Initial Comments:
Based on the findings of an onsite unannounced home care agency complaint survey conducted on May 9, 2024 and offsite on May 14, 2024, May 16, 2024, and May 17, 2024, Red Lion Home Care, Inc., 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 on a review of consumer files (CF) and an interview with the president and director of compliance, the agency failed to provide services per service agreement with reasonable accommodation of individual needs and preferences for one (1) of three (3) CF's reviewed, (CF #1).
Findings include:
A review of CF's was conducted on May 9, 2024 at 10:25 AM, May 15, 2024 from 8:00 AM to 9:00 AM, and May 17, 2024 from 8:30 AM to 9:00 AM.
CF #1. Start of Care: 8/24/2023. Receives services authorized for eight (8) hours per day, five (5) days per week, Monday through Friday.
A review of Electronic Visit Verification (EVV) documentation via HHAeXchange software application revealed the following:
Shifts are labeled as 8:30 AM to 4:30 PM. All visits were documented and verified for the entire shift worked except for the following:
August 2023:
8/15/2023: Missed shift without documented for missed shift.
8/21/2023: Missed shift without documented for missed shift.
8/23/2023: Missed shift without documented for missed shift.
8/24/2023: Missed shift without documented for missed shift.
8/31/2023: Missed shift without documented for missed shift.
September 2023:
9/5/2023: Missed shift without documented for missed shift.
9/11/2023: Missed shift without documented for missed shift.
9/12/2023: Missed shift without documented for missed shift.
9/18/2023: Missed shift without documented for missed shift.
9/27/2023: 8:30 AM to 1 PM, missing three (3) hours and thirty (30) minutes with documented reason for early end of shift.
9/28/2023: Missed shift without documented for missed shift.
October 2023:
10/2/23: 8:30 AM to 1:00 PM, missing three (3) hours and thirty (30) minutes without documented reason for early end of shift.
10/3/23: 9 AM to 4:30 PM, missing thirty (30) minutes without documented reason for the late start of shift.
10/4/2023: 8:30 AM to 1 PM, missing three (3) hours and thirty (30) minutes has documented reason for early end of shift.
10/9/2023: 10 AM to 4:30 PM, missing one (1) hour and thirty (30) minutes has documented reason for late start of shift.
10/11/2023: Missed shift without documentation for missed shift.
10/17/2023: 8:30 AM to 12:30 PM, missing four (4) hours; consumer requested coverage until 12:30 PM only.
10/20/2023: Missed shift without documentation for missed shift.
10/23/2023: Missed shift without documentation for missed shift.
10/25/2023: 8:30 AM to 1 PM and 2:15 PM to 4:30 PM, missing one (1) hour and fifteen (15) minutes without documentation for the missing time.
10/26/2023: 10 AM to 4:30 PM, missing one (1) hour and thirty (30) minutes without documentation for the late start of shift.
November 2023:
11/1/2023: Missed shift without documentation for missed shift.
11/2/2023: Missed shift without documentation for missed shift.
11/3/2023: 8:30 AM to 2:45 PM, missing one (1) hour and forty-five (45) minutes. Last day with agency. Consumer requested caregiver be removed from case.
There is no documentation provided to show if agency attempted to provide alternative staffing.
An interview with the president and director of compliance on May 9, 2024 at approximately 11:00 AM confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for those individuals and/or practices identified in the deficiency statements?
For the individuals identified in the deficiency statements, we have gone back and recreated the explanations for why the shifts were missed, as well as what actions were performed by the Case Manager to try to provide alternate staffing. This information has been documented and archived in the Patient's file.
For the practices identified in the deficiency statements (failure to document why shift was missed; failure to document steps performed in attempting to provide alternate staffing), we have created a new Policy. In the past, we did not make clear to our Case Manages the proper protocol for when a shift was not serviced. This led to an inconsistency in which these matters were documented, with some Case Managers providing proper documentation, while others simply deleted the non-serviced shifts from our Calendar.
The new Policy (provided in full below) makes clear that whenever a shift is missed, it must NOT be deleted. In our system, the proper circumstance is to edit the shift to indicate that it was UNASSIGNED. (In order to edit a shift in this fashion, Reason Codes must be provided.)
MEMORANDUM
TO: All Red Lion Case Managers
From: Stuart Race, CEO
Date: 6/11/24
Re: Documenting Missed Shifts
As you are all aware, in the course of any given week, shifts are missed for numerous reasons. (refusal of service, hospital stay, et. al.) In the past, when this has occurred, many of these shifts have been simply deleted from the Calendar. This will no longer be something that is allowed to occur.
Going forward, any shift that is unserviced for ANY reason must be marked as UNASSIGNED in Axis.
To do so, you will need to provide a Reason Code indicating why the shift was unserviced.
In circumstances where the shift was missed due to a staffing issue, you must go into the Notes section of the Patient's file in Axis and document all of the steps that were taken (by you) to provide alternate staffing.
This is a compliance requirement. Failure to follow the instructions in this policy may result in discipline, including, but not limited to termination.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
Going forward, each week, our Operations Department will run a report that compares each Patient's Schedule (prescribed visits) to our Calendar (actual visits). In this report any visits that appear in the Schedule but do not appear in the Calendar were deleted. In this fashion, if a Case Manager ignores the new policy that requires unserviced visits to be marked Unassigned, and, instead, simply deletes them, we will know within the next week.
3. What measures (actions/forms/system changes, etc.) will be put in place to ensue that the deficient practice does not recur.
Unfortunately, there is no way to ensure that the deficient practice will not recur. If a Case Manager goes rogue and ignores the new policy/protocol set forth in the answer to #1 and deletes unserviced shifts, the deficient practice will occur.
In the same way, however, that the report referenced in the answer to #2 will work to identify other individuals having the potential to be affected the deficient practice, it will also ensure that our Compliance Department becomes aware of the "rogue" Case Manager within a few days of the incident occurring.
In these circumstances, we would be able to identify the deleted visits, recreate them in the Calendar, and edit them to reflect Unassigned with Reason Codes within, at the most, about one week of the occurrence.
Then we would deal with the Case Manager.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur. i.e. what quality assurance programs will be established/followed? Identify by position (no names, just title) who will be responsible for such monitoring and what forms or tools will be completed/retained to measure/substantiate the monitoring performed and frequency of monitoring.
Reference the report cited in the answers to #2 and #3: This weekly report will be available on the Monday after the service week has closed and will provide immediate feedback on what if any shifts were deleted (as opposed to edited Unassigned).
The production of the report will be the Quality Assurance Program.
The report will be produced internally by one of the Agency's Operations Department admins.
Any failures on the part of the Case Managers will immediately be reported to the Deputy Director of Compliance.
The re-creation of the visits referenced in the answer to #3 will be performed in Operations, including the interview with the Case Manager to determine why the shift was missed, and, in cases that involve a staffing issue, what steps were taken to provide alternate staff.
The adjustments to the Patient's file will be made by the Operations admin.
5. Date of when corrective action will be completed.
7/1/24
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