QA Investigation Results

Pennsylvania Department of Health
ARCADIA HOME CARE & STAFFING
Health Inspection Results
ARCADIA HOME CARE & STAFFING
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced complaint investigation survey completed December 13, 2019, Beaver County Homemakers was found not to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.




Plan of Correction:




51.3 (a) LICENSURE
NOTIFICATION

Name - Component - 00
51.3 Notification

(a) A health care facility shall
notify the Department in writing at
least 60 days prior to the intended
commencement of a health care service
which has not been previously provided
at that facility.

Observations:

Per 35 P.S. 448.813, "Authorization.--For the purpose of determining the suitability of the applicants and of the premises or for determining the adequacy of the care and treatment provided or the continuing conformity of the licensees to this act and to applicable local, State and Federal regulations, any authorized agent of the department may enter, visit and inspect the building, grounds, equipment and supplies of any health care facility licensed or requiring a license under this act and shall have full and free access to the records of the facility and to the patients and employees therein and their records, and shall have full opportunity to interview, inspect, and examine such patients and employees."

Based on observation, and staff (EMP) interview, the agency failed to maintain standards required by the Commonwealth. The agency failed to be subject to an unannounced inspection by authorized representatives of the Department.

Findings included:

On December 12, 2019, at 9:15 a.m. surveyor arrived at agency location for unannounced state license survey (complaint investigation). No staff were present at the location, and the office doors were locked.

On December 12, 2019, surveyor phoned agency twice, once at 9:23 a.m. and again at 9:49 a.m., but the calls were unanswered. The same day at 9:54 a.m. surveyor received a voicemail message from EMP1 (assistant zone coordinator) who confirmed the office was closed today (12/12/2019) due to corporate staff meeting.

A phone interview with EMP1 on December 12, 2019, at 1:20 p.m. confirmed agency office was closed, and that hours of operation are Monday through Friday, 8 a.m. to 4 p.m.










Plan of Correction:

Our facility will remain open Monday Friday, 8:00AM - 4:00PM with staff present. If the facility intends to be unavailable within the Monday Friday 8:00AM 4:00PM timeframe, the agency will submit in writing at least 60 days prior to the commencement of such event to the Department.


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:


According to "51.3 (g)," "For purposes of subsections (e) and (f), events which seriously compromise quality assurance and patient safety include, but not limited to the following: ... (6) Complaints of patient abuse, whether or not confirmed by the facility."

Based on review of a consumer file (CR1), and the Department's event reporting system (ERS), the agency failed to report an occurrence at the agency which could seriously compromise quality assurance or patient safety. The agency failed to report an allegation of consumer neglect.

Findings included:

Review of CR1 on December 13, 2019, at 9:50 a.m. showed the following note made by agency staff, "11/8/2019: ... PS [protective services] investigator, who is looking into a report of possible neglect by CHMI [County Homemakers Inc.]."

Review of ERS was conducted on December 13, 2019, at 3:45 p.m. The reporting period queried and reviewed was from 11/01/2019 to 12/13/2019. The results revealed, "There are currently no Events for this criteria [no submission for date range]."













Plan of Correction:

Administrative Staff has been counseled regarding the requirement to report to the Department "Complaints of patient abuse/ neglect, whether or not confirmed by the facility." Such reports will be submitted in the Department's event reporting system when the agency becomes aware of it.A spreadsheet will be created to track all reportable incidents/events. Incidents reports for the office will be sent to the incident report department for approval. The incident report department will be responsible to document all reportable incidents on the spreadsheet. The Director of Services will monitor the spreadsheet to ensure the company is meeting the reportable events guidelines.


Initial Comments:

Based on the findings of an onsite unannounced complaint investigation survey completed December 13, 2019, Beaver County Homemakers 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:




611.4(c) LICENSURE
Requirements for HCA and HCR

Name - Component - 00
Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.

Observations:


Per 35 P.S. 448.813, "Authorization.--For the purpose of determining the suitability of the applicants and of the premises or for determining the adequacy of the care and treatment provided or the continuing conformity of the licensees to this act and to applicable local, State and Federal regulations, any authorized agent of the department may enter, visit and inspect the building, grounds, equipment and supplies of any health care facility licensed or requiring a license under this act and shall have full and free access to the records of the facility and to the patients and employees therein and their records, and shall have full opportunity to interview, inspect, and examine such patients and employees."

Based on observation, and staff (EMP) interview, the agency failed to maintain standards required by the Commonwealth. The agency failed to be subject to an unannounced inspection by authorized representatives of the Department.

Findings included:

On December 12, 2019, at 9:15 a.m. surveyor arrived at agency location for unannounced state license survey (complaint investigation). No staff were present at the location, and the office doors were locked.

On December 12, 2019, surveyor phoned agency twice, once at 9:23 a.m. and again at 9:49 a.m., but the calls were unanswered. The same day at 9:54 a.m. surveyor received a voicemail message from EMP1 (assistant zone coordinator) who confirmed the office was closed today (12/12/2019) due to corporate staff meeting.

A phone interview with EMP1 on December 12, 2019, at 1:20 p.m. confirmed agency office was closed, and that hours of operation are Monday through Friday, 8 a.m. to 4 p.m.








Plan of Correction:

Our facility will be open, staffed and available to the Department Monday Friday, 8:00AM 4:00PM for the purpose of determining the suitability of the applicants and of the premises or for determining the adequacy of the care and treatment provided or the continuing conformity of the licensees to this act and to applicable local, State and Federal regulations to visit, inspect the building, grounds, equipment, and supplies and shall have full access to the records of the facility and to the patients and employees therein and their records and shall have full opportunity to interview, inspect, and examine such patients and employees.


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 direct care worker personnel files (PF), consumer files (CF), and staff (EMP) interview, the agency failed to ensure the direct care worker met minimum competency requirements for one (1) of one (1) personnel file (PF1) reviewed who cared for a consumer using a mechanical lift (CR1).

Findings included:

Review of CR1 on December 13, 2019, at 9:50 a.m. revealed start of service was 2/9/2019. Review of CR1's "Patient Profile [notes]" showed that beginning on 10/8/2019 agency helped CR1 acquire a mechanical lift (also known by brand name Hoyer) due to recent fall, and the agency's no manual lift policy above 15 pounds. On 11/7/2019, PF1 was using a Hoyer lift to transfer the patient in and out of the shower.

Review of PF1 on 12/13/2019 at 11:03 a.m. showed he/she was hired on 9/9/2019, and began working with CR1 on 9/27/2019. PF1 did not contain documentation to show agency provided Hoyer lift training to PF1 or evaluated his/her competency to use such lift.

Interview with EMP1 on December 13, 2019, at 11:08 a.m. confirmed PF1 used Hoyer lift to transfer the patient beginning 11/7/2019, and PF1 did not contain documentation to show Hoyer lift training or competency.

Interview with PF1 (EMP2) on December 13, 2019, at 1:05 p.m. confirmed he/she was not provided Hoyer lift training or competency review by the agency.











Plan of Correction:

Our facility will require any employee that will be operating a mechanical lift for the purpose of transferring a Consumer to complete a mechanical lift training. The training will be provided in written form and "hands on" with administration staff who has already been determined to be competent in using the lift. The employee must be evaluated as competent to use the lift safely.The Referral Center has been counseled on the new mechanical lift training requirement. The Referral Center will identify any new consumers we will be providing care to that require the use of a mechanical lift and will work with the Director of Service to ensure that all employees working with the Consumer are trained and deemed competent to work with the new Consumer. The Zone Coordinator has also been counseled on the new mechanical lift training requirements. The Zone Coordinator will be responsible to monitor schedules for the Consumers who use a mechanical lift to ensure that all PCAs working with that Consumer have received the training course to include the hands-on training.


611.55(e) LICENSURE
Competency Requirements

Name - Component - 00
(e) The home care agency or home care registry also shall include documentation in the direct care worker's file that the agency or registry has reviewed the individual's competency to perform assigned duties through direct observation, testing, training, consumer feedback or other method approved by the Department or through a combination of methods.

Observations:


Based on review of direct care worker personnel files (PF), consumer file (CF1), and staff (EMP) interview, the agency failed to maintain documentation in the personnel file to show it reviewed the direct care worker's competency to perform assigned duties for one (1) of one (1) personnel file (PF1) reviewed who cared for a consumer using a mechanical lift.

Findings included:

Review of CR1 on December 13, 2019, at 9:50 a.m. revealed start of service was 2/9/2019. Review of CR1's "Patient Profile [notes]" showed that beginning on 10/8/2019 agency helped CR1 acquire a mechanical lift (also known by brand name Hoyer) due to recent fall, and the agency's no manual lift policy above 15 pounds. On 11/7/2019, PF1 was using a Hoyer lift to transfer the patient in and out of the shower.

Review of PF1 on 12/13/2019 at 11:03 a.m. showed he/she was hired on 9/9/2019, and began working with CR1 on 9/27/2019. PF1 did not contain documentation to show agency provided Hoyer lift training to PF1 or evaluated his/her competency to use such lift.

Interview with EMP1 on December 13, 2019, at 11:08 a.m. confirmed PF1 used Hoyer lift to transfer the patient beginning 11/7/2019, and PF1 did not contain documentation to show Hoyer lift training or competency.

Interview with PF1 (EMP2) on December 13, 2019, at 1:05 p.m. confirmed he/she was not provided Hoyer lift training or competency review by the agency.







Plan of Correction:

Our facility will require any employee that will be operating a mechanical lift for the purpose of transferring a Consumer to complete a mechanical lift training. The training will be provided in written form and "hands on" with administration staff who has already been determined to be competent in using the lift. The employee must be evaluated as competent to use the lift safely. The documentation of the training will be maintained in the employee's personnel file.The Referral Center has been counseled on the new mechanical lift training requirement. The Referral Center will identify any new consumers we will be providing care to that require the use of a mechanical lift and will work with the Director of Service to ensure that all employees working with the Consumer are trained and deemed competent to work with the new Consumer. The Zone Coordinator has also been counseled on the new mechanical lift training requirements. The Zone Coordinator will be responsible to monitor schedules for the Consumers who use a mechanical lift to ensure that all PCAs working with that Consumer have received the training course to include the hands-on training. The ZC will audit the employees' file to ensure documentation that proves training and competency is present.