Based on the findings of an unnanounced onsite complaint investigation began November 16, 2022 and completed offsite on November 18, 2022 Brightstar Care of Southeastern PA was found not to be in compliance with the 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:
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.
Based on a review of consumer files (CF), agency documentation, and consumer service agreement, the agency failed to ensure the consumer received services with reasonable accommodation of individual needs and preferences for one (1) of three (3) consumer files reviewed (CF 1).
A review of Consumer files, schedules, and visit logs was conducted onsite on 11/16/22 between approximately 11:00 am to 1:21 pm..
Review of agency service agreement signed on 8/22/22 revealed CF1 to receive scheduled services from 800 am to 1230 pm and 400 pm to 800 pm Monday through Sunday.
Review of HHAeXchange Authorization (Managed Care Organization electronic DCW time record) revealed that CF1 was to receive waiver coverage for, " ...60 hours per week between 8/29 - 12/31/2022, 4290 units Meal prep, housekeeping, finance&med cueing, shopping, transportation, bathing, hygiene, dressing, locomotion, weight bearing transfers/mobility, toileting ... "
11/17/22 Review of CF1 Schedule and correlating missed visit log noted:
9/11/22 - 9/17/22 CF1 documentation of 45.25 hours of service with partial missed shifts on 9/13 and 9/14.
A review of the 9/13/22 missed visit log noted, " ...(agency employee) Removed from the schedule. Called CS to let her know that (agency employee) wouldn ' t be coming back, it wasn ' t a good fit and would work on finding another replacement. " No recorded service hours for 9/13/22 4pm to 8pm shift.
A review of the 9/14/22 missed visit log noted, " CS called this morning ...to see if any staff was found for this evening. I informed her not at this time. (Agency employee) was on for Thursday. She (CS) said okay that she would be fine. " No recorded service hours for 9/14/22 4pm to 8pm shift.
9/18/22 - 9/24/22 CF1 documentation of 47.5 hours of service with partial missed shifts on 9/22 and 9/23.
A review of the 9/22/22 missed visit log noted, " CS called in with agency employee A stating that she didn ' t want Agency employee B back ...she (Agency employee B) is the one 4-8 on weekends and we have been having a hard time finding new staff ...(CS) said she would be fine tonight and not to send her as long as agency employee A is coming in the morning she will be fine tonight without staff. Schedule deleted. " No recorded service hours for 9/22/22 4pm to 8pm shift.
A review of the 9/23/22 missed visit log noted, " CS called to say the aide wasn ' t there yet ...called (aide) no answer, left a message, told CS I would keep trying to reach her and a replacement, if she (aide) showed up to call us. CS said she would and if not she was ok, had a pull up on and had food to eat. " No recorded service hours for 9/23/22 4pm to 8pm shift.
9/25/22 - 10/1/22 CF1 documentation of 20.75 hours of service with missed shifts on 9/26, 9/27, 9/28, 9/29, 9/30, and 10/1.
A review of the 9/25/22 missed visit log noted, " (agency employee A) called off for Monday shift ... (agency employee K) agreed to cover 9-1, informed CS schedule updated. " No recorded service hours for the 9/26/22 4 to 8pm shift.
A review of the 9/27/2022 missed visit log noted, " (agency employee A) called off for morning shift, spoke with CS informed her of call off, she said she was up in her wheelchair and would be fine for a couple of hours while we looked for someone. " No recorded service hours for any shifts on 9/27/22.
A review of the schedule for 9/29/22 noted no recorded service hours for the 4-8pm shift. No documentation regarding the missed hours was within the missed visit log.
A review of the schedule for 9/30 and 10/1 noted no recorded service hours for any shifts. A review of the missed visit log documented, " ... (agency employee S) called off for first scheduled shift 9/30 @ 4pm. Called off for all shifts till Monday ... "
10/2/22-10/8/22 CF1 documented 39.75 hours of service with missed shifts on 10/2, 10/3, 10/6, and 10/8
A review of the schedule for 10/2/22 noted no recorded service hours. 9/30/22 missed visit log noted, " ... (agency employee S) Called off for all shifts till Monday (10/2). "
A review of the 10/3/2022 missed visit log noted, " (Agency Employee A) called in to say she wouldn ' t return to CS anymore ... (Agency Employee A) Removed from schedule. " No recorded service hours for the 10/3/2022 4pm - 8pm shift.
A review of 10/6/22 schedule noted a partial morning shift. Missed visit log documentation noted, " I (agency employee) told (agency employee N) to gather her things and make sure CS was safe and leave ... "
A review of the schedule for 10/8/22 lacked documentation of a 4 hour morning shift. Missed visit log documentation noted, " EE (Agency employee) no showed for shift today at 9 am ... "
10/9/22-10/15/22 CS received 42.5 hours of service with missed shifts on 10/9 and 10/10.
A review of the schedule for 10/9 and 10/10 revealed no recorded service hours. Missed visit log documentation on 10/9 noted, " EE (agency employee) no showed for shift today at 9am ... " Missed visit log documentation on 10/10 read, " EE (agency employee) NCNS (no call no show) for scheduled shift at 9am ... "
An interview with EMP4, the agency administrator, on 11/16/22 at approximately 1:30pm confirmed the above findings.
Plan of Correction:
Based off the review of findings: Two Current Policies will be updated.
A. Policy #4 - Service Agreement Policy will be updated to include the following: #5. 5. The client and/or the responsible party must place a backup on the emergency contact form. Once form is returned to the office, The Branch Manager and/or designated office staff will contact the said emergency contact/backup and responsible party to introduce ourselves as the consumers PAS Agency and ensure their cooperation as their backup in case of an emergency.
B. Policy number #19 Inability to Reach a Client or Replacement Caregivers Not Reporting for Duty
#4. In the instance where a caregiver has called off and/ or does not report for duty (no call/no show) or there is a late call-off for client care and no back up caregiver is able to be found, the client will be informed to utilize their back up plan for care. Based of the client's priority code determined by a RN at their assessment,
a. If the client is a priority 1 and care can not be provided by the agency, the clients emergency contact will be notified, their responsible party and if no answer and/or not able to provide necessary care accommodations, The office staff will immediately dispatch local EMS by dialing 911 to ensure the clients care and safety needs are met until care can be resumed in the home.
b. If the client is a priority 2 and care can not be provided by the agency within 24-48 hours, the clients emergency contact will be notified and/or their responsible party and if no answer and/or not able to provide necessary care accommodations, The office staff will immediately dispatch local EMS by dialing 911 to ensure the clients care and safety needs are met until care can be resumed in the home.
c. If the client is a priority 3 and care can not be provided by the agency after 72 hours, the office staff will contact the clients emergency backup and/or responsible party to inform of current situation.
Policies will be updated by 12/01/2022 and implemented with all office staff. Sign off forms showing acknowledgement of updated policies will be kept on file.