Initial Comments:
Based on the findings of an unannounced onsite complaint investigation survey completed on March 15, 2024, Agape's Love 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.
Observations:
Based on review of consumer files (CF) and interview with agency staff (EMP), the agency failed to provide develope a list of services to be provided to the consumer for three (3) of three (3) consumer files reviewed (CF1-3), and failed to service hours per agreement/authorization for two (2) of three (3) CFs reviewed (CF2 & 3).
Findings included:
Review of CF on March 14, 2024, between approximately 10:00am and 12:30pm revealed:
CF1, start of services (SOS) 8/15/18, time frame reviewed 2/21/24-3/10/24. CF failed to include evidence of a list of services to be provided to the consumer and updates to services with change in consumer condition.
CF2, SOS 2/27/24, time frame reviewed 2/27/24-3/10/24. Service agreement documents hours to be serviced Sunday- Saturday 8:00am -1:00pm and 6:00pm-8:00pm. Clock in records revealed that agency failed to service agreed upon hours. No documentation available to reflect reason for hours not provided. CF also failed to include evidence of a plan of care developed by the agency identifying the services required by the consumer while being cared for by agency caregivers.
Hours serviced:
2/28/24: 8:05am-1:03pm
2/29/24: 8:04am-3:00pm
3/1/24: 7:58am-8:46am
3/2/24: 8:05am-1:00pm
3/3/24: 8:03am-1:00pm
3/4/24: no services documented.
3/5/24: 8:03am-1:01pm and 5:52pm-7:14pm
3/6/24: 8:08am-12:55pm and 6:10pm-7:10pm
3/7/24: 5:50pm-7:00pm
3/8/24: 8:00am-11:58am
3/9/24: 8:01am-12:58pm
CF3, SOS 4/7/23, time frame reviewed 2/1/24-3/13/24. CF contained authorization for 39.75 hours/week dated 1/20/24-4/3/24. Review of clock in records revealed no services 2/1/24-2/26/24. No documentation of services provided 3/11/24. CF failed to contained documentation as to why services not provided. CF also failed to include evidence of a plan of care developed by the agency identifying the services required by the consumer while being cared for by agency caregivers.
Exit interview with on March 15, 2024, at approximately 1:30 with owner confirmed findings.
Plan of Correction:For this agency, the POC will be as follows:
1.When the agency accepts services with a member the member will be involved in all aspects of care. The owner and member will decide the needs of the member and the hours that the member was approved for. This will also include how many days are needed to satisfy the needs of the members. This will be discussed at the time of onboarding. The owner will have the member sign off on the Plan of Care and one will be given to the member, one kept in the file and make sure that the aide has a copy prior to rendering services.
2. The owner and member will decide the hours and days as needed as well as the aide that will be providing the services.
3. The owner will document all tasks that will be completed on each shift. If a task was not completed the agency will be notified and the owner will document in the members' file as to why. If the owner notices that specific tasks are repeatedly not done, the owner will then revisit the member to reevaluate their needs. If the needs are changed another Plan of Care will be done and distributed.
4.Each member is given a handbook on what to expect from the agency. If the owner needs to give the member a notice of termination this is also provided in the literature, we have provided the member.
4. Owner will check daily all employees clock in and clock out times to ensure the member is getting services that were agreed upon. If the agency does not fulfill all the hours in the day or week it will be documented by HHAExchange as to why all hours were not used. This will be checked daily and documented as needed by the owner.
5. If there are any changes in hours, condition another Plan of Care will be done and documented.
6. Owner will continue to contact by phone or onsite visit each member every 2 weeks up to month on Plan of Cares and if they need changed.
7. Upon hire each caregiver will be given a specific Plan of Care for each member to show what each member or members need done and they will document what reflects on their members' Care Plan. Staff will also be educated upon hire and during employment on reporting changes in conditions. This will be checked monthly and documented, if necessary, by the owner.
8. The owner will conduct monthly audits on the 1st of each month to ensure that all members have care plans, services are being rendered as developed, if there is a change in services that has been documented. Beginning the first of each month the owner will compare the plan of care with what was documented to ensure services are being rendered.
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