Initial Comments:
Based on the findings of an onsite complaint survey conducted on April 30, 2024. Countrywide Home Care, Inc., was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
51.3 (f) LICENSURE
NOTIFICATION
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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 review of the Pennsylvania (PA) Department of Health Event Reporting System, and an interview with the administrator, the home care agency (HCA) failed to notify the PA Department of Health in writing of an incident for one (1) of three (3) CF's, (CF #1) and of an incident for one (1) of three (3) PF's, (PF #1) .
Findings include:
Per the Pennsylvania Department of Health Event Reporting System Manual, "...Purpose: To provide a system to enter events per 28 PA Code - 51.3 that is readily available to all appropriate PA-DOH [Pennsylvania Department of Health] facilities, a simple process to insure consistent data entry and submission, and a source for quick and meaningful feedback on event notification submissions...All facilities are required to submit notification of events as defined in 28 Pa Code Chapter 51 to the Department of Health within 24 hours of occurrence or discovery. The Electronic Event Reporting System [ERS] is the mechanism the Department will use to meet this regulatory requirement..."
A review of the PA Department of Health Event Reporting System on April 30, 2024 contained no evidence that the home care agency submitted reports to the Department of Health Event Reporting System regarding consumer and direct care worker discrepancy of hours of service documentation.
In an interview with the Home Care Agency's Administrator conducted on April 30, 2024 at approximately 12:30 p.m, stated the event was not reported," the MCO (managed care organization) reported the situation back in April 2024 to APS (adult protective services)".
Plan of Correction:The agency promptly reported the aforementioned incident to the Department of Health's Event Report System on 05/06/2024. The staff will undergo mandatory reeducation regarding reportable incidents to DOH to ensure strict compliance with 28 Pa Code Chapter 51. The administrator of Countrywide Home Care will be held accountable for ensuring all reports are entered within 24 hours, without any exceptions.
Initial Comments:
Based on the findings of an unannounced onsite complaint investigation survey, conducted on April 30, 2024 Countrywide 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
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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 a review of consumer records (CR's) HHAeXchange calendar, electronic visit verification and an interview with the administrator, the agency did not provide service with reasonable accommodation of individual needs and preferences for one (1) of three (3) CRs. (CR #1).
Findings include:
A review of consumer record was conducted on April 30, 2024 at approximately 9:37 am.
CR # 1 Start of Care 10/20/2023 Receive services via waiver from Centene PA Health Wellness. Hours authorized from January 1, 2024, to April 7, 2024, were 294 hours, 21 hours per week, Monday through Friday.
A review of agency calendar and electronic visit verification forms shows the week of January 28, 2024, through February 3, 2024. January 30, 2024, direct care worker clocked in but did not clock out, EVV form filled out by consumer.
January 31, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
February 1, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
February 2, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
The week of February 4, 2024, through February 10, 2024 shows February 5, 2024 direct care worker clocked in but did not clock out, EVV form filled out by consumer.
February 6, 2024 direct care worker clocked in but did not clock out, EVV form filled out by consumer.
February 7, 2024 direct care worker clocked in but did not clock out, EVV form filled out by consumer.
February 8, 2024 direct care worker clocked in but did not clock out, EVV form filled out by consumer.
February 9, 2024 direct care worker clocked in but did not clock out, EVV form filled out by consumer.
The week of February 11, 2024, through February 17, 2024 shows February 12, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
February 13, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
February 14, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
February 15, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
February 16, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
The week of February 18, 2024, through February 24, 2024 shows February 19, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
February 20, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
February 21, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
February 22, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
February 23, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
The week of February 25, 2024, through March 2, 2024 shows February 26, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
February 27, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
February 28, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
February 29, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
March 1, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
The week of March 3, 2024, through March 9, 2024, March 4, 2024 direct care worker clocked in but did not clock out, EVV form filled out by consumer.
March 6, 2024 direct care worker clocked in but did not clock out, EVV form filled out by consumer.
March 7, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
March 8, 2024 direct care worker clocked in but did not clock out, EVV form filled out by consumer.
The week of March 10, 2024, through March 16, 2024 shows March 11, 2024 direct care worker failed to clock in but did clock out, EVV form filled out by consumer.
March 12, 2024 direct care worker did not clock in or clock out, EVV form filled out by consumer.
March 13, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
March 14, 2024 direct care worker clocked in and but did not clock out, EVV form filled out by consumer.
March 15, 2024 direct care worker clocked in but did not clock out, EVV form filled out by consumer.
The week of March 17, 2024, through March 23, 2024 shows March 18, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
March 19, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
March 20, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
March 21, 2024 direct care worker did not clock in or out, EVV form filled out by consumer.
March 22, 2024 direct care worker clocked in but did not clock out, EVV form filled out by consumer.
The week of March 24, 2024, through March 30, 2024 shows March 25, 2024 direct care worker clocked in but did not clock out, EVV form filled out by consumer.
March 26, 2024 direct care worker clocked in but did not clock out, EVV form filled out by consumer.
March 27, 2024 direct care worker clocked in but did not clock out, EVV form filled out by consumer.
March 28, 2024 direct care worker clocked in but did not clock out, EVV form filled out by consumer.
March 29, 2024 direct care worker clocked in but did not clock out, EVV form filled out by consumer.
A review of CR#1 general notes was conducted on April 30, 2024 at approximately 1:17 p.m.
"On 4/3/2024 at 10:30 a.m. providing agency outreach to service coordinator (SC) due to participant /caregiver still not clocking in and out the right way. Also (SC) know that we had direct care worker come into the office on 3/29/24 for verbal warning... (SC) stated she is going to call direct care worker and patient to have another talk with them also let (SC) know that our General Manager called the rehab center to do employment verification., that the caregiver kept clocking in and out from... Our General Manager found out that the caregiver also works there and is overlapping schedules."
An interview with the administrator conducted on April 30, 2024 at 1:15 pm confirmed the above findings.
Plan of Correction:Countrywide Home Care provided care to a participant for a total of 273 hours out of 294 from January 1st, 2024 until March 29th, 2024, with a schedule for 21 hours per week. However, the agency faced issues with a family caregiver's Electronic Visit Verification (EVV) compliance and took steps to resolve it at a management level. When the situation became unmanageable, the agency sought assistance from the Service Coordinator and reported the matter to Adult Protective Services (APS).
Despite the EVV compliance issue, the participant always confirmed that the services were provided, and the agency verified the visits by manual EVV forms. However, the agency recognizes the importance of ensuring compliance and plans to review the records of all caregivers whose EVV rate is below 50%. The agency will use all available methods and tools to improve these rates, and an internal audit will be conducted by the end of Q2, with the completion of this project expected by the end of Q3. The agency is determined to ensure that EVV compliance of each caregiver is higher than 75%.
The participant's engagement with the services remains the same, and the agency will verify each unconfirmed visit with additional verification. The agency is committed to providing quality care to all its clients and will take all necessary steps to ensure compliance with EVV requirements.
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