Initial Comments:
Based on the findings of an onsite unannounced complaint investigation survey conducted on February 27, 2024 and concluded on March 8, 2024, Caregivers America, 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:
611.55(e) LICENSURE
Competency Requirements
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(e) The home care agency or home care registry also shall include documentation in the direct care worker's file that the agency or registry has reviewed the individual's competency to perform assigned duties through direct observation, testing, training, consumer feedback or other method approved by the Department or through a combination of methods.
Observations:
Based on a review of Report of Neglect (RON) #988961, employee files (EFs), agency caregiver handbook & training manual, consumer handbook, Guidance to Home Care Agencies and Registries Licensed by Pennsylvania Department of Health, 2/23/2017 document, observation of Hoyer lift equipment, and interviews with agency staff (EF#11 - 12), the agency failed to assess and maintain documentation of the direct care workers' competency to perform safe consumer transfer from bed to chair, prior to consumer assignment, in five (5) out of seven (7) EFs reviewed (EFs#2-4, #7-8).
Findings include:
Review conducted on February 27, 2024, at approximately 8:00 AM, Report of Neglect (RON) #988961 revealed: Reported suspicion for lack of direct care worker (DCW) education/competency using the Hoyer lift equipment for consumer transfer.
Review conducted on February 27, 2024, at approximately 11:30 AM to 12:45 PM, of employee files (EFs) revealed:
EF#2 date of hire (doh) 12/7/2023, assigned to CF#1, expired on 12/23/23; no onhire documentation of specialized equipment Hoyer lift competency assessment by agency staff.
EF#3 doh 12/11/23, assigned to CF#1, no onhire documentation of specialized equipment Hoyer lift competency assessment by agency staff.
EF#4, doh 12/7/23, no onhire documentation of specialized equipment Hoyer lift competency assessment by agency staff.
EF#7 doh 3/7/23, assigned to CF#1, no onhire documentation of specialized equipment Hoyer lift competency assessment by agency staff.
EF#8 doh 8/31/23, assigned to CF#1, no onhire documentation of specialized equipment Hoyer lift competency assessment by agency staff.
Review conducted on February 27, 2024, at approximately 9:50 AM, agency Consumer Handbook revealed: (page 7) "Direct Care Worker Expectations ... The following screening is performed for new hires: ... Competency Testing for skill and knowledge in the following core areas: ... Ambulation/Transferring, ... ."
Review conducted on February 27, 2024, at approximately 9:55 AM, Direct Care Worker & Home Health Aide Training Manual included: "Section Two Procedural Guidelines and Skills Check, Skill #36 Use of a Hoyer Lift steps 1-6 outlined. "
Review conducted on March 1, 2024, at approximately 1:00 PM, "Guidance to Home Care Agencies and Registries Licensed by Pennsylvania Department of Health, 2/23/2017" revealed: " On November 23, 2016 the Wolf Administration issued a policy clarification through the departments of Health, Human Services, and State that clarifies the types of non-skilled services/activities that can be performed by direct care workers (DCWs) to assist individuals with disabilities with activities of daily living that could be performed independently but for their disability. ... Definitions Direct Care Worker: individual employed by a home care agency or referred by a home care registry to provide home care services to a consumer. Home care services: the term encompasses the following activities: (i) Personal care - the term includes, but is not limited to, assistance with self-administered medication, feeding, oral, skin, and mouth care, shaving, assistance with ambulation, bathing, hair care and grooming, dressing, toileting, and transfer activities. ... Home Care Agency/Registry Responsibility Prior to assigning a DCW employee to provide the non-skilled activities/services included this policy, the home care agency or registry must evaluate the DCW and document that the DCW has receiving training and demonstrated competency in any specialize care activities/services that the DCW will provide to the consumer, per 28. PA. Code Section 611.55. Training and demonstrated competency must be individualized for each consumer, take into consideration the service delivery preferences of the consumer, and emphasize delivery methods that ensure the safety and maintain the dignity of the consumer. "
Observation conducted on February 27, 2024, at approximately 10:00 AM, a Hoyer lift consumer transfer equipment being stored in the agency's conference room.
Interview conducted on February 27, 2024 at approximately 12:30 PM, with agency office manager EF#12 revealed: During Face to Face interview and orientation of new direct care worker (DCW), office manager/EF#12 will ask if new DCW staff have experience in use of a Hoyer lift (specialized consumer/patient transfer equipment). If the new DCW replies "yes, I have experience.", then EF#12 accepted this verbal statement and assumed the prior skill experiences are sufficient. Agency does not require observation/validation of this physical skill demonstration by a new DCW.
Interview conducted on February 29, 2024, at approximately 12:50 PM, with EF#11/Quality Assurance Specialist revealed: "To her knowledge, very few non-medical consumers require the use of a Hoyer transfer lift; during orientation, each new DCW must review and attest by written signature on their orientation completion form to understand the contents of agency Direct Care Worker & Home Health Aide Training Manual, Version 1.0. This manual included "Section Two Procedural Guidelines and Skills Check, Skill #36 Use of a Hoyer Lift steps 1-6 outlined."; new DCWs are not required to physically demonstrate their competency using the Hoyer transfer lift; and if a consumer obtains new Hoyer lift equipment which may require the agency to perform a 1:1 training with DCW return demonstration, agency staff educator will initiate this updated equipment training with the assigned DCW."
Plan of Correction:All administrative employees that play a role in the orientation and scheduling of employees will receive training on competency requirements.
Agency Policies and Procedures will be updated to ensure compliance with competency requirements. All new employees will receive hands on training, observation and assessment of Hoyer lift competency in a classroom setting or in participant's home. Training will be conducted by an RN or trained and competent designee. Training will be documented on "Total-Mechanical-Lift-Competency Checklist".
100% review will take place on active census to identify participants with Hoyer lifts. Assessments and trainings will be conducted with the active employees identified during survey and employees identified in internal review that are providing care to the identified Hoyer lift dependent participants.
To monitor the branches continuous performance and improvement the Quality Assurance Department will conduct 10% personnel chart audits quarterly.
Above will be completed by 04.27.2024
611.56(a) LICENSURE
Health Screening
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(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.
Observations:
Based on a review of Centers for Disease Control (CDC) guidelines, caregiver handbook, consumer handbook, agency policy, agency employee files (EFs), and interview with agency administrator, it was determined the agency failed to ensure direct care workers, prior to consumer contact, that the individual had been screened for and was free from active mycobacterium tuberculosis (TB) for one (1) of seven (7) EFs reviewed (EF#3).
Findings include:
Review conducted on February 27, 2024, at approximately 10:30 AM, CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005, "... Baseline testing for M. Tuberculosis infection is recommended for all newly hired health care workers [HCWs]...If TST [tuberculin skin testing] is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative...If the first-step TST result is negative, the second-step TST should be administered 1--3 weeks after the first TST result was read...A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST result within the previous 12 months, a single TST can be administered in the new setting...This additional TST represents the second stage of the two-step testing... ."
Review conducted on February 27, 2024, at approximately 9:45 AM, agency Caregiver Handbook revealed: (page 23) "Tuberculosis (TB) Testing TB testing and or health screenings may be required in your state. All medical results will be documented in your personnel file, maintained in a separate confidential file, and retained in accordance with state or federal law.
Review conducted on February 27, 2024, at approximately 9:50 AM, agency Consumer Handbook revealed: (page 7) "Direct Care Worker Expectations ... The following screening is performed for new hires: ... Tuberculosis Screenings ... ."
Review conducted on February 27, 2024, at approximately 10:10 AM, agency policies (1) Tuberculosis Screening revealed: "Policy Direct Care Workers, ... and any staff that will have contact with a consumer are required to have a Tuberculosis (TB) screening and TB Risk Assessment upon hire and receive annual TB education in accordance with CDC guidelines. ... 2-Step TB Skin Test PPD Guidelines items 1-5 describes process."
Review conducted on February 27, 2024, at approximately 11:30 AM, EFs revealed:
EF#3 doh 12/11/23, assigned to CF#1, missing onhire #2 TB skin test.
Interview conducted on February 27, 2024, at approximately 12:30 PM, with agency office manager/EF#12 confirmed above findings.
Plan of Correction:All administrative staff will receive a reeducation on requirements of "Tuberculosis (TB) Testing TB testing and or health screenings".
Local branch will ensure employee #3 completes a tuberculosis screening and a 2step PPD or QuantiFERON gold test to confirm employee is free of TB.
Local branch will conduct review on 100% of personnel charts to ensure compliance with TB requirements.
To ensure deficiency does not reoccur, local branch will utilize the "Compliance log" upon completion of the onboarding process and prior to authorizing employee to provide care to participants.
To monitor the branches continuous performance and improvement the Quality Assurance Department will conduct 10% personnel chart audits on a quarterly basis.
Above will be completed by 04.27.2024.
611.56(b) LICENSURE
Health Screening
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(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.
Observations:
Based on a review of Centers for Disease Control (CDC) guidelines, caregiver handbook, consumer handbook, agency policy, agency employee files (EFs), and interview with agency administrator, it was determined the agency failed to ensure each direct care worker completed annual tuberculosis (TB) risk education for one (1) of seven (7) EFs reviewed (EF#6).
Findings include:
Review conducted on February 27, 2024, at approximately 9:30 AM, CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005, revealed: "... all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually."
Review conducted on February 27, 2024, at approximately 9:45 AM, agency Caregiver Handbook revealed: (page 23) "Tuberculosis (TB) Testing TB testing and or health screenings may be required in your state. All medical results will be documented in your personnel file, maintained in a separate confidential file, and retained in accordance with state or federal law.
Review conducted on February 27, 2024, at approximately 9:50 AM, agency Consumer Handbook revealed: (page 7) "Direct Care Worker Expectations ... The following screening is performed for new hires: ... Tuberculosis Screenings ... ."
Review conducted on February 27, 2024, at approximately 10:10 AM, agency policy (1) Tuberculosis Screening revealed: "Policy Direct Care Workers, ... and any staff that will have contact with a consumer are required to have a Tuberculosis (TB) screening and TB Risk Assessment upon hire and receive annual TB education in accordance with CDC guidelines.; and item 5. Annually, the employee or applicant must complete TB education, which includes how TB spreads, signs/symptoms of TB infection, and TB risk factors, and complete a TB questionnaire."
Review conducted on February 27, 2024, at approximately 11:30 AM, EFs revealed:
EF#6 doh 11/22/22, assigned to CF#1, missing annual TB education/risk assessment.
Interview conducted on February 27, 2024, at approximately 12:30 PM, with agency office manager/EF#12 confirmed above findings.
Plan of Correction:All administrative staff will receive a reeducation on requirements of "Tuberculosis (TB) Testing TB testing and or health screenings".
Local branch will ensure employee #6 completes an annual tuberculosis screening.
Local branch will conduct review on 100% of personnel charts to ensure compliance with TB requirements.
To ensure deficiency does not reoccur, local branch will utilize the "Skill and Qualifications" field in EHR to ensure staff is reminded of upcoming compliance due dates for field personnel.
To monitor the branches continuous performance and improvement the Quality Assurance Department will conduct 10% personnel chart audits on a quarterly basis.
Above will be completed by 04.27.2024.
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 files (CFs), agency service hours provided, agency consumer handbook, agency policy, and interviews with agency staff, the agency failed to provide care and service hours as documented on consumer home care plan in one (1) of three (3) CFs reviewed (CF#1).
Findings include:
Review conducted on February 27, 2024, at approximately 10:15 AM, of CFs revealed:
CF#1, start of care 12/20/23, personal service agreement/Home Care Plan revealed:
-Written Frequency of Care hours (as of 12/7/24) are:
- " Sunday 7 AM to 7 PM (total 12 hours)
-Monday through Friday 7 AM to 3 PM & 3 PM to 11 PM (total 16 hours); and
-Saturday 7 AM to 7 PM (total 12 hours)."
-CF#1 transferred her service care hours into current agency with 3 direct care workers from previous agency (EF#2-4).
-CF#1's Back-Up care plan documents:
What is the back-up plan? One of the other caregivers/family
If the back-up plan is a specific individual, what is the individual ' s name no answer provided.
Relationship to Consumer: no answer provided.
Phone Number: no answer provided. "
Emergency Contact (listed) EF#4/name, Relationship Caregiver/daughter. "
CF#2, soc 12/1/2022, no findings.
CF#3, soc 9/6/23, no findings.
Review conducted on February 27, at approximately 10:00 AM, agency policy Back Up/Contingency Plans: "1. The company will follow an individual's ISP in regard to the frequency and duration of services. 2. If the ISP cannot be followed because of the regular direct care worker is unavailable, the company will institute one of the following back up/contingency plans. Individual and their families will be made aware of these plans upon the start of service in the "New Consumer Packet ": "a. If the individual has more than one regular direct care worker, the other direct care workers will be contacted to fill the open shift; or b. The Care Coordinators for each office will attempt to identify qualified individuals who can accommodate the back-up/contingency; or c. If qualified individuals cannot be located for that time period, the Care Coordinators will be responsible for performing as the direct care worker for the time specified; or d. In emergency situations where a Care Coordinator or other qualified individual is unavailable to provide services, the identified natural support person will be notified so they can provide natural support to the individual. This will be considered a last resort/emergency - only option."
Review conducted on February 27, 2024, at approximately 10:10 AM, agency Consumer Handbook PA Licensed Home Care Agency Version 7.1 revealed: Page 5 " BACK-UP PLAN FOR CARE ... Our agency will make every effort to identify staff for your selected and preferred schedule. However, we can not guarantee care at any time due to the unpredictable nature of staffing in a home care environment. Emergencies, inclement weather, and other unexpected events may delay or result in a cancellation of care for certain days/time. We ask that you consider and have prepared non-paid family members, friends or neighbors to help in these back-up situations."
Interview conducted on February 27, at approximately 11:00 AM with agency care coordinator EF#1 revealed:
-CF#1 start of care date 12/20/23, initiated personal service agreement/Home Care Plan with three DCWs from a previous home care agency (EFs#2-4). EF#2 expired on 12/23/23. EFs #3 and #4 continued providing care for CF#1 and additional EFs #7, #9, and #10 were added into the care team.
Interview conducted on February 27, at approximately 2:00 PM with agency care coordinator EF#1 revealed:
-CF#1 start of care date 12/20/23, initiated personal service agreement/Home Care Plan with three DCWs from a previous home care agency (EFs#2-4). EF#2 expired on 12/23/23. EFs #3 and #4 continued providing care for CF#1 and additional EFs #7, #9, and #10 were added into the care team.
-EF#1 did not enter related care issues or conversations with insurance company service coordinator into the HHA communication system. The communication details from CF#1, EF#4, and service coordinator were stored in the agency ' s work cell phone. EF#1 transcribed these communications into a word document on February 27, 2024 for surveyor review. These transcripts revealed:
1. Frequent text communications by EF#1 to Service Coordinator related to lack of DCWs to provide care and services to CF#1 (140 hours/week); and requested decreased services hours to 72 hrs/week on 1/23/24.
2. Frequent text communications by EF#1 to CF#1 from 12/26/23 to 2/26/24 (23 pages) related to missed care shifts and frequent DCW call-offs.
EF#1 confirmed EF#4 call-off scheduled care shifts for CF#1 in January and February 2024: 1/16/24, 1/30/24, 2/7/24, 2/9/24, 2/13/24, 2/23/24, 2/26-27/23. This individual DCW called the client first with the care shift cancellation and then notified the agency supervisor. The agency supervisor/care coordinator were not able to fulfill CF#1 ' s immediate care shift needs due to limited staffing availability.
Review conducted on February 29, 2024, at approximately 9:00 AM to 11:00 AM,of Centene PA Health Wellness Insurance company service hours for CF#1 revealed:
12/20/23 to 12/31/23Max hours 240, 12 days in certification period
*CF#1 received 101.5 care hours for this certification period.
1/1/24 to 1/21/24 Max hours 420, 21 days in certification period
*CF#1 received 183.9 care hours for this certification period.
1/22/24 to 2/16/24 Max hours 356.75, 26 days in certification period
*CF#1 received 204.29 care hours for this certification period.
Interview conducted on February 29, 2024, at approximately 12:50 PM, EF#11 confirmed agency failed to provide allotted care and service hours for CF#1 as documented on her home care plan.
Plan of Correction:All administrative staff will be reeducated on components of provider responsibilities with regard to providing care and servicing hours as documented on consumers home care plan.
Local branch is unable to correct deficiency for CF#1 as time for correction has expired due to dates and hours identified have passed.
Branch will conduct 100% consumer chart review to complete a crosscheck on consumer homecare plans for accuracy and to ensure hours are being serviced appropriately.
To ensure deficiency does not reoccur, Regional Manager for branch will be required to review all new homecare plans for accuracy and to ensure care is being provided according to hours authorized on a monthly basis until 100% compliance is achieved for 2 consecutive months.
To monitor the branches continuous performance and improvement the Quality Assurance Department will conduct 10% consumer charts audits on a quarterly basis.
Above will be completed by 04.27.2024.
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