QA Investigation Results

Pennsylvania Department of Health
COMPASSIONATE HOME CARE SERVICES INC
Health Inspection Results
COMPASSIONATE HOME CARE SERVICES INC
Health Inspection Results For:


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Initial Comments:


Based on the findings of an unannounced onsite state licensure complaint survey completed May 21, 2024, Compassionate Home Care 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:




611.51(a) LICENSURE
Hiring or Rostering Prerequisites

Name - Component - 00
Prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. (3) Require the individual to submit a criminal history report, in accordance with the requirements of 611.52 (relating to criminal background checks), and a ChildLine verification, if applicable, in accordance with the requirements of 611.53 (relating to child abuse clearance).

Observations:


Based on a review of employee files and an interview with the agency Administrator, the agency failed to conduct a face-to-face interview, prior to hire, for one (1) out of two (2) employee files (EF) reviewed (EF#2).

Findings include:

A review of EFs was conducted on May 21, 2024 at approximately 10:00 a.m. Employee date of hire (DOH) is listed below.

EF#2 DOH 04/03/24: No documentation provided conducting a face-to-face interview, prior to hire.

An interview conducted with the agency Administrator on May 21, 2024 at approximately 12:30 p..m. confirmed the above findings.


Repeat deficiency.










Plan of Correction:

1.The Administrator or designee will conduct and document the face-to-face interview prior to hire.

2. The Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice.

3. The Administrator will train the HR assistant to use the new employee onboarding checklist to ensure the deficient practice does not recur.

4. The Administrator or designee shall review every new employee file before they are assigned for orientation in addition to auditing 10% of every employee files quarterly.

5. This corrective plan of action will be completed by July 1, 2024



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 employee files and an interview with the agency Administrator, agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for two (2) out of two (2) employee files (EF) reviewed (EF#1, EF#2).

Findings include:

A review of EFs was conducted on May 21, 2024 at approximately 10:00 a.m. Employee date of hire (DOH) is listed below.

EF#1 DOH 04/03/24: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Drivers License issue date 03/16/23 with an expiration date of 03/15/27. 'Application for Employment' record was reviewed. Previous employer listed with no address with 'Start and End Date:' "01/2024-03/2024." No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 04/03/22-03/16/23.

EF#2 DOH 04/03/24: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Identification Card issue date 05/13/22 with an expiration date of 05/31/26. 'Application for Employment' record was reviewed. Previous employer listed with no address with 'Start and End Date:' "January-March." No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 04/03/22-05/13/22.


An interview conducted with the agency Administrator on May 21, 2024 at approximately 12:30 p..m. confirmed the above findings.


Repeat deficiency.










Plan of Correction:

1. The Administrator or designee shall request that stated employees will need a Dept of Aging criminal check conducted

2. The Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice.

3. The Administrator will train the HR assistant to use the new employee onboarding checklist to ensure the deficient practice does not recur.

4. The Administrator or designee shall review every new employee file before they are assigned for orientation in addition to auditing 10% of every employee files quarterly.

5. This corrective plan of action will be completed by July 1, 2024



611.55(a) LICENSURE
Competency Requirements

Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.

Observations:


Based on a review of employee files and an interview with the agency Administrator, the agency failed to ensure documentation showing direct care workers, prior to providing services to consumers, completed/demonstrated an initial competency training covering all required sixteen (16) subject areas for two (2) of two (2) employee files (EF) reviewed (EF#1, EF#2).

Findings include:

A review of EFs was conducted on May 21, 2024 at approximately 10:00 a.m. Employee date of hire (DOH) is listed below.


EF#1 DOH 04/03/24: No documentation provided of initial competency training containing all sixteen (16) required elements. Documentation provided of a competency test completed on 04/01/24. The competency test did not include/but not limited to the following required subjects: Recognizing changes in the consumer nor Shaving.

EF#2 DOH 04/03/24: No documentation provided of initial competency training containing all sixteen (16) required elements. Documentation provided of a competency test completed on 03/29/24. The competency test did not include/but not limited to the following required subjects: Recognizing changes in the consumer nor Shaving.


An interview conducted with the agency Administrator on May 21, 2024 at approximately 12:30 p..m. confirmed the above findings.


Repeat deficiency.








Plan of Correction:

1.The Administrator will revise the competency test to include the following missing required subjects: Recognizing changes in the consumer and Shaving; in addition to ensuring that stated employees must complete revised required initial competencies.

2.The Administrator will conduct an audit of the entire employee files to identify and ensure no other employees have been affected by the same deficient practice.

3. The Administrator will train the HR assistant to use the new employee onboarding checklist to ensure the deficient practice does not recur.

4. The Administrator or designee shall review every new employee file before they are assigned for orientation in addition to auditing 10% of every employee files quarterly.

5. This corrective plan of action will be completed by July 1, 2024.



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 consumer files, agency staffing calendar/completed visits documentation, and an interview with the agency Administrator, agency failed to ensure services were provided as agreed upon for two (2) of two (2) consumer files (CF) reviewed (CF#1, CF#2).

Findings include:

A review of CFs was conducted on May 21, 2024 at approximately 10:30 a.m. Consumer start of service (SOS) is listed below.

CF#1 SOS 03/25/24: This consumer is the subject of a AAA (Area Agency on Aging)-Northampton Event Report dated 04/28/24 (Event #1) and a AAA (Area Agency on Aging)-Northampton event report dated 05/08/24 (Event #2).
Both event reports allege that services were not provided as agreed upon (hours provided) and as a result the consumer fell while alone.

This consumer obtains personal care services through a waiver program. Per the agency Administrator and per the consumer service agreement with the agency, the consumer recieves 24/7 care.

A review of the agency staffing calendar/time sheet (April 2024-May 2024) on 05/21/24 at approximately 11:00 a.m. revealed the following missed hours:

04/09/24: 6:15 a.m.-8:00 a.m.
04/10/24: 6:00 a.m.-8:00 a.m.
04/11/24: 6:00 a.m.-9:00 a.m.
04/16/24: 6:00 a.m.-8:00 a.m.
04/17/24: 8:00 a.m.-9:30 a.m.
04/18/24: 8:00 a.m.-11:00 a.m.
04/19/24: 6:15 p.m.-7:45 p.m.
04/20/24: 8:15 a.m.-4:15 p.m.
04/21/24: 6:15 p.m.-7:45 p.m.
04/23/24: 6:00 a.m.-8:15 a.m.
04/24/24: 6:00 a.m.-8:00 p.m.
04/25/24: 6:00 a.m.-8:15 a.m.
04/26/24: 1:30 p.m.-6:00 p.m.
04/28/24: 6:15 p.m.-8:00 a.m.
04/30/24: 6:00 a.m.-8:00 a.m.

05/02/24: 6:00 a.m.-8:15 a.m.
05/04/24: 8:00 a.m.-12:45 p.m.
05/07/24: 6:15 a.m.-8:00 a.m.
05/08/24: 6:00 a.m.-10:45 a.m.
05/09/24: 6:00 a.m.-8:15 a.m.
05/10/24: 8:00 a.m.-11:00 a.m.
05/11/24: 1:45 a.m.-8:00 p.m.
05/14/24: 6:00 a.m.-8:30 a.m.


Per the agency Administrator on 05/21/24 at approximately 11:30 a.m., the missed hours listed above were agency staffing issues.
No documentation provided of a back-up plan to provide services in the consumer agreement.


CF#2 SOS 02/14/24: Per the agency Administrator and per the consumer service agreement with the agency, the consumer recieves care in (3) hour increments.

A review of the agency staffing 'Visit List' (April 2024-May 2024) on 05/21/24 at approximately 11:00 a.m. revealed the following:

04/02/24: 2 hours/3 hours
04/05/24: 2 hours/3 hours
04/17/24: 2 hours/3 hours
04/19/24: 1 hours/3 hours

Per the agency Administrator on 05/21/24 at approximately 11:30 a.m., the missed hours listed above were agency staffing issues.
No documentation provided of a back-up plan to provide services in the consumer agreement.


An interview conducted with the agency Administrator on May 21, 2024 at approximately 12:30 p..m. confirmed the above findings.








Plan of Correction:

1. The Administrator will create a policy for a back-up plan if the agency cannot provide services in the consumer agreement.
2. The Administrator will conduct an audit of the entire client files to identify and ensure no other clients have been affected by the same deficient practice.
3. The Administrator or designee will use the new client onboarding checklist to ensure the deficient practice does not recur.
4. The Administrator or designee shall review every new client file before they are assigned a staff in addition to auditing 10% of every client files quarterly.
5. This corrective plan of action will be completed by July 1, 2024