Initial Comments:
Based on the findings of an onsite unannounced state license survey and complaint investigation completed April 13, 2022, Helping Hands Home Care Service 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 (f) LICENSURE
NOTIFICATION
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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 a consumer file (CR1), and staff (EMP) interviews, the agency failed to report and incident that could seriously compromise quality assurance or patient safety. More specifically, the agency failed to submit one (1) of one (1) instance of bed begs-- a Health Department reportable disease.
Findings included:
Per the Department's ERS Manual, "PA Department of Health (PA-DOH) Event Notification Internet Site Overview - Facilities ... Purpose: To provide a system to enter events per 28 PA Code - 51.3 that is readily available to all appropriate PA-DOH 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 is the mechanism the Department will use to meet this regulatory requirement. ... The following is a list of all Categories that should be submitted: ... Health Department Reportable Diseases."
Review of CR1 on April 12, 2022, at 9:07 a.m. and again at 9:45 a.m. with EMP1 showed services commenced on 1/31/2022. Agency became aware of CR1's bed bug incident on 3/28/2022 according to agency documentation contained in CR1, "12:28 p.m. [direct care worker] contacted office refusing to go back to the client due to a bed bug infestation."
Interview with EMP1 on April 12, 2022, at 11 a.m. confirmed above findings and incident was not reported to ERS. EMP1 not aware bed bugs were a health department reportable disease.
Plan of Correction:- On 4/20/22, leadership was trained on section 28 Pa. Code 51.3 along with list of reportable disease
o https://www.health.pa.gov/topics/Reporting-Registries/Pages/Reportable-Diseases.aspx
- Effective 4/20/22, leadership will send items that meet reportable disease to owner who will make the proper submission.
- Owner will be reviewing ERS Manual and training staff accordingly.
o https://sais.health.pa.gov/CommonPOC/content/FacilityWeb/attachment.asp?messageid=3349&filename=ERS+NCF+Facility+Manual%2Epdf&attachmentnumber=2
- Owner will remind staff of regulations during weekly meetings.
- - Starting 5/9/22, a weekly spot check of clients that have missed shifts will be completed to see if any meet reporting criteria. Audits will be tracked in master spreadsheet. This will continue for until August. If nothing has been missed audits will move to monthly basis.
- Corrective action date of Monday, May 30th.
Initial Comments:
Based on the findings of an onsite unannounced state license survey and complaint investigation completed April 13, 2022, Helping Hands Home Care Agency 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:
611.55(a) LICENSURE
Competency Requirements
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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 review of direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to ensure direct care workers met minimum competency requirements in accordance with subsection (c) prior to providing services to consumers for six (6) of six (6) personnel files reviewed (PF1-PF6).
Findings include:
According to subsection (c): A competency examination or training program developed by an agency or registry for a direct care worker who will provide personal care must address the following additional subject areas: 1. Bathing, shaving, grooming, and dressing; 2. Hair, skin, and mouth care; 3. Assistance with ambulation and transferring; 4. Meal preparation and feeding; 5. Toileting; 6. Assistance with self-administered medications.
The following employees completed the "ADULT RESIDENTIAL LICENSING ... Direct Care Staff Training Course" prior to consumer contact, but the training course did not include the required subjects of confidentiality; consumer control and the independent living philosophy; recognizing changes in the consumer that need to be addressed; shaving and mouth care; assistance with ambulation and transferring; feeding; toileting; and assistance with self-administered medications.
The following employee files also contained "Home Health Aide Training" which was an 11-page document containing 60 questions. The document was not graded, and the front page showed, "Appropriate answer in bold." Interview with EMP1 on April 12, 2022, at 11:30 a.m. confirmed findings and noted, "Go over it with them as part of onboarding program... not graded." In addition to the above findings, the document did not contain the subjects of shaving, mouth care, and assistance with self-administered medications. EMP1 confirmed this and noted that the subject of assistance with self-administered medications is in the employee handbook and is covered during orientation, "In handbook which we read to them [during orientation]."
Personnel files were reviewed with EMP1 on April 12, 2022, at 10 a.m., and again on April 13, 2022, at 1 p.m.
PF1 was hired on 1/5/2021 and began providing services to consumers the same day.
PF2 was hired on 2/24/2021 and began providing services to consumers on 3/1/2021.
PF3 was hired on 10/1/2021 and began providing services to consumers on 10/4/2021.
PF4 was hired on 1/13/2022 and began providing services to consumers on 1/13/2022.
PF5 was hired on 2/6/2022 and began providing services to consumers on 2/17/2022.
PF6 was hired on 2/21/2022 and began providing services to consumers on 3/1/2022.
Review of email from EMP1 on April 13, 2022, at 1 p.m. confirmed above findings.
Plan of Correction:- Ongoing - Continue with Adult Residential Licensing test.
- 4/28/22 – Implemented enhanced/updated Home Health Aide Training by
o Making this a written test that each applicant must pass before they can be hired.
o Include sections of shaving, mouth care and assistance with self-administered medications.
- Owner train all staff on enhanced hiring process on 4/22/22.
- Starting on 5/9/22, after the file is completed by Recruiting, the file will be reviewed by Office Staff to ensure everything is present. That office staff will sign employee file, so we know who reviewed.
- Starting on 5/9/22, on a weekly basis, office will conduct review of new hires to ensure everything is present. This will be tracked in master excel document.
- Corrective action date of Monday, May 30th.
611.57(d) LICENSURE
Documentation
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(d) The home care agency or home care registry shall maintain documentation on file at the agency or registry of compliance with the requirements of this section which shall be available for Department inspection.
Observations:
Based on review of consumer files (CF) and staff (EMP) interview, the agency failed to maintain documentation to show the consumer was notified of changes to their service agreement for one (1) of six (6) consumer files reviewed (CF1).
Findings include:
Per 611.57(a) of this section, "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."
CR1 was reviewed on April 22, 2022, at 9:07 a.m. with EMP1. The consumer signed her service agreement on 1/25/2022 and services commenced on 1/31/2022. The consumer's service agreement was for 75 hours per week. Per EMP1 visits/hours were missed on 2/13, and 2/21, 3/21, 3/28/, 3/29 and 3/31/2022. There was no documentation to show the consumer was notified of the above changes to her service agreement. Interview with EMP1 at time of review confirmed above findings.
Plan of Correction:- While we always notify client of possible change of schedule, system wasn't document correctly.
- On 4/14, all staff were reminded/retrained on proper documentation.
- Owner and Area Managers have been reminding staff during our daily morning meeting.
- Starting 5/9/22, on a weekly basis, office staff will conduct spot checks missed or canceled shifts to ensure the proper notes were put into the system. This will be tracked in a master excel document. This will continue until items are not being missed. At this point, it will become a monthly process.
- Corrective action date of Monday, May 30th.
Initial Comments:
Based on the findings of an onsite unannounced state license survey and complaint investigation completed April 13, 2022, Helping Hands Home Care Service was found to be in compliance with the requirement of 35 P.S. 448.809 (b).
Plan of Correction:
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