Initial Comments:
Based on the findings of an unannounced offsite state home care agency complaint survey completed on 1/3/24, Bridge City Home Care LLC, 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 (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 a review of the home care agency's (HCA) complaint and incident log, and an interview with the Complaince Manager CM#1, the agency failed to document reportable events as per the Pennsylvania (PA) Department of Health's (DOH) Event Reporting System (ERS) manual for two (2) incidents (INC): INC#1, and INC#2.
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..."
A review of ERS on December 20, 2024, encompassing the time frame of 01/01/2023 to 12/20/2024 found that the HCA had not reported any incidents to the DOH as defined in 28 Pa Code Chapter 51.
A review of the HCA's Complaint and Incident Log was conducted on January 7, 2025 at approximately 11:30 AM. Two events, reportable to the DOH, were identified. The Incident Date (ID) is indicated below.
INC#1 ID 11/08/2024 was reported to the HCA on 11/08/2024 as an event whereby the consumer "fell and broke her thigh bone," and was admitted to the hospital. The incident occurred while the caregiver was on site providing services.
INC#2 ID 07/22/2024 involved email communication between the Complaince Manager, (MCO) Service Coordinator (SC) and the HCA. The SC reported to the HCA that s/he had requested an exterminator for bed bugs in the home. The SC was unable to validate if the exterminator had provided services. The HCA documented that services were put on hold until resolution of the bedbug situation. The HCA also documented that a direct care worker (DCW) reported that s/he had been bitten by the bedbugs. The HCA recommended to the DCW that s/he go to urgent care or his/her primary physician for evaluation.
None of the two (2) incidents were reported to the DOH via the ERS as required by 28 Pa Code Chapter 51.
An interview with the Complaince Manager on January 7, 2025 starting at 12:10 PM confirmed the above findings.
Plan of Correction:Bridge City Home Care, LLC relies on caregivers, clients, and/or Payor Service Coordinators to provide details on hospitalizations and incidents. We as an agency take these matters seriously. In reviewing the information provided in this CAP, we do not have any documentation that this information was provided to Bridge City by the caregiver, client, and/or Payor Service Coordinator.
Bridge City is making strides in ensuring that these issues are being addressed. Bridge City intends to do the following:
1) Sending out weekly texts through HHAx, notifying the caregivers that they should be reporting hospitalizations, incidents, etc.
2) Re-education of all office team members regarding incident reporting by 2/14/2024
3) Re-education to Caregivers on what an incident is and the need to report to the office, this will be done through HHAx and completed by 2/21/2025
Initial Comments:
Based on the findings of an offsite state home care agency complaint survey completed on 1/3/24, Bridge City Home Care LLC, 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
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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 observation, and email, the agency failed to maintain standards required by the Commonwealth. The agency failed to be subject to an unannounced inspection by authorized representatives of the Department.
Findings Include:
Per 35 P.S. 448.813, "Authorization.--For the purpose of determining the suitability of the applicants and of the premises or for determining the adequacy of the care and treatment provided or the continuing conformity of the licensees to this act and to applicable local, State and Federal regulations, any authorized agent of the department may enter, visit and inspect the building, grounds, equipment and supplies of any health care facility licensed or requiring a license under this act and shall have full and free access to the records of the facility and to the patients and employees therein and their records, and shall have full opportunity to interview, inspect, and examine such patients and employees."
Agency didn't provide accessible employee files, or consumer files in compliance with survey investigation guidelines.
Several attempts were made to obtain access of files to be reviewed at the agency's location by both telephone calls and emails. The following is the documented attempts to obtain access to the needed docments to be reviewed for an investigation.
December 5, 2024 1:15 PM:
Attempted to contact the agency via phone. Left a voicemail as no one answered. Did not receive a call back.
December 9, 2024 1:26 PM:
Called Bridge City Home Care to request administrator contact regarding a complaint.
Spoke with an office assistant who stated no administrator was available.
December 10, 2024 4:03 PM:
Third emial sent in attempt to gain access to documents is as follows:
"I am have been attempting to speak with someone at the administration level. I called and left a message at 1:26 pm on Monday 12/9/24. I just attempted to call the office again today. There is an urgent matter that I need to address with your agency."
Surveyor spoke with CM#1 1/2/24 at 10:00 who confirmed the following:
Only one staff member has full access to the files, and this individual is frequently out of the office providing direct care.
Concern Raised: Difficulty reaching the agency. Despite informing staff that the call was from the Department of Health, it took three phone call attempts and a third email before receiving a response.
An interview with CM#1 1/2/24 at 10:00 confirmed the above findings.
Plan of Correction:Bridge City understands the importance of being present for drop-ins and ensuring personnel is on-site to answer calls and provide information as necessary.
By 2/14/2025, all Office Team Members will be re-educated on how to handle incoming phone calls, emails, or site-visits from external regulatory agencies, such as the Department of Health. In addition, an alternate on-site administrator will be identified to cover the main administrator in the times of absences. This will be communicated during the re-education on 2/14/2025.
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 review of Consumer Files (CF) and the an interview with the Compliance Manager, the agency failed to ensure services were received with reasonable accommodation of individual needs for one (1) of three (3) CFs. CF#1. The agency failed to provide service hours as outlined in the service contract for the consumer.
Findings include:
A review of CF's was conducted on 1/2/25 approximately at 1000 AM.
A review of CF#1 schedule and missed vists information shows:
CF#1 Start of care date 3/28/23, service auth and signed service agreement are for 24-hour care 7 days a week.
CF#1 experienced a total of 86 hours and 45 minutes of missed care from September to December 2024.
Monthly Breakdown of Missed Hours:
MonthTotal Missed HoursSignificant Gaps Identified
September15 hours, 45 minutesNotable: Sept 20 (9-hour, 45 minute gap)
October29 hours, 30 minutesNotable: Oct 13 (8-hour gap, Oct 19 (6-hour gap)
November35 hours, 30 minutesNotable: Nov 19 (10-hour, 30-minute gap)
Copliance Manager (CM) interview conducted on 1/2/25 at approximately 10:00 AM confirmed the above findings.
Plan of Correction:After re-reviewing the data on the specific client, requested by the Department of Health, we respectfully disagree with part of this finding. Our review of this individual finds that all hours from September to November are accounted for and were delivered.
Bridge City does understand the importance of Reporting Shift Changes and/or Missed Visits and Staffing Policies. Operations intends to re-educate Office Staff of Missed Shift Reporting, Staffing Policies, and ensuring proper documentation is present within the HHAx system. We intend to have this complete by 2/14/2025.
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