Initial Comments:
Based on the findings of a complaint survey completed on April 24, 2023, Senior Adult Concierge Service was found to not be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
51.3 (f) LICENSURE
NOTIFICATION
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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 Event Report #908149", it was determined the agency failed to ensure incident reporting on the Department of Health Event Reporting System, to be reported immediately after incident for one (1) out of one (1) Event Report (Event Report #908149) and failed to ensure resubmitting the Event Report after rejection from the Department for one (1) out of one (1) Event Report (Event Report #908149").
Findings include:
On 4/24/2023 at approximately 10:30 AM, review of Event Report #908149, revealed the agency to be made aware of incident in report on 2/19/2023. The incident was reported on the event reporting system on 3/6/2023, not immediately.
Event Report #908149 was rejected on 3/13/2023 for incompleteness, as of 4/24/2023 at 10:30 AM, was not yet resubmitted by the agency.
Plan of Correction:We have resubmitted the outstanding Event Reporting to the Department of Health Event Reporting System.
We are implementing a new process within our company for Event Reporting to the Department of Health Event Reporting System.
The persons that will be responsible for corrections title is,
Owner
Manager
Owner will be the first person that will be advised of any incident and will follow the written procedure of reporting all information to Department of Health Event Reporting System and Aging and Adult Systems.
First step.
As soon as we are aware of and incident, we will collect all internal incident reports and any oral notes as well.
Complete our incident report with the need corrective actions if needed.
Repot to Department of Health Event Reporting System . within the first 24 hours of and incident.
We have dedicated a staff that will monitor all reporting to Department of Health Event Reporting System and Aging and Adults Agency, for rejection of a report or follow up information and approvals of information submitted.
If rejected, we will have corrective information in 24 hours of notices.
We will complete all investigations in a timely manner and document our steps taken to ensure that are in compliance of state regulations.
Initial Comments:
Based on the findings of a complaint survey completed on April 24, 2023, Senior Adult Concierge Service was found to not 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:
611.4(c) LICENSURE
Requirements for HCA and HCR
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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:
Based on review of the "Older Adults Protective Service Act", agency Event Report #908149" and agency Incident Report #1, it was determined the agency failed to ensure reporting to the local Area on Aging office/Adult ProtectiveService office immediately after an alleged abuse incident for one (1) out of one (1) Incident Report Reviewed (Incident Report #1).
Findings include:
Review of "Older Adults Protective Service Act", on 4/24/2023 at approximately 11:00 AM states:
"10225.103. Definitions.
The following words and phrases when used in this act shall have the meanings given to
them in this section unless the context clearly indicates otherwise:
"Administrator."
The person responsible for the administration of a facility. The term includes a
person responsible for employment decisions or an independent contractor.
"Agency."
The local provider of protective services, which is the area agency on aging or the
agency designated by the area agency on aging to provide protective services in
the area agency's planning and service area.
10225.701. Reporting by employees.
(a) Mandatory reporting to agency.--
1. An employee or an administrator who has reasonable cause to suspect that a
recipient is a victim of abuse shall immediately make an oral report to the agency.
If applicable, the agency shall advise the employee or administrator of additional
reporting requirements that may pertain under subsection (b). An employee shall
notify the administrator immediately following the report to the agency.
2. Within 48 hours of making the oral report, the employee or administrator shall
make a written report to the agency. The agency shall notify the administrator that
a report of abuse has been made with the agency.
3. The employee may request the administrator to make, or to assist the employee to
make, the oral and written reports required by this subsection."
On 4/24/2023 at approximately 10:30 AM, review of Event Report #908149, revealed the agency to be made aware of incident in report on 2/19/2023. There was no documentation the agency notified the local Area on Aging office/Adult ProtectiveService office.
On 4/24/2023 at approximately 10:45 AM, review of Incident Report #1, revealed allegations of "indecent exposure" and of Direct Care Worker #1 "playing with himself in presence of client" (Consumer #1), occuring on 2/18/23, with the agency writing their follow-up action on 2/21/2023. There was no documenation of the agency notifying the local Area on Aging office/Adult ProtectiveService office of the allegation.
Plan of Correction:As part of our Company reporting process, our dedicated staff member will be responsible for reporting any individual incident to the Mandatory reporting agency of Aging and Adult Agency within immediately hours of notices of an incident.
Our dedicated staff member will submit all reports, oral and written. To the local agency that the incident happens in.
As well as making sure that Department of Health Event Reporting System is also send the incident report as well within the first 24 hours.
Our staff will also be trained and given a refresher course on what issues are considered Mandatory for reporting to all departments. Department of Health Event reporting System and Aging and Adults.
We have reported the incident to Aging and Adult Services and resubmitted to the Department of Health Event Reporting System.
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
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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 upon personnel file review and an email from the agency administrator, it was determined the agency failed to ensure documentation of two satisfactory references for direct care workers prior to hire for four (4) out of four (4) personnel files (PF) reviewed (PF#1- PF#4).
Findings include:
Personnel files were reviewed on 4/24/2023 from approximately 8:30 AM-9:30 AM revealing the following:
PF#1 (Date of hire (DOH) 6/15/2022): No documentation of two satisfactory reference checks.
PF#2 (DOH: 2/10/2023): No documentation of two satisfactory reference checks.
PF#3 (DOH: 5/13/2022): One (1) documented reference check in personnel file, not two (2).
PF#4 (DOH: 2/06/2023): No documentation of two satisfactory reference checks.
An email received from the agency administrator on 4/20/2023 at approximately 4:39 PM states "I would give them paperwork to fill out and I have not consistently gather all needed information. "
Plan of Correction:As stated, before per covid, we had a Pre-Associates Checklist. We will be utilizing this paper again to ensure that all paperwork and testing is completed upon assigning to case.
Owner
Manager
1. Face to Face interview.
2. Contact Date/Source.
3. Additional Interview Notes and Date.
4. References Contacted, Name and date
contacted. with 3 of them.
5.Applicant Status (Hire, Not Hire, Type of Employee, Regular, Temporary).
6. Position Type (Full Time, Part Time).
7.Available Start Date.
8. Official Start Date.
9.All Senior Adult Concierge Service Associates will need to provide a copy of the below. We will ask for update information periodically and on yearly basis.
This is the information. on the form that will be collected at interview.
1. First Name and Last Name/ Driver Licenses/ State ID. yes/ no/ date completed.
2. Social Security Card. yes/ no/ date completed.
3.PA State police Background check. yes/ no/ date completed.
4. CNA Certificate/MA Certificate/ HHA Certificate/ List of any other Certificate or Verification Form. yes/ no/ date completed.
5. PA State Competency Test. yes/ no/ date completed.
Interviewer signature and date.
As part of the correction action I have done the two references checks for the direct care staff I didn't have the information for.
611.52(a) LICENSURE
Criminal Background Checks
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The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.
Observations:
Based upon personnel file review and an email from the agency administrator, it was determined the agency failed to ensure each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application for four (4) out of four (4) personnel files (PF) reviewed (PF#1- PF#4).
Findings include:
Personnel files were reviewed on 4/24/2023 from approximately 8:30 AM-9:30 AM revealing the following:
PF#1 (Date of hire (DOH) 6/15/2022): Pennsylvania State Police Background Check dated 3/04/2023, 8 months and 17 days after hire.
PF#2 (DOH: 2/10/2023): Pennsylvania State Police Background Check dated 3/08/2023, 26 days after hire.
PF#3 (DOH: 5/13/2022): Pennsylvania State Police Background Check dated 3/04/2023, 9 months and 19 days after hire.
PF#4 (DOH: 2/06/2023): Pennsylvania State Police Background Check dated 3/22/2023, 44 days after hire.
An email received from the agency administrator on 4/20/2023 at approximately 4:39 PM states " I would give them paperwork to fill out and I have not consistently gather all needed information. "
Plan of Correction: We have implemented our Pre- Associates Checklist. No one will be hired without all the proper steps completed on the Pre- Associates Checklist and Background checks in hand.
Owner
Manager
We are now able to do all background with our mobile devices and back Grounds can be done on spot of interview.
We check background one a year and have advice staff if there's a change in there background we are to be adviced immediately.
We have updated the background checks for direct care staff.
All background, reference checks, and testing will be completed before any New direct care worker will be sent out to care for any consumer.
We will use the Temple University Direct Care Staff Training and Competency test as well as AxisCare training to keep staff in compliance with state laws of compensate regulations.
We are also looking into Stat Training programs to keep staff in good standing. and informed of new updates changes in the home healthcare field.
611.55(a) LICENSURE
Competency Requirements
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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 upon personnel file review and an email from the agency administrator, it was determined the agency failed to ensure the agency's direct care worker to have completed a satisfactory competency prior to assignment for three (3) out of four (4) personnel files reviewed (PF#2-PF#4).
Findings include:
Personnel files were reviewed on 4/24/2023 from approximately 8:30 AM-9:30 AM revealing the following:
PF#2 (Date of hire (DOH): 2/10/2023): No documentation of a satisfactory competency.
PF#3 (DOH: 5/13/2022): Competency dated 2/26/2023, not at the time of hire.
PF#4 (DOH: 2/06/2023): PF contained a completed exam answer sheet dated 2/05/2023 with no grade to determine if competent. No copy of the test present to determine if test contained required topics.
An email received from the agency administrator on 4/20/2023 at approximately 4:39 PM states " I would give them paperwork to fill out and I have not consistently gather all needed information. "
Plan of Correction:The current roster is using the Temple University Harrisburg Direct Care Staff Training Competency Test.
Those we have had some problem logging on for the new Temple University Direct Care Test, we will make sure that the testing is completed and meets PA Dept of Health regulations.
Owner and Manager will be
responsible for implementing the plan of correction.
All current staff have a Competency test in file.
As well as AxisCare training and looking to start the Stat Training for ongoing training to keep the roster staff in compliance of competency training and new information to Home Health Aide staff.
611.57(c) LICENSURE
Information to be Provided
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(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 consumer file (CF) review and an email from agency administrator, it was determined the agency failed to ensure, prior to the commencement of services, the consumer, the consumer's legal representative or responsible family member was provided with the following information: 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, The hours when those services will be provided, and The hiring and competency requirements applicable to direct care workers for one (1) out of three (3) consumer files reviewed (CF#2)
Findings included:
CF#1-CF#3 were reviewed on 4/24/2023 from approximately 9:30 AM-10:30 AM revealing the following.
CF#2 (Start of care (SOC): 11/01/2022): No documentation of 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, The hours when those services will be provided, and The hiring and competency requirements applicable to direct care workers present in the file.
An email received from the agency administrator on 4/20/2023 at approximately 4:39 PM revealed the above information to be left in CF#2's residence.
Plan of Correction:Our Service Agreement and Acknowledgment on the first page it shows the daily services that the client would check off to have performed daily.
Owner and Manager are responsible for the monitoring and implementation of the plan of correction.
Consumer files are in a secure file cabinet.
We will maintain a copy of all consumer information packet onsite at office 322 Walnut Street Phoenixville Pa 19460. As well we will keep all files for 7 years.
I will email a copy of service agreement so that you can see the details.
The second paper states the Financial Guaranty agreement.
1. type of charge. Holidays, Minimum Hours, Days and Hours to be Worked, Hourly Rate, etc...
A total of the hours and days of the week are in the bottom two boxes on this page as well.
All clients are also given a welcome booklet that has all the required information that the state requires all agency to provide all consumers with.
611.57(d) LICENSURE
Documentation
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(d) The home care agency or home care registry shall maintain documentation on file at the agency or registry of compliance with the requirements of this section which shall be available for Department inspection.
Observations:
Based on consumer file (CF) review and an email from agency administrator, it was determined the agency failed to ensure documentation required in the consumer file to be stored at the agency for one (1) out of three (3) consumer files reviewed (CF#2)
Findings included:
CF#1-CF#3 were reviewed on 4/24/2023 from approximately 9:30 AM-10:30 AM revealing the following.
CF#2 (Start of care (SOC): 11/01/2022): No documentation of 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, The hours when those services will be provided, and The hiring and competency requirements applicable to direct care workers present in the file.
An email received from the agency administrator on 4/20/2023 at approximately 4:39 PM revealed the above information to be left in CF#2's residence.
Plan of Correction: Our plan for current Client and Personnel files will be kept in individual folder which will be kept in a secure file cabinet. At our home office.
Owner and Manager will be responsible for monitoring and maintaining all current files.
All clients have a book in their homes that have a list of duties that are to be performed daily. There are care notes, notes paper for notes, a cleaning list for the month, BM sheet, daily meal planning, Dr. Appt., shopping and errands.
We have setup AxisCare which has everything on it. We plan to use this and the paper book as backup only one everyone has login to the new system. this system has, Login and out, ADL's, Care plan, Notes, Geo mapping, trainings, updating of changes to personal records, etc... And we have already started it.
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