Initial Comments:
Based on the findings of an unannounced onsite Home Care Agency State Complaint Survey conducted on February 20, 2024 and offsite on February 28, 2024, 365 Health Services LLC was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
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 on the review of the complaint's allegations, email communications, and the Pennsylvania Department of Health's Event Reporting System, the agency did not report misplacement of client ' s property for one (1) of one (1) consumer records reviewed (CR #1).
Findings include:
A review of emails from the CR#1 to the provider was conducted on 2/20/24 and revealed the following:
On 2/9/2024, a direct care worker (DCW) was accused of attempting to order $200 worth of food off client's cellphone without client's consent and stole kitchen items.
On 2/15/24, a DCW was accused of stealing bathroom items from client's bathroom.
A review Department of Health (DOH) Event Reporting System (ERS) was conducted on 2/20/2024 at approximately 1:00 PM and revealed the following:
There was no report of above theft allegations.
An Interview with the executive director on February, 20, 2024 at approximately 3:00 P.M. confirmed the above findings.
Plan of Correction:The agency has corrected their practices and is following the state guidelines under 51.3 (g)(1-14) LICENSURE NOTIFICATION which is outlined in the agency Policy # QM 3.0 Incident Reporting which specifies that the agency management staff will submit notification of events in the Electronic Event Reporting System [ERS] as defined in 28 Pa Code Chapter 51 to the Department of Health within 24 hours of occurrence or discovery any of the following events: (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. Furthermore, it is understood, that the purpose of this per the Pennsylvania Department of Health Event Reporting System Manual, is "...To provide a system to enter events per 28 PA Code - 51.3 that is readily available to all appropriate PA-DOH [Pennsylvania Department of Health] facilities, a simple process to insure consistent data entry and submission, and a source for quick and meaningful feedback on event notification submissions...and the Electronic Event Reporting System [ERS] is the mechanism the Department will use to meet this regulatory requirement..."
An inservice education will be held by 03/22/2024 with all management staff who need to be aware of the incident reporting process and what must be reported in the ERS system to the Pennsylvania Department of Health per state regulation 51.3 (g)(1-14) LICENSURE NOTIFICATION and agency Policy # QM 3.0 Incident Reporting.
Documentation of the inservice including: minutes, attendance and handouts will be maintained onsite and available for review. The Executive Director is responsible.
Incident Reporting will be added to the agency orientation checklist so that it is reviewed with all new employees upon orientation.
The Executive Director is responsible.
Completion date for all elements: 03/22/2024
The Executive Director is responsible.
Initial Comments:
Based on the findings of an unannounced complaint investigation survey, conducted on on February 20, 2024 and offsite on February 28, 2024, 365 Health Services LLC was found 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:
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