Initial Comments:
Based on the findings of an offsite unannounced home care agency state re-licensure survey conducted on April 29, 2025 and May 2, 2025, 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 personnel files (PF) an, 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 2, 2025 at approximately 12:00 PM revealed the following:
CF #1. Start of Care: 4/1/2025; Receives services as authorized by UPMC for sixteen (16) hours per day seven (7) days per week. A review of consumer ' s visit calendar revealed that PF #1 worked 8 AM to 4 PM on Saturday, 4/5/2025; 8 AM to 4 PM on Sunday, 4/6/2025; 8 AM to 4 PM on Monday, 4/7/2025; and 8 AM to 4 PM on Wednesday, 4/9/2025.
A review of consumer ' s care plan states the following tasks to be completed each visit: housework/chores; shopping; transportation; hygiene; dressing upper; dressing lower; locomotion; toilet use; bed mobility; and eating.
A review of consumer ' s task list report for the above dates revealed the following:
4/5/2025: During shift 8 AM to 4 PM, no tasks were completed.
4/6/2025: During shift 8 AM to 4 PM, the following tasks were not completed: Feeding; laundry; supervision; toileting; transferring; and transportation. Carenotes state, " No notes available " .
4/7/2025: During shift 8 AM to 4 PM, no tasks were completed.
4/9/2025: During shift 8 AM to 4 PM, no tasks were completed.
An interview with the director of compliance on May 2, 2025 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 statement(s).
During our review of this issue, our agency discovered a fault within our AxisCare system failing to properly capture all ADLs for manually edited shifts. Moving forward, we will ensure that all shift ADLs are properly logged prior to our weekly shift verification and billing process.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
We will identify potential deficiencies by reviewing all active Patients to verify their care plan setup in our system aligns with the patient's intake form and service authorizations. This will ensure all pertinent ADLs are available for the caregiver to document in their mobile clock outs. Manually edited shifts and timesheets will be reviewed with this criterion.
3. What measures (actions/forms/system changes, etc.) will be put in place to ensure that the deficient practice does not recur?
On a weekly basis, our agency will send clock in/out reminders to caregivers. This reminder will emphasize the importance of completing and documenting all ADLs listed in the patient's care plan via a timesheet or our mobile app.
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.
Once we have identified and corrected any existing deficiencies, our agency will continuously review ADL documentation as part of our quarterly internal auditing process. Each quarter we will review a sample of our total patient files to determine if their documented ADLs align with their authorized care plan.
5. Date of when the corrective action will be completed.
8/1/2025
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