Initial Comments:
Based on the findings of an onsite unannounced complaint survey completed April 9, 2024 Abraham Home Care was found not to be in compliance with the following 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:
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:
Per 35 P.S. 448.813, "Authorization.--For the purpose of determining the suitability of the applicants and of the premises or for determining the adequacy of the care and treatment provided or the continuing conformity of the licensees to this act and to applicable local, State and Federal regulations, any authorized agent of the department may enter, visit and inspect the building, grounds, equipment and supplies of any health care facility licensed or requiring a license under this act and shall have full and free access to the records of the facility and to the patients and employees therein and their records, and shall have full opportunity to interview, inspect, and examine such patients and employees."
Based on observation, and staff (EMP) interview, the agency failed to maintain standards required by the Commonwealth. The agency failed to be subject to an unannounced inspection by authorized representatives of the Department.
Findings included:
Surveyor attempted to conduct unannounced on-site complaint survey at the agency's registered location (5817 Penn Ave Pittsburgh, PA) on 3/11/24 at 10:28 a.m. open hours posted on the agency door indicated the agency is open Monday through Friday 9:00 a.m. to 4:00 p.m. the registered phone number that was also posted on the business sign 412 677 9955 was called and message indicated number was out of services. The listed emergency contact number 412 294 2555 was called and the Administrator answered and indicated the agency was closed that day, and the office hours are Monday to Friday 9:00 a.m. to 4:00 p.m.
Surveyor attempted to conduct unannounced on-site complaint survey at the agency's registered location (5817 Penn Ave Pittsburgh, PA), on 3/26/24, at 8:30 a.m. while in route a message was left at the emergency number, on arrival at 9:00 a.m. the business was closed, the posted phone number was called and rang numerous times without picking up. Surveyor remained onsite until 9:30 a.m. with no employee appearing or calling back. At 1:23 p.m. the Administrator called and left and a voicemail, it was returned at 3:00 p.m. and the Administrator indicated he would be in the following day on 3/27/24, at 9:00 a.m.
Surveyor attempted to conduct on-site complaint survey at the agency's registered location (5817 Penn Ave Pittsburgh, PA), on 3/27/24, at 9:00 a.m. surveyor arrived on site agency was closed, both number were called, at 9:30 a.m. the surveyor left the site, the Administrator did not return calls that day.
Surveyor sent email to agency's registered email on 3/27/24 Wednesday: at 2:20 p.m. requesting the following 2 items by 4:00 p.m. the same day:
1). A list of all consumers on Service from 12/1/23 to today, with Start of Service dates and Direct Care Workers Name. Please include those currently on service, and those who discharged over this time, and discharge date if applicable.
2) A list all current employees and any that separated since 12/1/23. Please include title and hire date, and separation date if applicable.
On 4/1/24, and 11:19 a.m. the Administrator returned an email with the above information.
On Friday 4/5/24 at 2:43 p.m. the Administrator was called and indicated he would be in the office on Monday 4/8/24, at 9:00 a.m.
On Monday 4/8/24, at 7:49 a.m. the Administrator texted that he could not be there until 1:00 p.m.
On Tuesday 4/9/24, at 1:44 p.m. the Administrator confirmed that he failed to be available during the agency operating hours on the above dates and times and failed to return an email requesting information on consumers and employees for five days.
Plan of Correction:The owner of the agency has reviewed the findings from the Department of Health. The agency's office hours are Monday-Friday, 9a-4p. in the event that the office hours will change or if the office will be closed on a particular day, the agency will email the Department of Health in advance to prevent a reoccurrence of a surveyor conducting a unannounced visit and the office being unexpectedly closed. The agency will also grant access to the receptionist so that she can open the office whenever the administrator isn't available. This process will monitored by the agency's owner whenever the office is closed or the office hours are changed to ensure This plan of correction is effective. If unexpected closure due to power outage the closure will be submitted on the ERS.
611.57(a) LICENSURE
Consumer Rights
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(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 review of consumer records (CR), and staff (EMP) interview, the agency failed to ensure consumers received services with reasonable accommodation of individual needs and preferences for two (2) of three (3) consumer records reviewed (CR1 and CR2).
Findings Included:
A review of consumer records on 4/9/24 from approximately 9:41 a.m. to 1:30 p.m. revealed the following.
A review of CR1's consumer record on 4/9/24, at 9:41 a.m. indicated her Start of Service Date was 3/25/21, and the agency failed to have the consumer sign the agreement. Listed hours of Care were Sunday to Saturday 12:00 a.m. to 6:00 p.m.
A review of the HHA Exchange Authorization Agreement Authorization notes on 4/9/24, at 11:53 a.m. revealed the following:
Authorization notes for 10/4/23 to 1/20/24, indicated "hours increased from 45 to 50".
Authorization notes for 1/21/24 to 1/4/25, consumer "hours increased from 45 to 50".
A review of CR1's HHA Exchange Calendar for December of 2023, indicated that from 12/25/24 to 12/31/24, the agency had not verified/documented or completed any hours of care.
A review of CR1's HHA Exchange Calendar for January of 2024, revealed that from 1/1/24 to 1/31/24, the agency had not verified/documented or completed any hours of care.
A review of CR1's HHA Exchange Calendar for February of 2024, revealed that from 2/1/24 to 2/29/24, the agency had not verified/documented or completed any hours of care.
A review of CR1's HHA Exchange Calendar for March of 2024, revealed it was blank and the agency did not appear to be a provider for CR1 at that time.
A review of CR2"s service agreement dated 9/16/21, indicated her SOS was 9/16/21, and Listed hours of care was Monday to Friday 10:00 a.m. to 4:00 p.m.
A review of CR2's HHA Exchange Calendar for March of 2024, indicated that the Agency did not provided services on any Tuesday of the 5th ,12th , 19th and 26th of 2024. That he the agency had not verified/documented or completed any hours of service on the 22nd, 25th, 27th, 28th, and 29th of that month.
During interviews on 4/9/24 at 10:35 a.m. and 1:44 p.m. confirmed that CR2 did not want care on services on Tuesdays during March of 2024, and he did have a new service agreement or any documented communication with the consumer or services coordinator to indicate that was CR2's preference. That her caregiver quit on 3/22/24, and he had no one to provide care, so CR2 dropped his agency from services.
During interviews on 4/9/24, at 11:32 a.m. and 1:44 p.m. the Administrator confirmed that CR1 was not receiving her hours of care from the agency and he has no documentation on her missed visits, and he has no signed services agreements to list the agency hours of care on CR1.
Plan of Correction:The owner has reviewed the survey. As it pertains CR and CR2, our agency started their services during Covid, at that time we weren't doing face to face assessments. Moving forward if we're ever restricted from doing face to face assessments, again. We would send the consumer their service agreement in the mail for them to sign and return.
CR1: Although we received an authorization for 50 hours per week, the client would only allow us to service for 30. In the future if the consumer refuses all of their hours we would request a new authorization to reflect the client's requested schedule.
CR2: The participant receives a shot for their MS diagnosis that makes them really tired. Therefore they rather stay in bed all day and not receive services. We acknowledge that this issue is due to lack of documentation. We will be sure to document refused shifts in the HHA interface.
The corrective actions will be monitored by the owner of the agency to ensure that there aren't any recurrences of these deficiencies. The owner of the agency will also audit all of our consumer files to be sure that they are in compliance.
The plan of correction and the review of the rest of our consumer files will be implemented, immediately.
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