QA Investigation Results

Pennsylvania Department of Health
CARESENSE HOME CARE
Health Inspection Results
CARESENSE HOME CARE
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced state complaint survey completed offsite on November 17, 2023, Caresense Home Care was found not to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.






Plan of Correction:




51.3 (f) LICENSURE
NOTIFICATION

Name - Component - 00
51.3 Notification

(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.

Observations:

Based on a reviews of the electronic reporting system (ERS), consumer files (CF), and staff (EMP) interview, the agency failed to report an event within 24 hours of discovery that seriously compromised quality assurance and patient safety for one (1) of three (3) files reviewed (CF1)

Findings Include:

CF1 Start of Service (SOS) 2/8/23, review of Schedule and Plan of Care indicated the agency would provide 16 hours of care a day on the 11:00 p.m. to 7:00 a.m. and 7:00 a.m. to 3:00 p.m. shifts, by his Direct Care Worker (DCW) EMP 4.

Review of agency notes completed by EMP 1 Branch Manager dated 10/30/23, at 2:48 p.m. indicated they received call from CF1's sister to make us aware of CF1's passing and ask why DCW EMP4 was not there on Sunday? The sister also confirmed she was working with the police regarding his death... the sister stated she was shocked to learn her brother passed away from a heroin overdose.

Review of agency notes completed by, EMP 1 Branch Manager notes dated 10/30/23, not timed, indicated EMP 3 Staffing Coordinator had been trying to get a hold of CF1's Direct Care Worker (DCW) EMP 4 all day due to no clock in or outs since 10/29/23. That DCW EMP4 did call sometime around 5:00 p.m. and stated she had been sick ... and stated that she had not been to the CF1's residence since 10/24/23. DCW EMP4 stated the client felt bad for her she and offered to clock her in/out and she could give him $200.00 for doing it ... EMP1 Branch Manager asked if this ever happened before, and DCW EMP4 stated it happened once before, but could not recall any months or date etc... EMP 1 Branch Manager explained this was fraud and she was immediately terminated.

During an interview on 11/16/23, at 12:45 p.m. EMP1 Branch Manager confirmed that the agency did not report the above event into ERS, and they still did not have contact information for the police.




Plan of Correction:

1. For CF1#, Branch Manager reported the incident through the Department of Health, Event Reporting System.
2. In the future, Branch Manager will ensure that all incidents are entered immediately through the Department of Health, Event Reporting System.
3. Regional Manager will train all office staff in incident reporting and timely reporting to ensure that the deficient practice does not recur
4. Branch Manager will audit 25% of consumer files every 6 months to monitor that the deficient practice will not recur. Documentation will be in consumer HHAx charts.
5. Corrective action plan will be completed by 12/30/2023



Initial Comments:

Based on the findings of an onsite unannounced state licensure complaint survey completed November 17, 2023, Caresense Home Care 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:




611.52(c) LICENSURE
Federal Criminal History Record

Name - Component - 00
If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code 15.144(b) (relating to procedure).

Observations:

Based on review personnel files (PF), and Branch Manager interview, the agency did not obtain a federal criminal history record for one of three personnel files reviewed (PF4).

Findings include:

A review of employee personnel files (PF) was completed on 11/15/23, from approximately 12:52 p.m. to 2:56 p.m..

PF4 Date of Hire 10/7/21 , review of State Patch dated 10/1/21, indicated please confirm identifiers provided. Positive Identification cannot be made without fingerprints the Pennsylvania state police response does not preclude the existence of criminal records, which might be contained in the repositories of other local, state, or federal criminal justice agencies. The PF did not contain fingerprints.

During an interview on 11/15/23, at 2:56 p.m. the Branch Manager confirmed the above findings





Plan of Correction:

1. PF4# is no longer employed with CareSense.
2. Branch Manager will conduct employee file audit make sure no other individuals have been affected by the same deficient practice. Documentation of audit will be in employee files.
3. HR Manager will audit all new employees files, before starting, to ensure that if they have lived in PA for 2 years they have a FBI fingerprint.
4. Branch Manager will audit 25% of employee files every 6 months to monitor that the deficient practice will not recur. Documentation will be in employee files.
5. Corrective action plan will be completed by 1/16/2023



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 review of consumer files (CF), and staff interview (EMP), the agency failed to ensure consumers received reasonable accommodation of needs and preferences for two (2) of three (3) consumer files reviewed (CF1 and 2).

Findings include:

Review of consumer files on 11/16/23 from 11:40 a.m. to 1:10 p.m. revealed:

CF1 Start of Service (SOS) 2/8/23, review of Schedule and Plan of Care indicated the agency would provide 16 hours of care a day on the 11:00 p.m. to 7:00 a.m. and 7:00 a.m. to 3:00 p.m. shifts, by his Direct Care Worker (DCW) Emp 4.

Review of CF1's HHAExchange clock in hours by EMP4 DCW revealed on 2/8/23, she clocked in at 11 p.m. and then clocked out at 3:00 p.m. on 2/9/23, a total of 16 consecutive hours, further review revealed that EMP4 continued to clock 16 work days consecutively with no days off for the next 259 days, until 11/24/23.

CF2 SOS 7/30/19, review of agency supplied client roster on 11/16/23, revealed the agency is currently providing CF2 24 hours of care daily.

CF2, HHA Exchange clock in hours reviewed from August to October of 2023, by DCW EMP5 revealed the following:

Clocked in on 8/2/23, at 8:00 p.m., then clocked out on 8/4/23, at 8:00 a.m. a total of 36 consecutive hours.

Clocked in on 8/8/23, at 8:00 p.m., then clocked out on 8/12/23, at 8:00 a.m. a total of 60 consecutive hours.

Clocked in on 8/16/23, at 8:00 p.m. then clocked out on 8/19/23, at 8:00 a.m. a total of 60 consecutive hours.

Clocked in on 9/6/23, at 8:00 p.m. then clocked out on 8/8/23, at 12:00 a.m. a total of 52 consecutive hours.

Clocked in on 9/13/23, at 8:00 p.m. then clocked out on 8/16/23, at 12:00 a.m. a total of 52 consecutive hours.

Clocked in on 9/28/23, at 12:00 a.m. then clocked out on 9/30/23, at 8:00 a.m. a total of 52 consecutive hours.

Clocked in on 10/10/23, at 8:00 a.m. then clocked out on 10/13/23, at 8:00 a.m. a total of 72 consecutive hours.

Clocked in on 10/26/23, at 12:00 a.m. then clocked out on 11/1/23, at 12:00 a.m. at total of 144 consecutive hours.

During an interview on 11/16/23, at approximately 1:00 p.m., EMP 1 Branch Manager and EMP 3 Staffing Coordinator confirmed that they allowed DCW EMP 4 to clock 259 16 hour days in a row, until they interviewed EMP 4 on 10/30/23, and she admitted to having the CF1 clock hours for her in exchange for giving him $200.00. EMP 2 Staffing Coordinator confirmed that they let DCW EMP 5 clock extended hours at CF2's by letting EMP 2, sleep in a chair next to CF2's bed.




Plan of Correction:

1. Staff will be retrained in the importance of delivering care according to consumer needs and preferences. Backup staff will be identified.
2. Branch Manager will conduct a file audit of consumer schedules to make sure no other individuals have been affected by the same deficient practice. Documentation of audit will be in consumer files.
3. Staffing Coordinators will check live consumer schedules periodically to ensure that the deficient practice does not recur.
4. Branch Manager will audit 25% of consumer files every 6 months to monitor that the deficient practice will not recur. Documentation will be in consumer HHAx file.
5. Corrective action plan will be completed by 12/30/2023