Initial Comments:
Based on the findings of an onsite unannounced home care agency state relicensure survey conducted on February 16, Orchid Home Health Services, Inc. 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 (f) LICENSURE
NOTIFICATION
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51.3 Notification
(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.
Observations:
Based on interview with the agency administrator on February 16, 2022, it was determined that the agency was unaware of the notification requirements under 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A to the Department of Health (DOH) of any events that could compromise quality assurance or patient safety.
Findings include:
The agency administrator was unable to provide a copy of the Event Reporting Manual that the agency was to use to report any events that could compromise quality assurance or patient safety. These events must be reported within 24 hours of occurrence or discovery.
Interview with the agency administrator on February 16, 2022, at 9:30 a.m. revealed that he was unaware of the notification requirements or the electronic system used to submit the reports to DOH.
Plan of Correction:Administrator for Orchid Home health services has successfully created login for Event reporting on 02/16/2022. Going forward reportable events will be reported in the Event reporting system.
Agency will assign Care Coordinator to report events in the Event reporting system. Agency Administrator will be assigned to monitor weekly that reportable events are submitted as required.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state relicensure survey conducted on February 16, 2022, Orchid Home Health Services, Inc. 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(a) LICENSURE
Requirements for HCA and HCR
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A current copy of this Chapter shall be maintained at the home care agency or home care registry.
Observations:
Based on observations and interview with the agency administrator on February 16, 2022, it was determined that the agency did not maintain a copy of the state licensure regulations for home care agencies and registries as required.
Findings include:
Observations of the office space and interview with the agency administator on February 16, 2022, at 9:30 a.m., revealed that there was no copy of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries on the premises.
Plan of Correction:The Agency administrator printed copy of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries on the premises on 02/17/2022 and is placed in a folder inside the administrator's office.
611.4(b) LICENSURE
Requirements For HCA And HCR
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28 PA Code Chapter 51, applicable to all entities licensed as Health Care facilities under the Act, applies to Home Care Agencies and Home Care Registries licensed under this Chapter.
Observations:
Based on observations and interview with the agency administrator on February 16, 2022, it was determined that the agency did not maintain a copy of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A regarding notification as required.
Findings include:
Observations of the office space and interview with the agency administator on February 16, 2022, at 9:30 a.m., revealed that there was no copy of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A on the premises.
Plan of Correction:Administrator at Orchid Home Health Services printed copy of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A on 02/17/2022 and is placed inside a folder in the administrator's office.
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 rights form and interview with the agency administrator on Febraury 16, 2022, it was determined that the agency failed to address termination of consumer services for nine (9) of nine (9) consumer records (CR1-CR9) ) reviewed. .
Findings include:
Review of the consumer rights form for nine (9) consumers (CR1-CR9) from 10:00 a.m.-11:00 a.m., revealed that the agency failed to include, as required, that the consumer was 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.
Interview with the agency administrator at 11:30 a.m., confirmed the above findings.
Plan of Correction:Agency will add following line in the consumer application on page 9, point 39 under CONSUMER BILL OF RIGHTS:
"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."
Intake coordinator will be assigned to monitor that 10 days termination notice is signed by Consumer attesting he/she has been informed about the termination regulations.
Agency Administrator will be responsible to monitor the implementation of Plan of correction.
Intake Manager will audit all consumer file and redo current consumers application to address findings.
611.57(b) LICENSURE
Prohibitions
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(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.
Observations:
Based on a review of consumer rights form and interview with the agency administrator on February 16, 2022, it was determined that the agency failed to address the required consumer protection prohibitions for nine (9) of nine (9) consumer records (CR1-CR9) ) reviewed. .
Findings include:
Review of the consumer rights form for nine (9) consumers (CR1-CR9) from 10:00 a.m.-11:00 a.m., revealed that the agency failed to include, as required, that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.
Interview with the agency administrator at 11:30 a.m., confirmed the above findings.
Plan of Correction:Agency will add the following line in the consumer application on page 9, point 40(Prohibitions)under CONSUMER BILL OF RIGHTS:
"No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry."
Intake coordinator will be assigned to monitor that consumers are informed about the prohibition as mentioned in the application. Intake coordinator will be required to obtained signature from consumers attesting he/she has been informed.
Agency Administrator will be responsible to monitor the implementation of Plan of correction.
Intake Manager will audit all consumer file and redo current consumers application to address findings.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state relicensure survey conducted on February 16, 2022, Orchid Home Health Services, Inc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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