Initial Comments:
Based on the findings of an onsite state re-licensure survey completed 1/23/24, Punya Home Care LLC was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite state re-licensure survey completed 1/23/24, Punya Home Care LLC was found not to be in compliance with the 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:
611.4(c) LICENSURE
Requirements for HCA and HCR
Name - Component - 00
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 a review of Department guidance, the agency's consumer information packet and brochure, consumer records (CR), and interviews with agency staff (EMP), the agency failed to ensure services were provided under the scope of the home care agency's state license by employing direct care workers (DCW) who provided services outside of the agency's licensure scope for two (2) out of five (5) CRs reviewed. (CRs 2 and 5).
Findings included:
Per the "Guidance to Home Care Agencies and Registries Licensed by Pennsylvania Department of Health" policy clarification, February 23, 2017, " Definitions ...Specialized care - Nonskilled services/activities unique to the consumer ' s care needs that facilitate the consumer ' s health, safety and welfare, and ability to live independently ... "
A review of agency consumer brochure on 1/22/24 at approximately 10:00 am noted, " Non-Medical Services ...Grocery Shopping & Meal Preparation ...Laundry/Linens & Light Housekeeping ...Medication Reminders ...Showering & Grooming Supervision ...Companionship & Conversations ... "
A review of Consumer Records on 1/22/24 between approximately 2:00 pm - 3:00 pm revealed:
CR2: Start of Service (SOS) 10/8/23. CR contained a document titled, Participant Service Agreement signed on 10/8/23 that did not list " wound care " as a service to be provided.
CR5: SOS 6/8/23. CR contained a Participant Service Agreement signed on 6/8/23 that did not list assessment of temperature, pulse, or blood pressure as a service to be provided.
A review of agency Electronic Visit Verification (EVV) documentation system, HHAexchange, on 1/22/24 between approximately 3:00 pm to 4:00 pm revealed:
CR2: Start of Service (SOS) 10/8/23. EVV entry dated 11/1/23 timed 9:35-23:58 created by EMP3 documented, " 143 ...Personal Care ...Wound Care ... " EVV entry dated 1/5/24 timed 7:00-23:00 created by EMP3 documented, " ...143 ...Personal Care ...Wound Care ... " CR2's Participant Service Agreement did not include wound care.
CR5: SOS 6/8/23. EVV entries dated 1/4/24 timed 17:57-23:55 created by EMP2 documented, " 235 ...Take Temperature ...236 ...Take Pulse ...237 ...Take Blood Pressure ... " EVV entry dated 1/5/24 timed 17:58-23:56 created by EMP2 documented, " 235 ...Take Temperature ...236 ...Take Pulse ...237 ...Take Blood Pressure ... " CR5's Participant Service Agreement did not include assessment of temperature, pulse, or blood pressure.
An interview with EMP1, Administrator, on 1/22/24 at approximately 3:00 pm verified that agency did not provide the specialized service of wound care and that vital signs were not a part of CR5 ' s service plan.
The findings were reviewed with EMP1, Administrator, on 1/22/24 at approximately 4:00 pm.
Plan of Correction:
Plan of Correction
Exit date 01/23/2024
611.4(c) LICENSURE
Requirements for HCA and HCR:
On 01/24/2024, around 2 pm, the agency conducted in person training to EMP3 to explain needs and services to CR2 or any other participants. EMP3 signed the training sheet and agreed that EMP3 understood all work duties that EMP3 was supposed to provide.
On 01/25/24, around 10:30am, EMP1 conducted in person training to EMP2 to explained that participants services agreement of CR5. EMP2 signed the training sheet and agreed that EMP2 understood the services agreement and services that EMP2 was supposed to provide to CR5 or any other participants.
Agency is working to provide in-person training to all Direct Care Workers and internal employees to explain and train how to perform their duties as per service agreement and particular participant POC (Plan of Care). The agency will have all training documentation signed by all active direct care workers and internal employees within 60 days of exit date i.e. 01/23/2024.
To avoid reoccurrence of the same problem, agency administrator will monitor HHA Exchange system every 2 weeks to ensure direct care workers are doing their duties as per part of agency listed services.
611.57(c) LICENSURE
Information to be Provided
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(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 consumer records (CR), agency documentation, and employee interviews (EMP), the agency failed to provide consumers with an information packet listing: (1) The department's complaint hotline (1-800-254-5164) and telephone number of the ombudsman program with the local Area Agency on Aging for five (5) of five (5) CRs reviewed CRs 1 - 5.
Findings include:
Agency document titled Participant Service Agreement was reviewed on 1/22/24 at approximately 11:00 am and did not contain Department of Health Hotline and Local Area Ombudsman contact information.
CR1: Start of Service (SOS): 5/29/23. Participant Service Agreement did not include the Department of Health hotline or telephone number for the local area ombudsman program.
CR2: SOS 10/8/23. Participant Service Agreement did not include the Department of Health hotline or telephone number for the local area ombudsman program.
CR3: SOS 6/8/23. Participant Service Agreement did not include the Department of Health hotline or telephone number for the local area ombudsman program.
CR4: SOS 6/12/23. Participant Service Agreement did not include the Department of Health hotline or telephone number for the local area ombudsman program.
CR5: SOS 6/8/23. Participant Service Agreement did not include the Department of Health hotline or telephone number for the local area ombudsman program.
An interview with EMP1, Administrator, on 1/22/24 at approximately 4:00 pm verified the agency's Participant Service Agreement did not include the required information.
Plan of Correction:Date:01/29/2024
Plan of Correction
Exit date 01/23/2024
611.57(c) LICENSURE
Information to be Provided:
1.Corrective action that we've accomplished for those individuals identified deficiencies are the following:
-EMP1 corrected participant service agreement by providing following information.
-Department of Health Hotline
1-(800)-254-5164
-Area Agency on Aging (Allegheny County)
(412)-350-4234
-EMP1 visited CR1 to provide new copy of participant service agreement. CR1 signed the copy of participant service agreement and agreed CR1 received and understood them.
- EMP1 visited CR2 to provide a new copy of participant service agreement. CR2 signed the copy of participant service agreement and agreed CR2 received and understood them.
- EMP1 visited CR3 to provide a new copy of participant service agreement. CR3 signed the copy of participant service agreement and agreed CR3 received and understood them.
- EMP1 visited CR4 to provide a new copy of participant service agreement. CR4 signed the copy of participant service agreement and agreed CR4 received and understood them.
- EMP1 visited CR5 to provide a new copy of participant service agreement. CR5 signed the copy of participant service agreement and agreed CR5 received and understood them.
2. Agency will identify other individuals having the potential to be affected by the deficiency practices by reviewing all participants services agreement.
3. The measure (actions/forms/system changes) agency did to ensure that the deficiency practice does not reoccur are as follows:
- (EMP1), will provide Department of Health Hotline number and local area agency of aging contact information based on counties we provided services in their service agreement that are Allegheny, Washington, Beaver, Butler, Westmoreland, and Fayette.
-Compliance manager will monitor their service agreement every quarterly to make sure everything is documented correctly.
4. EMP1 will monitor all practices of deficiency every quarterly to ensure deficiencies will not recur.
-EMP1 will conduct quarterly audits and keep everything documented to make sure this kind of deficiencies will not occur again.
Initial Comments:
Based on the findings of an onsite state re-licensure survey completed 1/22/24, Punya Home Care LLC was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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