QA Investigation Results

Pennsylvania Department of Health
CAREGIVERS AMERICA, LLC
Health Inspection Results
CAREGIVERS AMERICA, LLC
Health Inspection Results For:

This is the only survey for this facility

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Initial Comments:

Based upon the findings of an offsite unannounced complaint investigation survey conducted between 11/6/ 2020-11/9/2020, Caregivers America, was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.





Plan of Correction:




Initial Comments:


Based upon the findings of an offsite unannounced complaint investigation survey conducted between 11/6/ 2020-11/9/2020, Caregivers America, was found to be not 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:




611.52(c) LICENSURE
Federal Criminal History Record

Name - Component - 00
If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code 15.144(b) (relating to procedure).

Observations:


Based upon review of agency policy, personnel files (PF), interview with quality and staff development manager (EMP #1), agency failed to obtain a federal criminal history record for one (1) of three (3) files reviewed. ( PF # 3).

Findings included:

Review of agency policy on 11/6/2020 between approximately 3:00 PM-3:15 PM titled " Selecting and Hiring Direct Care Workers" stated " If the perspective employee is unable to provide \ documents, agency will ensure the perspective employee obtains a satisfactory FBI clearance"

Review of PF on 11/6/2020 between approximately 1:15 PM-1:45 PM revealed:

PF # 3, Date of Hire (DOH) 1/30/2020; documentation present of New York state driver's license and record on application of work history revealed residency 7/22/2018-11/26/2018 in New York state.
Most current job 12/26/2018- 6/19/2019 in York PA.
No evidence FBI screening was conducted.


Interview with EMP # 1 on 11/6/2020 between approximately 3:15 PM-4:00 PM confirmed above findings.








Plan of Correction:

1. In regards to PF#3: DCW was hired on 01/30/2020. During an internal bi-monthly chart review, conducted on 03/11/2020, Quality and Staff Development Manager informed Care Coordinator that DCW needed to be registered for Department of Aging FBI Fingerprints as soon as possible due to lack of PA residency. Care Coordinator registered DCW for Department of Aging Fingerprints on 03/11/2020 and scheduled an appointment for DCW to have them processed on 03/16/2020 at 10:50am in Red Lion, PA. During another internal bi-monthly chart review, conducted on 07.15.2020, Regional Manager discovered that agency did not receive DCW's Department of Aging Fingerprint results. Regional Manager immediately contacted DCW via phone call to inquire if DCW had her Fingerprints processed. DCW admitted that she forgot and did not have her Fingerprints processed. Regional Manager terminated DCW's employment effective immediately on 07.15.2020. Quality and Staff Development Manager contacted previous DCW via phone call on 11/10/2020 to inquire if DCW would be willing to have her Department of Aging FBI Fingerprints processed to update her personnel file. Previous DCW refused.

2. 100% of active employee charts will be reviewed for accuracy by 12/21/2020. This will ensure compliance of all employees' federal criminal history records. Also, ten different employee charts will be reviewed on a bi-monthly basis to ensure compliance.

3. Office's administrative personnel will be re-trained by the Quality and Staff Development Manager on the below listed items to support compliance in these areas.

This training began on 11/11/2020. The company feels that the office's administrative personnel will be confident in the process no later than 12/21/2020 after all questions and concerns can be addressed.

a. Ensuring that agency is obtaining acceptable documentation to prove 2 consecutive years of PA residency in a timely manner. If not applicable, ensuring that agency is registering DCWs for Department of Aging FBI Fingerprints in a timely manner and following through with the process of obtaining the results by 90 days from DCW's date of hire.

4. Regional Manager will be responsible for ensuring that the office's administrative personnel is following through with adhering to compliance of employees' federal criminal history records. To do this, the Regional Manager will review 10 employee charts on a bi-monthly basis and will document adherence accordingly in chart audit logs. Any discrepancies will require immediate follow up from the office's administrative personnel.



611.54(a)(7) LICENSURE
Provisional Hiring

Name - Component - 00
The period of provisional hire of an individual who is and has been, for a period of 2 years or more. A resident of Pennsylvania, may not exceed 30 days. The period of provisional hire of an individual who has not been a resident of Pennsylvania for two years or more may not exceed 90 days.

Observations:


Based upon review of agency policy, personnel files (PF), interview with quality and staff development manager (EMP #1), agency failed to terminate provisional hire after ninety (90) days for one (1) of three (3) files reviewed. ( PF # 3).

Findings included:

Review of agency policy on 11/6/2020 between approximately 3:00 PM-3:15 PM titled " Provisional hiring" stated" (8.) an applicant who has not been a resident of Pennsylvania (PA) for 2 years or more shall not serve a provisional period of more than ninety (90) days"


Review of PF on 11/6/2020 between approximately 1:15 PM-1:45 PM revealed:

PF # 3, Date of Hire (DOH) 1/30/2020; documentation present of New York state driver's license and record on application of work history revealed residency 7/22/2018-11/26/2018 in New York state.
Most current job 12/26/2018- 6/19/2019 in York PA.
Last day worked 7/15/2020. ( seventy-five (75) days past the 90 day limit).


Interview with EMP # 1 on 11/6/2020 between approximately 3:15 PM-4:00 PM confirmed above findings.













Plan of Correction:

1. In regards to PF#3: DCW was hired on 01/30/2020. During an internal bi-monthly chart review, conducted on 03/11/2020, Quality and Staff Development Manager informed Care Coordinator that DCW needed to be registered for Department of Aging FBI Fingerprints as soon as possible due to lack of PA residency. Care Coordinator registered DCW for Department of Aging Fingerprints on 03/11/2020 and scheduled an appointment for DCW to have them processed on 03/16/2020 at 10:50am in Red Lion, PA. During another internal bi-monthly chart review, conducted on 07.15.2020, Regional Manager discovered that agency did not receive DCW's Department of Aging Fingerprint results. Regional Manager immediately contacted DCW via phone call to inquire if DCW had her Fingerprints processed. DCW admitted that she forgot and did not have her Fingerprints processed. Regional Manager terminated DCW's employment effective immediately on 07.15.2020. Quality and Staff Development Manager contacted previous DCW via phone call on 11/10/2020 to inquire if DCW would be willing to have her Department of Aging FBI Fingerprints processed to update her personnel file. Previous DCW refused.

2. 100% of active employee charts will be reviewed for accuracy by 12/21/2020. This will ensure compliance of all employees' federal criminal history records and 90 day provisional hiring. Also, ten different employee charts will be reviewed on a bi-monthly basis to ensure compliance.

3. Office's administrative personnel will be re-trained by the Quality and Staff Development Manager on the below listed items to support compliance in these areas.

This training began on 11/11/2020. The company feels that the office's administrative personnel will be confident in the process no later than 12/21/2020 after all questions and concerns can be addressed.

a. Ensuring that agency is obtaining acceptable documentation to prove 2 consecutive years of PA residency in a timely manner. If not applicable, ensuring that agency is registering DCWs for Department of Aging FBI Fingerprints in a timely manner and following through with the process of obtaining the results by 90 days from DCW's date of hire.
b. Ensuring that all DCWs who fail to obtain Department of Aging FBI Fingerprint results by 90 days from date of hire will be terminated from employment immediately.

4. Regional Manager will be responsible for ensuring that the office's administrative personnel is following through with adhering to compliance of employees' federal criminal history records and 90 day provisional hiring. To do this, the Regional Manager will review 10 employee charts on a bi-monthly basis and will document adherence accordingly in chart audit logs. Any discrepancies will require immediate follow up from the office's administrative personnel.



611.57(c) LICENSURE
Information to be Provided

Name - Component - 00
(c) Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.

Observations:


Based upon review of agency consumer booklet, consumer files (CF), interview with quality and staff development manager (EMP #1), agency failed to inform consumer of costs and fees for services for three (3) of three (3) files reviewed. ( CF # 1-3).

Findings included:

Review of consumer booklet on 11/6/2020 between approximately 3:00 PM-3:15 PM revealed form titled care plan " has a section titled Payment Method, with a box checked " other "


Review of CF on 11/6/2020 between approximately 1:45 PM-2:45 PM revealed:

CF # 1, Start of Service (SOS) 3/16/2020; consumer care plan had box checked other with " CHC Waiver" documented. No documentation consumer was informed of their cost for services.

CF # 2, SOS 8/24/2020; consumer care plan had box checked other with " CHC MCO" documented. No documentation consumer was informed of their cost for services.

CF # 3, SOS 4/22/2020; consumer care plan had box checked other with " CHC Waiver" documented. No documentation consumer was informed of their cost for services.



Interview with EMP # 1 on 11/6/2020 between approximately 3:15 PM-4:00 PM confirmed above findings.








Plan of Correction:

1. In regards to CF #1, CF #2, and CF #3: Agency did inform these three consumers of costs and fees for services. Quality and Staff Development Manager contacted the two previous Care Coordinators who completed agency's Home Care Plans with consumers via phone calls to inquire if this information was discussed during the initial assessment visit. Both previous Care Coordinators confirmed that this information was discussed verbally with the consumers, just not indicated on agency's Home Care Plan, by writing $0 next to CHC MCO. Agency orders 15,000 Home Care Plans at a time. When the Managed Care was implemented on 01/01/2020, agency still had thousands of Home Care Plans in inventory. Being as Attendant Care Waivers, CommCare Waivers, Independence Waivers, and PDA Waivers were transitioned to CHC Waivers, and since $0 is indicated next to each of those Waivers on agency's Home Care Plan, agency did not think it would be unacceptable to write CHC MCO on the "other" line, without $0 next to it. Quality and Staff Development Manager contacted these three consumers via phone calls on 11/11/2020 to reiterate that there are $0 costs and fees for services.

2. 100% of active consumer charts will be reviewed for accuracy by 12/21/2020. This will ensure that all consumers' were informed of the costs and fees for services. Also, ten different consumer charts will be reviewed on a bi-monthly basis to ensure compliance.

3. Office's administrative personnel will be re-trained by the Quality and Staff Development Manager on the below listed items to support compliance in these areas.

This training began on 11/11/2020. The company feels that the office's administrative personnel will be confident in the process no later than 12/21/2020 after all questions and concerns can be addressed.

a. Ensuring that administrative personnel are informing consumers of costs and fees for services during initial assessment/intake.
b. Ensuring that $0 is indicated on agency's Home Care Plan for each consumer who is a CHC Waiver.

4. Regional Manager will be responsible for ensuring that the office's administrative personnel are following through with the above mentioned. To do this, the Regional Manager will review 10 consumer charts on a bi-monthly basis and will document adherence accordingly in chart audit logs. Any discrepancies will require immediate follow up from the office's administrative personnel.



Initial Comments:

Based upon the findings of an offsite unannounced complaint investigation survey conducted between 11/6/ 2020-11/9/2020, Caregivers America, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).










Plan of Correction: