Initial Comments:
Based on the findings of an onsite unannounced complaint investigation survey conducted on Febraury 5, 2022 and continued off-site Febraury 13, 2024, Golden Hearts Home Health, Llc, was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
51.3 (e) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification
(e) If a health care facility is
aware of information which shows that
the facility is not in compliance with
any of the Department's regulations
which are applicable to that health
care facility, and that the
noncompliance seriously compromises
quality assurance or patient safety,
it shall immediately notify the
Department in writing of its
noncompliance.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for the failure to comply and the
steps which the health care facility
shall take to bring it into compliance
with the regulation.
Observations:
Based on review of Pennsylvania Department of Health Event Reporting System (ERS), policy/procedures, agency documentation, email correspondence and interviews with executive director and clinical managers, it was determined that the agency failed to notify the Department of Health (DOH) of reportable incidents for one (1) of one (1) incident identified. IN#1.
Findings include:
IN #1 on February 5, 2024, prior to the survey, revealed no reported incidents through the Department's Event Reporting System (ERS) in regard to reported complaint.
An interview with agency manager on 2/5/24 between 11:50 AM-11:55 AM revealed: "I didn ' t enter an event."
Plan of Correction:I will report all incidents through the ERS (Event Reporting System)with in 24 hours after the report is made to Golden Hearts Home Health, LLC.
Initial Comments:
Based on the findings of an onsite unannounced home care agency complaint investigation survey conducted on Febraury 5, 2024 and continued off-site Febraury 13, 2024, Golden Hearts Home Health, 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 Clients ' Golden Hearts Home Health consumer agreement and consent for home care services, clients ' files, agency complaint log and interview with agency administrator, the agency failed to ensure the consumer received services as agreed upon for three (3) of three (3) consumer files (CR # 1-CR # 3)
Findings:
Review of Consumer Records (CR) on 2/5/24 from 11:05 AM-11:59 AM revealed the following:
Review of CR # 1 revealed: CR # 1 and agency administrator had only a verbal agreement that client needed to find his own caregivers for agency to hire due to client ' s living situation.
Review of client ' s HHAeXchange (Home care software management platform) member authorization form revealed that client was authorized for four (4) hours of services per day for twenty-eight (28) hours total per week until 9/1/23 when client was authorized for six (6) hours of services per day for a total of forty-two (42) hours total per week.
a.Client received the following hours of service in June:
May 28-June 3---nineteen (19) hours
June 4-June 10---eight (8) hours and thirty (30) minutes
June 11-June 17-twenty-nine (29) hours
June 18-June 24-twenty-five (25) hours
June 25-July 1---twenty-eight (28) hours and thirty (30) minutes
July 2-July 8-twenty-eight (28) hours
July 9-July---twenty-seven (27) hours and forty-five (45) minutes
July 16-July 22---twenty-eight (28) hours
July 23-July 29---twenty-four (24) hours and forty-five (45) minutes
b.Client cancelled a total of four (4) shifts during June and there was eleven (11) shifts were the caregiver stated that they either couldn ' t clock in or clock out from client ' s home due to poor internet connection.
c.Client received the following hours of service from October through December:
October 1-October 7---zero (0) hours
October 8-October 14-seven (7) hours
October 15-October 21-twenty-eight (28) hours
October 22-October 28---twenty-seven (27) hours and thirty (30) minutes
October 29-November 4-thirty-five (35) hours and fifteen (15) minutes
November 5-November 11-thirty-four (34) hours and thirty (30) minutes
November 12-November 18-thirty-five (35) hours
November 19-November 25-zero (0) hours
November 26-December 9-zero (0)-per agency administrator, client was staying with a friend in Waynesboro during this time.
December 10-December 16-sixteen (16) hours
December 17-December 23-seven (7) hours and forty-five (45) minutes with December 22 being the last day client received services.
Review of CR # 2 on 2/5/24 revealed: SOC: 1/11/22; consumer was approved for twenty-eight (28) hours per week, four (4) hours per day.
a.Client received the following hours of service from November through January:
October 29-November 4---twenty-four (24) hours
November 5-November 11---twelve (12) hours
November 12-November 18-sixteen (16) hours
November 19-November 25-eleven (11) hours and thirty (30) minutes
November 26-December 2---twenty-one (21) hours
December 3-December 9-twenty-three (23) hours and fifteen (15) minutes
December 10-December 16---nineteen (19) hours and fifteen (15) minutes
December 17-December 23---twenty-one (21) hours and fifteen (15) minutes
December 24-December 30---nineteen (19) hours and twenty-five (25) minutes
December 31-January 6---eighteen (18) hours and fifteen (15) minutes
b.One caregiver was removed during December due to client not liking her nor wanting her back.
Review of CR # 3 on 2/5/24 revealed: SOC: 1/20/23; consumer was approved for ninety-four (94) hours and thirty (30) minutes per week, thirteen (13) hours and thirty (30) minutes per day in October, ninety-one (91) hours per week, thirteen (13) hours per day in November and fifty-six (56) hours per week, eight (8) hours per day in December.
a.Client received the following hours of service from November through January:
October 29-November 4---sixty-nine (69) hours with the client canceling two (2) hours and thirty (30) minutes.
November 5-November 11---eighty-one (81) hours
November 12-November 18-seventy-two (72) hours and twenty-five (25) minutes
November 19-November 25-sixty-eight (68) hours
November 26-December 2---sixty-nine (69) hours and thirty (30) minutes
December 3-December 9-sixty (60) hours and thirty (30) minutes
December 10-December 16---fifty-one (51) hours and twenty-five (25) minutes
December 17-December 23---sixty (60) hours and fifteen (15) minutes
December 24-December 30---thirty-nine (39) hours and twenty-five (25) minutes
December 31-January 6---forty-two (42) hours and twenty-five (25) minutes
An email received from the agency administrator on 2/13/24 at 2:46 PM confirmed the above findings.
Plan of Correction:If we cannot staff a client even if it is hours that we are trying to help another company out with covering we will be sure to inform the service coordinators as we have always done, then we will do missed visit report and file it appropriately with all. I will also inform service coordinator if the clients decide on different days and hours then what they have as verbiage or the authorization states as far as less hours. In the event the home is not safe I do now have in place a signed document for all new clients to sign as well as will report it and have all documents on file.
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