Initial Comments:
Based on the findings of an onsite unannounced State relicensure survey completed 9/16/2021, Nations Choice Home Health Care Llc was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
51.3 (f) LICENSURE
NOTIFICATION
Name - Component - 00
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 review of the agency documentation, Pennsylvania (Pa.) Department of Health (DOH) Event Reporting System (ERS), staff (EMP) interviews the agency failed to ensure event reporting to the Pennsylvania (Pa.) Department of Health ERS system for one (1) staff member whom was diagnosed COVID-19 positive from March 2020 to 9/14/2021.
Findings Include:
Review of the departments event reporting system guide on 9/16/2021 at approximately 9:00 PM revealed, "Health department Reportable Diseases COVID-19 Quick Start Guide COVID-19 records are reportable within 24 hours after being diagnosed ...Health Department Reportable Diseases (Covid-19) - If you select Event Type = Health Department Reportable Diseases and Event-Sub-type = Covid-19, the Reportable Disease Detail section will appear. You will be required to add at least one Reportable Disease Detail record before submitting the event to DOH. There are two ways to enter information. It should be noted that both methods can be used during the same event. You can manually enter data and/or upload a spreadsheet/s..."
Review of the departments PAHAN updates on 9/16/2021 at approximately 9:00 PM revealed, "PENNSYLVANIA DEPARTMENT OF HEALTH 2021 - PAHAN - 563 - 04-09-UPD UPDATE: Interim Infection Prevention and Control Recommendations for Healthcare Settings during the COVID-19 Pandemic DATE: 4/09/2021 ...
II. RECOMMENDED INFECTION PREVENTION AND CONTROL (IPC) PRACTICES WHEN CARING FOR A PATIENT EXPOSED TO COVID-19 OR WITH COVID-19 INFECTION ...A. Establish Reporting within and between Healthcare Facilities and to Public Health Authorities
Implement mechanisms and policies that promote situational awareness for facility staff including infection control, healthcare Epidemiology, facility leadership, occupational health, clinical laboratory, and frontline staff about patients with suspected or confirmed SARS-CoV-2 infection and facility plans for response.
Communicate and collaborate with public health authorities. Facilities should designate specific persons within the healthcare facility who are responsible for communication with public health officials and dissemination of information to HCP, patients and visitors..."
Review of the departments PAHAN updates on 9/16/2021 at approximately 9:00 AM revealed, "PENNSYLVANIA DEPARTMENT OF HEALTH 2020 - PAHAN - 524 - 09-10-UPD UPDATE: Interim Infection Prevention and Control Recommendations for Patients with Known or Patients Under Investigation for 2019 Novel Coronavirus (COVID-19) in a Healthcare Setting DATE: 9/10/2020 ...II. RECOMMENDED INFECTION PREVENTION AND CONTROL (IPC) PRACTICES WHEN CARING FOR A PATIENT WITH SUSPECTED OR CONFIRMED SARS-COV-2 INFECTION
K. Establish Reporting within and between Healthcare Facilities and to Public Health Authorities
Implement mechanisms and policies that promote situational awareness for facility staff including infection control, healthcare Epidemiology, facility leadership, occupational health, clinical laboratory, and frontline staff about patients with suspected or confirmed SARS-CoV-2 infection and facility plans for response.
Communicate and collaborate with public health authorities. Facilities should designate specific persons within the healthcare facility who are responsible for communication with public health officials and dissemination of information to HCP..."
An interview was conducted with EMP1 on 9/15/2021 at approximately 10:07 AM as to if any staff and/or consumers were confirmed Covid-19 positive since March 2020. EMP1 confirmed one (1) staff member Covid positive while services were being provided. EMP1 confirmed a report was not submitted to the Pennsylvania (Pa.) Department of Health (DOH) Event Reporting System (ERS).
An exit interview with the director of operations on 9/15/2021 at approximately 2:10 PM confirmed the above findings.
Plan of Correction:Nations Choice LLC resubmitted the report on the ERS portal on 9/21/21.
Nations Choice LLC will always be entering in the ERS portal within 24 hours of having a positive reportable disease.
Nations Choice LLC has made it that as soon as we have a positive case the Director of Operations is notified and all of the information such as onset of symptoms, wearing ppe, when were you at your consumers last are asked to ensure the proper report is completed.
51.13 (b) LICENSURE
CIVIL RIGHTS COMPLIANCE RECORDS
Name - Component - 00
51.13. Civil rights compliance records
(b) Copies of the health care
facility's nondiscriminatory policy
shall be posted in locations
accessible to the facility's staff and
the general public.
Observations:
Based on a facility tour of the agency and staff (EMP) interview, the agency failed to post a copy of the agency's nondiscriminatory policy in a location accessible to the staff and the public.
Findings included:
A tour of the agency conducted on 9/15/2021 at approximately 10:07 AM revealed, a employee nondiscriminatory policy was not posted in a location accessible to the agency staff or public. (EMP1) confirmed an agency patient nondiscrimination policy was not posted within the facility.
An exit interview with the director of operations on 9/15/2021 at approximately 2:10 PM confirmed the above findings.
Plan of Correction:Nations Choice LLC corrected this deficiency by placing the nondiscrimination policy on the wall.
Nations Choice LLC has the policy posted so that employees, consumers and guest have access to it.
We will not be taking the policy down.
Nations Choice LLC's director of Operations will be checking monthly to make sure the policy is up and visible to everyone.
Initial Comments:
Based on the findings of an onsite unannounced State relicensure survey completed 9/16/2021, Nations Choice Home Health Care Llc. was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.
Plan of Correction:
611.51(b) LICENSURE
Direct Care Worker Files
Name - Component - 00
Files for direct care workers employed or rostered shall include documentation of the date of the face-to-face interview with the individual and of references obtained. Direct Care Worker files also shall include other information as required by § 611.52, § 611.53, if applicable, § 611.54, § 611.55 and § 611.56 (relating to criminal background checks, child abuse clearance, provisional hiring, competency requirements; and health evaluations).
Observations:
Based on review of agency policy, personnel files (PF) and staff interview, it was determined the agency failed to include documentation of the date of references obtained for one (1) of five (5) PF's reviewed (PF1).
Findings included:
A review of the agency's employee handbook on 9/15/2021 at approximately 11:05 AM revealed, "JOB DESCRIPTION FOR: Direct Care Worker JOB CLASSIFICATION ...QUALIFICATIONS ...Applicant must be bondable and meet or exceed minimum qualifications for each of the following background checks: criminal background investigation, professional reference checks and give permission to submit to random drug testing..."
A review of PF1 on 9/15/2021 at approximately 11:30 AM revealed, date of hire (DOH) 9/7/2021, PF4 did contain two (2) reference. The references were complete, but no documentation of the completion dates could be confirmed.
An exit interview with the director of operations on 9/15/2021 at approximately 2:10 PM confirmed the above findings.
Plan of Correction:Nations Choice LLC has corrected this deficiency by adding a document that Director of Operations will sign when the reference checks are completed.
Nations Choice LLC will be calling reference as soon as the interview is completed to ensure that references are completed.
Nations Choice LLC created a document that the applicant sings, the person calling the reference and the director of operations signs before the employee goes into the field.
Director of operations signing off on the paperwork means that it was completed and references were checked with a date on them.
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 on a review of the policy, personnel files (PF) and staff interview, it was determined the agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for two (2) of five (5) PF who were not a resident of Pennsylvania for the 2 years immediately preceding date of hire (PF2 and PF3).
Findings included:
Review of the employee handbook on 9/15/2021 at approximately 12:50 PM revealed, "MANDATORY BACKGROUND CRIMINAL CHECK AND EMPLOYEE CONSENT: (Agency) requires all employees prior to any offer off employment; all employees must successfully pass a state mandatory criminal background check. (Agency) is prohibited from hiring and or retaining any individual(s) with a prohibited conviction or Department of Aging ineligibility determination. (Agency) Background Check investigation adheres to the Background Investigation guidelines as required under PA code 611.52 (a-j) ...(B) STATE POLICE CRIMINAL HISTORY RECORD: If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police Criminal history record. (C) FEDERAL CRIMINAL HISTORY RECORD: 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...(D) PROOF OF RESIDENCY: 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..."
Review of PF2, on 9/15/2021 at approximately 12:00 PM revealed, date of hire (DOH) 4/5/2021 A Pennsylvania driver's license issued with an issue date of 11/5/2020. A federal criminal history check was completed as of 9/8/2020 from the Pennsylvania Department of Human Services. No federal criminal history record and/or letter of determination from the Pennsylvania Department of Aging was available for review.
Review of PF3, on 9/15/2021 at approximately 12:20 PM revealed, date of hire (DOH) 4/17/2021 A Pennsylvania identification card with an issue date of 11/19/2020. Documentation within the PF revealed a federal criminal history check completed as of 2/28/2018 from the Pennsylvania Department of Human Services. No federal criminal history record and/or letter of determination from the Pennsylvania Department of Aging was available for review.
An exit interview with the director of operations on 9/15/2021 at approximately 2:10 PM confirmed the above findings.
Plan of Correction:Nations Choice LLC has corrected this deficiency by adding a document that Director of Operations will sign when the 2 year proof of residency or Fingerprints through the department of Aging are completed.
Nations Choice LLC will be getting the proof of residency or the Department of aging fingerprints before the employee is scheduled for orientation
Nations Choice LLC created a document that the proof of residency is scanned on with the date of proof and also the type of proof that it is.
Director of operations signing off on the paperwork means that it was completed and 2 year proof of residency or the department of aging fingerprints were received and placed in the employees file.
611.57(a) LICENSURE
Consumer Rights
Name - Component - 00
(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 the agency policy, consumer records (CR) and staff (EMP) interview, the agency failed to involve the consumer in the service planning process and to receive services with reasonable accommodation of individual needs and preferences for five (5) of five (5) CR reviewed (CR1-CR5).
Findings included:
Review of the agency policy on 9/15/2021 at approximately 12:50 PM revealed, "PATIENT PROTECTION AND PATIENTS BILL OF RIGHTS & RESPONSIBILITIES: (A) Consumer rights. 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 services 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. (c) Information to be provided. 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 tis easily read and understood...(3)...The hours when those services will be provided..."
A review of CR1 on 9/15/2021 at approximately 12:55 PM start of services 8/13/2021 revealed: The CR contained a service authorization waiver from the County office of Area on Aging with the designated hours of allotted time per week for services. No agency service agreement was available within the CR to confirm that the agency had met with consumer/consumer representative to discuss the individual schedule of days and times.
A review of CR2 on 9/15/2021 at approximately 1:05 PM start of services 4/21/2021 revealed: The CR contained a service authorization waiver from the County office of Area on Aging with the designated hours of allotted time per week for services. No agency service agreement was available within the CR to confirm that the agency had met with consumer/consumer representative to discuss the individual schedule of days and times.
A review of CR3 on 9/15/2021 at approximately 1:34 PM start of services 4/7/2021 revealed: The CR contained a service authorization waiver from the County office of Area on Aging with the designated hours of allotted time per week for services. No agency service agreement was available within the CR to confirm that the agency had met with consumer/consumer representative to discuss the individual schedule of days and times.
A review of CR4 on 9/15/2021 at approximately 1:40 PM start of services 3/29/2021 revealed: The CR contained a service authorization waiver from the County office of Area on Aging with the designated hours of allotted time per week for services. No agency service agreement was available within the CR to confirm that the agency had met with consumer/consumer representative to discuss the individual schedule of days and times.
A review of CR5 on 9/15/2021 at approximately 1:45 PM start of services 8/1/20201 revealed: The CR contained a service authorization waiver from the County office of Area on Aging with the designated hours of allotted time per week for services. No agency service agreement was available within the CR to confirm that the agency had met with consumer/consumer representative to discuss the individual schedule of days and times.
An exit interview with the director of operations on 9/15/2021 at approximately 2:10 PM confirmed the above findings.
Plan of Correction:Nations Choice LLC has corrected this deficiency by adding an schedule agreement that all the consumers will have.
Nations Choice LLC will make sure that this document goes in the intake packet so that when the intake/placement coordinator goes to do the intake the consumer agrees on a time and is aware of the time that they will be receiving.
Nations Choice LLC created a document that the consumer signs agreeing to the times for their care, the intake/placement coordinator signs this as well. A copy is placed in the consumers binder in the home and one on file in the consumers file at the office.
Director of operations signing off on the paperwork means the consumer and the agency have agreed on the times that are on the schedule agreement and they both parties are agreed upon.
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 on a review of the consumer records (CR) and staff interview, the agency failed to provide required information in writing to the consumers/consumer representatives prior to the commencement of services for five (5) of five (5) CRs reviewed (CR1-CR5).
Findings included:
Review of the employee handbook on 9/15/2021 at approximately 12:50 PM revealed, "PATINET PROTECTION AND PATIENTS BILL OF RIGHTS & RESPONSIBILITIES: (A) Consumer rights. 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 services 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. (c) Information to be provided. 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 tis easily read and understood ...(3) ...The hours when those services will be provided ...(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 o9n Aging (AAA)."
Documentation review revealed a listing provided by the agency for the Agency On Aging Berks County Pennsylvania. No client was being provided services in Berks county by the agency at the time of survey.
A review of CR1 on 9/15/2021 at approximately 12:55 PM start of services 8/13/2021 revealed: No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
2. The local Area Agency on Aging's Ombudsman Program telephone number.
A review of CR2 on 9/15/2021 at approximately 1:05 PM start of services 4/21/2021 revealed: No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
2. The local Area Agency on Aging's Ombudsman Program telephone number.
A review of CR3 on 9/15/2021 at approximately 1:34 PM start of services 4/7/2021 revealed: No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
2. The local Area Agency on Aging's Ombudsman Program telephone number.
A review of CR4 on 9/15/2021 at approximately 1:40 PM start of services 3/29/2021 revealed: No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
2. The local Area Agency on Aging's Ombudsman Program telephone number.
A review of CR5 on 9/15/2021 at approximately 1:45 PM start of services 8/1/20201 revealed: No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
2. The local Area Agency on Aging's Ombudsman Program telephone number.
An exit interview with the director of operations on 9/15/2021 at approximately 2:10 PM confirmed the above findings.
Plan of Correction:Nations Choice LLC has corrected this deficiency fixing the phone number for the correct county Area of Aging.
Nations Choice LLC will make sure that this document goes in the intake packet so that when the intake/placement coordinator goes to do the intake the consumer has the correct information for the local Area of Aging.
Nations Choice LLC fixed the document with the correct Area of Aging number on it. Current consumers had their information updated in their binder at their home with their signature so it know that they are been updated. New Consumers will have the correct area of agency phone number due to the document being updated. A copy is placed in the consumers binder in the home and one on file in the consumers file at the office.
Director of operations will checking monthly to make sure that all of information is completed and correct with the local area of aging number.
Nations Choice LLC has corrected this deficiency by adding an schedule agreement that all the consumers will have.
Nations Choice LLC will make sure that this document goes in the intake packet so that when the intake/placement coordinator goes to do the intake the consumer agrees on a time and is aware of the time that they will be receiving.
Nations Choice LLC created a document that the consumer signs agreeing to the times for their care, the intake/placement coordinator signs this as well. A copy is placed in the consumers binder in the home and one on file in the consumers file at the office.
Director of operations signing off on the paperwork means the consumer and the agency have agreed on the times that are on the schedule agreement and they both parties are agreed upon
Initial Comments:
Based on the findings of an onsite unannounced State relicensure survey completed 9/16/2021, Nations Choice Home Health Care Llc was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
|