QA Investigation Results

Pennsylvania Department of Health
CHERISH YOUR LOVE ONES, LLC
Health Inspection Results
CHERISH YOUR LOVE ONES, LLC
Health Inspection Results For:


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Initial Comments:

Based on the findings of a complaint investigation completed onsite on September 1, 2020, Cherish Your Love Ones, Llc was found not to be in compliance with the following requirement 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 review of the Department's event reporting system (ERS), agency documentation, and staff (EMP) interview, the agency failed to report an instance of alleged misappropriation of consumer property.

Findings included:

Review of ERS on August 31, 2020, at 3 p.m. revealed the agency had not submitted any incidents to ERS.

Review or the Department's "ERS Manual," for "PA Department of Health (PA-DOH) Event Notification Internet Site Overview - Facilities" on August 31, 2020, at 3 p.m. showed, "Purpose: To provide a system to enter events per 28 PA Code - 51.3 that is readily available to all appropriate PA-DOH 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 is the mechanism the Department will use to meet this regulatory requirement. ... The following is a list of all Categories that should be submitted: ... "Misappropriation of Patient/Resident Property."

Review of documentation maintained at agency on September 1, 2020, revealed agency became aware of an allegation of misappropriation of the consumer's property as early as June 23, 2020; per the consumer, "[EMP2] was going to be buying a tablet for me. He took my debit card, bought the tablet, but never gave it to me. Also, the carers [direct care workers] took a paid TV table of mine, I asked for this to be returned and it never was."

An interview with EMP1 on September 1, 2020, at 12 p.m. confirmed above findings. When EMP1 was asked why he/she did not report the incident to ERS he/she replied, "Never heard of it."









Plan of Correction:

The agency will report all incidents in the Pa Deepartments ERS system within 24 hours of Event Notication to the agency. The Office Manger will report all incidents in the ERS System within 24 hours. The Administrator and Officer Manger will review all incidents every week to make sure they are in the system. The agency will maintain written document of all indidents filed in the ERS system as evidence of compliance.


Initial Comments:

Based on the findings of a complaint investigation completed onsite on September 1, 2020, Cherish Your Love Ones was found not to be in compliance with the following requirement 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(b) LICENSURE
Requirements For HCA And HCR

Name - Component - 00
28 PA Code Chapter 51, applicable to all entities licensed as Health Care facilities under the Act, applies to Home Care Agencies and Home Care Registries licensed under this Chapter.

Observations:


Based on review of the Department's event reporting system (ERS), agency documentation, and staff (EMP) interview, the agency failed to report an instance of alleged misappropriation of consumer property in accordance with 28 PA Code Chapter 51, applicable to all entities licensed as Health Care facilities under the Act, applies to Home Care Agencies and Home Care Registries licensed under this Chapter.

Findings included:

Review of ERS on August 31, 2020, at 3 p.m. revealed that agency had never submitted any incidents to ERS.

Review or the Department's "ERS Manual," for "PA Department of Health (PA-DOH) Event Notification Internet Site Overview - Facilities" on August 31, 2020, at 3 p.m. showed, "Purpose: To provide a system to enter events per 28 PA Code - 51.3 that is readily available to all appropriate PA-DOH 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 is the mechanism the Department will use to meet this regulatory requirement. ... The following is a list of all Categories that should be submitted: ... "Misappropriation of Patient/Resident Property."

Review of documentation maintained at agency on September 1, 2020, revealed agency became aware of an allegation of misappropriation of the consumer's property on June 23, 2020; per the consumer "[EMP2] was going to be buying a tablet for me. He took my debit card, bought the tablet, but never gave it to me. Also, the carers [direct care workers] took a paid TV table of mine, I asked for this to be returned and it never was."

An interview with EMP1 on September 1, 2020, at 12 p.m. confirmed above findings. When EMP1 was asked why he/she did not report the incident to ERS he/she replied, "Never heard of it."









Plan of Correction:

The agency will use the Electronic Event Reporting System within 24 hours of notification to the agency, of Misappropriation of Patient/ Ressient Property. The agency will maintain documentation of all reports. The Office Manger The Office Manger will use the Electronic Event Reporting System within 24 hours. The Administrator and Office Manger will do a weekly reveiws to make sure there is no complaints of patients property mishandled. The agency will use Critical Incident Forms as written documention.


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 on review of a consumer record (CR) and staff (EMP) interview, the agency failed to maintain documentation on file of compliance with the requirements of this section for one (1) of one (1) consumer file reviewed (CR1). Specifically, the agency did not document CR1's involvement in modifications (service planning process) to his/her service agreement.

Findings included:

Review of CR1 on September 1, 2020, at revealed a service authorization active until 2/25/2020. The consumer was to receive 16 hours of services per day. The consumer received partial services on 2/17 (8 hours), no services on 2/18, 2/19, and 2/20, and partial services on 2/21/2020 (8 hours).

An interview with EMP1 on September 1, 2020, at 11:25 a.m. confirmed above findings, "No staff to go in there starting that Monday the 17th [February] ... Tuesday didn't have nobody through Thursday the 20th."

EMP1 confirmed he/she did not document that he/she notified the consumer that there would be a change in services provided, "No I did not [document]. I called her up [for 2/17] and told her I had no one to come in [but I didn't document it]. EMP1 noted that for 2/18, 2/19, 2/20, and 2/21/2020 he/she called CR1 and told her agency had no staff available for part of the day and/or for the entire day. EMP1 noted he/she notified the consumer of changes on a daily basis, "by at least 7 [a.m.] o'clock."











Plan of Correction:

The agency will document any missed visit to the comsumer when the is no direct worker. Documention will be kept on file. The Administrator will record any missed visits and keep documentation on file. The Administrator snd Office Manger will reveiw all missed visits weekly, and record/document each one of them. The agency will use written Missed Visit Forms for documention of any miseed visit and it is also documented in the HHA system in the computer.