Initial Comments:
Based on the findings of an onsite unannounced State relicense survey completed 12/11/2023, PA Home Life 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 12/11/2023, PA Home Life 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 policy, personnel files (PF) staff (EMP) interview, it was determined the agency failed to obtain verification of two (2) positive references for the applicant for two (2) of seven (7) PF reviewed (PF4 and PF6).
Findings included:
A review of agency employee handbook was conducted on 12/5/2023 at approximately 9:25 AM revealed. "...Interviewing-Interviewing also involves a variety of factors: *Telephone screening to determine if candidates meet the job description *Initial one-on-one interviews * Checking references and criminal backgrounds *Graining the consensus of interviewers to hire or not to hire Before extending an employment offer and upon the applicant ' s prior agreement, at least one applicant reference must be checked. Every attempt is made to obtain two references. Inquiries are to be made in a professional manner requesting only factually verifiable and job-related information. The reference data is used only as a supplemental information for the hiring decision..."
Review of PF4 was conducted on 12/5/2023 at approximately 11:10 AM, with a date of hire 11/15/2023. The PF did not contain evidence of two references having been verified as positive by the agency.
Review of PF6 was conducted on 12/5/2023 at approximately 11:23 AM, with a date of hire 3/13/2023. The PF did contain one positive reference, but a second reference could not be verified as being completed.
An exit interview was conducted with the administrator and director of operations on 12/5/2023 at approximately 1:45 PM which confirmed the above findings.
Plan of Correction:In reference to PF4, the Direct Care Worker is no longer employed with us so no change was made to her file.
In reference to PF6, admin staff completed and verified one additional positive reference check on 12/19/23 using the references given at time of hire. Reference form was completed and added to the file, file is now compliant.
In the future, admin staff has agreed to add tasks to our Wellsky program that allow us to note and be reminded when references have not been completed, this went into effect on 12/6/2023. These tasks are checked multiple times per day. We plan to monitor this by continuing to check the task list throughout the day. Additionally, our quarterly QA committee will begin auditing employee files prior to their meetings to ensure compliance is continued. Our next QA meeting is scheduled for 2/7/2024.
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 policy, consumer records (CR) and staff (EMP) interview, the agency failed to involve the consumer in the service planning process and to receive services with reasonable accommodation of individual needs and preferences for four (4) of seven (7) CR's reviewed (CR2, CR3, CR4 and CR7).
Findings included:
A review of agency intake information packet was conducted on 12/5/2023 at approximately 9:20 AM revealed. "...Consumer's Rights and Responsibilities...Quality of Care, Consumers have the right...*To receive information containing a listing of the available home care services that will be provided by the direct care worker and the identity of the worker who will provide the services, the hours when those services will be provided and the fees and total costs for those services on an hourly or weekly basis...*To participate in the planning of the service, and be involved in the service planning process and in planning changes in the services, and to be advised they have a right to do so and receive reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk..."
A review of CR2 on 12/5/2023 at approximately 12:05 PM revealed start of services 3/30/2023 end of service 7/12/2023. Per the "CONSUMER SERVICE PLAN (and) Client Financial Authorization" services were listed on the client financial authorization..." Service Order ...Frequency 4X/week, Days M, T, Th, F, AM/PM-PM (circled) afternoon" Per clients May 2023 calendar services were provided on the requested days. The surveyor could not confirm from the agency documentation that scheduled times were reviewed with the consumer or consumer representative for approval.
A review of CR3 on 12/5/2023 at approximately 12:15 PM revealed start of services 11/7/2023. Per the "CONSUMER SERVICE PLAN (and) Client Financial Authorization " services were listed on the client financial authorization... Service Order...Frequency 4Xweek, Days M, T, Th, F, AM/PM-between 11a-2p" Review of the clients November 2023 calendar services were provided on the requested days. The times services were provided did not match the hours requested by the consumer for Mondays, Tuesdays and Thursdays. The surveyor could not confirm from the agency documentation that scheduled times were reviewed with the consumers or consumer representative for approval.
A review of CR4 on 12/5/2023 at approximately 12:20 PM revealed start of services 10/25/2023. Per the "CONSUMER SERVICE PLAN (and) Client Financial Authorization" services were listed on the client financial authorization... "Service Order ...Frequency 6.5 hrs/wk, Days-M 2, W 2.5, F 2 AM/PM-PM (circled)." Per clients November 2023 calendar services were provided on the requested days. The surveyor could not confirm from the agency documentation that scheduled times were reviewed with the consumers or consumers representative for approval.
A review of CR7 on 12/5/2023 at approximately 12:50 PM revealed start of services 2/9/2023. Per the "CONSUMER SERVICE PLAN (and) Client Financial Authorization" services were listed on the client financial authorization... "Service Order...Frequency 4hr/WK." The surveyor could not confirm from the agency documentation that scheduled times or days were reviewed with the consumers or consumers representative.
An exit interview was conducted with the administrator and director of operations on 12/5/2023 at approximately 1:45 PM which confirmed the above findings.
Plan of Correction:In reference to CR2, the client is deceased so no change was made to his file.
In reference to CR3, admin staff reached out by phone on 12/19/2023 to confirm the requested schedule for the rest of December 2023 and January 2024 and received verbal confirmation from the client/client representative. Admin staff then placed a note in the electronic file (Wellsky) that schedule was requested and confirmed, then mailed a paper schedule to the client on 12/19/2023.
In reference to CR4, admin staff reached out by phone on 12/19/2023 to confirm the requested schedule for the rest of December 2023 and January 2024 and received verbal confirmation from the client/client representative. Admin staff then placed a note in the electronic file (Wellsky) that schedule was requested and confirmed, then mailed a paper schedule to the client on 12/19/2023.
In reference to CR7, admin staff reached out by phone on 12/19/2023 to confirm the requested schedule for the rest of December 2023 and January 2024 and received verbal confirmation from the client/client representative. Admin staff then placed a note in the electronic file (Wellsky) that schedule was requested and confirmed, then mailed a paper schedule to the client on 12/19/2023.
Following the audit on 12/5/2023, Director of Operations (DOO) edited the Service Plan Form used for all client's intakes to reflect the tentative schedule discussed at the intake, the type of services to be provided with the hour breakdown, the tentative Direct Care Worker to start services and a note stating a new schedule will be mailed out with any changes post-intake. These sections are followed by a place for the consumer or consumer representative to sign stating they reviewed all of the above.. This form has officially replaced the old one on 12/6/2023 and has been used at intakes following ever since.Completion of this section of the Service Plan Form will be checked and signed off on by the admin completing the intake as well as being checked and signed by an additional admin staff member within 2 weeks of the intake being completed. Continued monitoring will be completed by our Consumer Record Review Committee quarterly, their next meeting is scheduled for 2/7/2024.
611.57(c) LICENSURE
Information to be Provided
Name - Component - 00
(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 agency policy, consumer records (CR) and staff (EMP) interview, the agency failed to provide required information in writing to the consumers/consumer representatives prior to the commencement of services for three (3) of seven (7) CRs reviewed (CR1, CR2 and CR4).
Findings included:
A review of agency intake information packet was conducted on 12/5/2023 at approximately 9:20 AM revealed. "...Consumer's Rights and Responsibilities...Quality of Care, Consumers have the right...*To receive information containing a listing of the available home care services that will be provided by the direct care worker and the identity of the worker who will provide the services, the hours when those services will be provided and the fees and total costs for those services on an hourly or weekly basis ...*To participate in the planning of the service, and be involved in the service planning process and in planning changes in the services, and to be advised they have a right to do so and receive reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk ... "
A review of CR1 on 12/5/2023 at approximately 11:45 AM revealed start of services 11/30/2023. No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
A review of CR2 on 12/5/2023 at approximately 12:05 PM revealed start of services 3/30/2023. No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
A review of CR4 on 12/5/2023 at approximately 12:20 PM revealed start of services 10/25/2023. No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
An exit interview was conducted with the administrator and director of operations on 12/5/2023 at approximately 1:45 PM which confirmed the above findings.
Plan of Correction:In reference to CR1, admin staff reached out by phone on 12/19/2023 to confirm the requested schedule for the rest of December 2023 and January 2024 and received verbal confirmation from the client/client representative. Admin staff then placed a note in the electronic file (Wellsky) that schedule was requested and confirmed, then mailed a paper schedule to the client on 12/19/2023.
In reference to CR2, the client is deceased so no change was made to his file.
In reference to CR4, admin staff reached out by phone on 12/19/2023 to confirm the requested schedule for the rest of December 2023 and January 2024 and received verbal confirmation from the client/client representative. Admin staff then placed a note in the electronic file (Wellsky) that schedule was requested and confirmed, then mailed a paper schedule to the client on 12/19/2023.
Following the audit on 12/5/2023, Director of Operations (DOO) edited the Service Plan Form used for all client's intakes to reflect the tentative schedule discussed at the intake, the type of services to be provided with the hour breakdown, the tentative Direct Care Worker to start services and a note stating a new schedule will be mailed out with any changes post-intake. These sections are followed by a place for the consumer or consumer representative to sign stating they reviewed all of the above. This form has officially replaced the old one on 12/6/2023 and has been used at intakes ever since. Completion of this section of the Service Plan Form will be checked and signed off on by the admin completing the intake as well as being checked and signed by an additional admin staff member within 2 weeks of the intake being completed. Continued monitoring will be completed by our Consumer Record Review Committee quarterly, their next meeting is scheduled for 2/7/2024.
Initial Comments:
Based on the findings of an onsite unannounced State relicense survey completed 12/11/2023, PA Home Life was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
|