Initial Comments:
Based on the findings of an onsite unannounced State relicensure survey completed 3/3/2022, Bayada Home Health Care Inc. was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed 3/3/2022, Bayada Home Health Care Inc. was found not to be in compliance with the following requirements 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:
611.52(d) LICENSURE
Proof of Residency
Name - Component - 00
The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation
Observations:
Based on a review of the agency policy, personnel files (PF) and staff (EMP) interview it was determined the agency failed to show proof of residency in this Commonwealth for the 2 years preceding the date of hire (DOH) for two (2) of seven (7) PFs reviewed (PF3 and PF4).
Findings included:
A review of the agency policy on 3/2/2022 at 11:27 AM revealed: Policy "0-17105 CRIMINAL BACKGROUND CHECKS, CLEARANCES, AND REQUIRED SCREENINGS-PA OFFICES ...3.0 COVERED EMPLOYEES AND BACKGROUND CHECK REQUIREMENTS. 3.1 A state Police Check is required for all field employees and contracted personnel, and any Director or other office staff ...who may have direct contact with client and who are hired after July 1, 1998. 3.1.1 Home Care Licensure (non-medical): Also required for all office, field, contracted staff, and owner whether or not they may have direct contact with a client. 3.2 An FBI Background Check conducted through the PA Dept. of Aging is also required for any field employees and contracted personnel, and office staff who may have direct contact with a client, and who have not lived in Pennsylvania for two years (without Interruption) immediately preceding the date of application ... "
A review of PF3 on 3/2/2022 at approximately 1:10 PM, date of hire (DOH) 11/19/2021 revealed: There was a Pennsylvania driver's license with an issue date of 4/22/2021. There was no additional documentation in PF to show agency verified proof of residency in this Commonwealth for two (2) years immediately preceding the date of hire.
A review of PF4 on 3/2/2022 at approximately 1:22 PM, date of hire (DOH) 11/9/2020 revealed: There was a certification of birth and was a Pennsylvania driver's license with an issue date of 5/31/2019. There was no additional documentation in PF to show agency verified proof of residency in this Commonwealth for two (2) years immediately preceding the date of hire.
An interview was conducted with the director, clinical manager, client services manager and recruiting associate on 3/2/2022 at approximately 3:30 PM that confirmed the above findings.
Plan of Correction:Based on an analysis of the specific deficiencies cited, the corrective plan and actions taken are to address the lack of demonstrated knowledge resulting in failure to show proof of residency in the Commonwealth for the 2 years preceding the date of hire (DOH) to determine whether an FBI background check is required to be conducted through the Pennsylvania Department of Aging. The plan of correction will be completed through comprehensive focused education.
Proof of residency documentation has been requested for employee #3. If the requested information is not provided by 3/25/2022, the employee will be sent for an FBI background check conducted through the Pennsylvania Department of Aging.
Employee #4 no longer works for this Agency.
By 3/25/2022 the Director/designee will educate all office staff on policy Criminal Background Checks, Clearances, and Required Screenings – PA Offices, 0-17105 with emphasis on the requirements for conducting background checks and the indicators to determine when an FBI background check is required to be conducted through the Pennsylvania Department of Aging when the employee has not lived in Pennsylvania for two years (without interruption) immediately preceding the date of application.
By 5/2/2022 the Director/designee will complete an audit of all active employee files to ensure evidence of an FBI background check conducted through the Pennsylvania Department of Aging is present when the employee does not have proof of residence of living in Pennsylvania for two years (without interruption) immediately preceding the date of application. Any employees identified as missing the required background check will have one completed.
Effective 3/28/2022 for three months, the Director/designee will review weekly the records of all new hires and provisionally hired employees to ensure their background checks are completed in accordance with Agency policy and state regulation. The expected compliance threshold will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members by the Director/designee. Subsequently, sustained improvement will be monitored through quarterly employee file reviews conducted as a required component of the Organizations Quality Assurance and Performance Improvement program.
The Director has overall responsibility for implementation and oversight of the plan.
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 a review of the agency consumer records (CR) and staff (EMP) interview, the agency failed to involve the consumer in the service planning process and to receive services with reasonable accommodation of individual needs and preferences for one (1) of seven (7) CR's reviewed (CR5).
Findings included:
Review of the agency's documents on 3/2/2022 at approximately 11:10 AM revealed: "CLIENT RIGHTS AND RESPONSIBILITIES SUPPLEMENT: The following rights are afforded to (Agency) clients in accordance with Pennsylvania regulation for home care agencies, in addition to those rights and responsibilities stated in the (Agency) Home Health Care Admission Booklet, Section 2: To be involved with the service planning process and to receive services with reasonable accommodation of the individual needs and preferences, except where the health and safety of the direct care worker is at risk..."
A review of CR5 on 3/2/2022 at approximately 3:05 PM revealed start of services 9/27/2021. The hours when services would be provided per the " (PA Home Care Services) " document was 8:00 AM to 8:00 PM Monday through Sunday. A review of the Schedule from 12/27/2021 through 2/24/2022 revealed the following shifts were not serviced by the agency. The following shifts were not reported to the service coordinator. Per review of agency documentation. The surveyor was unable to verify services were provided per service agreement.
The following shifts were not serviced:
12/30/2021 5:00 PM -9:00 PM
12/31/2021 5:00 PM -9:00 PM
1/1/2022 5:00 PM -9:00 PM
1/3/2022 5:00 PM -9:00 PM
1/9/2022 5:00 PM -9:00 PM
1/10/2022 5:00 PM -9:00 PM
1/12/2022 5:00 PM -9:00 PM
1/13/2022 5:00 PM -9:00 PM
1/19/2022 5:00 PM -9:00 PM
1/21/2022 5:00 PM -9:00 PM
2/2/2022 5:00 PM -9:00 PM
2/12/2022 5:00 PM -9:00 PM
2/13/2022 5:00 PM -9:00 PM
2/16/2022 8:00 AM-4:00 PM and 5:00 PM -9:00 PM
2/19/2022 8:00 AM-4:00 PM and 5:00 PM -9:00 PM
2/20/2022 5:00 PM -9:00 PM
2/21/2022 8:00 AM-4:00 PM and 5:00 PM -9:00 PM
2/23/2022 8:00 AM-12:00 PM
An interview was conducted with the director, clinical manager, client services manager and recruiting associate on 3/2/2022 at approximately 3:30 PM that confirmed the above findings.
Plan of Correction:Based on an analysis of the specific deficiencies cited, the corrective plan and actions taken are to address the lack of demonstrated knowledge resulting in failure to involve the consumer in the service planning process and to receive services with reasonable accommodation of individual needs and preferences. The plan of correction will be completed through comprehensive focused education.
By 3/25/2022 the Director/designee will educate all office staff on policy Missed Visits/Hours, 0-6277 with emphasis on the requirement to document justification for missed hours and the importance of communicating, and documenting the communication, of missed hours with the client and supports coordinator as appropriate.
Effective 3/28/2022 for three months, the Director/designee will review weekly the missed shift report and associated client records for the presence of documented communication of the missed shift to the client as well as the supports coordinator, as appropriate. The expected compliance threshold will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members by the Director/designee.
The Director has overall responsibility for implementation and oversight of the plan.
Initial Comments:
Based on the findings of an onsite unannounced State relicensure survey completed 3/3/2022, Bayada Home Health Care Inc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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