AGENCY COMPLAINT/GRIEVANCE

1. WHAT IS A COMPLAINT/GRIEVANCE:

A complaint or concern presented regarding the agency or the care provided by agency staff.

2. WHO MAY VOICE A COMPLAINT/GRIEVANCE:

A client, family member or client representative may voice/present a grievance about the Agency or care/services provided by agency staff.

3. INVESTIGATION ABOUT PRESENTED COMPLAINTS/GRIEVANCES:

Our agency is required to actively investigate any complaint or grievance received. The Agency Director will oversee the investigation process which may include, but not be limited to:

• Interviews with client/family member
• Interviews with staff
• Review of client records
• Review of staff notes, visit reports
• Agency logs/on-call reports

4. NOTIFICATION ABOUT AGENCY GRIEVANCE POLICY/PROCESS:

a. CLIENTS:  Upon admission to our Agency, all clients/family members are advised of our Agency Complaint/Grievance policy/process and provided a copy of our agency GRIEVANCE POLICY/Form.

 b. STAFF: According to agency policy, upon hire (at orientation) & annually, our Agency provides training/ review with all staff on the client complaint/grievance policy/process.

Individuals never receive any retaliation/discrimination for voicing grievances.

5. QA OVERSIGHT:

Ongoing & as part of our Annual Evaluation, the Agency QA program will review all complaints to determine for trends & improvements

6. REVIEW AGENCY GRIEVANCE POLICY

Grievance Policy:  

POLICY:

It is the policy of Milestone Home Care LLC to respond to and investigate each and every complaint/concern presented by a Client/family member with all complaints reviewed quarterly.

PROCEDURE:

Our Agency has an established grievance/complaint protocol for Clients to express concerns/complaints related to the services received. All staff are educated upon hire and ongoing and Clients, on admission and ongoing of the complaint procedure.     Our Agency has an established system to record, respond and resolve a participant’s complaint.      

1. Our complaint forms will included the following:

a.          Name of the participant.

b.         Nature of the complaint.

c.          Date of the complaint.

d.         Provider’s actions to resolve the complaint.

e.          Participant’s satisfaction to the resolution of the complaint.

        2.  Our Agency will:

a.        Review our complaint system at least quarterly to:

                                                              i.      Analyze the number of complaints resolved to the participant’s satisfaction.

                                                            ii.      Analyze the number of complaints not resolved to the participant’s satisfaction.

                                                          iii.       Measure the number of complaints referred to the Department for resolution.

b.      Develop a QA Plan when the numbers of complaints resolved to a participant’s satisfaction are less than the number of complaints not resolved to a participant’s satisfaction.

c.       Submit a copy of the provider’s complaint system procedures to the Department upon request.

d.      Submit the information under subsection a. above to the Department upon request.

       3. COMPLAINT PROCEDURE:

       Grievances will be submitted to the Agency Director or designee who will respond to the complaint within ten (10) days.  Notification of the decision within 30 days and establish in writing a 30 day period to affect the resolution/remedy.

       The Agency Director shall conduct a complete investigation of the complaint. This investigation will, afford all interested persons an opportunity to submit evidence relevant to the complaint. After which, the Agency Director will present a determination to the Client, which will include information on their right to appeal the decision.

       The Governing Body shall issue a written decision in response to the appeal no later than 30 days after its filing.

       All Clients/family filing a verbal or written concern/complaint with our Agency shall be free of any discrimination or repercussions due to the filing.

       The Agency Director will maintain all files/records of our Agency relating to grievances/complaints.  The Client record will also include documentation of the complaint.

Client Grievance ADMISSION FORM

Our Agency is committed to providing excellence in Client service.

We will give full consideration to your issues and make an effort to resolve any issues to your satisfaction.

We will provide you every opportunity to voice grievances without discrimination, fear of reprisal, or any discrimination from our Agency or its employees.

If you have any concerns at all, please:

Tell us: either verbally or in writing, the Agency Director or Supervisor or any staff member you are comfortable with. They will ensure the concern is presented to the Agency Director.  If you call after business hours, the Agency Director will be in contact with you the next business day.

The Agency Director will contact you and will help to resolve the complaint/concern to your satisfaction.  They will look at all aspects surrounding the grievance, investigation, and resolution. 

You will be notified of the Agency Director’s decision within thirty (30) days.

If you are dissatisfied with the outcome of the complaint investigation, you may request that the Agency Director submit an appeal with Our Agency’s Governing Body.

You may also file a concern/complaint with:

 PA Home Care Complaint Hotline at 866-826-3644.

The PA Ombudsman office at: 717-651-2001.

You may file a grievance/concern with our Agency at any time without fear of reprisal.

Please contact us at:

AGENCY NAME:  ________________________________________________________________

AGENCY DIRECTOR NAME: ______________________________________________________

AGENCY TELEPHONE: ___________________________________________________________

OBJECTIVES

Upon completion of this annual mandatory educational program the participant should be able to:

1. Define critical incidents as found in 55PA. Code 52.3

2. Define Mandatory reporters

3. Reporting of critical incidents

4. Define process of Reporting

5. Define Risk Management

6. Define quality assurance/performance improvement 

OFFICE OF LONG TERM LIVING

INTRODUCTION

You will meet many people during your course of work with our agency. It is important that we as caregivers protect the health and welfare of our participants. Our Participants put their faith and trust in us to protect them and not harm them or let others harm them. The Office of Long Term Living(OLTL) in Pennsylvania has established legislation to protect Adults between the ages of 18 and 59 with disabilities or are over the age of 60.  Critical Incidents must be reported to the OLTL in a timely fashion so action may be taken to protect and defend adults when in situations which are dangerous and inappropriate. Anyone regardless who commits or causes in injustice to the participant regardless of employment or not with the agency must be reported to the OLTL. Every participant in our agency is guaranteed that are staff will not cause mental, physical abuse, neglect or exploitation of any kind to the participant. 

Critical Incidents

An occurrence of an event that jeopardizes the participant’s health or welfare including:

1.      Death, serious injury or hospitalization of a participant. Pre-planned hospitalizations are not critical incidents.

2.      Provider and staff member misconduct including deliberate, willful, unlawful or dishonest activities.

3.      Abuse, including the infliction of injury, unreasonable confinement, intimidation, punishment or mental anguish, of the participant. Abuse includes the following:

(A)      Physical abuse.

(B)       Psychological abuse.

(C)       Sexual abuse.

(D)      Verbal abuse.

(E)       Neglect.

(F)       Exploitation.

4.      Service interruption, which is an event that results in the participant’s inability to receive services and that places the participant’s health or welfare at risk.

5.      Medication errors that result in hospitalization, an emergency room visit or other medical intervention.(OLTL, 2015)

DEFINITIONS

Physical Abuse- is any intentional and unwanted contact with you or something close to your body. Examples of physical abuse include: Scratching, punching, biting, strangling or kicking.

Psychological Abuse- (also referred to as psychological violence, emotional abuse or mental abuse) is a form of abuse, characterized by a person subjecting, or exposing, another person to behavior that may result in psychological trauma, including anxiety, chronic depression, or post-traumatic stress disorder.

Sexual Abuse – also referred to as molestation, is usually undesired sexual behavior by one person upon another. When force is immediate, of short duration, or infrequent, it is called sexual assault. The offender is referred to as a sexual abuser.  The term also covers any behavior by an adult or older adolescent towards a child to stimulate any of the involved sexually. The use of a child, or other individuals younger than the age of consent, for sexual stimulation is referred to as child sexual abuse or statutory rape

Verbal Abuse- is described as a negative defining statement told to the victim or about the victim, or by withholding any response, thereby defining the target as non-existent. (Bullying)

Neglect- a form of abuse where the perpetrator is responsible for caring for someone who is unable to care for himself or herself but fails to do so.

Neglect may include the failure to provide sufficient supervision, nourishment, or medical care, or the failure to fulfill other needs for which the victim cannot provide themselves. The term is also applied when necessary care is withheld by those responsible for providing it from animals, plants, and even inanimate objects. Neglect can carry on in a child’s life falling into many long-term side effects such as: physical injuries, low self- esteem attention disorders, violent behavior, and can even cause death.

Restraint- any physical, chemical or mechanical intervention that is used to control acute, episodic behavior that restricts the movement or function of the individual or a portion of the individual’s body. Use of restraints and seclusion are both: restrictive interventions, are actions or procedures that limit an individual’s movement, a person’s access to other individuals, locations, or activities, or restricts the participant’s rights.

Exploitation –means the illegal or improper use of an incapacitated or dependent adult or that adult’s resources for another’s profit or advantage 

Service Interruption- an event that results in the participant’s inability to receive services and that places the participant’s health or welfare at risk. This includes involuntary termination by the agency and failure of the participant’s back up plan. If these events occur, the agency must have a backup plan for temporary stabilization.

MANDATORY REPORTERS

Mandated reporters are people who have regular contact with vulnerable people such as disabled persons, and senior citizens, and are therefore legally required to ensure a report is made when abuse is observed or suspected. 55PA. Code 52.3 requires that all Service Coordinators and providers are mandatory reporters under the law.

Definitions

Service Coordinators -A staff member who provides service coordination services

Provider- Agency

Everyone regardless of their role in the agency is considered a mandatory reporter. If any critical incident as described prior is discovered by any staff member it should be reported immediately to the Service Coordinator or Designee.

Reporting

All Service Coordinators and providers (agencies) are required to report critical incidents. Before reporting the incident, measures must be taken immediately to protect the participant.

1. Safeguard the health and welfare of the participant (Call 911 if determined to be needed)

2. Contact the Service Coordinator (agency office to report)

3. Service Coordinator or agency will Contact Adult Protective Services (aged 18-59) 1-800-490-8505, Older Adult Protective Services (over 60 years of age) 1-800-254-5164

4. within 48 hours, the Service Coordinator or agency that discovers or has independent knowledge of the critical incident is to submit a critical incident report to the Office of Long term living.

5. If the incident occurs over the weekend, a written report must be entered the first business day after the incident occurred.

6. Incidents are to be entered Enterprise Incident Management (EIM) (if participant 18-59) or Social Assistance Management (SAMS) (if participant is 60 or older) or through the RA-Incident@pa.gov (if the participant is age 60 or older and the incident is being submitted by the agency)

Report Format

All critical incidents must be documented as specified below and initial reports must include the following:

·         report information

·         Participant demographics

·         OLTL program information

·         event details and type

·         description of the incident

      ·      actions taken to immediately secure the participant’s well-being

Attendant care, COMMCARE, Independence and OBRA waivers and the ACT 150 program are required to report incidents using: EIM (OLTL’s Incident management system) and must ensure staff have been trained and available to report incidents in the time frame required (48 hours of the conclusion of the critical incident investigation)

Aging waiver- must fill out critical incident reporting form and submit via email to RA-Incident@pa.gov use the SAMS system

 The Agency must inform the participant’s Service Coordinator within 24 hours of an incident. If the participant needs immediate intervention, providers must immediately contact the Service Coordinator if 911 is not called

OLTL may require additional information after review of the incident from the Service Coordinator or agency.

Notice to the Participant

1. Agency staff that discovered or first became aware of the critical incident is to notify the participant (and representative if requested by the participant) that a critical incident report has been filed.

2. A copy of the notice need to be provided to the participant within 24 hours. It must be understandable and language appropriate accessible format).

3. If the participant’s representative is suspected to be involved in the critical incident, the representative should not be notified.

4. Within 48 hours of the conclusion of the critical incident investigation, the Service Coordinator must inform the participant of the resolution and measures implemented to prevent recurrence.

5. Participant has the right to provide input into the resolution and measures implemented to prevent recurrence of the critical incident.

6. If the representative of the participant is not suspected to be involved in the critical incident, the participant may request the representative be informed upon discover and conclusion – this must be documented in the critical incident report. All information must be provided in an understandable and appropriate language accessible format

 Participant Involvement

1. Participant has right to not report incidents

2. Participant has right to decline further investigation

3. Participants also have the right to refuse involvement in the critical incident investigation.

4. Participant has a right to have an advocate present during any interviews and/or investigations resulting from a critical incident report.

5. If the participant chooses not to report an incident or declines further intervention, the critical incident must still be reported and the Service Coordinator must investigate the incident.

6. Documentation is to be kept indicating that the participant did not wish to report the incident or declined interventions.

7. If the incident involves potential danger to the participant, the Service Coordinator needs to inform the participant that they are a mandated reporter and are required by law to report and submit the incident to protective services.

8. The participant must also be informed by the Service Coordinator that their services may be jeopardized if they are putting themselves or others at risk.

Investigation of Critical Incidents

1. Service Coordinators are responsible for investing reports of critical incidents that they discover or have independent knowledge of, as well as incidents submitted to them by providers.

2. If the critical incident involved the Service Coordinator or Service Coordination Entity (SCE), the SC or SCE should not investigate and should turn the investigation over to OLTL immediately.

Types of Investigations

1.Onsite- conducted for fact finding

o   sequence of events

o   Interview of witnesses

o   Observation of the participant and/or environment if needed

o   If patient hospitalized the SC is to meet with hospital social workers and the attending physician to ensure hospital staff are aware of the incident to ensure a safe disposition.

o   . If the incident is medically involved, it is recommended that a nurse or the nurse consultant accompany the SC.

2. Telephone Investigation-

o   review of incident report reveals facts are missing

o   . additional information is required

Incident Report Qualifications

1. fact and sequences of events is outlined with sufficient detail;

2. preventative action through the service plan is either not required or is implemented and documented;

3. the participant is not placed at any additional risk.

EIM OR SAMS (OLTL REPORTING SYSTEMS)

https://www.hhsapps.state.pa.us/eim/   Need to get access prior to having to use(EIM)

https://agenet.state.pa.us/vpn/index.html. Need to get access prior to having to sue (SAMS)

1. When the investigation is completed, the SC must enter the following information into EIM or SAMS within 30 calendar days of the discovery of the incident:

·         Actions taken to secure the health and safety of the participant

·         Changes made to the individual service plan as a result of the incident

·         Measures taken to prevent or mitigate recurrence of the critical incident

2. If the SC is unable to conclude the initial investigation within 30 days, the SC is to request an extension from OLTL through EIM

3. All information of an alleged incident involving a participant is considered confidential

4. In the care of suspected abuse, neglect, and exploitation, SC’s are expected to ensure for the health and welfare of participants and to cooperate with protective service investigators.

EMPLOYEE REMOVAL OR SUSPENSION

1. The agency will remove any agency and/or participant-directed employee until an investigation has been completed.  

2.  The employee is to have no contact with the participant

3. The employee will be suspended until the investigation is completed

4. Based on the circumstances the employee suspended may or not may be paid based upon the alleged incident and employment policies of the agency.

5. If the employee works for a participant-directed employer, the employee is required to be suspended without pay and the participant’s back up plan put into place.

Backup plan:

1. temporary transfer to agency model of service delivery

2. placement of additional skilled services i.e. nursing services

These will occur until the investigation is concluded.

 Prevention of Abuse and Exploitation of Participants

It is our responsibility as an agency to look out for and to help those in our communities who are elderly or have disabilities. After all, it’s everyone’s business to stop adult abuse, neglect, and exploitation.

1. If   it isn’t your money than it is a crime to have the participant’s money in any format: check, cash, credit card, and bank accounts. Financial exploitation is illegal or improper use of another person’s money or property for personal profit or gain. Financial exploitation of adults who are elderly or disabled is an increasing problem and protecting them from becoming victims is everyone’s business.

2. Look for physical signs of abuse: 

·         Injury that has not been cared for properly

·         Injury that is inconsistent with explanation for its cause

·         Pain from touching

·         Cuts, puncture wounds, burns, bruises, and welts

·         Dehydration or malnutrition without illness-related cause

·         Poor Coloration

·         Sunken eyes of cheeks

·         Inappropriate administration of medication

·         Soiled clothing or bed

·         Frequent use of hospital or health care/doctor shopping

·         Lack of necessities such as food, water, or utilities

·         Lack of personal effects, pleasant living environment, personal items

·         Forced Isolation

3. Look for behavioral signs of abuse:

·         Fear

·         Anxiety, agitation

·         Anger

·         Isolation, withdrawal

·         Depression

·         Non-responsiveness, resignation, ambivalence

·         Contradictory statements, implausible stories

·         Hesitation to talk openly

·         Confusion or disorientation

4. Look for Caregiver signs of abuse:

·         Prevents elders form speaking to or seeing visitors

·         Anger, indifference, aggressive behavior toward elder

·         History of substance abuse, mental illness, criminal behavior, or family violence

·         Lack of affection toward the elder

·         Flirtation or coyness as possible indicator of inappropriate sexual relationship

·         Conflicting accounts of incidents

·         Withholds affection

5. Signs of financial abuse

·          Sudden changes in bank account or banking practice

·         Unexplained withdrawal of a lot of money by a person accompanying the victim

·          Adding additional names on a bank signature card.

·         Unapproved withdrawal of fund using an ATM card

·         Sudden changes in a will or other financial documents

·          Unexplained missing funds or valuables

·         Providing substandard care

·         Unpaid bills despite having enough money

·          Forged signature for financial transactions or for the titles of property

·         Sudden appearance of previously uninvolved relatives claiming their rights to a person’s affairs and possessions

·         Unexplained sudden transfer of assets

·         Providing unnecessary services

·         Complaints of financial exploitation

  If you suspect abuse or you have seen any of the following, please contact the service coordinator as soon as possible or your supervisor so investigation may begin. You may have just saved someone’s life.

 Critical Incident Reporting: Participants

 POLICY:

It is the policy of our Agency to provide accurate and timely documentation of unusual occurrences, accidents, and incidents, to:

a. Review and evaluate episodes which are disruptive of our Agency.

b. Examine the conditions which jeopardize the safety of Consumers/employees.

c. Determine which incidents require fact finding.

PROCEDURE:

Any employee who witnesses or is involved in a situation that is inconsistent with the mission of our Agency is required to file an incident report. Accidents, incidents and unusual occurrences are reported immediately to the supervisor and are followed by a written report within 24 hours of occurrence.  Complete all sections of the incident report form.

a. The person with the most knowledge about the incident is the one who

completes the form.

b. When referring to other employees, use their initials and title.

c. When referring to participants, use their initials and participant record number.

d. Only document the facts, what is seen or heard, etc., avoid assumptions and

judgments. Keep statement objective.

e. Use direct quotes when possible.

f. Identify witnesses, if a witness was present when the event

occurred) or, if there is no witness state: “None”.

g. Notify the Agency Service Coordinator

TYPES OF ACCIDENTS, INCIDENTS, UNUSUAL OCCURRENCES:  

Reportable Incidents and Focused Occurrences

Some examples:

a. death, serious injury, unexpected hospitalization of a participant

b. employee misconduct including deliberate, willful, lawful, or dishonest activities

c. abuse- infliction of injury unreasonable confinement, intimidation, punishment, or mental anguish, of the participant, physical abuse, psychological abuse, sexual abuse, verbal abuse, neglect, exploitation, service interruption, medication errors that result in hospitalization, an emergency room visit or other medical intervention

PARTICIPANT ABUSE, NEGLECT, MISTREATMENT IS A MANDATORY REPORTABLE EVENT!

ALL EMPLOYEES ARE MANDATED REPORTERS TO THE AGENCY

PARTICIPANT COMPLAINT RESOLUTION

 Any complaint filed by the Participant will be investigated and resolved within 48-72 hours. The Participant will be notified of the outcome of the investigation and changes to be made if any needed.  All complaints will be documented on complaint log and discussed at the next quarterly QA meeting.

Complaints- dissatisfaction with program operations, activities, or services received, or not received.

Critical Incidents are not complaints, program fraud or financial abuse

Program Fraud- claims submitted for services or supplies that were not provided, excessive charges for services and supplies

If the complaint is one of critical incident status, then the procedure will be followed as set forth by the OLTL 55 Pa. Code 52

DEPARTMENT-ISSUED POLICIES AND PROCEDURES

The following information is available at your request as an employee regarding the reporting of Critical Incidents at any time during your employment. Critical Incident reporting in-servicing is mandatory for all employees yearly and at date of hire. The following policies and procedures are to be reviewed as needed and yearly:

1. The purpose of the Office of Long Term Living

2. Definition of Critical Incidents

3. Definition of physical abuse, psychological abuse, sexual abuse, verbal abuse, neglect, exploitation, and restraint.

4. Mandatory reporting

5. Mandatory reporters

6. Reporting

7. Investigation of critical incidents

8. Employee removal or suspension

9. Protective services

10. Risk Mitigation

11. Quality Management plan

12. Department-Issued policies and procedures

 RISK MANAGEMENT  

A means of dealing with risk liability stemming from an agency’s operations. This portion of the PI/QA program identifies:

1. areas of exposure risking injury to participants  

2. means of avoiding “risk type” of injury to participant- utilization of

3. Critical Incident reports

4. avoiding malpractice claims

5. Improving the quality of care given to participants

6. All recommendations which are generated through our PI/QA program are recorded in the minutes of the meetings.

7. The PI/QA committee analyzes and assesses the effectiveness of the committee credentials to improve the agencies performance.

QUALITY MANAGEMENT PLAN

Policy: Our agency believes in fostering ongoing improvement of the organization’s performance through performance improvement quality assurance (PI/QA) program. It is the policy of the agency to have in place a program to measure performance and quality of service delivery.

Procedure:

The agency believes that performance improvement/quality assurance is designed to determine the quality of care homecare participants receive, utilizing methods of evaluating these services provided by the professional staff. Quality is defined and measured in terms of participant outcomes. This agency believes every participant is entitled to optimum healthcare and its’ employees should be motivated toward achieving such care. Employee motivation is nurtured by management staff supportive of excellence, fiscal accountability and positive change. Committees monitor, trend and manage outcomes in the PI/QA program:

1. PI/QA Committee

   Subcommittees Include:

  1. Corporate compliance/Ethics

  2. Office Management Committee (safety/customer feedback)

Committees will meet quarterly to review information gathered, discuss

Program Goal:

To assure all available resources are used to provide each participant the best care possible. To evaluate participant care in terms of outcomes, identify any deficits in care, correct deficits with appropriate actions, and evaluate the effect of the correct action.

Program Objectives:

1. To monitor and evaluate the quality of participant care, delivered at optimal level and in a safe manner.

2. To develop and utilize standards to monitor and evaluate professional practice and agency service to participants.

3. To utilize the participant record as a source of information reviewing 10% of the records of the overall caseload (active and discharged) to identify the quality of participant care; identify deficits in care, set up of corrective action and evaluate the effectiveness of these corrective actions.

4. To design a method of problem identification, assessment, solution and evaluation of corrective action.

5. To develop a system of documenting quality assurance activities as well as documenting the results of these activities and submitting these results to the appropriate person/committee.

6. To provide a method of identifying and the integration of risk management utilization review and other activities as a means of providing comprehensive PI/QA program.

Program Integration:

All staff members of the Agency are committed to the Agency’s PI/QA program. This program focuses on monitoring and evaluating all activities, functions, and standards relating to participant care, education, and administration of participant/service outcomes.

Quarterly summaries of all activities including record reviews will be reported to PI/QA committee by all subcommittees.

Summary reports will be presented to the PI/QA Committee. Recommendation by this committee will be made to the administrator and Governing body for review.

PI/QA meetings:

1. will be held the first of the month at the beginning of each quarter

2. Critical Incidents will be reviewed

3. Feedback regarding any possible suggestions for improvement or interventions for the prevention of critical incidents in the future.

4. Documentation of all outcomes from this meeting will be kept in a binder.

Conclusion

Critical Incidents are not complaints, which are dissatisfaction with the agency program operations, activities or services received, nor not received. Critical incidents are NOT program fraud and financial abuse. Critical Incidents are occurrences of an event that jeopardizes the participant’s health or welfare: death, serious injury, abuse, sexual abuse, verbal abuse, neglect, exploitation, service interruption, and medication errors that result in hospitalization. Critical Incidents are serious infractions that must be reported immediately to the service coordinator. All employees are considered mandatory reporters of critical incidents.  An investigation will occur and while the investigation is occurring the employee maybe removed or suspended until the completion of the investigation. Policies and Procedures have been created for reporting, investigating, and prevention of these critical Incidents. If ever there is a question of a critical incident, please contact the service coordinator immediately no matter what time of day. We are all here to protect and defend our participants. Our participants put their faith and trust in us every day to look out for their well-being.

References:

Pennsylvania Department of Human Services- Office of Long Term Living Bulletin (4/16/2015)

http://www.dhs.pa.gov/learnaboutdhs/dhsorganization/officeoflongtermliving(2016)

OBJECTIVES

Provide an overview of Agency compliance.

Describe Agency methods for monitoring compliance

Review issued PA DHS Policy & Procedures

INTRODUCTION

Rules follow up where ever we go. Home care is no different. 

There are rules created by multiple entities that must be followed for compliance

Some of these entities may include state government, individual state government programs (ie. Medicaid), federal government agencies, local government, individual program participant rules and agency policy & procedures, best practices in the industry.

These compliance rules or regulations are set up to protect clients, the rights of clients and to best ensure quality of service.

 REGULATORY COMPLIANCE:

Our Agency services are provided to clients based upon state regulation, agency policy, and applicable federal regulation.  Our Agency Director is responsible for overall agency compliance with applicable rules/regulations.

These regulations determine what services we provide and how we provide those services.

Our agency must be in compliance with regulation to continue to operate & provide services to clients in these programs.

STAFF TRAINING:

Upon hire (at orientation) and ongoing, when changes occur but at least annually, our Agency provide training on agency policy & applicable regulation.

At any time staff have any questions regarding regulations or if they wish to review agency policy/procedures, they are to advise the Agency Director of their request.  Policies will be made available and review of regulations will be arranged with the staff member.

ONGOING COMPLIANCE MONITORING:

There are many ways our agency monitors compliance with applicable rules/statutes/regulation/Agency policy.

These methods include but are not limited to:

• Client record reviews- for compliance with agency policy/state regulations
• Record audits- to ensure components match policy/procedures
• QA programs- ongoing monitoring for areas of improvement can identify issues
• Client/family feedback- through satisfaction surveys
• Supervisory encounters
• Annual Agency Evaluation process
• Agency committees- provide review of various aspects of agency function that may identify compliance issues

REVIEW OF ISSUED PA DHS POLICY & PROCEDURES

Milestone Home Care diligently reviews and implements policies and procedures mandated by the Pennsylvania Department of Human Services (PA DHS) specifically tailored to the waiver program in which our agency actively participates. By adhering to these guidelines, we ensure the delivery of high-quality care and support services to individuals enrolled in the program, fostering their well-being and independence.

OBJECTIVES

1. Define what constitutes Fraud & Financial Abuse in home care.
2. Describe Agency systems in place to prevent fraud & financial abuse.
3. Explain actions to take if you identify fraud or financial abuse.

INTRODUCTION

Fraud… just the word has a negative connotation….. a feeling of a wrong doing….. well Fraud is just that….

Fraud & financial abuse exists in many industries. The home care industry does provide many opportunities to commit fraud & financial abuse including, but not limited to service delivery, billing, and reporting, just to name a few.

The consequences for committing fraud or financial abuse in home care are severe, including fines, incarceration and being permanently expelled from gaining license in the industry again.

1. DEFINITIONS:

• FRAUD: Wrongful or criminal deception intended to result in financial or personal gain.
• FINANCIAL ABUSE:

 the illegal or unauthorized use of property, payments, money, or other valuables.

2. FRAUD/FINANCIAL ABUSE in the home care setting may include:

• Knowingly submitting, or causing to be submitted, false claims or making misrepresentations of fact to obtain a state/federal health care payment for which no entitlement would otherwise exist
• Knowingly soliciting, receiving, offering, and/or paying remuneration to induce or reward referrals for items or services reimbursed by state/federal health care programs

EXAMPLES OF FRAUD AND ABUSE IN HOME CARE, APPROPRIATE FOR REPORTING MAY INCLUDE but not be limited to:

• Falsifying Claims/Encounters

• Billing for services not rendered
• Billing separately for services in lieu of an available combination code
• Misrepresentation of the service/supplies rendered (billing brand name for generic drug, up-coding to more expensive service than was rendered, billing for more time or units of service than provided)
• Altering claims
• Submission of any false data on claims, such as date of service, provider or prescriber of service
• Duplicate billing for the same service
• Billing for services provided by unlicensed or unqualified persons
• Billing for used items as new

• Administrative/Financial

• Falsifying credentials
• Fraudulent enrollment practices
• Fraudulent third-party liability reporting
• Offering free services in exchange for a recipient’s program identification number
• Providing unnecessary services/overutilization
• Kickbacks-accepting or making payments for referrals
• Concealing ownership of related companies

• Recipient Fraud and Abuse

• Forging or altering prescriptions or orders
• Using multiple ID cards
• Loaning his/her ID card
• Reselling items received through the program
• Intentionally receiving excessive drugs, services or supplies

• Abuse of Recipients

• Physical, mental, emotional or sexual abuse
• Discrimination
• Neglect
• Providing substandard or inappropriate care

• Denial of Services

• Denying access to services
• Limiting access to services
• Failure to refer to needed specialist
• Underutilization

3. AGENCY SYSTEMS IN PLACE TO PREVENT FRAUD & FINANCIAL ABUSE:

Our agency has in place various systems to prevent fraud & financial abuse.

• Client Chart reviews– which focus on appropriate services rendered to client who are in need of the service, adherence to agency & state policy/regulation.
• Billing systems of checks & balances to coordinate services/visits rendered with actual services/visits billed for & ongoing accounts.
• Ongoing financial reporting/review-to provide oversight for agency financials, including accounts payable, payroll, budgeting, accounts receivables, etc.
• Annual Agency Evaluation- to provide a review of all agency services/programs, including financial.
• QA Program to evaluate various types of Agency data & identify any systems/processes that need improvement & create/put in place a plan to make improvements to systems/quality of care issues.

4. REPORTING MEDICAID FRAUD

It is the responsibility of every staff member to report any suspected fraud or financial abuse.

REPORTS CAN BE MADE TO:

• THE AGENCY: Any suspicion of fraud or financial abuse should immediately report to your supervisor/Agency Director.
• STATE MEDICAID OFFICE: who is tasked with running this provider program and protecting their participants and the program from fraud & financial abuse.

PA Department of Human Services Welfare Fraud Tip Line at 800-932-0582

• OFFICE OF INSPECTOR GENERAL (OIG):

The OIG protects the integrity of HHS’ programs, including Medicare & Medicaid, and the health and welfare of its beneficiaries. The OIG operates through a nationwide network of audits, investigations, inspections,  and other related functions. The Inspector General is authorized to, among other things, exclude individuals and entities who engage in fraud or abuse from participation in Medicare, Medicaid, and other Federal health care programs, and to impose CMPs for certain violations related to Federal health care programs.

OIG Fraud Hotline

Phone: 1-800-HHS-TIPS (1-800-447-8477) or

TTY 1-800-377-4950

Fax: 1-800-223-8164

Online:       Forms.oig.hhs.gov/hotlineoperations/index.aspx

Mail:

U.S. Department of Health & Human Services

Office of Inspector General

ATTN: OIG Hotline Operations

P.O. Box 23489

Washington, DC 20026

OBJECTIVES 

Upon completion of this educational program the participant should be able to:

1. Define abuse and neglect.
2. Recognize risk factors associated with abuse.
3. Identify suspected cases of abuse and abusers.
4. Discuss domestic violence.
5. Discuss the reasons why caregiver abuse may occur.
6. Explain the process of reporting client abuse and neglect

INTRODUCTION

Elder abuse is a crime that can occur in any setting by formal or informal caregivers. Formal caregivers are individuals who are volunteers or paid employees and are connected to the social service or health care systems. Informal caregivers are those persons who are family members or friends, and who account for 75% of majority of care provided to impaired elders living in the community. Statistics reveal that a high percentage of reported elder abuse cases are caused by informal caregivers. It is the unreported cases that there are no data reported, and is cause for concern. Formal caregivers need to be aware of the problem of elder abuse, share the knowledge with others, report issues or concerns, and be involved in prevention measures by making a commitment to reach out to those who are vulnerable.

DEFINITION OF ABUSE

Elder abuse is any intended, knowing, or careless act that causes potential or actual harm to an older person. The harm may be physical, mental, emotional, or financial. The abuse may include neglect and mistreatment, and misappropriation of the client’s personal property.

 TYPES OF ABUSE (National Center on Elder Abuse, 2016)

Physical abuse is the use of physical force that may result in bodily injury, physical pain or discomfort, or actual impairment. Examples of physical abuse may include, but are not limited to, striking (with or without an object), hitting, pushing, shoving, beating, shaking, slapping, kicking, pinching, and burning. Additional examples may include inappropriate use of drugs, use of physical restraints, force-feeding, and any other kind of physical punishment.

Emotional or psychological abuse is the causing of infliction of anguish, pain, or distress by performing verbal or nonverbal acts. Emotional or psychological abuse may include, but is not limited to, verbal assaults, threats, intimidation, insults, humiliation, and harassment. Additionally, treating an elder as an infant/child, isolating the client from others and activities, restricting communication, using the “silent treatment”, and enforced social isolation are also examples of emotional and psychological abuse.

Sexual abuse is a non-consensual or unwanted sexual contact of any kind (forced, tricked, threatened or coerced) with an elderly person, whether or not the person is capable of giving consent or not. Examples of sexual abuse may include, but are not limited to unwanted touching, all forms of sexual assault and battery, such as coerced nudity, sodomy, rape, and sexually explicit photography.

Financial or Material Exploitation is the misappropriation of a client’s personal property, and includes the illegal or improper use of an elder person’s funds, property or assets. Examples of financial/material exploitation may include, but are not limited to, cashing a client’s checks without permission, forging a client’s signature, misusing or theft of a client’s money or possessions, coercing or deceiving a client into signing any document, and the improper use of conservatorship, guardianship, or power of attorney.

Abandonment is the desertion of an elder by an individual with assumed responsibility for the care of that person, or by a person with physical custody of the elder. The individual may be a formal or informal caregiver for the elder person.

Self-neglect is a behavior of the client that threatens his/her own health or safety, and is evidenced by the client’s refusal or failure to eat adequate food, drink enough fluids, wear adequate clothing, seek shelter, maintain personal hygiene, take prescribed medication, and observe safety precautions. This behavior is not deemed to be self-neglect if the client is mentally competent, understands the consequences of his/her actions, and makes a voluntary decision to behave in ways that threaten his/her health or safety as a matter of personal choice. The actions and behaviors should be reported to the formal caregiver’s supervisor and documented in the medical record.

RISK FACTORS

Elder abuse can occur in any client setting, therefore, all elders are at potential risk. The elder client is never to be considered responsible for any abuse inflicted upon them. The perpetrator is responsible. There are some factors that may contribute to clients being at a higher risk of abuse, such as persons who are:

• Socially isolated, lonely, or lack family or social support networks.
• Mentally compromised and therefore have increased dependence on the abuser.
• Vulnerable to problems of the abuser, such as the abuser being financially dependent on the victim, having a mental or emotional illness, alcohol or drug abuse problem, or being of an aggressive or hostile personality.
• Prone to self-neglect.

DEFINITION OF NEGLECT

Neglect, as differentiated from self-neglect, is the refusal or failure to provide necessary care, obligations or duties to the elder client. Neglect may include, but is not limited to, failure of the responsible person to pay for necessary services needed by the elderly client, failure to provide for basic life necessities such as food, water, clothing, personal hygiene, shelter, medicine, safety, comfort, and other essentials. Neglect may also include withholding meals or fluids, ordered treatments or hygiene; failure to assist with physical aids such as hearing aids, glasses, or dentures; and deliberate incorrect documentation of care rendered. Failure to provide social stimulation and ignoring the client are further examples of neglect.

IDENTIFICATION OF ABUSE AND ABUSERS

It is often difficult to identify elder abuse, or the perpetrator of the abuse. In many cases it is a family member who is involved, but not necessarily the informal caregiver. Stress and emotional instability of a family member may cause the unwanted behaviors. Adding to the problem is the fact that the elder client may not be physically or mentally capable of reporting the abuse because of being isolated, or too fearful or ashamed to tell anyone. The individual may be threatened or coerced into silence. As a formal caregiver, you should be aware of signs and symptoms of elder client abuse of all types, since a client may suffer from more than one type. Any and all cases of suspected or actual abuse should be reported immediately to the supervisor, and in turn to the state agency.

Possible Characteristics of Abusers

• Dependence on alcohol or drugs.
• History of abuse or domestic violence.
• Family dysfunction, dependency, or history of mental illness.
• Personal pressures such as economic stressors.
• History of long-term negative personality traits such as, hypercritical, bad temper, tendency to blame others for problems.
• Formal caregivers with criminal records (agency failed to do an employee background check).
• Employees who are overworked, have high turnover rates, and receive inadequate training for the caregiver position.
• Caregivers lack compassion, and empathy for the elderly and disabled.

Possible Signs of Elder Abuse

• Bruises, welts, pressure marks, burns, blisters, rope marks, slap marks, and explanations that do not “fit” with the explanation for the injury should arouse suspicion and should be reported to the supervisor.
• The client seems to withdraw from routine, normal activities, decreased alertness, sadness, unexplained fears, and unusual behaviors that may signal emotional abuse or neglect.
• Bruises or infected lesions around the breasts, genital area, unexplained venereal diseases, vaginal or anal bleeding, and the client report of being sexually assaulted or raped.
• Unexplained sudden changes in finances, altered wills, trusts, bank withdrawals, loss of property, and checks written as “gifts or loans” may be indicative of elder exploitation.
• Changes in personal effects such as need for medical or dental care, poor hygiene, overgrown hair and nails, untreated bedsores, and unusual weight loss are signs of neglect or mistreatment.

DOMESTIC VIOLENCE

Domestic violence is controlling behavior by one household member that is directed toward another member. Domestic violence includes any form of assault, battery, or criminal offence that causes bodily harm or death. Also included are such examples as name-calling or verbal abuse, isolation from family or friends, withholding funds, or threats of physical harm or sexual abuse. Individuals, who have been abused as children, many times become abusers themselves. Although no one knows exactly the number of elder abuse cases that exist, evidence reported by the National Center on Elder Abuse estimates that there are about 1-2 million elders who have been injured, exploited, or mistreated in the United States. Research figures suggest that only one in fourteen domestic elder abuse incidents is reported to authorities. As the population ages, the risks of elder abuse likewise increases. Suspected abuse must be reported, and caregivers have an obligation and responsibility to do so.

CAREGIVER ABUSE

Abuse of clients by formal caregivers can occur. Examples of physical abuse by formal caregivers include, but are not limited to hitting, rough handling, hurrying the client, threats, curses, actions or behaviors that cause client low self esteem, unwanted physical contact, gestures or remarks, misuse of a client’s money or personal possessions, including eating a client’s food, or stealing money or material objects. Trust your instincts. If you feel that something is wrong, it probably is. Notify your supervisor. One does not need to witness the abuse to report it. Suspected abuse should be reported. Let the authorities investigate and make the determination.

Caregivers who abuse clients are often individuals who are tired and overworked. They may have personal problems that interfere with their job performance; they easily lose patience and do not handle stress well. Some caregivers have been, or are, abused themselves, and resolve problems or issues by using abusive methods.

Prevention of abuse is the best alternative. As a caregiver, be aware of your feelings. Eat balanced meals and get enough rest before going to work. If a client is annoying, or unmanageable, withdraw from the situation. Make sure that the client is safe, and exit the room. Avoid confrontation. You may need to be reassigned from the case. There is never an excuse for client elder abuse.

YOU ARE A MANDATORY REPORTER – Should elder abuse be suspected, be observant and report your suspicions. It is a legal and ethical responsibility. If you do not report abuse, you are as guilty as the perpetrator of the abuse, and can be held legally responsible.

REPORTING ABUSE/NEGLECT

It is extremely important to report all and any suspected or actual client abuse as soon as it is discovered. Notify the supervisor, and follow instructions. You do not need to prove abuse in order to report it. If the supervisor does not take action, the caregiver is obligated to do so. If the client suffers serious injury or harm, the police need to be notified. Adult Protective Services should also be called. Many states have toll-free numbers for reporting elder abuse. The National Center on Elder Abuse Web-site has every state’s number for reporting elder abuse.

Report Elder Abuse/Neglect

Go to: www.elderabusecenter.org and click on to “Where to Report Abuse”

Or call your state abuse hotline listed in your Agency Abuse policy.

Or notify the local police department

SUMMARY

Elder abuse in the home setting is a reality, and one that the formal caregiver may suspect or encounter. It is important to know the different types of abuse and be able to identify signs of elder client abuse and neglect. Domestic violence is more common than even the number of reported cases. Be alert for possible signs, and know the agency’s procedures for reporting abuse and neglect. It is every caregiver’s legal responsibility to report suspected or actual abuse.  Report immediately to your supervisor and the state abuse hotline.

Accordion Content

INTRODUCTION

Milestone Home Care LLC emphasizes the delivery of quality care and services to patients through an effective Quality Assurance (QA) program. QA involves the participation of every agency employee and encompasses various measures such as service performance, timeliness of care, patient satisfaction, adherence to regulations, and agency policies. QA starts from the orientation day of each employee.

QUALITY ASSURANCE DEFINITION:

QA is the process of meeting quality standards and maintaining care at an acceptable level. It involves systematic monitoring and evaluation of service quality to ensure continuous improvement. QA aims to identify and address areas for improvement, thereby enhancing care delivery and patient quality of life.

PROGRAM GOALS AND OBJECTIVES:

• Ensure optimal utilization of resources to provide the best service to consumers.
• Evaluate service outcomes, identify deficits, take corrective actions, and assess their effectiveness.
• Monitor and evaluate service quality, develop standards, and utilize consumer records for assessment and improvement.
• Identify, hire, and retain qualified personnel and evaluate their competency regularly.
• Document QA activities and results, integrating risk management and utilization review for comprehensive QA.

PROGRAM INTEGRATION:

All staff members are committed to the QA program, focusing on monitoring, and evaluating activities for consumer/service outcomes. The Agency Director coordinates the QA program, with summaries reported to the office for review.

PROGRAM AUTHORITY/RESPONSIBILITY:

The Governing Body holds final responsibility for service quality and organization practice.

The QA Committee centrally coordinates monitoring and evaluation activities, reporting to the Agency Director and Governing Board.

QA COMMITTEE COMPOSITION:

The QA Committee comprises the Agency Director, supervisors/managers, representatives from different services, and administrative staff.

CONSUMER SERVICE PROCESS:

Consumer Record Review (CRR) evaluates structure, process, and outcome criteria, aiming for a threshold of 80% or above. Any criteria falling below 80% will be examined, corrective action planned, implemented, and accelerated for effectiveness. A summary of these record reviews is completed.

Continuity of Care involves assessing staff productivity, availability, and capability.

COMMITTEE RESPONSIBILITIES:

1. QA Consumer Record Review (CRR):

    Delegate tasks for completing consumer audits and compile summary reports.

2. Safety/Feedback Committee:

    Ensure safety checks, handle incident reports, collect feedback, and manage consumer    complaints.

3. Ethics Committee:

   Address ethical issues related to employees or consumers and report to the QA Committee.

4. QA Committee:

   Provide professional advice, oversee subcommittee activities, receive and analyze reports, and recommend improvements to the Governing Body.

Overall, the QA program aims to ensure continuous improvement in service quality and consumer outcomes through systematic monitoring, evaluation, and corrective actions.