QA Investigation Results

Pennsylvania Department of Health
CARING MATTERS HOME CARE 029
Health Inspection Results
CARING MATTERS HOME CARE 029
Health Inspection Results For:


There are  6 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:

Based on the findings of an unannounced onsite state relicensure and followup survey completed on November 14 and 15, 2017, Caring Matters Home Care 029 was found not to be in compliance with the requirements of 28 PA Code, 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 review of agency policy, agency submissions to the Department of Health (Department) online event reporting system (ERS), agency internal complaint and incident logs, and staff interviews (EMP), it was determined the agency failed to notify the Department of consumer complaints and incidents that could have seriously compromised patient safety.

Findings included:

Review of the agency's submissions to the Department's online ERS on November 9, 2017, at approximately 1:30 PM as part of pre-survey preparation revealed that the agency had no reports filed.

Review of agency policy "Reporting Critical Incidents" on November 15, 2017, at approximately 11:00 AM revealed" ... Critical Incident ... (v) Exploitation ... An employee must call their supervisor an their supervisor will take the following steps; ... (iv) Document concerns and actions taken to protect the adult in the electronic Incident Management (EIM) System ..."
Note: This policy does not address Department of Health Event Reporting System.

Telephone interview with EMP13 and EMP15 on November 15, 2017, at approximately 10:15 AM to inquire about the complaints and who submits reports in ERS for the agency, EMP15 replied, "I do ... there should be two folders at the receptionist desk, one for incidents and one for complaints ..."

Review of agency complaint log for 2017 on November 15, 2017, at approximately 10:33 AM revealed on 3/10/17 an allegation of theft was received from a consumer and investigated by the agency.

Interview with EMP13 and EMP15 via telephone on November 15, 2017, at approximately 11:45 AM confirmed the above findings. When asked by this surveyor if this event was reported to ERS, EMP15 replied," I notified DHS [Department of Human Services] ... "








Plan of Correction:

Caring Matters Home Care 029 will correct this deficiency by making sure that all occurrences of an event at the facility, which could seriously compromise quality assurance or patient safety, will be reported within 24 hours to the Department of Health in writing through the Department of Health Event Reporting System (ERS). We will also report the steps taken to rectify said situation. In order to protect patients in similar situations, we will review prior incidents that were not reported in ERS system and enter them into said system. All future critical incidents will be reported in writing though the ERS. All employees will be notified that any serious incidents must be reported to the Director of Human Resource or the Director of Client Care. Once a critical report is obtained and verified, a report will be submitted to the ERS within 24 hours. The Director of Client Care will monitor any serious complaints on a daily basis. The Director of Human Services will monitor and enter complaints in the ERS on a daily basis. The CEO will monitor complaints on a daily basis and ensure the reports are being entered into the ERS system in a timely manner.
This corrective action will be complete by 1/3/2018



Initial Comments:

An onsite unannounced followup and state relicensure survey completed on November 14 and 15, 2017, found that Caring Matters Home Care 029 had not corrected all of the deficiencies cited under 28 Pa. Code, Part IV, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries. The deficiencies were cited as a result of a followup and state relicensure survey completed on June 30, 2017.



Plan of Correction:




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 review of written Plan of Correction submitted by the agency in response to previous survey and personnel files (PF) and staff interviews (EMP), it was determined that the agency failed to ensure proof of residency in Pennsylvania for 2 years prior to date of hire for five (5) of nine (9) direct care worker personnel files reviewed (PF1, 2, 4, 5, and 7).

Findings Included:

Review of the written Plan of Correction on November 9, 2017 at approximately 1:30 PM revealed " ... Completion Date: ... 08/29/2017 ...In order to protect patients in similar situations all files will be reviewed ... will monitor the hiring process on a weekly basis using a form that needs to be check [sic] off stating an applicant is ready for hire ... form will be used to make sure that all applicants records are complete and in the file before they are employed ... "

Review of PF1 on 11/14/17, at approximately 11:19 AM revealed a date of hire (DOH) 11/8/17. The PF contained a Pennsylvania's Driver license that was issued on 8/18/16.

Review of PF2 on 11/14/17 at approximately 11:10 AM revealed a DOH 10/30/17. The PF contained a Pennsylvania's Driver license that was issued on 6/1/16.

Review of PF4 on 11/14/17 at approximately 11:23 AM revealed a DOH 10/21/17. The PF contained a Pennsylvania's Driver license that was issued on 5/4/16.

Review of PF5 on 11/14/17, at approximately 10:40 AM revealed a DOH 10/6/17. The PF contained a Passport that was issued on 4/30/14.

Review of PF7 on 11/14/17, at approximately 10:27 AM revealed a DOH 9/26/17. The PF contained a Pennsylvania's Driver license that was issued on 2/23/16.

Interview with the EMP13 and EMP15 on November 14, 2017 at approximately 2:30 PM confirmed the above findings.

Repeat deficiency 6/30/17





Plan of Correction:

Caring Matters Home Care 029 will correct this deficiency by making sure that PF1, 2, 4, 5 and 7 have proof of residency for at least two years prior to the date of hire using the following documents: (1) Motor vehicle records, such as a valid driver ' s license or a State a 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. In order to protect patients in similar situations, we will also review all personnel files and make sure all employees have furnished proof of residency for at least two years.
The Director of Client Care will monitor new hires and ensure that residency requirements are meet prior to hire date on a daily basis.
The Director of Human Services will monitor new hires and ensure that residency requirements are meet prior to hire on a weekly basis.. The CEO will monitor new hires on a monthly basis to make sure that residency requirements are in order.
This corrective action will be complete by 1/3/2018



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 review of written Plan of Correction submitted by the agency in response to previous survey, personnel files (PF), and CDC guidelines, and staff interview (EMP), it was determined that the agency failed to ensure that each employees with direct consumer contact were screened for mycobacterium tuberculosis (TB) in accordance with CDC guidelines for two (2) of ten (10) personnel files (PF11 and 12) reviewed that were to have been corrected by 8/29/17 and four (4) of nine (9) files reviewed that were hired after 8/29/17 (PF 4, 5, 6, and 7).

Findings Included:

The CDC guidelines state that all Health Care Workers (HCW) should received baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis...HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease....The TST result should be read by a designated, trained HCW 48-72 hours after the TST is placed. If the TST was not read between 48-72 hours, ideally, another TST should be placed as soon as possible and read within 48-72 hours....A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST within the previous 12 months, a single TST can be administered in the new setting. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(RR-17) http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.

Review of the written Plan of Correction on November 9, 2017 at approximately 1:30 PM revealed" ... Completion Date: ... 08/29/2017 ... Upon our investigation, we found that ... PF#2 ... PF#10 had valid documentation of a negative TST, but there was not documentation of a second step TST completed ...we are working on getting all of the step results ... All new employees will be required to get a two-step TB and documentation must be in their file before hire ... "

Review of personnel files on November 15, 2017, between approximately 9:15 AM and 10:30 AM that were to have been corrected by 8/29/17 revealed:

Review of PF#11 (PF2 from previous survey) on 11/15/17 at approximately 9:30 AM revealed date of hire (DOH) 1/6/17. The PF contained documentation of a negative result TST completed on 1/1/17 and results of a chest radiograph completed on 7/20/17. There was no documentation of a second step TST completed.

Review of PF#12 (PF10 from previous survey) on 11/15/17 at approximately 10:24 AM revealed DOH 7/8/16. The PF contained documentation of a negative TST completed on 8/29/16, and results of a chest radiograph completed on 7/23/17. There was no documentation of a second step TST completed.

Review of personnel files that were hired after 8/29/17 revealed:

Review of PF4 on 11/14/17 at approximately 11:23 AM revealed a DOH 10/21/17. The PF contained results of a chest radiograph completed on 10/17/17. There was no documentation of a two step TST completed.

Review of PF5 on 11/14/17, at approximately 10:40 AM revealed a DOH 10/6/17. The PF contained a negative reading TST completed on 10/4/17 and the second TST given 10/9/17 (less than 7 days). There was no documentation of a two step TST completed.

Review of PF6 on 11/14/17, at approximately 10:53 AM revealed a DOH 9/25/17. The PF contained results of a chest radiograph completed on 9/19/17. There was no documentation of a two step TST completed.

Review of PF7 on 11/14/17, at approximately 10:27 AM revealed a DOH 9/26/17. The PF contained a negative reading TST completed on 1/20/17, 1/12/16 and 1/19/16 from her previous employer. Additionally the PF contained results of a chest radiograph completed on 9/25/17. There was no documentation of a single step TST completed upon hire.

Interview with EMP13 and EMP15 on 11/14/17 at approximately 2:30 PM confirmed the above findings. EMP15 explained "... previous auditors told us [agency] that chest xrays were acceptable ..." When asked by this surveyor if the agency had a policy for tuberculosis screening EMP15 replied, "No."

Repeat deficiency 6/30/17





Plan of Correction:

Caring Matters will ensure that all potential employees will have received baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. HCW's with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease .The TST result should be read by a designated, trained HCW 48-72 hours after the TST is placed. If the TST was not read between 48-72 hours, ideally, another TST should be placed as soon as possible and read within 48-72 hours. A second TST is not needed if the
HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST within the previous 12 months, a single TST can be administered in the new setting. PF#11, 12, 4, 5
6, and 7 will become compliant with the above CDC guidelines. In order to protect patients in similar situation, all employee files will be reviewed and updated to reflect compliance with the above CDC guidelines.
The Director of Client Care will monitor new hires and ensure that baseline tuberculosis screenings based on the CDC guidelines are meet on a daily basis.
The Director of Human Services will monitor new hires and ensure that baseline tuberculosis screenings based on the CDC guidelines are meet on a daily basis.
The CEO will monitor new hires new hires and ensure that baseline tuberculosis screening based on the CDC guidelines are meet on a weekly basis.
This corrective action will be complete by 1/3/2018.




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 review of written Plan of Correction submitted by the agency in response to previous survey, consumer records (CR), and agency consumer information packet and staff interviews (EMP), the agency failed to provide, prior to the commencement of services, the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA) in the county for which the consumer resides for four (4) of eleven (11) consumer records reviewed (CR 1, 3, 10 and 11).

Findings Included:

Review of the written Plan of Correction on November 9, 2017 at approximately 1:30 PM revealed" ... Completion Date: ... 08/29/2017 ... will do spot checks to make sure that files are in compliance. In order to protect patients in similar situations all files will be reviewed to make sure they in compliance ... "

Review of the agency consumer information packet conducted on 11/14/17 at approximately 10:10 AM revealed contact information for the local area of aging was provided for Allegheny and Chester counties.

Review of CR1 on 11/14/17 at approximately 11:55 AM revealed a signed service agreement dated 10/20/17. The CF listed the consumer's residence was in Westmoreland County.

Review of CR3,on 11/14/17 at approximately 12:08 AM revealed a signed service agreement dated 10/17/17. The CF listed the consumer's residence was in Westmoreland County.

Review of CR10 on 11/14/17 at approximately 1:00 PM revealed a signed service agreement dated 10/12/17. The CF listed the consumer's residence was in Westmoreland County.

Review of CR11 on 11/14/17 at approximately 1:08 PM revealed a signed service agreement dated 10/20/17. The CF listed the consumer's residence was in Westmoreland County.

Exit interview conducted with EMP13 and EMP15 at approximately 1:00 PM on 11/15/17 confirmed that the consumer information packet contained AAA ombudsman contact information for two counties: Allegheny and Chester.

Repeat deficiency 6/30/17





Plan of Correction:

Caring Matters Home Care 029 will ensure that all clients prior to the commencement of services will receive the telephone number of the Ombudsman Program located within the local Area Agency on Aging (AAA) in the county for which the consumer resides. CR1, CR3, CR10, and CR11 will receive a written copy of the telephone number of the Ombudsman Program located in Westmoreland County
In order to protect clients in similar situations, all current and future clients that live in Westmorland County will received a written copy of the telephone number of the Ombudsman Program located in Westmoreland County. We will also maintain a copy of the telephone number of the Ombudsman Program located in Westmoreland County that the client received in the consumer's file. We will create a different welcome packet that contains Ombudsman information pertinent to each county.
The Director of Operations will monitor and ensure that clients have the number of the Ombudsman program located in their county prior to the commencement of services. He will monitor this service on a weekly basis. The Director of Client Care will monitor and ensure that clients have the number of the Ombudsman program located in their county prior to the commencement of service. He will monitor this service on a weekly basis.
This corrective action will be complete by 1/3/2018.



Initial Comments:

Based on the findings of an unannounced onsite state relicensure and followup survey completed on November 14 and 15, 2017, Caring Matters Home Care 029 was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: