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 onsite state re-licensure survey conducted on May 17, 2024, Angels On Call was found not to be in compliance with the following requirement of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.







Plan of Correction:




51.3 (g)(1-14) LICENSURE
NOTIFICATION

Name - Component - 00
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 agency policies/procedures and the Pennsylvania (PA) Department of Aging and the PA Department of Health (DOH) Event Reporting System (ERS) websites, and based on interview with the administrator, the agency failed to submit a report of five (5) of six (6) consumer related allegations to the PA DOH ERS website which were reported to the agency in 2024.


Findings included:

On May 17, 2024 at approximately 12:41 PM, review of the agency policy titled "Incident Management & Reporting" revealed the following under "Procedures": 1. The agency administrator will assume overall responsibility for ensuring...b. Incidents are properly reported...

On May 17, 2024 at approximately 2:30 PM, review of the PA Department of Aging website (https://www.aging.pa.gov) revealed the following:
Protective Services ...The Older Adults Protective Services Act protects Pennsylvanians 60 years of age and older against physical, emotional, or financial abuse as well as exploitation, neglect, or abandonment. Reporting of abuse is mandatory for employees and administrators in care settings ...
What is Financial Exploitation? Financial exploitation is the misuse or theft of assets, and it can happen to anyone. It can come in the form of unauthorized bank withdrawals, check fraud, misuse of credit cards, scams and theft of property. It is currently the fastest-growing form of elder abuse.

During interview conducted on May 17, 2024 at approximately 9:23 AM, the administrator reported the agency received a total of five (5) reports of theft of consumer property (misappropriation of consumer property) in 2024. The administrator reported the theft allegations were dated 01/08, 01/30, 03/13, 04/11 and 04/25/2024.

On March 17, 2024 between the approximate times of 9:23 AM and 2:55 PM, review of the PA DOH ERS website revealed reportable incidents included "Misappropriation of Patient/Resident Property".
There was no documentation on the PA DOH ERS website which provided evidence that the agency had submitted a report to the PA DOH ERS website under the aforementioned category for the above referenced theft allegations reported to the agency in 2024.


During interview conducted on May 17, 2024 at approximately 1:10 PM, the administrator confirmed the agency failed to submit a report to the PA DOH ERS website for the above referenced theft allegations.












Plan of Correction:

Agency will report all incidents which would be included in the category below. Reports shall be entered into the Incident Reporting site of Department of Health.

Complaints of patient abuse, whether or not confirmed by the facility.

Monitoring will be completed by the Director of Quality & Compliance via comparing Act 70 forms received to the DOH ERS system for involved office location, Facility ID#.

Reporting will be completed by the Director of Quality & Compliance, effective immediately.

Completion date: May 27, 2024



Initial Comments:

Based on the findings of an onsite state re-licensure survey conducted on May 17, 2024, Angels On Call was found 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:




Initial Comments:

Based on the findings of an onsite state re-licensure survey conducted on May 17, 2024, Angels On Call was found not to be in compliance with the following requirements of 35 P.S. 448.809 (b).





Plan of Correction:




35 P. S. 448.809b LICENSURE
Photo Id Reg

Name - Component - 00
Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.


(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.



Observations:

Based on review of documentation and observation of the agency's photo identification (ID) badge and based on interview with the administrator, the agency failed to ensure the job title for direct care workers ("Caregiver") occupied a one-half inch tall strip as close to the bottom edge of the photo ID badge as practicable.

Findings include:

On May 17, 2024 at approximately 12:44 PM, review of the "Caregiver Employee Handbook" revealed the following under "Employee Badge": Angels on Call employee badges are required to be worn during working hours...
On May 17, 2024 at approximately 9:37 AM, observation of a photo ID badge revealed the job title "Caregiver" was located on the left, midsection of the ID badge.
There was no evidence that the "Caregiver" job title occupied a one-half inch tall strip as close to the bottom edge of the photo ID badge as practicable.

During interview conducted on May 17, 2024 at approximately 1:10 PM, the administrator confirmed there was no evidence that the job title "Caregiver" occupied a one-half inch tall strip as close to the bottom edge of the photo ID badge as practicable.









Plan of Correction:

Agency ID Badge Template has been updated to the correct formatting per guidelines and has been implemented as of May 17, 2024.

Office Manager is responsible for ensuring the correct template is being used for all future ID Badges.

Monitoring of Plan of Correction will be completed by the Director of Quality & Compliance by requesting to view completed badges periodically during an internal review.