Initial Comments:
Based on the findings of an unannounced, on-site complaint investigation survey conducted on December 16, 2022, Angels on Call 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:
611.57(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 upon review of consumer files (CFs) and interview with office manager (EMP #1), agency failed to provide services and hours per the service agreement for three (3) of three(3) CFs reviewed. (CF #1, CF# 2 and CF# 3)
Findings include:
Review of consumer files (CF) was conducted on December 16, 2022, between approximately 9:00 a.m. and 10:00 a.m. revealed the following:
CF# 1, Start of Service (SOS), 4/25/2022: ' Initial Assessment of Client ' signed by the consumer on 4/19/2022 states, " ...Back Up Care Plan Family ....Caregiver Needed: Monday: 10 am - 12 pm, Tuesday: 10 am - 12 pm and Thursday: 10 am - 1 pm ... "
Calendar, schedule, and daily tasks sheets reviewed for date range of September 1, 2022, to November 30, 2022.
On 9/1/22, shift provided from 10a-11a. Agency did send out a mass email via ' Carefinder ' within their computerized system to all available caregiver requesting someone to pick up full shift but failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 9/5/22, shift provided from 10a-11:30a. Agency did send out a mass email via ' Carefinder ' within their computerized system to all available caregiver requesting someone to pick up full shift after being notified by the consumer ' s family that the caregiver did not arrive for shift.
On 9/8/2022, no shift provided. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form.
On 9/12/22, shift provided from 10a-11:30a. Agency failed to provide documentation of agency attempting to find coverage for missing shift hours and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 9/13/22, shift provided from 10a-11a. Agency failed to provide documentation of agency attempting to find coverage for missing shift hours and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 9/19/22, shift provided from 10a-11:30a. Agency failed to provide documentation of agency attempting to find coverage for missing shift hours and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 9/20/2022, no shift provided. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form.
On 9/22/22, shift provided from 10:30a-11:30a. Agency failed to provide documentation of agency attempting to find coverage for missing shift hours and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 9/26/22, shift provided from 10a-11:45a. Agency failed to provide documentation of agency attempting to find coverage for missing shift hours and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 9/27/2022, no shift provided. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form.
On 10/4/2022, no shift provided. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form.
On 10/6/22, shift provided from 10a-11:30a. Agency failed to provide documentation of agency attempting to find coverage for missing shift hours and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 10/24/22, shift provided from 10a-11:30a. Agency failed to provide documentation of agency attempting to find coverage for missing shift hours and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 11/8/2022, no shift provided. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift hours and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 11/10/22, shift provided from 1p-1:30p. Agency failed to provide documentation of agency attempting to find coverage for missing shift hours and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 11/21/22, shift provided from 10a-11:30a. Agency did send out a mass email via ' Carefinder ' within their computerized system to all available caregiver requesting someone to pick up full shift. Agency failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 11/22/2022, no shift provided. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift hours and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
CF# 2, SOS, 4/15/2022: ' Initial Assessment of Client ' signed by the consumer on 4/08/2022 states, " ...Back Up Care Plan Wife ....Caregiver Needed: Monday: 9:30 am - 1:30 pm and Friday: 9:30 am - 1:30 pm.
Calendar, schedule, and daily tasks sheets reviewed for date range of September 1, 2022, to November 30, 2022.
On 9/9/22, shift provided from 9:30a-1p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 9/12/22, shift provided from 9:30a-1p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 9/16/22, shift provided from 9:30a-1:15p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 9/19/22, shift provided from 9:30a-1:15p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 9/23/22, shift provided from 9:30a-1:15p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 9/26/22, shift provided from 9:30a-1:15p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 9/30/22, shift provided from 9:30a-1:p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 10/3/22, shift provided from 9:30a-1:15p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 10/7/22, shift provided from 9:30a-1:15p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 10/10/22, shift provided from 9:30a-1:p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 10/14/22, shift provided from 9:30a-1:p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 10/17/22, shift provided from 9:30a-1:15p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 10/24/22, shift provided from 9:30a-1:p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 10/28/22, shift provided from 9:30a-1:p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 10/31/22, shift provided from 9:30a-1:p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 11/4/22, shift provided from 9:30a-1:15p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 11/7/22, shift provided from 9:30a-1:15p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 11/11/22, shift provided from 9:30a-1:p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 11/14/22, shift provided from 9:30a-1:15p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 11/18/22, shift provided from 9:30a-1:15p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 11/21/22, shift provided from 9:30a-1:15p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 11/25/22, shift provided from 9:30a-11:30a. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
On 11/28/22, shift provided from 9:30a-1:15p. No documentation provided why shift was not provided according to hours within " Initial Assessment of Client " form. Agency failed to provide documentation of agency attempting to find coverage for missing shift time and failed to document agency contacting consumer to notify them of unable to staff entire shift hours.
CF# 3, SOS, 3/7/2022: Agency note from 3/4/2022 states, " Spoke with [Consumer ' s name] on 3/7/2022 and advised [daughter ' s name] will be the direct care worker and is scheduled for 25 hrs/week ... "
Agency note from 3/7/2022 states, " Client name [Client ' s name] schedule: 7-3 Mon and Friday 9am to 5:30 pm ....Backup Plan: Daughter ....Daughter is her consumer direct CG [caregiver] ... "
Calendar, schedule, and daily tasks sheets reviewed for date range of September 1, 2022, to November 30, 2022.
Agency provided 24 hours and 45 minutes for the week of 9/5/2022-9/10/22. No documentation provided of why the scheduled 25 hours were not provided this week.
Agency provided 24 hours and 30 minutes for the week of 9/19/2022-9/24/22. No documentation provided of why the scheduled 25 hours were not provided this week.
An interview with the agency EMP #1 conducted on December 16, 2022 at approximately 12:00 p.m. confirmed the above findings.
Plan of Correction:Documentation will be entered on shifts as to why all hours were not provided to client, as authorized. Agency staff will notify the client when coverage is not available and ensure their safety by having their backup plan utilized, if applicable.
The agency will retrain office staff regarding the patients' rights; 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.
Agency staff will be trained on documentation standards.
The agency will train the office Staff of how to not only review Patients' rights at onboarding but to ensure the client is educated and understands their right to be involved in the planning as well as have multiple agencies provide care.
The agency will train staff and educate client's that as a provider we are required to give at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services if we are unable to provide care.
Client files will be reviewed by the Compliance Team for compliance, after intake.
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