QA Investigation Results

Pennsylvania Department of Health
COMPLETE HOMECARE PA
Health Inspection Results
COMPLETE HOMECARE PA
Health Inspection Results For:


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Initial Comments:

Based upon the findings of an unannounced onsite complaint investigation survey conducted on 11/3/2020, Complete Home Care PA, was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.







Plan of Correction:




Initial Comments:

Based upon the findings of an unannounced onsite complaint investigation survey conducted on 11/3/2020, Complete Home Care PA, was found to be not 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:




611.54(a)(7) LICENSURE
Provisional Hiring

Name - Component - 00
The period of provisional hire of an individual who is and has been, for a period of 2 years or more. A resident of Pennsylvania, may not exceed 30 days. The period of provisional hire of an individual who has not been a resident of Pennsylvania for two years or more may not exceed 90 days.

Observations:


Based upon review of policy, personnel files (PF), interview with administrator ( EMP # 1), agency failed to obtain criminal background check within thirty (30) days for provisional hire of two (2) of four (4) employees. ( PF # 2, PF # 3).

Findings included:

Review of agency policy on 11/30/2020 at approximately 10:30 AM-11:30 AM titled " Criminal Background Check Requirements" stated " Provisional Hiring (h) the period of provisional hire of an individual who is and has been, for a period of 2 years or more, a resident of this Commonwealth, may not exceed 30 days."

Review of PF on 11/3/2020 between approximately 10:30 AM-11:30 AM revealed:

PF # 2, Date of Hire (DOH) 2/12/2019; Pennsylvania (PA) state police criminal history record obtained 7/17/2019 which was one hundred and sixty three (163) days past date of hire.

PF # 3, DOH 6/27/2020; Pennsylvania (PA) state police criminal history record obtained 10/20/2020 which was one hundred and fifteen (115) days past date of hire.


Interview with EMP # 1 on 11/3/2020 at approximately 3:00 PM confirmed above findings.
















Plan of Correction:

The employee will produce proof of residency or be pulled from shift until a FBI Fingerprinting check can be completed. Agency has hired a full time staff member solely focusing on compliance. The Compliance person is responsible for ensuring compliance during the hiring process and the Administrator is responsible for monitoring compliance on a biweekly basis.

A random Employee file check initiated by the Administrator will occur every 14 days with a sample of new hires to ensure ongoing compliance. The Administrator is responsible for completing random audits to ensure POC implementation is accurate

Agency is also working with a Home care consultant to come in and preform file audits to ensure we are in good standing.



Furthermore, the agency has updated QMP to reflect the goal of having reg compliant files. The random file audit check has been changed to monthly instead of quarterly.



611.55(e) LICENSURE
Competency Requirements

Name - Component - 00
The competency review must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction.

Observations:


Based upon review of policy, personnel files (PF), interview with administrator ( EMP # 1), agency failed to show evidence of an annual competency for one (1) of three (3) files reviewed. ( PF # 2).

Findings included:

Review of agency policy on 11/30/2020 at approximately 10:30 AM-11:30 AM titled " Competency Requirements" stated " (4.) competency will be measured on an annual basis..."

Review of PF on 11/3/2020 between approximately 10:30 AM-11:30 AM revealed:

PF # 2, Date of Hire (DOH) 2/12/2019; initial competency documented as completed 1/17/2019. No evidence presented annual competency was completed.



Interview with EMP # 1 on 11/3/2020 at approximately 3:00 PM confirmed above findings.












Plan of Correction:

Agency has hired a full time staff member solely focusing on compliance. The staff member is responsible for ensuring compliance during the hiring process and the Administrator is responsible for monitoring compliance on a biweekly basis.

A random Employee file check initiated by the Administrator will occur every 14 days with a sample of new hires to ensure ongoing compliance.

A full staff meeting has been scheduled for the 2nd week of December to complete annual competency training for all employees. We will also use that opportunity to obtain any missing documents for employee files.



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 upon review of consumer files (CF) and interview with administrator ( EMP # 1), agency failed to show evidence consumer was informed of ten (10) day notice of discharge for one (1) of three (3) files reviewed. ( CF # 2).

Findings included:

Review of CF on 11/30/2020 between approximately 11:30 AM- 12:30 PM and 1:00 PM-2:00 PM revealed:

CF # 2, Start of Service (SOS) 7/20/2020; no evidence consumer was given admission documents included in client intake packet. Form titled PA Consumer Notice of Direct Care Worker Status has a block at the bottom of the form stating " I have the right to receive 10 calendar days advance notice of termination of services.." This block is to be initialed by consumer at admission but was left blank and not initialed by consumer.

Interview with EMP # 1 on 11/3/2020 at approximately 3:00 PM confirmed no evidence consumer was given admission packet to review/ sign at time of admission. Administrator confirmed above findings.














Plan of Correction:

Our client intake packet is up to DOH standards, the issue is that that intake packet was not completed in a timely fashion. Agency has hired a full time staff member solely focusing on compliance. The staff member is responsible for ensuring compliance during the hiring process and the Administrator is responsible for monitoring compliance on a biweekly basis.

Agency has also developed a checklist of items that must be completed before services can begin and the use of Microsoft Teams and a client document spreadsheet will track the progress of needed items.

A random Employee file check initiated by the Administrator will occur every 14 days with a sample of new hires to ensure ongoing compliance.

A full staff meeting has been scheduled for the 2nd week of December to complete annual competency training for all employees. We will also use that opportunity to obtain any missing documents for employee files.


611.57(b) LICENSURE
Prohibitions

Name - Component - 00
(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

Observations:


Based upon review of consumer files (CF) and interview with administrator ( EMP # 1), agency failed to show evidence consumer was informed agency is prohibited from acting as guardian or power of attorney for consumer for one (1) of three (3) files reviewed. ( CF # 2).

Findings included:

Review of CF on 11/30/2020 between approximately 11:30 AM- 12:30 PM and 1:00 PM-2:00 PM revealed:

CF # 2, Start of Service (SOS) 7/20/2020; no evidence consumer was given admission documents included in client intake packet. Untitled form stating " I have been informed that no \ staff may assume power of attorney or have guardianship over me while I am a client of the company." This block is to be initialed by consumer at admission but block was left blank and not initialed by consumer.

Interview with EMP # 1 on 11/3/2020 at approximately 3:00 PM confirmed no evidence consumer was given admission packet to review/ sign at time of admission. Administrator confirmed above findings.












Plan of Correction:

Our client intake packet is up to DOH standards, the issue is that that intake packet was not completed in a timely fashion. Agency has hired a full time staff member solely focusing on compliance. The staff member is responsible for ensuring compliance during the hiring process and the Administrator is responsible for monitoring compliance on a biweekly basis.

Agency has also developed a checklist of items that must be completed before services can begin and the use of Microsoft Teams and a client document spreadsheet will track the progress of needed items.

A random Employee file check initiated by the Administrator will occur every 14 days with a sample of new hires to ensure ongoing compliance.

A full staff meeting has been scheduled for the 2nd week of December to complete annual competency training for all employees. We will also use that opportunity to obtain any missing documents for employee files.


611.57(c) LICENSURE
Information to be Provided

Name - Component - 00
(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 upon review of consumer files (CF) and interview with administrator ( EMP # 1), agency failed to show evidence consumer was given an information packet with required information for one (1) of three (3) files reviewed. ( CF # 2).

Findings included:

Review of CF on 11/30/2020 between approximately 11:30 AM- 12:30 PM and 1:00 PM-2:00 PM revealed:

CF # 2, Start of Service (SOS) 7/20/2020; no evidence consumer was given information packet including list of available services to be provided, hours services are to be provided, fees/cost of services, who to contact at the Department for licensure information, complaint hotline contact information, Ombudsman contact information, hiring and competency requirements for direct care workers (DCW) , and tax disclosure form.

Interview with EMP # 1 on 11/3/2020 at approximately 3:00 PM confirmed no evidence consumer was given admission packet to review/ sign at time of admission. Administrator confirmed above findings.









Plan of Correction:

Our client intake packet is up to DOH standards, the issue is that that intake packet was not completed in a timely fashion. Agency has hired a full time staff member solely focusing on compliance. The staff member is responsible for ensuring compliance during the hiring process and the Administrator is responsible for monitoring compliance on a biweekly basis.

Agency has also developed a checklist of items that must be completed before services can begin and the use of Microsoft Teams and a client document spreadsheet will track the progress of needed items.

A random Employee file check initiated by the Administrator will occur every 14 days with a sample of new hires to ensure ongoing compliance.

A full staff meeting has been scheduled for the 2nd week of December to complete annual competency training for all employees. We will also use that opportunity to obtain any missing documents for employee files.


611.57(d) LICENSURE
Documentation

Name - Component - 00
(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 upon review of consumer files (CF) and interview with administrator ( EMP # 1), agency failed to show evidence consumer was given admission packet to review and signature of receipt for one (1) of three (3) files reviewed. ( CF # 2).

Findings included:

Review of CF on 11/30/2020 between approximately 11:30 AM- 12:30 PM and 1:00 PM-2:00 PM revealed:

CF # 2, Start of Service (SOS) 7/20/2020; no evidence consumer was given admission documents to review and sign.

Interview with EMP # 1 on 11/3/2020 at approximately 3:00 PM confirmed no evidence consumer was given admission packet to review/ sign at time of admission. Administrator confirmed above findings.








Plan of Correction:

Our client intake packet is up to DOH standards, the issue is that that intake packet was not completed in a timely fashion. Agency has hired a full time staff member solely focusing on compliance. The staff member is responsible for ensuring compliance during the hiring process and the Administrator is responsible for monitoring compliance on a biweekly basis.

Agency has also developed a checklist of items that must be completed before services can begin and the use of Microsoft Teams and a client document spreadsheet will track the progress of needed items.

A random Employee file check initiated by the Administrator will occur every 14 days with a sample of new hires to ensure ongoing compliance.

A full staff meeting has been scheduled for the 2nd week of December to complete annual competency training for all employees. We will also use that opportunity to obtain any missing documents for employee files.

Due to 2 Administrative staff testing COVID positive back to back our office with one presumed positive the office is currently working remotely. We plan to get the intake packet completed as soon as everyone is cleared. We did sign a contract with Bolt that will allow us to electronically present and obtain signatures on intake documents.


Initial Comments:

Based upon the findings of an unannounced onsite complaint investigation survey conducted on 11/3/2020, Complete Home Care PA, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).








Plan of Correction: