Initial Comments:
Based on the findings of an onsite unannounced complaint investigation conducted on 05/15/2024 and offsite 5/17/24, Aidewell Home Care LLC, was found to not be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
51.3 (g)(1-14) LICENSURE
NOTIFICATION
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51.3 Notification
(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.
Observations:
Based on review of Pennsylvania Department of Health Event Reporting System (ERS), agency patient notes, and staff interview, it was determined that the agency failed to notify the Department of Health (DOH) of a reportable event immediately upon becoming aware.
Findings include:
Per the Pennsylvania Department of Health Event Reporting System Manual, "...Purpose: To provide a system to enter events per 28 PA Code - 51.3 that is readily available to all appropriate PA-DOH [Pennsylvania Department of Health] facilities, a simple process to insure consistent data entry and submission, and a source for quick and meaningful feedback on event notification submissions...All facilities are required to submit notification of events as defined in 28 Pa Code Chapter 51 to the Department of Health within 24 hours of occurrence or discovery. The Electronic Event Reporting System [ERS] is the mechanism the Department will use to meet this regulatory requirement..."
After an interview with the administrator on 05/15/2024 at approximately 1:00 pm revealed that a direct care worker (DCW) reported alleged abuse towards the consumer to the agency.
A review of an agency note on 05/15/2024 at approximately 1:30 pm revealed that the agency was aware of the event 4/30/2024.
Review of the ERS System 05/17/2024 at approximately 2:00 pm revelaed there was no event report to the DOH.
An interview on 05/15/2024 at 1:30 pm with the administrator and staff, confirmed the above findings.
Plan of Correction:Policy and Procedure Revision:
- Notification Policy Update: Revise the agency's policy and procedures to ensure all reportable events are submitted to the DOH within 24 hours of occurrence or discovery, in accordance with 28 PA Code - 51.3.
- Clear Guidelines: Include clear guidelines and a checklist for identifying and reporting events that seriously compromise quality assurance and patient safety.
- Training and Education:
- Staff Training: Conduct mandatory training sessions for all staff members on the updated reporting procedures, emphasizing the importance of timely reporting of events to the DOH.
- Regular Refreshers: Implement regular refresher courses and drills to reinforce the correct procedures for event notification.
- Monitoring and Compliance:
- Compliance Audits: Establish a routine audit process to monitor compliance with the notification policy. Audits will be conducted monthly for the first six months and quarterly thereafter.
- Documentation: Maintain detailed records of all reportable events, including the date of occurrence, date of discovery, and date of notification to the DOH.
- Responsibility and Accountability:
- Designated Personnel: Assign a designated staff member responsible for overseeing the event reporting process to ensure compliance with DOH requirements.
- Accountability Measures: Implement accountability measures for staff members who fail to adhere to the reporting guidelines, including additional training or disciplinary actions if necessary.
- Continuous Improvement:
- Feedback Mechanism: Create a feedback mechanism for staff to report any issues or suggestions related to the event reporting process.
- Review Meetings: Hold regular review meetings to discuss compliance with the notification policy and identify any areas for improvement.
By implementing this plan of correction, the agency aims to prevent future occurrences of delayed notifications and ensure compliance with Pennsylvania Department of Health regulations.
Initial Comments:
Based on the findings of an unannounced complaint investigation survey, conducted onsite 05/15/2024 and offsite 5/17/24, Aidewell Home Care, LLC, was found to not 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:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
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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 on a review of personnel files (PF) and an interview with the administrator, the agency failed to provide documentation of two satisfactory references for two (2) of three (3) PF 's, PF # 1 and 3.
Findings:
A review of PF 's was conducted on 05/15/2024 at approximately 1:00 pm:
PF#1 Date of hire: 03/21/2024 only contained one documented reference verification.
PF#3 Date of hire : 11/06/2023 did not contain documentation of any reference verifications.
An interview with the administrator on 05/15/2024 at approximately 1:30 pm am confirmed the above findings.
Plan of Correction:Immediate Actions:
- Obtain Missing References: The agency will immediately obtain and document the missing satisfactory references for PF #1 and PF #3.
- Documentation Update: Ensure that all current personnel files are reviewed and updated to include the required two satisfactory references.
- Policy and Procedure Update:
- Hiring Policy Revision: Update the hiring policy to include a checklist for verifying that two satisfactory references are obtained and documented prior to hiring or rostering any direct care worker.
- Procedure Implementation: Implement the revised hiring policy by 06/15/2024.
- Training and Education:
- Staff Training: Conduct training sessions for HR staff by 06/30/2024 on the importance of obtaining and documenting two satisfactory references before hiring.
- Training Materials: Develop and distribute training materials that outline the updated procedures for reference checks.
- Monitoring and Compliance:
- Regular Audits: Implement a monthly audit process starting 07/01/2024 to review personnel files and ensure compliance with the reference verification requirements.
- Audit Documentation: Maintain detailed records of audit findings and corrective actions taken to address any deficiencies.
- Accountability and Enforcement:
- Responsibility Assignment: Assign a specific HR staff member responsible for overseeing the reference verification process.
- Enforcement: Implement accountability measures for HR staff who fail to comply with the reference verification policy, including retraining or disciplinary actions as needed.
- Feedback and Continuous Improvement:
- Feedback Mechanism: Establish a feedback mechanism by 07/15/2024 for HR staff to report any issues or suggestions related to the reference verification process.
- Review Meetings: Hold quarterly review meetings starting 07/15/2024 to discuss compliance status and identify opportunities for further improvement in hiring practices.
By implementing this plan of correction, Aidewell Home Care, LLC aims to ensure that all direct care workers meet the prerequisites for hiring or rostering, in compliance with the requirements of 28 Pa. Code, Chapter 611.
611.52(d) LICENSURE
Proof of Residency
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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 review of direct care worker personnel files (PF) and an interview with the Administrator, the agency failed to document proof of Pennsylvania (PA) 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 for two (2) of three (3) PFs.
(PFs # 1 and 3).
Findings include:
A review of PF on 05/15/2024, at approximately 1:00 pm revealed the following:
PF 1 : Date of Hire 03/21/2024 contained a Pennsylvania driver's license issued 07.13.2023. There was no verifiable documentation of Pennsylvania residency for the two (2) years preceding the date of hire.
PF3: Date of Hire: 11/06/2023, contained a Pennsylvania driver's license issued 09/04/2023. There was no verifiable documentation of Pennsylvania residency for the two (2) years preceding the date of hire.
An interview with the Administrator on 05/15/2024, at approximately 1:30 pm confirmed the above findings.
Plan of Correction:Obtain Missing Documentation:
The agency will immediately request and obtain additional proof of residency documentation for PF #1 and PF #3 to verify PA residency for the two years preceding their hire dates.
- Update Personnel Files: Ensure that the personnel files for PF #1 and PF #3 are updated with the necessary proof of residency documents.
- Policy and Procedure Update:
- Residency Verification Policy: Update the hiring policy to include a clear process for verifying and documenting PA residency for the required two years prior to hiring.
- Document Checklist: Implement a checklist for HR staff to ensure that all required proof of residency documents are collected and verified before finalizing the hiring process.
- Policy Implementation Date: Revised policies to be implemented by 06/15/2024.
- Training and Education:
- Staff Training: Conduct training sessions for HR staff by 06/30/2024 on the updated residency verification policy, emphasizing the importance of obtaining and documenting proof of residency.
- Training Materials: Develop and distribute detailed training materials outlining acceptable forms of proof of residency and the documentation process.
- Monitoring and Compliance:
- Regular Audits: Implement a monthly audit process starting 07/01/2024 to review personnel files and ensure compliance with the residency verification requirements.
- Audit Documentation: Maintain detailed records of audit findings and corrective actions taken to address any deficiencies.
- Accountability and Enforcement:
- Responsibility Assignment: Assign a specific HR staff member responsible for overseeing the residency verification process.
- Enforcement: Implement accountability measures for HR staff who fail to comply with the residency verification policy, including retraining or disciplinary actions as needed.
- Feedback and Continuous Improvement:
- Feedback Mechanism: Establish a feedback mechanism by 07/15/2024 for HR staff to report any issues or suggestions related to the residency verification process.
- Review Meetings: Hold quarterly review meetings starting 07/15/2024 to discuss compliance status and identify opportunities for further improvement in hiring practices.
By implementing this plan of correction, Aidewell Home Care, LLC aims to ensure that all direct care workers meet the prerequisites for proof of residency, in compliance with the requirements of 28 Pa. Code, Chapter 611.
611.57(a) LICENSURE
Consumer Rights
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(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 consumer files (CF) and an interview with the administrator, the agency failed to provide services per service agreement with reasonable accommodation of individual needs and preferences for two (2) of four (4) CF's, (CF # 2 and 4)
Findings include:
A review of CF's was conducted on 05/15/2024 at approxiatemly 11:00 am and an offsite on 5/17/2024 at approximately 11:00 am am revealed:
CR #2. Start of Care: 04/15/2023 File contained documentation from the Waiver Services program that consumer was to receive Direct Care Workers (DCWs) for 119 hours weekly in April 2024. DCW Timesheets were reviewed from April 2024 to May 2024. There were multiple documented weeks where reduced hours were documented including (all hours are approximate): 04/15/24-04/21/24 (missing 23 hours), 04/22/24-04/28/24 (missing 11 hours), 04/29/24-05/05/24 (missing 16.5 hours).There is no documentation provided to show if the agency attempted to provide alternative staffing.
CR#4. Start of Care: 07/15/2023. File contained documentation from the Waiver Services program that consumer was to receive Direct Care Workers (DCWs) for 49 hours weekly. Timesheets were reviewed of August 2023, September 2023, and October 2023. There was one documented week where reduced hours were documented including (all hours approximate) 08/28/23 - 09/03/2023 (missing 45 minutes). There is no documentation provided to show if the agency attempted to provide alternative staffing.
An interview with the administrator on 05/15/2024 at approximately 2:00 pm confirmed the above findings.
Plan of Correction:- Documentation Update:
Ensure all service gaps and attempts to provide alternative staffing are documented in the respective consumer files.
- Policy and Procedure Update:
- Service Continuity Policy: Revise the policy to include specific procedures for addressing and documenting service gaps and efforts to provide alternative staffing.
- Notification Requirements: Update procedures to ensure consumers receive written notice of any anticipated service interruptions and efforts made to accommodate their needs.
- Policy Implementation Date: Revised policies to be implemented by 06/15/2024.
- Training and Education:
- Staff Training: Conduct training sessions for all staff by 06/30/2024 on the updated policies and procedures related to service continuity and consumer rights.
- Training Materials: Develop and distribute detailed training materials outlining the procedures for addressing service gaps and notifying consumers.
- Monitoring and Compliance:
- Regular Audits: Implement a monthly audit process starting 07/01/2024 to review consumer files and ensure compliance with service agreements and documentation requirements.
- Audit Documentation: Maintain detailed records of audit findings and corrective actions taken to address any deficiencies.
- Accountability and Enforcement:
- Responsibility Assignment: Assign a specific staff member responsible for overseeing service continuity and ensuring compliance with consumer rights policies.
- Enforcement: Implement accountability measures for staff who fail to comply with the service continuity and consumer rights policies, including retraining or disciplinary actions as needed.
Feedback and Continuous Improvement:
- Feedback Mechanism: Establish a feedback mechanism by 07/15/2024 for consumers and staff to report any issues or suggestions related to service continuity and consumer rights.
- Review Meetings: Hold quarterly review meetings starting 07/15/2024 to discuss compliance status and identify opportunities for further improvement in service delivery and consumer satisfaction.
By implementing this plan of correction, Aidewell Home Care, LLC aims to ensure that all consumers receive services in accordance with their individual needs and preferences, and that any service interruptions are properly documented and communicated. This will help to comply with the requirements of 28 Pa. Code, Chapter 611.
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