QA Investigation Results

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


There are  5 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an onsite unannounced State relicense survey completed 3/17/2022, 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 3/17/2022, 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:




611.56(b) LICENSURE
Health Screening

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(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.

Observations:


Based on review of agency policy, personnel files (PF) and staff (EMP) interview it was determined the agency failed to ensure an updated screening for mycobacterium tuberculosis (TB) at least every twelve (12) months for one (1) of five (5) PFs reviewed who were employed by the agency for at least 12 months (PF4).

Finding included:

A review of agency policy on 3/17/2022 at approximately 10:40 AM revealed: "REVISED Guidance for Home Care Agencies, Home Health Care Agencies and Hospices During COVID-19 Pandemic May 20, 2020 The Department of Health (Department) has received questions regarding the operation and management of home care, home health care, and hospice agencies in relation to the COVID-19 health emergency. This additional information is provided to help you understand and operationalize the guidance provided by the Governor and the Secretary of Health as well as the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC). The Department provides the following guidance, which supersedes the information issued on March 21, 2020: ... 9. Pre-employment Health Screening. The requirement for an initial baseline 2 step Mantoux skin test for tuberculin skin testing is temporarily suspended. All applicants must complete an individual risk assessment and symptom evaluation prior to hire."
A review of PF#4 on 3/16/ at approximately 1:25 PM revealed date of hire 6/1/2018. Initial TB screening was conducted on 11/14/2017. No documentation was available to confirm TB screening was conducted since 11/14/2017.

An exit interview was conducted with the service coordinator on 3/17/2022 at approximately 3:34 PM which confirmed the above findings.





Plan of Correction:

0710
The Agency TB policy and CDC guidelines will be followed every 12 months.
All employee files will be reviewed by the HR department and Home Care Coordinator on an ongoing basis to ensure all documentation is in the employee file and in compliance with the guidelines.



611.57(a) LICENSURE
Consumer Rights

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(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 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 two (2) of seven (7) CR's reviewed (CR 1 and CR4).

Findings included:

Review of the agency's documents on 3/16/2022 at approximately 11:10 AM revealed: "(Agency) Client Rights and Responsibilities ...Client Rights ...4. You have the right to participate in the development and periodic review of a service plan designed to meet your needs ...10. You have the right to be informed in advance of changes associated with your service ... "

A review of the CR1 with a start of services of 9/17/2020, was conducted on 3/16/2022 at approximately 1:55 PM which revealed, documentation within the CR listed the initial days but did not provide times for services to be provided. The surveyor could not confirm from the agency documentation consumers individual service planning needs and preferences were reviewed.

A review of the CR4 with a start of services of 8/27/21, was conducted on 3/16/2022 at approximately 2:20 PM which revealed, " Progress Notes ...We will see client this week on Sat-Sun-Tues & Thurs. Sat @ 1230 PM ... " No documentation times for services to be provided could be identified within the PF. The surveyor could not confirm from the agency documentation consumers individual service planning needs and preferences were reviewed.

An exit interview was conducted with the service coordinator on 3/17/2022 at approximately 3:34 PM which confirmed the above findings.







Plan of Correction:

0800
The nurse, 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 are to be provided. The client notification form or related documentation was missing along with visit pattern change. All staff will be educated by 04/15/2022 to notify the office immediately if a client requests a time or day change so it can be documented and placed in client file that same day. Moving forward scheduler will ensure all changes are documented and placed in client file that same day.



Initial Comments:


Based on the findings of an onsite unannounced State relicensure survey completed 3/17/2022, Alsm At Home was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: