Initial Comments:
Based on the findings of an onsite unannounced State relicensure survey completed 10/12/2023, Caregivers America 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 unannounced state relicensure survey completed 10/12/2023, Caregivers America LLC 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:
611.51(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 review of agency documents and personnel files (PF), and staff (EMP) interview, it was determined the agency failed to obtain 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 for two (2) positive references for the applicant for two (2) of five (5) direct care worker (DCW) PFs reviewed (PF2 and PF3).
Findings included:
A review of agency "Consumer Handbook PA Licensed Home Care Agency" on 10/11/2023 at approximately 10:48 AM revealed, " ...DIRECT CARE WORKER EXPECTATIONS ...Direct care workers are bonded and insured for your protection. Each applicant undergoes background checking/competency testing in order to be deemed eligible for hire. The following screening is performed for new hires: Reference Checks (minimum of 2 satisfactory results) ... "
Review of PF#2, date of hire (DOH) 9/12/2022 was conducted on 10/11/2023 at approximately 12:40 PM. The PF contained evidence of the agency completing two (2) references on 9/5/2022. The agency references could not confirm that the source was from a former employer or other person not related to the individual that could affirm the ability of the individual to provide home care services.
Review of PF#3, date of hire (DOH) 2/8/2023, was conducted on 10/11/2023 at approximately 1:10 PM. The PF contained evidence of the agency completing two (2) references on 2/2/2023. The agency references could not confirm that the source was from a former employer or other person not related to the individual that could affirm the ability of the individual to provide home care services.
An interview was conducted with the care coordinator and quality assurance manager on 10/11/2023 at approximately 2:30 PM which confirmed the above findings.
Plan of Correction:PR#2 & PR #3 The local branch Care Coordinator will re-do reference checks to confirm that source is from a former employer or other person not related to the employee and that could affirm the employees ability to provide homecare services.
All employees that play a role in the onboarding process of will receive a training to reeducate on Hiring or Rostering Prerequisites conducted by the Quality Assurance Audit Support Specialist.
100% active personnel chart audit will be completed by the Audit Support Specialist and the local branch Care Coordinator to ensure all files are in compliance.
To ensure ongoing compliance after the Corrective Action Date the Quality Assurance Department will conduct Quarterly internal audits and enforce internal plans of corrections whenever applicable.
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 the agency client service agreement, consumer records (CR) and staff (EMP) interview, the agency failed to involve the consumer in the service planning process and to accommodation of individual needs and preferences for four (4) of five (5) CR's reviewed (CR1-CR4).
Findings included:
A review of agency "Consumer Handbook PA Licensed Home Care Agency" on 10/11/2023 at approximately 10:48 AM revealed, "...Consumer Bill of Rights & Responsibilities, Questions regarding your rights and responsibilities may be voiced at any time by calling your local office. 1. The right to complete, current information about your care, treatment, and rights in terms you and your family can understand. 2. The right to be involved in the service planning process and to receive services with reasonable accommodation of your needs and preferences, unless the health and safety of the direct care worker is at risk ...4. The rights to know of changes in your services/care before those changes occur..."
A review of CR1 on 10/11/2023 at approximately 1:35 PM, start of services 7/17/2022, revealed: A form labeled "(Agency) Home Care Plan...Frequency of Care...Mon: 12:00 PM-2:00 PM, Wed 12:00 PM-2:00 PM, Fri: 12:00 PM-2:00 PM, (Marked) As requested by consumer (varies)..." The "General Activity Report" for the month of September 2023 was reviewed. The following dates services were not provided per the service agreement schedule: 9/4/2023, 9/8/2023, 9/11/2023, 9/13/2023 and 9/27/2023. For dates services were provided during the month of September times did not match the home care plan. The surveyor requested any documentation to confirm the consumer was informed/participated in the change in schedule. No additional documentation was made available to the surveyor for review.
A review of CR2 on 10/11/2023 at approximately 1:43 PM, start of services 5/29/2022, revealed: A form labeled "(Agency) Home Care Plan...Frequency of Care ...Sun: 9:00 AM-5:00 PM, Mon: 9:00 AM-5:00 PM, Tues: 9:00 AM-5:00 PM Sat: 9:00 AM-5:00 PM, (Marked) As requested by consumer (varies) ..." The "General Activity Report" for the month of September 2023 was reviewed. The following dates services were not provided per the service agreement schedule: 9/11/2023 and 9/18/2023. For all dates services were provided during the month of September times did not match the home care plan. The surveyor requested any documentation to confirm the consumer was informed/participated in the change in schedule. No additional documentation was made available to the surveyor for review.
A review of CR3 on 10/11/2023 at approximately 2:02 PM, start of services 2/19/2023, revealed: A form labeled "(Agency) Home Care Plan...Frequency of Care ...Mon: 9A-3P and 4:30 P-9P, Tue: 9A-3P and 4:30 P-9P, Wed 9A-3P and 5P-9P, Thurs: 9A-3P and 4:30 P-9P, Fri: 9A-3P and 4:30 P-9P, Sat: 9A-3P and 4:30 P-9P ..." The "General Activity Report" for the month of September 2023 was reviewed, including all split shifts. For dates services were provided during the month of September times did not match schedule listed on the home care plan. The surveyor requested any documentation to confirm the consumer was informed/participated in the change in schedule. No additional documentation was made available to the surveyor for review.
A review of CR4 on 10/11/2023 at approximately 2:08 PM, start of services 1/1/2023, revealed: A form labeled "(Agency) Home Care Plan...Frequency of Care...Mon: 9A-2P, Wed 9A-2P, Fri: 9A-2P..." The "General Activity Report" for the month of September 2023 was reviewed. The following dates services were not provided per the service agreement schedule: 9/13/2023, 9/15/2023 and 9/18/2023. For all dates services were provided during the month of September times did not match schedule listed on the home care plan. The surveyor requested any documentation to confirm the consumer was informed/participated in the change in schedule. No additional documentation was made available to the surveyor for review.
The surveyor could not confirm from the agency documentation that scheduled changes in times and/or days were reviewed with the consumer or consumer representative.
An interview was conducted with the care coordinator and quality assurance manager on 10/11/2023 at approximately 2:30 PM which confirmed the above findings.
Plan of Correction:CR#1, CR#2, CR#3 & CR#4
All employees that play a part in the participants scheduling will receive a training to reeducate on consumer rights and service planning process, Training will be conducted by the Quality Assurance Audit Support Specialist.
Local Care Coordinator and Audit Support Specialist will complete 100% chart audit and General Activity Report Audit by the corrective action date of 12/12/2023 on active consumers that were serviced from 9.1.2023 to 9.30.2023 to ensure branch is compliant with the consumers service planning process.
To ensure ongoing compliance after the Corrective Action Date the Quality Assurance Department will conduct Quarterly internal audits and enforce internal plans of corrections whenever applicable.
Initial Comments:
Based on the findings of an onsite unannounced State relicensure survey completed 10/12/2023, Caregivers America LLC was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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