QA Investigation Results

Pennsylvania Department of Health
CHRIST THE KING AT HOME
Health Inspection Results
CHRIST THE KING AT HOME
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite home care agency state re-licensure survey conducted on May 14, 2024, Christ The King At Home - Dubois was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.




Plan of Correction:




Initial Comments:

Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on May 14, 2024, Christ the King at Home - Dubois, 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:




611.51(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 review of personnel files (PF) the agency failed to ensure, prior to assignment, that two satisfactory references were obtained for two (2) of seven (7) files reviewed. PF #2 and PF#7.

Findings include.

Review of personnel files completed on May 14, 2024, between approximately 10:00AM and 11:30AM revealed the following:

5/14/2024 review of PF#2 at approximately , Date of Hire (DOH): 7/11/2023. contained incomplete documentation of two (2) satisfactory references being obtained.

PF#7, DOH: 1/17/2024. contained incomplete documentation of two (2) satisfactory references being obtained.

5/14/2024 at approximately 1:00PM interview conducted with Human Resource representative (EMP#3) confirmed the above findings. "That's on me. I used the blanket reference check form and did not include the date."










Plan of Correction:

Human Resource will modify reference check form to include signature by supervisor checking pending hires references and date. Modification of reference form will be completed and implemented prior to June 1st, 2024.

References will be completed prior to hire of new employee, all references will be signed and dated by supervisor completing reference checks.

Human Resource department will add signature and date to new hire check list required on referrals to monitor referrals prior to hire. Check list will be signed off by HR department approving checks have been completed prior to hire.


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/client records (CR), review of facility new client admission packet - disclosure information and interview with Human Resource representative (EMP#3), the agency failed to notify consumer of right that the consumer 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..." for seven (7) of seven (7) CR's reviewed. (CR1, CR2, CR3, CR4, CR5, CR6 and CR7).

Based on information provided by EMP#3 upon entrance interview on May 14, 2024, at approximately 9:30am, the agency had approximately 70 consumers on services.

Findings include:

Review of consumer records completed on May 14, 2024, between approximately 11:45am - 1:15pm revealed the following:

CR1, Start of Care (SOC): 1/12/2023, contained no documentation of notification that the consumer receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services.

CR2, SOC: 2/13/2024, contained no documentation of notification that the consumer receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services.



CR3, SOC: 1/8/2024 contained no documentation of notification that the consumer receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services.



CR4, SOC: 11/15/2023, contained no documentation of notification that the consumer receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services.



CR5, SOC: 10/26/2023, contained no documentation of notification that the consumer receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services.



CR6, SOC: 10/7/2022, contained no documentation of notification that the consumer receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services.



CR7, SOC: 4/10/2024, contained no documentation of notification that the consumer receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services.



Interview conducted on May 14, 2024, at approximately 1:30 pm with EMP3 confirmed the above findings.











Plan of Correction:

Clients admission packet is modified to to inform the client of termination of services by the Home Care Agency. Clients will receive notice of termination of services at least 10 calendar days advance, in written form.


611.57(b) LICENSURE
Prohibitions

Name - Component - 00
(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

Observations:


Based on review of consumer records (CR), facility new client admission packet and employee (EMP) interviews it was determined the agency failed to provide the following information to the consumer, the consumer's legal representative or responsible family member prior to the commencement of services that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry." for seven (7) of seven (7) CR's reviewed. (CR1, CR2, CR3, CR4, CR5, CR6 and CR7).

Findings include:

Review of consumer records completed on May 14, 2024, between approximately 11:45am - 1:15pm revealed the following:

CR1, Start of Care (SOC): 1/12/2023, contained no documentation of notification of the prohibition that No individual as a result of the individual's affiliation with the
agency may assume power of attorney or guardianship over a consumer utilizing the services of that agency and that agency may not require a consumer to endorse checks over to the agency.

CR2, SOC: 2/13/2024, contained no documentation of notification of the prohibition that no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of that agency and that agency may not require a consumer to endorse checks over to the agency.


CR3, SOC: 1/8/2024, contained no documentation of notification of the prohibition that no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of that agency and that agency may not require a consumer to endorse checks over to the agency.


CR4, SOC: 11/15/2023, contained no documentation of notification of the prohibition that no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of that agency and that agency may not require a consumer to endorse checks over to the agency.


CR5, SOC: 10/26/2023, contained no documentation of notification of the prohibition that no individual as a result of the individual's affiliation with theagency may assume power of attorney or guardianship over a consumer utilizing the services of that agency and that agency may not require a consumer to endorse checks over to the agency.


CR6, SOC: 10/7/2022, contained no documentation of notification of the prohibition that no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of that agency and that agency may not require a consumer to endorse checks over to the agency.


CR7, SOC: 4/10/2024, contained no documentation of notification of the prohibition that no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of that agency and that agency may not require a consumer to endorse checks over to the agency.


Interview conducted on May 14, 2024, at approximately 1:30 pm with EMP3 confirmed the above findings.












Plan of Correction:

Modification to admission packet to include prohibition that no individual as a results of affliction with agency may assume power of attorney or guardianship of a consumer utilizing services of Christ the King manor at Home.
Christ the King Manor at Home also may not require a client to endorse checks to the agency or caregivers. Caregivers are also not permitted to sign and/or fill out any of the clients check information.


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 reviews of consumer/client records (CR), agency new client service agreement and staff (EMP) interviews, the agency failed to provide the following information prior to the commencement of services.
"(c) Information to be provided. 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:...
...(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)" for seven (7) of seven (7) consumer records reviewed (CR1 - CR7).


Findings Included:

Review of consumer records on May 14, 2024, between approximately 11:45am - 1:15pm revealed the following:

CR1, Start of Care (SOC): 1/12/2023, did not contain evidence that the consumer was provided the telephone number for The Department's complaint Hot Line (1-800-254-5164) or the contact information of the Ombudsman Program located with the local Area Agency on Aging (AAA).

CR2, SOC: 2/13/2024,did not contain evidence that the consumer was provided the telephone number for The Department's complaint Hot Line (1-800-254-5164) or the contact information of the Ombudsman Program located with the local Area Agency on Aging (AAA).

CR3, SOC: 1/8/2024, did not contain evidence that the consumer was provided the telephone number for The Department's complaint Hot Line (1-800-254-5164) or the contact information of the Ombudsman Program located with the local Area Agency on Aging (AAA).

CR4, SOC: 11/15/2023, did not contain evidence that the consumer was provided the telephone number for The Department's complaint Hot Line (1-800-254-5164) or the contact information of the Ombudsman Program located with the local Area Agency on Aging (AAA).

CR5, SOC: 10/26/2023, did not contain evidence that the consumer was provided the telephone number for The Department's complaint Hot Line (1-800-254-5164) or the contact information of the Ombudsman Program located with the local Area Agency on Aging (AAA).

CR6, SOC: 10/7/2022, did not contain evidence that the consumer was provided the telephone number for The Department's complaint Hot Line (1-800-254-5164) or the contact information of the Ombudsman Program located with the local Area Agency on Aging (AAA).

CR7, SOC: 4/10/2024, did not contain evidence that the consumer was provided the telephone number for The Department's complaint Hot Line (1-800-254-5164) or the contact information of the Ombudsman Program located with the local Area Agency on Aging (AAA).

Interview conducted on May 14, 2024, at approximately 1:30 pm with EMP3 confirmed the above findings.












Plan of Correction:

Human Resource and Service coordinator modified the admission packet. Modification includes handout to the client and acknowledgement, along with education on how to contact the local Area Agency on Aging and the Ombudsman Program at each local Area Agency on Aging. Contact information also implemented includes The Department's Complaints Hot Line (1-800-254-5164)


Initial Comments:

Based on the findings of an onsite home care agency re-licensure survey completed on May 14, 2024, Christ the King at Home - Dubois, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: