QA Investigation Results

Pennsylvania Department of Health
CAS HOME HEALTH CARE INC.
Health Inspection Results
CAS HOME HEALTH CARE INC.
Health Inspection Results For:

This is the only survey for this facility

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an onsite unannounced complaint investigation survey completed April 21, 2021, CAS Home Care Inc., was found NOT to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.








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 upon a complaint investigation, it was determined that the agency failed to notify the Department about a complaint regarding theft of patient property, for one of three Consumer Files reviewed, (CF). (CF#1).

On April 16, 2021, a review of the Complaint Intake, updated March 22, 2021, and review of consumer files, revealed that on January 29, 2021, CF#1 reported that a credit card had been used by a Direct Care Worker employed by the Agency. The agency launched a full investigation. A search in the Department's Event Reporting System, (ERS), revealed that the agency had failed to submit this report of financial exploitation in the ERS.

On April 16, 2021, 2:30 p.m., it was confirmed with the Director of Nurses, that the agency had not notified the Department of this event.











Plan of Correction:

To be in Compliance with 51.3 (g) (1-14) LICENSURE NOTIFICATION CAS Home Care has submitted the compliant reported by (CF) regarding the theft of her property: (money taken from her debit card) to the Department of Health through ERS May 4, 2021.

CAS Home Care assures that the Department of Health will be notified of all events that compromise consumer quality assurance and safety.

The Director of Nursing will submit all critical events through the ERS to the Department of Health.

The Administrator will monitor for compliance.




Initial Comments:


Based on the findings of an onsite unannounced complaint investigation survey completed April 21, 2021, and off-site continued on April 21, 2021, CAS Home Health Care Inc., 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:




611.57(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 review of Consumer Files, admission packet, and interview with the Director of Nursing, it was determined that the agency had failed to render services with reasonable accommodation of individual needs and preferences, for one, (1), of three Consumer Files reviewed. (CF#1).

Findings include:

On April 16, 2021, at approximately 11:00 a.m., three Consumer Files were reviewed to include the subject of the complaint.
On April 16, 2021, at approximately 12:20 p.m., a review of CF #1, revealed a Start of Care on December 3, 2010. A review of a document titled, HHAexchange Patient Calendar, dated January 2021, revealed that CF#1 was to receive five, (5), hours of care, five, (5), days a week. The documented confirmed that the following visits were missed:
January 4, 2021-No document provided by the agency to confirm a reason for missed visit.
January 18, 2021- No document provided by the agency to confirm a reason for missed visit.
January 26, 2021-A document provided by agency confirmed that DCW called-out to the Consumer, but not the office.
On April 16, 2021, at approximately 2:30 p.m., it was confirmed that there missed visits. The Director stated that at times the Direct Care Workers were not able to get into the house, and the Consumer would not answer the phone.

****

Based on review of Consumer Files, admission packet, and interview with the Director of Nursing, it was determined that the agency had failed to inform the Consumer of the right to receive at least 10 calendar days advance written notice of the intent of the home care agency for three, (3), of three (3), Consumer Files reviewed. (CF#1).

Findings Include:

On April 16, 2021, at approximately 12:20 p.m., a review of CF #1, revealed a Start of Care on December 3, 2010. There was no evidence that the Consumer was notified of the right 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.


On April 16, 2021, at approximately 12:40 p.m., in an interview with the CF #2, revealed a Start of Care on December 31, 2018. There was no evidence that the Consumer was notified of the right 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.

On April 16, 2021, at approximately 1:10 p.m., a review of CF #3, revealed a Start of Care on May 17, 2012. There was no evidence that the Consumer was notified of the right 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.

On April 16, 2021, at approximately 2:30 p.m., it was confirmed that home care Consumers were not notified of the right 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.














Plan of Correction:

To be in Compliance with 611.57 (a) LICENSURE: Consumer Rights
CAS Home Care assures that all Consumers receive documentation explaining their rights with reasonable accommodation of their needs and preferences.

The Consumer Rights have been revised to include: A 10 calendar days notice prior to termination of services which will be in writing and a consumer signature will obtained as their understanding. (CF#1) FILE has been updated.

All consumers are receiving the revised Consumer Rights. Signatures copies are maintained in the Consumer files.

CAS Home Care assures that documentation of any missed visits be documented in HHA Exchange with reasons for the missed visits.

The Staffing Coordinator will call the consumer and inquire about the status of the visit. The Coordinator will offer to replace Director Care Worker.

All Direct Care Workers will receive in-servicing on calling out to the Agency and to report all Consumer refusals of services immediately to the Agency.

The Consumers are being instructed to notify the Agency when their Direct Care Worker does not report for their services.

The Staffing Coordinator Manager will monitor for all missed visits and documentation is appropriate; will assist with scheduling as needed.

The Assistant Director of Nursing will follow-up with the Consumer for Safety; will assist with scheduling as needed.

The Director of Nursing will monitor for compliance.

The Administrator will provide oversight.


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 upon review of the agency admission packet, Consumer files, and interview with the Director of Nursing, it was determined that the agency failed to provide information to the Consumer that it is prohibited from assuming power of attorney, or requiring a consumer to endorse checks over to the agency while utilizing services for three (3), of three (3) Consumer Files (CF), reviewed. (CF #1, 2, and 3).

Findings include:

Review of the agency admission packet revealed no prohibition information inside of the packet for the Consumer, to prevent or warn individuals associated with the agency from assuming power of attorney, or requiring a consumer to endorse checks over to the agency.

1. On April 16, 2021, at approximately 12:20 p.m., a review of CF #1, revealed a Start of Care on December 3, 2010. Further review revealed no evidence that the agency disclosed to the Consumer, that the agency was prohibited from assuming power of attorney, or requiring a consumer to endorse checks over to the agency while utilizing agency services.

2.On April 16, 2021, at approximately 12:40 p.m., in an interview with the CF #2, revealed a Start of Care on December 31, 2018. Further review revealed no evidence that the agency disclosed to the Consumer, that the agency was prohibited from assuming power of attorney, or requiring a consumer to endorse checks over to the agency while utilizing agency services

3. On April 16, 2021, at approximately 1:10 p.m., a review of CF #3, revealed a Start of Care on May 17, 2012. Further review revealed no evidence that the agency disclosed to the Consumer, that the agency was prohibited from assuming power of attorney, or requiring a consumer to endorse checks over to the agency while utilizing agency services.

In an interview with the Director of Nursing on April 16, 2021, at approximately 2:30 p.m., it was confirmed the there was no documentation in the admission packet, or consumer records that the agency had disclosed to the Consumer, that the agency was prohibited from assuming power of attorney, or requiring a consumer to endorse checks over to the agency while utilizing agency services.









Plan of Correction:

To be in Compliance with 611.57 (b) LICENSURE

CAS HOME CARE has added to files (C# 1,2,3)

CAS HOME CARE assures that all consumers receive information prohibiting the agency from assuming power of attorney, or requiring a consumer to endorse checks over to the agency while utilizing agency services.

This information has been added to the admission packets.

All consumer files will be audited every 60 days by The Care Conference Team for compliance.

The administrator will provide oversight.


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 upon review of the agency's admission packet, Consumer files, and interview with the Director of Nursing, it was determined that the agency failed to provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the required information for three (3), of three (3) consumer Files (CF), reviewed. (CF #1, 2, and 3).


Findings include:


On April 16, 2021, at approximately 12:20 p.m., a review of CF #1, revealed a Start of Care on December 3, 2010. Further review revealed no documentation to show the consumer was provided an informational packet containing the following information:

1. Who to contact at the Department of Health for information about regulations and/or home care agency/registry compliance
2. The local Area Agency on Aging's Ombudsman Program telephone number
3. The hiring and competency requirements of direct care workers.
4. the consumer disclosure notice regarding employee or independent contractor status of direct care workers and the resultant tax and insurance obligations and other responsibilities

On April 16, 2021, at approximately 12:40 p.m., in an interview with the CF #2, revealed a Start of Care on December 31, 2018. Further review revealed no documentation to show the consumer was provided an informational packet containing the following information:

1. Who to contact at the Department of Health for information about regulations and/or home care agency/registry compliance
2. The local Area Agency on Aging's Ombudsman Program telephone number
3. The hiring and competency requirements of direct care workers.
4. the consumer disclosure notice regarding employee or independent contractor status of direct care workers and the resultant tax and insurance obligations and other responsibilities


On April 16, 2021, at approximately 1:10 p.m., a review of CF #3, revealed a Start of Care on May 17, 2012. Further review revealed no documentation to show the consumer was provided an informational packet containing the following information:

1. Who to contact at the Department of Health for information about regulations and/or home care agency/registry compliance
2. The local Area Agency on Aging's Ombudsman Program telephone number
3. The hiring and competency requirements of direct care workers.
4. the consumer disclosure notice regarding employee or independent contractor status of direct care workers and the resultant tax and insurance obligations and other responsibilities

In an interview with the Director of Nursing on April 16, 2021, at approximately 2:30 p.m., it was confirmed the there was no documentation in the admission packet, or consumer records that the agency had provided to the consumer, the consumer's legal representative or responsible family member an information packet containing the required information.












Plan of Correction:

To be in compliance with 611.57 (c) LICENSURE:
CAS Home Care has provided Consumers #1,2 and 3 with information regarding: 1.Department of Health information about regulations and home care agency compliance

2. The local Area Agency on Aging ombudsman program telephone number (800)254-5164

3. The hiring and competency requirements of the Direct Care Worker.

4. The Consumer Disclosure Notice regrading employees.

Cas Home Care ensures that documentation will be added to the admission packet to be maintained in the consumer files.

All existing consumers and/or their legal representative or responsible family members will be provided with the documentation.

The consumer files will be audited every 60 days by The File Review Team.

The Director of Nursing and Assist Director of Nursing will monitor for compliance.

Administrator will provide oversight.