CAREGIVERS AMERICA LLC
Health Inspection Results For:
There are 3 surveys for this facility. Please select a date to view the survey results.
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Initial Comments:
Based on the findings of an on-site unannounced complaint survey completed 7/16/2024, Caregivers America 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
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 a review of agency policy, review of the Department's online Event Reporting System (ERS), complaint report and staff (EMP) interview the agency failed to notify the Department in writing of an event that could seriously compromise quality assurance or patient safety for one (1) of three (3) complaints reviewed.
Findings Included:
Focused review of the agency policy on 7/15/2024 at approximately 10:25 AM revealed, " Consumer Handbook PA licensed Home Care Agency ...EVENT REPORTING Home Care Agencies are to report significant incidents regarding direct care workers and consumers. Please, assist our offices in meeting this requirement, by notifying our offices when an out-of-the-ordinary incident occurs such as the following (this list is not a list of all incidents, but instead is a list of the most common incidents): a. Consumer/Direct care worker fall b. Transfer/Admission to hospital due to an accident or injury c. Consumer/Direct care worker death d. Complaints of Abuse or Neglect, confirmed or not ... "
Focused review of the Department event reporting on 7/15/2024 at approximately 10:25 AM revealed, "PA Department of Health (PA-DOH) Event Notification Internet Site Overview - Facilities Effective March 9, 2021 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. Web Site Address: The web site address for the Events Program is: ... "
Review of the agency documents was conducted on 7/15/2024 at 1:15 PM which revealed, the claim EMP4 was working at other employment while scheduled to be providing services to CR2. Review of the agency " Home Care Plan " revealed section " Frequency of Care " marked were the days Monday through Friday with two different times indicated. " 7am-3pm " and " 930AM-530PM. " The client schedule was reviewed for the following dates from 5/1/2024 to 6/3/2024. Listed was the category " Sched Start 9:30 Sched End 17:30.
The following dates confim "Clocked End" times after 2:00 PM: 5/1/2024, 5/2/2024, 5/3/2024, 5/6/2024, 5/7/2024, 5/8/2024, 5/9/2024, 5/10/2024, 5/15/2024, 5/16/2024, 5/17/2024, 5/28/2024,5/31/2024, 6/1/2024 and 6/3/2024.
Review of the Complaint report was conducted on 7/15/2024 at 1:15 PM revealed, NE4 confirmed EMP4 working 2:00 PM- 10:00 PM at (other employment).
An interview with EMP1 on 7/15/2024 at approximately 12:50 PM was conducted. The surveyor asked if EMP1 was aware of this event being reported to the Pennsylvania Department of Health Event Reporting System. EMP1 was unaware of any report that had been submitted.
An interview was conducted on 7/15/2024 at approximately 2:10 PM with the care coordinator which confirmed the findings.
Plan of Correction:All administrative staff will be reeducated to focus on Fraud, Waste and Abuse upon hire by using specific examples. Administrative staff will reeducate active field staff on our Fraud, Waste, and Abuse Policy.
This will be done now, by emailing and texting our Fraud, Waste, and Abuse policy. Specifically drawing their attention to "SITUATIONAL EXAMPLE #2: A personal care worker billed and received payment for hours of service provided to individual needing assistance while the personal care worker was on duty at another job." Upon hire and annually when reviewing the Department of Health Waiver and Training form administrative staff will focus on specific examples of fraud, waste and abuse.
To monitor the branch's continuous performance and improvement the Quality Assurance Department will REVIEW ONE COMPLAINT AND ONE EVENT during their quarterly audit. Unsatisfactory findings will be escalated.
Above will be completed by 08.30.2024
How reports received will be submitted:
Regional Directors, Regional Managers, Quality Assurance Nurses, and/or Care Coordinators must report all major and minor incidents in writing. Operations is responsible for maintaining and implementing up-to-date procedures for incident investigation and reporting according to regulatory guidelines. The Incident Support Specialist, or when unavailable an alternative designee, is responsible for the completion of all investigation, documentation and/or incident reporting responsibilities. The Incident Support Specialist is responsible for ensuring timeliness guidelines are met. All minor incidents occurring to consumers and direct care workers, whether witnessed or not, should be at a minimum, discussed with a local office representative and documented within the consumer and/or direct care worker's file, as applicable. All major/serious incidents should follow protocol as instructed by Operations. Document incident on the PA Incident Form. Immediately notify the consumer's emergency contact, POA, family member, or representatives when applicable. Email and/or phone the consumer's Supports Coordinator/Care Manager. If SC does not answer, the Care Coordinator will document and send a secure email to case manager including Participant's Name, Date of birth, Date and time of incident, Brief description of the incident, Participant's current condition, Actions taken to mitigate risk to the Participant, Reporter's name, agency, and contact information. Perform investigative duties to support decision making and reporting requirements. Perform proper event reporting procedures according to the Department of Health, Office of Long-Term Living, Office of Developmental Programs, Bureau of Autism Services, and other applicable regulatory guidelines. All incidents should have a well-documented resolution and plan to prevent this type of incident from occurring in the future
Initial Comments:
Based on the findings of an on-site unannounced complaint survey completed on 7/16/2024, Caregivers America was found not to be in compliance with the following requirement 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:
611.52(d) LICENSURE
Proof of Residency
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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 with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation
Observations:
Based on a review of agency policy, personnel files (PF) and staff interview, the agency failed to verify proof of residency for one (1) of three (3) PF reviewed (PF2).
Findings included:
Focused review of the agency policy on 7/15/2024 at approximately 10:25 AM revealed, " Consumer Handbook PA licensed Home Care Agency ...DIRECT CARE WORKERS EXPECTATIONS As a consumer, you can expect a professional and dedicated Direct care worker to assist you in your daily activities ...The following screening is performed for new hires: Reference Checks (Minimum of 2 satisfactory results) *State Criminal Background *Child Abuse Clearances, as applicable *FBI Background Checks, as applicable *FBI Background Checks, as applicable *Megan ' s Law Background Checks, as applicable *Tuberculosis Screenings *Randomized Drug Testing *Professional License verification, as applicable *Skill Training Course *Competency Testing for skill and knowledge ...*Online Learning opportunities, as needed ... "
A review of PF2 was conducted on 7/15/2024 at approximately 10:50 AM, the date of hire (DOH) was 9/5/2023, a Pennsylvania identification card was issued 2/16/2023 used as proof of residency. There was no additional documentation made available by the agency to verified proof of residency in this Commonwealth for two (2) years immediately preceding DOH.
An interview was conducted on 7/15/2024 at approximately 2:10 PM with the care coordinator which confirmed the findings.
Plan of Correction:All administrative staff will receive a reeducation on requirements of background checks.
Local branch will ensure PF2 completes the Department of Aging Fingerprinting.
To ensure deficiency does not reoccur the agency has begun using a third-party for screenings.
To monitor accuracy of screenings the Quality Assurance Department will conduct 10% personnel chart audits on a quarterly basis.
Above will be completed by 08.16.2024
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