Powerback Rehab: A Case Study

The reporting party (RP) stated that 92 year old resident Delora Lovelock DOB: 1/15/24 was residing in the facility from 5/15/2015 to 6/4/2015. Prior to admission the facility was informed that the resident had a broken femur and could not bear weight. The resident required two caregivers to transfer. Initially the facility assessed the resident and accepted her into the facility. Subsequently the resident was not provided the care necessary. The resident was transferred by one caregiver that resulted in the resident's trip to the emergency room where she was diagnosed with contusions to her ribs. The RP stated that prior to admission that the caregivers were trained in transferring resident however the caregiver had no idea how to transfer a resident from bed to

SC received a telephone call on 10/16/2015 stared 9:34 and end at 9:41 am from Tricia Crooks at Liberty Resources Home Choices (LRHC) Community Outreach and Enrollment Leader. Stating that she spoke Pa and he wants to resume his service order with LRHC for PAS service. SC informed SC that this information will first need to verify with Pa. SC expressed concerns about LRHC being able to fulfill service since they had the case unstaffed for over two weeks (09/25/15-10/15/2015). Tricia apologized on behalf of LRHC, and stated that they have someone assigned and is ready to go all is needed is the resumed service order ASAP. SC again explained to Tricia that Pa has to confirm this besides Pa was very adamant about switching provider because the

CPSW did a home visit to meet with Ms. Berner and to discuss about her safety plan since the children are moving with her on10/29/16 from the foster provider. Ms. Berner was late for her appointment and CPSW waited a 40 minutes for Ms. Berner. Ms. Berner apologized for being late. CPSW explained Ms. About safety plan. Ms. Berner understood and she signed them. Ms. Berner stated that she will be doing a house arrest for two weeks and the recommendation of her criminal court is to obey law and continue taking her medication on time and seeing her therapist. Also, cooperating with her PO and CPSW. CPSW consulted with the supervisor and she has approved both children to move back with Ms. Berner. Goal 1-2

At 1005 this clinician made contact with the patients CPS caseworker who reports he was scheduled to meet with the son at his daycare. He reports he met with her roommate who made him aware the patient was taken away from the home by ambulance. In addition, the roommate also reported

CCIB received a Corrective Plan of Action (CAP) detailing the visit to the home on 10/18/17 by Service Coordinator, Sally Cano. Ms. Cano arrived at the home, but no one was there. Ms. Cano proceeded to check Delta Home 3 (located next door) and found 2 of Delta Home Care IV residents along with residents from Delta Home Care 3 at the home. As Ms. Cano was leaving, she observed a bus arrive at the Delta Home Care 2. The bus driver reported that there was no staff at the home and that the residents were waiting outside. It was observed the Delta Home Care 2, 3, and IV to be lacking staff. On 10/19/17, RP and Quality Assurance specialist (QAS) Jesus Ozeda went to the facility to observe the staff to resident ratios and to collect the staff schedules

Frankie Tilmon continues to be out of treatment compliance. Frankie has missed his last four appointments, 7/2/15, 7/9/15, 7/16/15, and 7/30/15. Frankie contacted this provider on 7/6 to apologize for missing his appointment on 7/2 and was reminded of his next appointment on 7/9, which he agreed to attend. On 7/15 Frankie contacted this provider to apologize for missing his treatment appointment on 7/9 and agreed to make his appointment the following day, which he failed to appear for. On 7/16 Frankie contacted this provider to again apologize for missing his appointment and wanted to confirm his next scheduled appointment day/time. I told Frankie that his appointment day and time has not changed; it was on Thursdays at 4pm. Frankie told

CCIB Intake received a call from resident Eugene Kunz DOB 2/8/24 in room #6. Mr. Kunz call to state he wanted to remove his daughter Joyce as his Power of Attorney (POA) and pay his $3000 rent each month. According to the caller he has residing in the facility for approximately 3 1/2 years and wanted to return to his home, however due to his slight dementia he was having difficulty with his memory and therefore could not return to his home. Conversely the caller described how his daughter would have him examined by physician who would give him 3 words at the beginning of his examination and at the end would ask him the 3 words. Unfortunately the caller could never recall the 3 words and thus was unable to return to his home. Recently the caller

On 03/11/2016 SC met with Pa in her apartment for a RA visit. Pa 's Agency Model PAS aide was not present while SC was there. The Pa appeared poorly groomed and dressed in dark color clothes. The apartment was dirty and cat litter and feces on the table and floor. All utilities are in working order. The Pa reported numerous hospitalizations between Temple University and Episcopal University. The Pa did know the exact dates of admission and/or discharge. However, the Pa stated that reasons for admission were either asthma exacerbation; COPD and/or fluid around the Lungs. The SC placed call to Temple University Hospital medical records department and inquiries about Pa admission and discharges. The SC was placed on hold for a long time and when the SC did speak with the receptionist she stated that most of the Pa admission was at Episcopal Hospital Temple University and she did not have the time to go over every admission she provided the SC with the medical records department telephone number for Episcopal. The SC thanks her for her time and end call. The dates of ER visits and hospital admissions are as follows: 11/2015, 12/2015, 3/1/2016-3/4/2016, 3/5/2016-3/6/2016; and two ER visits 2/29/2016 and 3/7/2016 at Temple University. SC reviewed Pa’s services and per Pa he is receiving services in the type, scope, amount, frequency and duration as specified in the ISP. But the SC reasons to doubt that the Pa is receiving service according to the ISP. The SC arrived at the Pa’s

SC placed call to Pa and CG Annette on 01/5/16. SC asked Antoinette about her employment status with provider to be Sweet Home Health Care and she reported that she was still waiting to hear from the provider. SC informed Annette that it has been over 60 days since Pa’s was approved for service and has not us it. SC asked how Pa’s personal need is are being met and Antoinette reports that she is proving care to Pa. Annette said she did everything and is waiting for the agency. SC end call with Antoinette and placed call to agency. SC got the agency answering service and left detail message, identifying self, Pa, stated reason for calling, and contact informant.

SC completed monitoring telephone call with Pa on 1/20/2016. SC called Pa. Pa reported that ding “good”. Pa reported no new health problems, no medications, no falls, and no hospitalizations. Pa reported no outstanding doctor’s visits. Pa reported that’s he saw her PCP on 1/19/2016. SC reviewed Pa's ISP. Pa confirms that she is receiving services in the following type, scope, amount, frequency and duration of services specified in the ISP agency model aide via Total Home Health Care from 10-2PM, Monday through Sunday. Pa's aide provides assists her with the completion of ADLs, IALDs and supervision as needed. Pa has PERS system which gives her access to emergency medical service. Pa also, receives HMD from PCA weekly. She reported being satisfied

SC, Jennifer Stoker contacted the provider, Pam Provider via telephone. SC introduced herself and told provider that she was Bo’s. Pam noted she got MIW for Bo. Parkland police has pick him up. SC noted to Pam she have to allow Bo to come into the home. SC noted she talk with Consumer rights and services (CRS). SC informed Pam that CRS noted she has to continue to be BO provider until he chose to move. It is not her decision to try to get Bo to leave. Pam noted SC need to from BO somewhere to stay once he is released from the hospital. Pam noted SC need to find him a placement. SC noted to Pam that Is her reasonability as Bo

On 6/16/15, PACT team received a voice mail message from person’s served sister letting PACT know that, “person served was not feeling well yesterday and having breathing problems. I took her to PCP yesterday and he gave her an EKG and sent her to the ER.” On same day, PACT staff made attempts to contact individual’s sister to obtain more information, but they were failed. Staff had no information as to the whereabouts of person served i.e. what hospital she was in. Attempts were also made on 6/17/15, to contact the primary care physician, Dr. Sherer, at his office, but the office was closed and no information could be obtained. Person’s served sister left another message on 6/18/15 stating person served was at Hackensack University Medical

SC complete monitoring phone call with Pa on o3/28/2016. The Pa stated that Tiffany wants him to switch to another PAS provider Progressive Health Care because they offer more money and she wants more hours. The asked the Pa what is that he wants and he stated that he is fine with the way things are now. The SC told the Pa that things will remain as is and if he wants to switch in the feature then he most call the SC himself and request that change. The Pa agrees and the SC continues with monitoring call review use of medical service and ISP. The Pa, who reported no falls, hospitalization, changes in health status or medication reported by Pa. Pa reports receiving all services as outlined in ISP. He remains satisfied with the services and feels

SC placed a call to Pa’s DCW/dtr Maria and completed monitoring phone call with her. The SC asked the DCW if the basement is cleaned and free of fleas. The SC informed that the SC will share this information with SCS and then housing will contact her directly to schedule another visit for housing inspection for stair ride assessment. The DCW then discussed various issues about the Pa’s home possible in foreclosures and what they are going to do about it. Pa reported no recent falls or hospitalizations or changes in health or functioning. Pa confirmed that she is received her services as specified in the ISP in the following type, scope, amount, frequency and duration: Pa receives Agency Model PAS 4 hours x 7 days per week (9:00am - 2:00pm).

SC received VM from Chris from Homelink stating that she called and spoke with Pa about service installation after talking about the other services Homelink provides. Chris reiterate there appointment and reason for visits and according to Chris Pa seem to not have any reclamation of what they had previously discussed a few short minutes later. Chris expressed concerned about Pa ability to properly use button to call for help. SC forwards the VM to SCS and later discussed s matter with SCS. SC express concern about Pa’s ability to remain safely in the community and SCS states she understands SC concern and she will discuss the matter with her supervisor on