QA Investigation Results

Pennsylvania Department of Health
ANGELS ON CALL
Health Inspection Results
ANGELS ON CALL
Health Inspection Results For:


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Initial Comments:


Based on the findings of an unannounced onsite state licensure complaint survey completed June 11, 2021, Angels on Call 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:




611.4(c) LICENSURE
Requirements for HCA and HCR

Name - Component - 00
Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.

Observations:


Based on observations and an interview with the agency Regional Operations Manager, agency failed to ensure that everyone entering the health care facility is screened and triaged for COVID-19 for one (1) of one (1) observations (Observation#1) and one (1) of one (1) interviews (Interview#1).

Findings include:

Pennsylvania Department of Health 'Health Alert Network' dated August 7, 2020 'Subject' 'Update: Interim Infection Prevention and Control Recommendations for Patients with known or Patients Under Investigation for 2019 Novel Coronavirus (COVID-19) in a Healthcare Setting' section (I) Recommended Routine Infection Prevention and Control (IPC) Practices During the COVID-19 Pandemic' (B) 'Screen and Triage Everyone Entering a Healthcare Facility for signs and symptoms of COVID-19':....symptom screening remains an important strategy to identify those who could have COVID-19 .......". "Screen everyone (patients, healthcare personnel, visitors) entering the facility for symptoms consistent with COVID-19 .....". "Actively take their temperature and document absence of symptoms consistent with COVID-19".

Observation #1: On June 11, 2021 at approximately 9:45 a.m. the state surveyor arrived at the agency office. No COVID-19 temperature screening nor symptom screening questions were conducted. The surveyor was escorted into the agency conference room by the Regional Operations Manager.
Interview #1: On June 11, 2021 at approximately 10:30 a.m. an interview was conducted with the agency Regional Operations Manager. The Regional Operations Manager was asked what the agency COVID-19 screening protocols are for people who enter the agency office. The Regional Operations Manager stated there is no screening process. No documentation of the Regional Operations Manager, the agency Field Coordinator, the agency Scheduler, nor an employee applicant who was at the office for an employee interview, being screened for COVID-19 upon entry into the agency office.
The agency failed to ensure adequate infection control practices by ensuring that everyone entering the health care facility is screened and triaged for COVID-19.



An interview conducted with agency Regional Operations Manager on June 11, 2021 at approximately 1:45 p.m. confirmed the above findings.









Plan of Correction:

01200 Finding:
Requirements for HCA and HCR: COVID
Agency will implement the CDC

Agency will begin to use the Facilities COVID-19 Screening tool and temperature screening for all visitors and/or staff upon entry into the office to conduct any type of business.

When completing the form, if any person answers any question with a "Yes" they will not have access into the office and will be provided with further instructions. (Page 2 of screening tool)

Completed screening forms will be scanned and uploaded unto the Agency shared drive, COVID Folder, on a weekly basis. This will be reviewed by the Quality Management Specialist weekly to ensure office is completing the requirements.






611.51(a) LICENSURE
Hiring or Rostering Prerequisites

Name - Component - 00
Prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. (3) Require the individual to submit a criminal history report, in accordance with the requirements of 611.52 (relating to criminal background checks), and a ChildLine verification, if applicable, in accordance with the requirements of 611.53 (relating to child abuse clearance).

Observations:


Based upon review of employee files and an interview with the agency Regional Operations Manager, the agency failed to provide documentation of obtaining not less than two (2) satisfactory references for one (1) out of two (2) employee files (EF) reviewed (EF#2).

Findings include:

A review of EFs was conducted on June 11, 2021 at approximately 10:15 a.m. Employee date of hire (DOH) is listed below.

EF#2 DOH 03/17/21: One reference check was completed by the agency owner on 01/12/21. No documentation provided of two references being obtained.

An interview conducted with agency Regional Operations Manager on June 11, 2021 at approximately 1:45 p.m. confirmed the above findings.









Plan of Correction:

0200 Findings:
EF#2 Hiring or Rostering Prerequisites
The agency has a current policy to ensure two reference checks are completed prior to employment. Agency will retrain office staff on June 25, 2021, to ensure that two satisfactory reference checks are made on all new staff prior to employment.
EF#2 Agency located the references that were completed for this individual and will add them to her personnel file. This will be completed by June 27, 2021.
In order to ensure future records, contain the required references, a checklist will be used for each new hire and maintained in each personnel file as well as a two-person confirmation that all
- New Hire Checklist used prior to date of hire to start preparing for new hire's arrival.
- Personnel File Checklist this is a two-person confirmation that all documents are received. To be kept in personnel file for auditing purposes.
- Office Manager Daily Checklist used for follow-up calls made for checking references on a daily basis.
The Office Manager will be responsible to pull 10 files per month until 90% compliance is complete. The Office Manager will be responsible for continued implementation of the plan of correction and ensure two reference checks are done prior to employment for all employees.




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 upon review of employee files and an interview with the agency Regional Operations Manager, agency failed to ensure proof of residency in Pennsylvania (Pa.) for 2 years immediately preceding date of hire, for one (1) out of two (2) employee files (EF) reviewed (EF#2).
Findings include:
A review of EFs was conducted on June 11, 2021 at approximately 10:15 a.m. Employee date of hire (DOH) is listed below.

EF#2 DOH 03/17/21: Agency failed to provide documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Pa. drivers license issued 11/25/20 with an expiration date of 11/30/24. A Pa. 'Department of Transportation Bureau of Drivers Licensing' '10 year report' contained no entries in the 'Original Issue Date' and the 'License Status' sections. Employment application was reviewed. Employment application lists an employer with no physical address with no 'Start Date' nor 'End Date" entries.
No documentation provided for proof of Pa. residency between 03/17/19-11/25/20.

An interview conducted with agency Regional Operations Manager on June 11, 2021 at approximately 1:45 p.m. confirmed the above findings.


Repeat deficiency.







Plan of Correction:

0330 Finding:
Proof of Residency

EF#2 Her employment has been terminated with this Agency due to no call/no show and not having worked since May 12, 2021.

Agency will retrain office staff on how to determine what documents are acceptable to prove residency, and if residency cannot be proven by said documents, the staff will need to be scheduled for a FBI background check. Training will occur on June 25, 2021.

Moving forward, the office manager will be responsible for reviewing all onboarding information upon hire to determine if proof of residency exists or if the new employee needs to be sent for an FBI background check through the Department of Aging.

Proof of residency will be tracked on the Personnel File Checklist to ensure all requirements are met at the time of onboarding. The Personnel File Checklist will be housed in the employee's personnel file.

The Office Manager will be responsible to pull 10 files per month until 90% compliance is complete and monitor the continued implementation of the plan of correction and ensure that all new hires have been verified for proof of residency.

The Quality Management Specialist will randomly review files for compliance on a monthly basis.


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 upon review of consumer files, agency staffing calendar, and an interview with the agency Regional Operations Manager, agency failed to ensure services were provided as agreed upon for two (2) of three (3) consumer files (CF) reviewed (CF#1, CF#3).

Findings include:

A review of consumer files and the agency staffing calendar was completed on June 11, 2021 at approximately 10:30 a.m. Consumer start of service (SOS) is listed below.

CF#1, SOS 12/14/20: Documentation provided of this consumer being serviced under a waiver program. The 'Initial Assessment of Client' section 'Back up Care Plan' dated 12/08/20 lists "No backup."
The service dates of 02/01/21-02/08/21 lists "Entire Period Hours: 88.00" ('Authorized Hours per Week' = "77.00"). The agency staffing calendar (02/01/21-02/08/21) lists employee hours worked, revealing 58 hours provided of the authorized 77 hours.
The service dates of 02/10/21-02/28/21 lists "Entire Period Hours: 85.5" ('Authorized Hours per Week' = "31.5"). The agency staffing calendar (02/14/21-02/20/21) lists employee hours worked, revealing 25 hours provided of the authorized 31.5 hours.

The service dates of 03/01/21-03/31/21 lists "Entire Period Hours: 465" ('Authorized Hours per Week' = "105"). The agency staffing calendar (03/07/21-03/13/21) lists employee hours worked, revealing 64 hours provided of the authorized 105 hours. The agency staffing calendar (03/14/21-03/20/21) lists employee hours worked, revealing 65 hours provided of the authorized 105 hours.

CF#3, SOS 11/01/20: Documentation provided of this consumer being serviced under a waiver program. The 'Initial Assessment of Client' section 'Back up Care Plan' dated 10/27/20 lists "None."
The service dates of 05/01/21-05/31/21 lists "Entire Period Hours: 744.00" ('Authorized Hours per Week' = "168.00"). The agency staffing calendar (05/02/21-05/28/21) lists the following employee hours worked:
05/02/21 reveals 23 hours provided of the authorized 24 hours.
05/03/21 reveals 16 hours provided of the authorized 24 hours.
05/04/21 reveals 20.5 hours provided of the authorized 24 hours.
05/06/21 reveals 22.5 hours provided of the authorized 24 hours.
05/13/21 reveals 23 hours provided of the authorized 24 hours.
05/21/21 reveals 20.5 hours provided of the authorized 24 hours.
05/24/21 reveals 22 hours provided of the authorized 24 hours.
05/26/21 reveals 23 hours provided of the authorized 24 hours.
05/27/21 reveals 22 hours provided of the authorized 24 hours.
05/28/21 reveals 21.5 hours provided of the authorized 24 hours.

The service dates of 06/01/21-06/30/21 lists "Entire Period Hours: 720.00" ('Authorized Hours per Week' = "168"). The agency staffing calendar (06/04/21-06/09/21) lists the following employee hours worked:
06/04/21 reveals 21.5 hours provided of the authorized 24 hours.
06/09/21 reveals 23.25 hours provided of the authorized 24 hours.

An interview was conducted with the agency Regional Operations Manager on 06/11/21 at approximately 1:15 p.m. Per the Regional Operations Manager, "The unfulfilled hours were the result of the agency not being able to provide staff for the consumer".


An interview conducted with agency Regional Operations Manager on June 11, 2021 at approximately 1:45 p.m. confirmed the above findings.








Plan of Correction:

0800 Finding:
Consumer Rights

Unfilled hours CF#1 and CF#3

Daily, the scheduling staff will review the open shift report and the on call report to determine who has an open shift and prioritize the clients based on status of backup plan, care needs, tagged as "at risk", etc.

All caregivers will be notified of open shift to obtain coverage for clients.

If the list of caregivers has been exhausted, calls will be made during the contracted shift to ensure the health and safety of the client.

This is monitored on a daily basis by the QMP.

The Agency staff will be retrained on July 25, 2021 on the importance to fill shifts for those clients who do not have a backup plan in place.