QA Investigation Results

Pennsylvania Department of Health
ALSM AT HOME
Health Inspection Results
ALSM AT HOME
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite unannounced State relicensure survey completed 6/16/2021, ALSM at Home was found 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:




Initial Comments:


Based on the findings of an onsite unannounced state relicensure survey completed 6/16/2021, ALSM at Home 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:




611.55(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 the agency policy, personnel files (PF) and staff interview, the agency failed to ensure direct care worker (DCW) competency/training was completed prior to assigning to provide services to consumers for one (1) of five (5) PF's reviewed (PF3).

Findings Included:

A review of the client packet on 6/15/2021 at approximately 12:14 PM revealed: "MANDATORY IN-SERVICES, TRAININGS AND MEETINGS. 1. The facility/program requires you to attend and/or participate in annual state and OSHA mandated in-services as appropriate for your facility/program, as well as additional in-services that are deemed mandatory by the supervisor, administrator, director or President/CEO. In some of our programs, mandatory training programs and in-service education is provided through a software program...Participation and compliance is required and is monitored via this system...In completed mandatory in-service trainings may lead to an administrative suspension until completed..."

A review of PF3 was conducted on 6/15/2021 at approximately 12:40 PM, the employees date of hire (DOH) was 5/30/2014, There was no evidence to confirm the direct care worker had demonstrated competency at the time of hire. The PF had no evidence of competency testing being completed.

An interview was conducted with the senior services manager, on 6/15/2021 at approximately 2:25 PM that confirmed the above findings.







Plan of Correction:

S0600 Competency testing will be performed on all new hires and then annually for all employees. The new hire competencies, along with the competency testing for all direct care employees will be revised to include all mandatory skills. The competency tests will be placed in the employee PF based on their anniversary of their last skills competencies.

The RN assessment nurse is responsible for all skills competencies for all new hires and current employees.


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 client handbook and consumer records (CR) and staff interview, the agency failed to involved the consumer in the service planning process and to receive services with reasonable accommodation of individual needs and preferences for four (4) of five (5) CR reviewed (CR1, CR3- CR5).

Findings included:

A review of the client packet on 6/15/2021 at approximately 12:14 PM revealed: "(Agency Service Agreement...1. SERVICES PROVIDED BY PROVIDER...B. Initial Consumer Service Plan...Client may participate in the development and implementation of the Client's Consumer Service Plan, and may include Client's authorized representative, if any, in making decisions about the services to be provided to Client..."

A review of CR1 on 6/15/2021 at approximately 1:20 PM, start of services 7/14/2016 revealed, The agency documentation in the CR did not list the initial days and times that confirmed the agency had meant consumer/consumer representative to discuss the individual service planning needs and preferences.

A review of CR3 on 6/15/2021 at approximately 1:35 PM, start of services 9/9/2013 revealed, The agency documentation in the CR did not list the initial days and times that confirmed the agency had meant consumer/consumer representative to discuss the individual service planning needs and preferences.

A review of CR4 on 6/15/2021 at approximately 1:40 PM, start of services 10/6/2016 revealed, The agency documentation in the CR did not list the initial days and times that confirmed the agency had meant consumer/consumer representative to discuss the individual service planning needs and preferences.

A review of CR5 on 6/15/2021 at approximately 1:50 PM, start of services 1/7/2020 revealed, The agency documentation in the CR did not list the initial times that confirmed the agency had meant consumer/consumer representative to discuss the individual service planning needs and preferences.

An interview was conducted with the senior services manager, on 6/15/2021 at approximately 2:25 PM that confirmed the above findings.






Plan of Correction:

0800 The client notification form or related documentation was missing some pertinent information. All forms will be reviewed and documentation will be placed in the file. Going forward, the RN will be responsible with coordinating with the scheduler on initial notification of dates, and times and direct service worker according to the client preferences and planning involvement and document this on the form or within the progress notes. Audits will be completed by the RN and scheduler on each client as their initial assessment is completed to ensure compliance.


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 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 four (4) of five (5) CR reviewed (CR1, CR3- CR5).

Findings included:

A review of CR1 on 6/15/2021 at approximately 1:20 PM, start of services 7/14/2016 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 6/15/2021 at approximately 1:35 PM, start of services 9/9/2013 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 CR4 on 6/15/2021 at approximately 1:40 PM, start of services 10/6/2016 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 CR5 on 6/15/2021 at approximately 1:50 PM, start of services 1/7/2020 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 was conducted with the senior services manager, on 6/15/2021 at approximately 2:25 PM that confirmed the above findings.






Plan of Correction:

0820 The RN upon initial assessment of client, will be responsible for documentation of the initial visit, completion of the notification form which indicates the identity of the direct service worker assigned, and the hours when services will be provided. The RN will work with the scheduler on ensuring the documentation is completed and placed in the file. Documentation of the initial visit will be noted in a progress note. The files that were missing documentation will be corrected according to the scheduled time and identity of the direct care worker. Audits will be completed on all client files to ensure compliance.


Initial Comments:


Based on the findings of an onsite unannounced State relicensure survey completed 6/16/2021, ALSM at Home was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: