QA Investigation Results

Pennsylvania Department of Health
Health Inspection Results
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Initial Comments:

Based on the findings of an offsite unannounced complaint survey conducted on May 13, 2021, May 14, 2021 and May 25, 2021, AmeriBest Home Care, LLC., 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

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.


Based on review of agency policies/procedures, consumer record (CR), and an interview with the quality assurance nurse, the agency failed to provide services as outlined on the patient's plan of care for one (1) of one (1) CR's reviewd, (CR #1).

Findings include:

A review of CR was conducted on May 14, 2021 at approximately 2:15 pm.
CR #1, Start of Care: 1/18/17. Services are provided under the Aging Waiver program and authorized for 24 hours per day, seven days a week. Agency documentation in HHA eXchange indicates that client ' s son is to provide care as a backup plan when agency is unable to provide service.
Daily visit documentation from April 1, 2021 through May 13, 2021 was reviewed.
Missed shifts were documented as follows:
4/6/2021: 10:00 pm - 9:00 am - PCA (Personal Care Aide) P called client to let them know they could not make their shift due to a family emergency but did not alert AmeriBest. Client made agency aware on the morning of 4/8/2021. Agency reached out to PCA P to educate on proper procedure, but voicemail was full, agency will follow up.
4/13/2021: 10:00 pm - 9:00 am - PCA P called out, agency was unable to staff case, client was informed.
4/23/2021: 9:00 am - 10:00 pm - PCA S called out for jury duty, client was made aware and agency was unable to staff the case.
5/8/2021: 10:00 pm - 9:00 am - PCA P called out due to no childcare, client declined additional coverage.
5/9/2021: 10:00 pm - 9:00 am - PCA P was a no call/no show, PCA P stated that she was knocking on client ' s door and there was no answer.

An interview with the quality assurance nurse on May 14, 2021 at approximately 2:00 pm confirmed the above findings.

Plan of Correction:

1. The QA Nurse will meet with the one consumer identified in this report to review her service plan and update her back-up caregiver plan. This discussion with the client will be documented in the client's file. This will be completed by June 30, 2021.

2. The Compliance Officer will create a standard operating procedure to define a requirement to capture a client's back-up caregiver at the time the client is being onboarded. A form to capture this information has been created. This form will be added to the new client onboarding booklet. A client's back-up caregiver is someone who may be able to assist the client on a short-term basis, which may be a few hours or a few days, in the event that an agency caregiver cannot be staffed for the client. The back-up caregiver may be a friend, family member, neighbor, or another agency caregiver if one is available. For new clients, the Service Coordinator should provide the client's back-up caregiver plan. When the Service Coordinator is unable to provide this information AmeriBest will request this information from the client and will verify the plan with the identified back-up caregiver. Contact information for the back-up caregiver will be recorded in the patient information system (HHA Exchange.) This new procedure will be implemented for all new clients beginning June 30, 2021.

3. Training will be delivered to the Nursing, Intake and Scheduling/Client Services Departments on the new Back-Up Caregiver procedure. This education will cover the need for identification of the client's back-up caregiver plan, how to confirm/verify the client's back-up caregiver, and how to record the back-up plan in HHA Exchange. Scheduling/Client Services Department staff will also be trained on procedures to address a client's back-up plan when we are unable to staff an agency caregiver. The QA Nurse will provide this training by June 28, 2021.

4. To confirm this new procedure is working effectively, audits will be conducted. The Compliance Officer conducts quarterly quality audits on new client documentation. Reviewing documentation of a client's back-up caregiver plan will be added to this quarterly audit. An initial audit for this item will be completed by July 24, 2021 and will include a 10% sample of new clients started since June 30, 2021.

5. As a Remedial Action, the QA Nurse will identify all current clients who do not have a back-Up caregiver plan identified in HHA Exchange. This list will be completed by June 25, 2021.

6. The QA Nurse and the Director of Nursing will create a plan to follow up with the Service Coordinators for each client lacking a defined back-up plan. In cases where the Service Coordinator is unable to provide the client's back-up plan, AmeriBest will contact the client to capture and verify the client's back-up caregiver plan. The target for completion of these missing back-up plans is July 24, 2021.