he would go to the Doc so the nurse called the Doc and he said he wants CR4 to go to the hospital so they came and picked him up. I wrote in his binder he went to hospital. CR4 didn't look good even his nurse said that."
A review of the Department's online Event Reporting System (ERS) on 9/26/2017 at approximately 2:00 p.m. revealed the aforementioned incident was never reported by the agency to the Department's ERS system.
An interview with EMP1 on 9/21/2017 at approximately 9:50 AM, was aware of any events reported to the event reporting system. EMP1 was unaware of any and " they would not be done here," EMP2 confirmed on 9/26/2017 at approximately 3:50 PM the incident was not reported to the Department's ERS system.
Plan of Correction:Response:
10/09—All Altoona Office Staff were a part of an Agency wide Conference call which was called "Abuse and Neglect Training." The agenda was focused on the types of abuse and a review of the Statutory Definitions of Abuse as outlined in the Adult Protective Services and Older Adult Protective services training slides. Other topics of discussion/training were, Responding to Reports of Abuse, Reporting Suspected Abuse to outside Entities, and Staff's role in Investigations of suspected abuse. (Please see agenda)
10/18—All DCW staff will receive in depth training on Reportable Incidents, Incident Management Process, a review of Statutory Definitions as outlined in Adult Protective Services and Older Adult Protective Services slides and a reminder of importance/expectation of a Mandated Reported, etc.
CRI Supervisory staff will continue Quality Assurance calls with Consumers while PCA's are present and remind both of importance of communication with the office in the event of any needs, changes, incidents in order for office staff to determine if something needs reported/investigated/etc.
CRI will also be mandating that in the event of an incident, the Office Supervisor or Mentor will immediately collect all observation logs that are in the home (CRI's documentation book). Typically, all logs are collected/submitted at the end of every month, but in the event of an incident, they will be collected at the same time of the incident report. Those logs will be reviewed by the Office Supervisor to determine if anything could have been done to prevent the incident occurring and/or what can be used to help from prevent from the situation getting worse or re-occurring going forward. In addition, any incidents causing health/safety concerns for the consumer, will also be reviewed with the CRI RN within 24 hours.
Corrections for Tag 0008 are to be in place within 30 days, November 16th 2017.
Initial Comments:
Based on the findings of an onsite unannounced revisit and a complaint investigation survey conducted 9/21/2017 and completed on 9/22/2017, Community Resouerces for Independence 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(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 a review of plan of correction submitted by agency in response to deficiencies cited 4/17/2017, agency policy, personnel files (PF) and staff (EMP) interview, it was determined the agency failed to conduct a face to face interview with the applicant or obtain verification of two (2) positive references for the applicant for (2) of five (5) PFs reviewed (PF1 and PF2).
Findings included:
Review of plan of correction submitted by agency in response to deficiencies cited 4/17/2017 on 9/22/2017 at approximately 12:54 PM revealed: "...checks references prior to employment... is reviewing its employee files and where reference check forms are not complete,... staff will conduct reference checks, signing and dating new reference forms, and attach the new reference forms to the prior reference forms. In cases where the person who conducted the reference check is available, that person will sign the reference forms with the current date and a note that the references were checked prior to before the PCA began working. The reference form for PF#8 shall be updated by May 31, 2017. PF#1 is no longer employed...will alter its systems to ensure that the problem does not recur by: The facility DCW supervisory staff and secretarial staff shall verify that reference check forms are complete and signed. Additionally, corporate HR will review incoming new employee hire information to double-check that reference forms are complete and signed. This additional check has already been implemented." Completion date 5/31/2017."
A review of the agency policies on 9/21/2017 at approximately 11:00 AM revealed: "Hiring Requirements for Direct Care Workers, Application and Screening...Each applicant for a Direct Care Worker position participates in a face-to-face interview with appropriate...staff as part of the employment screening process. At least two satisfactory, positive references are obtained on each Direct Care Worker. Professional references from prior employers are obtained when possible; references from relatives are not accepted..."
A review of the PFs conducted on 9/22/2017 at approximately 12:15 PM to 1:46 PM revealed the following:
PF#1, date of hire (DOH) 7/5/2017. The PF did not contain evidence of two references having been verified as positive by the agency. No additional documentation was provided by the agency, per the surveyor request.
PF#2, DOH 7/31/2017. The PF did not contain evidence of two references having been verified as positive by the agency. No additional documentation was provided by the agency, per the surveyor request.
An interview with the regional program manager on 9/22/2017 at approximately 2:00 PM confirmed the above findings.
Repeat deficiency
Plan of Correction:Response:
CRI has developed a form/spread sheet that will be submitted monthly by the Office Supervisor to the Director of H.R. and the Regional Manager for review/discussion. Please see attached spreadsheet which includes basic hire expectations from interview process through TB testing. The Supervisor will review and confirm each item was completed for a new hire. Once per month, CRI Regional Manager or an employee outside of the Altoona location assigned by Regional Manager will perform a "self audit" of the files associated with the prior month spread sheet to ensure the verification of those files is accurate and complete.
In addition, Human Resources will implement a Bi-weekly call with CRI Altoona to review information that may be outdated or about to be outdated(car insurance/driver's license/etc.) CRI has recently hired a new Secretary and a new Supervisor for the office. The Secretary will be responsible for reviewing a Missing Documentation Spread sheet which is a tickler system that will be used to stay ahead of needed/required information from PCA's. Please see in the attachments, letter that will be sent with Monthly schedules which will be sent out with Monthly schedules to inform any aide that may need to supply updated information. The letter indicates that the PCA will have 2 weeks from date of the letter, or the date of expiration, whichever is sooner, to provide the updated information and that failure will lead to them being removed from the schedule until the information is received.
Corrections for Tag 0200 are to be in place within 30 days, November 16th 2017.
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 plan of correction submitted by agency in response to deficiencies cited 4/17/2017, agency policy, personnel files (PF) 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 five (5) PFs reviewed (PF3).
Findings included:
Review of plan of correction on 9/22/2017 at approximately 12:54 PM submitted by agency in response to deficiencies cited 4/17/2017 revealed: "... has revised its policy and form to require new employees to provide proof of residency in Pennsylvania for at least the two years prior to hire. Acceptable documents are to include:
(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.
If a new employee cannot provide proof of residency in Pennsylvania for at least the two years prior to hire, the employee is to 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.
PF #10 shall be required to provide proof of residency in Pennsylvania for at least the two years prior to hire. This proof of residency shall be in place by May 31, 2017. If satisfactory proof of residency cannot be provided, this employee will be subject to a Federal criminal history record and a letter of determination from the Department of Aging.
...will alter its systems to ensure that the problem does not recur by: In addition to, and as a backup to, the facility DCW supervisory staff and secretarial staff tracking the proof of residency, corporate HR will review incoming new employee hire information to double-check that satisfactory proof of residency has been obtained by the facility. This additional check has already been implemented." Completion date 5/15/17.
A review of agency policy on 9/21/2017 at approximately 2:37 PM revealed "Criminal Background Check Policy, 2. Detailed Policy Statement...For employees who hae been a residents of Pennsylvania for tow years prior to the date of the request for a criminal history report, a Pennsylvania state Police Criminal record shall be obtained. For emplyees who have not been a resident of Pennsylvania for the two years immediately preceding the date of the request for a criminal histroy report, a federal criminal history record and a letter of determination from the PA Department of Aging, based on the individual's federal criminal record, in accordance with6 Ps Code 15.144(b). An employee is to furnish proof of residency through any of the following documents: Motor vehicle records, such as a valid drivers' license or a state-issued identification, Housing records, such as mortgage records or rent receipts, public utility records and receipts, such as electric bills, local tax records, A completed and 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....Proof of residency is to be maintained in the employee file...Rev [revised] 9/15/2016." Completion date 5/31/2017.
A review of personnel files on 2/3/2017 approximately between 11:10 AM to 2:07 PM revealed:
PF #3 date of hire (DOH) 8/22/2017, There was a Pennsylvania driver's license with an issue date of 10/1/2016. A "Certification of Birth" with a "date file 11-02-1995" was in the PF, no address was on the document. There was no additional documentation in the PF file to verified proof of residency in this Commonwealth for two (2) years immediately preceding the date of hire.
An interview with the regional program manager on 9/22/2017 at approximately 2:00 PM confirmed the above findings.
Repeat deficiency
Plan of Correction:Response:
CRI has developed a letter which will be sent out to ALL current staff who were either were found non compliant at the time of DoH onsite Audit and/or are found to be non compliant following a self audit by Regional Manager/office staff. Please see attached letter which includes Proof of Residency along with many other requirements such as Expiring car insurance, driver's license, etc.
In addition, CRI has developed a form (please see attached) that will be used by the Secretary when processing new hire paperwork. The Secretary will review the paperwork and will verify that Proof of Residency has been obtained and will sign/date verifying the proof. The form will be used to ensure that Proof of Residency was acquired on a specific date, and the employee is scheduled for their first shift on a specific date which will be a date after orientation and after verification of the Proof of Residency. If no satisfactory proof of residency is provided, then an FBI fingerprint check is to be ordered.
The Secretary will notify the Supervisor and Scheduler at time of review to notify them of new hires that we do have Proof of Residency for confirming they are approved to work. At time of review, The Secretary will also email Supervisor and Scheduler if a new hire has NOT provided Proof of Residency and therefore NOT eligible to work until submitted.
Corrections for Tag 0330 are to be in place within 30 days, November 16th 2017.
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 plan of correction submitted by agency in response to deficiencies cited 4/17/2017, agency policy, CDC (Center for Disease Control) guidelines, personnel files (PF) and staff (EMP) interview, it was determined the agency failed to conduct screening in accordance with CDC guidelines and agency policy for preventing the transmission of mycobacterium tuberculosis (TB) and proper completion of a two-step TB screening for two (2) of five (5) PFs reviewed (PF2, and PF3).
Findings included:
Review of plan of correction on 9/22/2017 at approximately 12:54 PM submitted by agency in response to deficiencies cited 4/17/2017 revealed: "PF#1 is an employee that is no longer employed with...PF#1 provided ... with a record of a prior TB test administered by a prior employer. We are unable to obtain additional documentation. PF#3's initial TB test and annual disclosures of symptoms were out of compliance. However, upon later record review it was discovered that the employee did not meet the TB requirements and was submitted for a two-step TB, with step one placed on 6/14/16 and read 6/17/16 and step two placed on 6/24/16 and read 6/24/16. PF#8 shall be instructed to have a second step of a two-step TB test completed by June 16, 2017. This facility is reviewing all DCW staff for timely completion of TB tests...will have out-of-compliance DCWs obtain TB screening or annual symptom screens by June 16, 2017... will alter its systems to ensure that the problem does not recur by: the Assistant to the HR Director in the HR department will track annual TB test dates/TB symptom screening dates in addition to, and as a backup to, the facility DCW supervisory staff and secretarial staff tracking the dates at the facility. This system change is already in effect." Completion date 6/16/2017.
A review of agency policy on 9/21/2017 at approximately 2:37 PM revealed, "MANDATORY REQUIREMENTS, Proof...of PPD (Tuberculosis) Test upon hire and prior to working with consumers, otherwise employee cannot be scheduled to work. A second step TB test is required for new employees and is to be placed no sooner than 7 days and no later than 21 days from the reading of the first step, otherwise the employee cannot be scheduled to work. Annual PPD's thereafter. (All Employees). "
A review on 2/22/2017 at approximately 12:40 PM. of "CDC MMWR Morbidity and Mortality Weekly Report Recommendations and Reports December 30, 2005/Vol. 54/No. RR-17 Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005", revealed "... Baseline testing for M. Tuberculosis infection is recommended for all newly hired HCWs [health care workers]...If TST [tuberculin skin testing] is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative...If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read...A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months, a single TST can be administered in the new setting...This additional TST represents the second stage of two-step testing..."
DCW PF#2, reviewed on 9/22/2017 at approximately 12:46 AM, date of hire 7/31/2017, showed a TST that was administered on 7/31/2017 and read on 8/2/2017 with negative results. No additional TST was documented to confirm a second TST was conducted per CDC guidelines. The DCW started with a consumer on 8/13/2017.
DCW PF#3, reviewed on 9/22/2017 12:58 PM, date of hire 8/22/2017, showed a TST that was administered on 8/22/2017 and read on 8/24/2017 with negative results. No additional TST was documented to confirm a second TST was conducted per CDC guidelines. The DCW started with a consumer on 8/25/2017.
An interview with the regional program manager on 9/22/2017 at approximately 2:00 PM confirmed the above findings.
Repeat deficiency
Plan of Correction:Response:
CRI will be implementing a 7 day reminder call by the office secretary. The purpose of this call is to contact the employee exactly 7 days from their 1st step TB test. The call's purpose will be to remind the PCA that they must get their 2nd step within the next 7 to 14 days or they will be removed from the schedule until they can meet this requirement. Additionally, the employee will be informed that failure to complete the 2nd step within 2 weeks of that phone call, this will result in immediate removal from the schedule until TB test is completed and could result in termination for failure to meet requirements as outlined in the interview/orientation process. Additionally, CRI Supervisor will schedule the 2nd step test as a paid shift thus the expectation that the aide would show for this test. If the aide does not make alternate arrangements and fails to show up for this scheduled TB test shift, then they would be removed from the schedule and would be recommended for termination as they would be considered a violation of our NO CALL/NO SHOW Policy which is grounds for immediate termination.
Additionally, as referenced in response to issue #3, CRI will be sending letters monthly with schedules that will indicate what will be expired/out dated soon. The list includes proof of PPD test and will be utilized to ensure yearly follow up.
Corrections for Tag 0701 are to be in place within 30 days, November 16th 2017.
ADDITION 11/06/17: Per auditor's recommendation, we add the following. Employees will be required to provide a record of Tuberculosis testing, using either the test facility's form or a CRI form, depending on the test facility's preference. The form shall identify the employee, the date the test was placed, the date the test was read, and the results of the reading (positive or negative). Employees will not be considered to have completed the TB test until said documentation has been submitted to CRI. Delays in submitting said documentation may result in the employee being taken off the active work schedule until the documentation is submitted.
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 plan of correction submitted by agency in response to deficiencies cited 4/17/2017, record of disscussion form, consumer records (CR) and staff 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) CRs reviewed (CR1-CR5).
Findings included:
Review of plan of correction on 9/22/2017 at approximately 12:54 PM submitted by agency in response to deficiencies cited 4/17/2017 revealed: "...provides a copy of the schedule to the consumer showing who will provide services and when. This schedule is provided either in person during a meeting prior to starting services, or mailed to the consumer prior to starting services...will alter its procedures by implementing a form to record the date and details when a consumer was informed of when services shall occur and who will be providing those services, whether the consumer is informed of this in person during a meeting and provided a schedule, or is informed via telephone when a schedule is being mailed. This form shall include detail on the dates/times that services are to be provided and the name of the direct care workers who will be providing those services, as well as specifics of other information provided. It shall indicate the date and time that the consumer was informed, how (in person or telephone), and by whom, including staff signature. In addition,...shall continue to provide the consumer with a paper copy of the schedule of services, which indicates who shall provide the services and when... retains a copy of the schedules provided to its consumers. The office secretary shall audit new consumer files to see that the forms have been placed in the consumer's file. The office supervisor shall be responsible to that office staff are completing the forms and placing the forms in the consumer's file. This new form and procedure shall be developed and implemented in the...(agency) office by Friday May 19, 2017." Completion date 5/15/17.
Findings include:
Based on review of the agency record of Discussion form on 9/21/2017 at approximately 2:25 PM revealed: . EMP2 provieded the surveyor with the a revised form on 9/21/2017 at approximately 2:25 PM, which was created by the agency to address the requirements of required information in writing to consumers/consumer representatives prior to the commencement of services. "...RECORD OF DISCUSSION WITH PARTICIPANT REQARDING SCHEDULE STARRTUP INFORMATION...INITIAL SCHEDULE TO BE REVIEW WITH CONSUMER: Inform the consumer: A paper schedule listeing the dates and times of serviece, and who will be provideing your services, is being mailed to you. In the meanwhile, here is your schedule for the first week. Your first date of service will be:..." The form provides the following information: days, times and DCW direct care workers name. The next section of the form is "SERVICES TO BE REVIEWED WITH CONSUMER: Inform the consumer: The service authorization or service order specifies that we are to provide the following Services for you (chek as per the Service Authorization/Order)..." The next section of the form is "I INFORMED THE PARTICIPANT OF THE ABOVE INFORMAITON (this form must be signed and dated by the person who spoke with the consumer)...Employee (print): Signature: Date of signature:" Rev 5-18-17
A review of CR1 on 9/21/2017 at approximately1:05 PM revealed start of services 8/21/2017. No documentation was made available to show the consumer/consumer representative was provided an information packet containing the following:
1. The services to be provided and the identity of the direct care worker who would provide services.
2. The hours when services would be provided.
3. Who to contact at the Department of Health for information about regulations and/or home care agency/registry compliance.
4. The local Area Agency on Aging's Ombudsman Program telephone number.
A review of CR2 on 9/22/2017 at approximately 9:45 AM revealed start of services 8/21/2017. No documentation was made available to show the consumer/consumer representative was provided an information packet containing the following:
1. The services to be provided and the identity of the direct care worker who would provide services.
2. The hours when services would be provided.
A review of CR3 on 9/22/2017 at approximately 11:20 AM revealed start of services 6/18/2017. No documentation was made available to show the consumer/consumer representative was provided an information packet containing the following:
1. The services to be provided and the identity of the direct care worker who would provide services.
2. The hours when services would be provided.
3. Who to contact at the Department of Health for information about regulations and/or home care agency/registry compliance.
4. The local Area Agency on Aging's Ombudsman Program telephone number.
A review of CR4 on 4/11/2017 at approximately 2:52 PM revealed start of services 6/20/2016. No documentation was made available to show the consumer/consumer representative was provided an information packet containing the following:
1. The services to be provided and the identity of the direct care worker who would provide services.
2. The hours when services would be provided.
3. Who to contact at the Department of Health for information about regulations and/or home care agency/registry compliance.
4. The Department of Health's complaint hotline.
5. The local Area Agency on Aging's Ombudsman Program telephone number.
6. The hiring and competency requirements of direct care workers.
A review of CR5 on 4/11/2017 at approximately 3:00 PM revealed start of services 11/1/2016. No documentation was made available to show the consumer/consumer representative was provided an information packet containing the following:
1. The services to be provided and the identity of the direct care worker who would provide services.
2. The hours when services would be provided.
3. Who to contact at the Department of Health for information about regulations and/or home care agency/registry compliance.
4. The local Area Agency on Aging's Ombudsman Program telephone number.
An interview with the regional program manager on 9/22/2017 at approximately 2:00 PM confirmed the above findings.
Repeat deficiency
Plan of Correction:Response:
CRI will be sending out a letter with the forms that have the Ombudsman and DoH Hotline numbers to all current consumers. The letters will be personalized per consumer and the consumer will be encouraged to place the forms and letter in the Binder provided in each home for CRI services. The letter itself will also include the numbers that are in the required forms for the consumer's benefit. A copy of the letter and copies of both forms will be stapled and placed in the consumer's file within the office. Going forward, Intakes completed beginning 10/10, each new consumer will be required to sign and date the form that has the Ombudsman and DoH hotline number. A copy of this signed documentation will be placed in the consumer's file.
The office secretary will be responsible for checking for a file copy of this signed form. Additionally, the 'self audit' from another CRI office, under the review of the regional manager, is to include a sampling of consumer files to review for compliance.
In addition, CRI will add a "bullet" to our cover sheet that is used at time of Intake with a new consumer. The "bullet" will reference that a copy of the DOH Hotline and Ombudsman numbers have been given to the consumer on that date of Intake.
Corrections for Tag 0820 are to be in place within 30 days, November 16th 2017.
ADDITION 11/06/17: In addition to providing the consumer with a copy of the schedule (which includes dates and times of service and the identity of the caregiver), and providing the consumer with a copy of the service authorization prepared by the service coordination entity, CRI also uses a form "RECORD OF DISCUSSION WITH PARTICIPANT REGARDING SCHEDULE STARTUP INFORMATION." This form includes a synopsis of the initial schedule to be reviewed with the consumer, and a review of the services to be performed. CRI also provides the consumer with a form "Hiring Requirements for Direct Care Workers" which describes the application and screening, background checks, training and competency development, and health screening processes for caregivers.
611.57(d) LICENSURE
Documentation
Name - Component - 00
(d) The home care agency or home care registry shall maintain documentation on file at the agency or registry of compliance with the requirements of this section which shall be available for Department inspection.
Observations:
Based on information reviewed and staff interview, the agency failed to keep consumer (CRs) at the agency of compliance with the requirements of this section and make information readily available for Department inspection.
Findings Included:
During the survey process consumer files were requested on 9/21/17 at approximately 11:45 AM. The agency was unable to provide the requested file CR1 until approximately 2:47 PM for review. EMP1 revealed on 9/21/17 at approximately 12:25 PM the files were being scanned by the Lewistown office and sent to this location and printed.
During the survey process an additional consumer file was requested on 9/22/17 at approximately 11:24 AM. The agency was unable to provide the requested file CR5 until approximately 12:16 PM for review. EMP1 revealed on 9/22/2017 at approximately 11:24 AM the files were being scanned by the Lewistown office and sent to this location and printed.
During the survey process the surveyor requested the following documentation for month of September 2017: medical/medication reminder log, observation log and service provision sheet for CR1 through CR5. EMP1 confirmed on 9/21/2017 at 12:41 AM that the requested information was in the black binders (which is kept at the consumers home) for the month of September, and that each months documentation is collected or turned in to the agency on the last day of the month. Documentation was not available upon the surveyors request for inspection.
An interview with the regional program manager on 9/22/2017 at approximately 2:00 PM confirmed the findings that CR1 and CR5 file were at the Lewistown PA location, and that the documention in the black binder is kept in the consumers home until the last day of the month and then collected..
Plan of Correction:Response:
The occurrence is rare as far as files being removed from the office, but in the event files are removed by the Regional Manager, copies will be faxed immediately upon arrival to the other location. It is CRI's policy that once paperwork is in the office, it typically remains in the office with the exception of mailing the originals to Corporate HR after copies are made for that specific office. However, in this situation, the Regional Manager who oversees the Altoona site, as well as the site in which the files were taken, was attempting to assist the office in getting the files copied and processed for their file cabinet, as well as to be able to be sent to Erie per Company policy. The Altoona Office had a staffing issue as well as a Copy Machine issue during the time frame of these files being transported to the Lewistown Office. The issues led to the perceived need for the Regional Manager to try and assist by taking the files to Lewistown.
Corrections for Tag 0830 are to be in place within 30 days, November 16th 2017.
ADDITION 11/06/17: A file sign-out sheet is being implemented, tracking the consumer's name, the date the file was signed out, the name of the person who signed out the file, and the date the file was returned. The office secretary shall be responsible for maintaining this file sign-out sheet.
Initial Comments:
Based on the findings of an onsite unannounced revisit and a complaint investigation survey conducted 9/21/2017 and completed on 9/22/2017, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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