QA Investigation Results

Pennsylvania Department of Health
1 PERSON AT A TIME
Health Inspection Results
1 PERSON AT A TIME
Health Inspection Results For:


There are  9 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an onsite unannounced followup and state relicensure survey completed January 9, 2019, 1 Person At A Time 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 followup and state relicensure survey completed January 9, 2019, 1 Person At A Time had not corrected the deficiencies cited under PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries. The deficiencies were cited as a result of a state re-licensure survey completed July 5, 2018. 1 Person At A Time was also found not to be in compliance with additional 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:




611.2(a) LICENSURE
License required

Name - Component - 00
Each physical location of the home care agency or home care registry must be separately licensed.

Observations:


Based upon interview with the agency Administrator, review of agency brochure, consumer records (CR), and personnel files (PF), the agency failed to obtain a separate state home care agency/registry license for the physical location located at 100 South Juniper street, 3rd floor, Philadelphia, PA 19107.

Findings included:

During entrance interview conducted with the agency Administrator (EMP1) on 1/9/19 at approximately 9:25 AM surveyor was provided with agency "brochure" by EMP1 upon surveyor request. Agency brochure review revealed the title of the agency and included but was not limited to the following: "...Currently, Our Service locations include:...Bucks County...Chester County...Philadelphia County...Montgomery County...100 S. Juniper Street 3rd Floor, Philadelphia, PA 15206..." EMP1 reported to surveyor the Philadelphia office location operated "under" the same license of the agency office physical location 6425 Living Place 2nd Floor, Pittsburgh, PA 15206 (Agency address on record with the Department of Health). EMP1 confirmed the Philadelphia, PA office location was not operating under a separate state home care agency/registry license. Surveyor requested phone number of Philadelphia office location and was told by EMP1 all calls are directed to the Pittsburgh office. EMP1 confirmed office hours for the Philadelphia location as 8:30 AM to 4:30 PM Monday through Friday with agency staff person present.

A review of ten (10) consumer records (CR) on 1/9/19 between approximately 11:15 AM and 1:25 PM revealed consumers CR1 and CR2 had documented home addresses located in Philadelphia County, PA. During review, EMP1 confirmed CR1 and CR2 services provided through the Philadelphia office location.

A review of nine (9) direct care worker personnel files (PF) on 1/9/19 between approximately 1:40 PM and 3:30 PM revealed direct care workers PF1 and PF2 resided in Philadelphia, PA. EMP1 confirmed direct care workers PF1 and PF2 were assigned to provide services to consumers CR1 and CR2 as aforementioned above through the Philadelphia, PA office location.

During an interview conducted on 1/9/19 at approximately 4:00 PM, the agency administrator (EMP1) confirmed the above findings.



















Plan of Correction:

1 Person AT A Time Administrator (EMP1) will hold In-Service training January 28th regarding the Physical location of the home care agency or home care registry must be separately licensed. Informing staff that the Philadelphia Office 100 S. Juniper Street 3rd Floor, Philadelphia, PA 19107 will cease and desist until further notice.
1 Person At A Time will discontinue all Philadelphia cases until we obtain a license for a Philadelphia location. Administrator will work with client MCO coordinators to ensure safety between client transfers without service interruption. Administrator will create a spreadsheet of the client service end dates and communication dates with MCO coordinators and send to Pennsylvania Department of Health's Division of Home Health February 8, 2019. 1 Person At A time will be removing Philadelphia office address and content from all literature, until we get an approved license from Pennsylvania Department of Health.
Intake coordinator will evaluate all client information to ensure proper proximity of our office location to provide services. Administrator and intake-coordinator will ensure that in the future we will only serve clients within our service area from 6425 Living Place 2nd Floor Pittsburgh, PA, 15206 operating license location. Administrator will conduct quarterly reviews of client files to ensure accuracy of client locations and our service area.



611.4(c) LICENSURE
Requirements for HCA and HCR

Name - Component - 00
Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.

Observations:


Based on review of the Health Care Facilities Act, Department records, consumer information packet, consumer records, and interview with the agency Administrator, the agency failed to maintain standards required by State authorities, specifically, the agency failed to be subject to an unannounced inspection by authorized representatives of the Department. The agency failed to ensure services were provided under the scope of the home care agency's state license by providing physician ordered skilled nursing services to three (3) of ten (10) consumer records reviewed (CR8, CR9, CR10), and the agency failed to ensure services were provided under the scope of the home care agency's state license by providing, specifically, a 24 hour on-call service, 7 days a week to ensure adequate medical care and to arrange service for patient emergencies.

Findings included:

Per 35 P.S. 448.813, "...Authorization.--For the purpose of determining the suitability of the applicants and of the premises or for determining the adequacy of the care and treatment provided or the continuing conformity of the licensees to this act and to applicable local, State and Federal regulations, any authorized agent of the department may enter, visit and inspect the building, grounds, equipment and supplies of any health care facility licensed or requiring a license under this act and shall have full and free access to the records of the facility and to the patients and employees therein and their records, and shall have full opportunity to interview, inspect, and examine such patients and employees..."

A review of Department records on 12/27/18 at approximately 3:30 PM in preparation for an unannounced survey to be conducted on 12/28/18 found agency office operating hours with staff present to be Monday through Friday, 8:30 AM to 4:30 PM, verified by agency owner on 6/4/18 via phone call with the Department. Surveyor attempted to conduct unannounced on-site survey on 12/28/18 at approximately 9:15 AM. There was no staff available to gain entry to the agency office to conduct the unannounced inspection. Surveyor attempted to contact agency via phone, with voice message left, while on-site to gain entry but was unsuccessful in contacting agency staff. Surveyor terminated on-site survey attempt at approximately 9:40 AM on 12/28/18. Email received from agency administrator on 1/2/18 at 12:42 PM stated "...This is to inform you...due to holidays on 12/28/18 our office staff was performing their operations from home and was communicating through On Call number...Please be noted that, our office will remain open from 8:30 AM till 4:30 PM (Monday through Friday)..."
An unannounced state survey was conducted at the agency office on 1/9/19 during the agency operating hours on record with the Department (8:30 AM - 4:30 PM). Agency administrator (EMP1) was present. During entrance interview on 1/9/19 at approximately 9:25 AM EMP1 confirmed the agency office operating hours with staff present as noted in the above findings. EMP1 confirmed agency office closed on the following dates: 12/26/18, 12/27/18, 12/28/18, 12/31/18, EMP1 stated "...we were working from home...[surveyor phone message from 12/28/18] was not received until staff came back in office, staff was only monitoring on call phone number for clients..."

A review of the agency "Patient Information Booklet" on 1/9/19 at approximately 10:35 AM revealed: "...SECTION II. AGENCY OVERVIEW...After Hours Coverage: We provide 24 hour on-call service, 7 days a week to ensure you receive adequate medical care...on-call coordinator is on-call to accept patient calls...and to arrange service for patient emergencies as needed...SECTION IX. ON-CALL GUIDELINES...on-call coordinator is available at our agency at all times...available after regular office hours for urgent conditions...The following is a list of some reasons for which you may need to contact our agency after regular office hours. CHEST PAIN: Chest pain usually requires that you be seen by your physician...or emergency room ...TEMPERATURES: Elevations in temperatures above 100[degrees] should be called in and instructions may be given over the telephone. A home visit may be necessary...RESPIRATORY DISTRESS: Severe respiratory distress usually requires evaluation by your physician. You may be instructed in ways to ease shortness of breath, proper use of respiratory aids or oxygen...CATHETERS: Catheters are not an emergency unless you are unable to urinate...If the catheter does not drain or comes out and you are unable to urinate, you may need to call. You will be taught to irrigate or remove the catheter if it becomes stopped. If it is leaking or comes out, pad yourself well...and call early in the morning so someone can be scheduled to visit...FEEDING TUBES: IF...comes out completely and you had a feeding at supper time, you can usually wait until the next morning unless you are diabetic...EMERGENCY CARE PLAN: Please call on-call at...if you experience any of the following symptoms or problems: Heart/Lung Problems: ...Increased shortness of breath...New onset irregular or rapid heartbeat...Signs of Infection: Increased redness...Wound gets bigger...Change in amount, color or odor of wound drainage...Diabetic Problems: Sudden weakness...Sweating spells...Sudden dizziness...Too Much Blood Thinner: Bleeding from the nose, mouth, gums, rectum, or surgical site... Urinary Problems: Foul odor to urine...Catheter not draining...Increased weakness...Other Problems: No bowel movement in 3 days...Change in balance, coordination, or strength. Fall with small or no injury. Change in mental status. Signs of high blood pressure or stroke...Call 911 if you experience any of the following: A fall with a broken bone or bleeding. Chest pain that medicine doesn't help. Difficulty breathing. Unable to wake patient. Severe or prolonged bleeding. Severe or prolonged pain..." During review of agency "Patient Information Booklet", surveyor asked administrator (EMP1) what agency does if consumer calls on-call telephone number with a problem listed under the "symptoms"? EMP1 stated "...would tell them to call doctor or call 911..."

During entrance interview conducted with the agency Administrator (EMP1) on 1/9/19 at approximately 9:25 AM surveyor asked EMP1 if agency provided specialized care to any consumers. EMP1 stated "...have two skilled cases with LPN visits..." Surveyor requested consumers with LPN skilled visits be identified for consumer record review. Agency intake coordinator (EMP2) identified 3 consumers receiving LPN services.

Consumer record (CR) reviews conducted on 1/9/19 between approximately 11:15 AM and 1:25 PM revealed:

CR8, Start of service 8/3/17, OLTL Service Authorization Form dated 7/29/17 revealed "...Independence Waiver...SERVICE AUTHORIZED (TYPE):...Home Health Nursing...Sunday through Saturday; as preferred by the Participant...DESIRED OUTCOME OF SERVICE: Home health nursing..." CR8 contained a "Home Health Certification and Plan of Care...Start of care 8/4/17...Certification period from 6/12/18 to 8/29/18 with physician signature dated 8/10/18...Orders For Discipline and Treatments...LPN MON-SAT 12 HRS/48 UNITS-WEEK-PER CONSUMER REQUEST, 2 VISITS DAILY AND PRN...Additional Orders...PERFORM ACLU CHECK (Blood sugar accuchecks) AND PULL UP INDICATED INSULIN AND HAND IT TO PT TO ADMINISTER 2 X DAILY, MEDICATION EDUCATION/MANAGEMENT, SKIN ASSESSMENT..." A review of written "Nursing Visit Records" from 12/1/18 to 12/30/18 revealed:
There was a "Nursing Visit Record" performed 3 times a day, for 1 hour each visit, every day from 12/1/18 to 12/30/18 (30 visits) by a skilled nurse (LPN, EMP8). there was only 1 visit record for each day with 3 separate Time in's/Time out's documented at the bottom of each visit note . "Skilled Observations" were completed on each visit record reviewed which included "...Vital Signs...Cardiovascular...Respiratory...Sensory...GU...Medication changes...Skin...Digestive/Nutrition...Musculoskeletal...Pain...Endocrine..." "Skilled Intervention/Teaching/Pt/Cg Response" section of each visit record reviewed had the following hand written note with the exact same verbiage on each visit reviewed: "Pt blood sugar checked each visit and insulin drawn up and given to patient each time. Pt injects self with insulin in LL ABD. ROM also done each visit. Pt non-compliant [with] diabetic diet..." "Coordination/Plan" section of visit note had "Conference with...PT (circled)... Regarding: 'Diabetic Diet - Fall Precautions'(hand written)..." on each visit reviewed.

CR9, Start of service 8/1/17, OLTL Service Authorization Form dated 8/2/17 revealed "...Independence Waiver...1 hour a day for injections (utilized Mondays, Wednesdays, and Fridays...DESIRED OUTCOME OF SERVICE: Skilled nursing (LPN)..." CR9 contained a "Home Health Certification and Plan of Care...Start of care 8/1/17...Certification period from 6/11/18 to 9/11/18 with physician signature dated 8/13/18...Orders For Discipline and Treatments...Continue Copaxone 40 mg Injections Subcutaneous every monday, Wednesday, Fridays. DX: MS...Additional orders... continue LPN on site visits 3 times per week for evaluation and assessment of Patients over all health needs...Continue PROM/AROM by LPN and HHA for strengthening and mobility on a daily basis..." A review of written "Nursing Visit Records" from 12/1/18 to 12/31/18 revealed:
There was a "Nursing Visit Record" performed 1 time a day for 1 hour, every day from 12/1/18 to 12/31/18 (31 visits) by a skilled nurse (LPN, EMP8). "Skilled Observations" were completed on each visit record reviewed which included "...Vital Signs...Cardiovascular...Respiratory...Neurological...Sensory...GU...Medication changes...Skin...Digestive/Nutrition...Musculoskeletal...Pain...Endocrine..." "Skilled Intervention/Teaching/Pt/Cg Response" section of each visit record reviewed had the following hand written note with the exact same verbiage on each visit reviewed: "Pt vitals checked each visit. ROM done each visit on all 4 extremities. pt given injection M-W-F lower abd for MS symptoms..." "Coordination/Plan" section of visit note had "Conference with...PT (circled)... Regarding: 'Fall risks - MS disease progression'(hand written)..." on each visit reviewed.

CR10, Start of service 3/12/18, most recent agency service agreement executed between consumer/consumer representative and agency dated 7/31/18. CR10 contained a "Home Health Certification and Plan of Care...Start of care 3/13/18...Certification period from 8/13/18 to 10/11/18 with physician name and address. No physician signature on Plan of care...Orders For Discipline and Treatments...LPN 1x/week for physical assessment, vital signs, medication assessment and response...Additional Orders...RN hours 2x/month for 60 days to perform LPN supervisory visits and Recertification/Plan of Care...Assessment of patient...Continue medications as ordered by physician and up date medications biweekly with LPN..." A review of written "Nursing Visit Records" from 12/1/18 to 12/31/18 revealed: There was a "Nursing Visit Record" performed 1 time a day for 1 hour on 12/1/18, 12/4/18, 12/18/18, 12/26/18 by a skilled nurse (LPN, EMP8). "Skilled Observations" were completed for each visit record reviewed which included "...Vital Signs...Cardiovascular...Respiratory...Neurological...GU...Medication changes...Pain...Endocrine...Mental Health/Affect..." "Skilled Intervention/Teaching/Pt/Cg Response" section of each visit record reviewed had the following hand written note with the exact same verbiage on each visit reviewed: "Pt med box filled + vitals checked. Pt weak. Tires easily...Pt states pain medication controlls (sic) pain..." "Coordination/Plan" section of visit note had "Conference with...PT (circled)... Regarding: 'Frequent rests'(hand written)..." on each visit reviewed.

During an interview conducted on 1/9/19 at approximately 4:00 PM, the agency administrator (EMP1) confirmed the above findings.

















Plan of Correction:

1 Person At A Time Administrator will conduct an In-Service training January 28 regarding applicable environment, health, sanitation and professional licensure standards and providing a 24 hour, 7 day a week on call service to ensure PAS services. Also to relay the message that 1 Person At A Time does not provide any skilled services.
Annually we are going to notify Pennsylvania Department of Health annual holiday schedules of 1 Person At A Time. Current literature and online information will be changed to reflect the current holiday schedule as well. 1 Person At A Time Administrator will be responsible for monitoring the updates of any changes to the Agencies office hours and holiday schedules.
1 Person At A Time Administrator will work with MCO coordinators to ensure safety between client transfers without service interruption of LPN skills visited consumers. Administrator will create a spreadsheet of the client MCO communications and service end dates. Spreadsheet will be sent to Pennsylvania Department of Health's Division of Home Health February 8, 2019.
1 Person At A time will not provide any skilled services. Administrator will evaluate each consumer care plan to make certain services required of 1 Person at A Time are non-skilled services. Administrator will conduct quarterly reviews of client files to guarantee all services provided by 1 Person At A Time are non-skilled services.



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 submitted plan of correction, personnel files (PF), and interview with agency administrator, the agency failed to obtain no less than two satisfactory references for eight (8) of ten (10) personnel files reviewed (PF2, PF3, PF4, PF6, PF7, PF8, PF9, PF10) and/or conduct a face to face interview with the individual for two (2) of ten (10) personnel files reviewed (PF7, PF10).

Findings included:

Agency submitted plan of correction (POC) for relicensure survey completed 7/5/18, read "Tag S200...Hiring or Rostering Prerequisites....Completion Date: 7/25/18 [agency's date of alleged compliance]...will review all employee files...to identify any instances of non-compliance...will communicate with non-compliant employees...and require...submission of verifiable reference...will review personnel files at time of hire and will conduct quarterly reviews...for compliance...will immediately implement a checklist...to make sure face-to face interview...is completed on all new hires..."

Personnel file (PF) reviews conducted on 1/9/19 between approximately 1:40 PM to 3:40 PM revealed:

PF2, Date of hire 12/18/16. There was no documented evidence of at least two satisfactory references completed. This file was not corrected as stated in the Plan of correction.

PF3, Date of hire 5/18/18. There was documented evidence of one satisfactory reference completed; There was no documented evidence of a second satisfactory reference completed. This file was not corrected as stated in the Plan of correction.

PF4, Date of hire 7/25/17. There was no documented evidence of at least two satisfactory references completed. This file was not corrected as stated in the Plan of correction.

PF6, Date of hire 5/18/18. There was no documented evidence of at least two satisfactory references completed. This file was not corrected as stated in the Plan of correction.

PF7, Date of hire 9/4/18. There was no documented evidence of at least two satisfactory references completed. There was no documented evidence of a face to face interview conducted with the individual.

PF8, Date of hire 7/31/17. There was documented evidence of one satisfactory reference completed; There was no documented evidence of a second satisfactory reference completed. This file was not corrected as stated in the Plan of correction.

PF9, Date of hire 9/24/18. There was documented evidence of one satisfactory reference completed; There was no documented evidence of a second satisfactory reference completed.

PF10, Date of hire 1/12/16. There was no documented evidence of at least two satisfactory references completed. There was no documented evidence of a face to face interview conducted with the individual. This file was not corrected as stated in the Plan of correction.

During an interview conducted on 1/9/19 at approximately 4:00 PM, the agency administrator (EMP1) confirmed the above findings.

Repeat deficiency 7/5/2018, 6/26/2015, 7/18/2012

















Plan of Correction:

1 Person At A Time Administrator will hold In-Service training January 28th regarding the requirement to obtain at least two satisfactory references for each new hire. Human Resources and Administrative Assistant will be trained on this policy.
1 Person At A Time Administrative Assistant and Administrator will review all employee files February 22nd to identify any instances of non-compliance regarding the two satisfactory verifiable references policy. Administrator & Administrative Assistant will communicate with any non-compliant employees February 25th and will require that they comply within a (3) day period, February 4th, to initiate the submission of the verifiable reference. March 1st agency will have the corrections completed and all references contacted, documented, and filed.
Administrator and Human Resource will evaluate each employee reference form when hired to ensure that every employee's reference form has been completed. To ensure the employee has provided this information and reference calls have been made the Administrator will conduct quarterly reviews of employee files.
Administrator will review all employee files at time of hire and utilize the "Personnel checklist" and "Application Cover Sheet". Both the "Personnel checklist" and "Application Cover Sheet" will have all the following information: (a) Criminal Background, (b) Child abuse clearance, (c) Physician Physical Status, and (d) TB status. All of all the required information an employee needs to be in compliance with employment regulations. Administrator will also conduct quarterly reviews thereafter for compliance with policies and procedures. The checklist being implemented regarding required information and documentation will be done prior to administering care to the consumer.



611.52(a) LICENSURE
Criminal Background Checks

Name - Component - 00
An applicant for employment as a member of the office staff for the home care agency or home care registry and the owner or owners of the home care agency or home care registry also are required to obtain a criminal history report in accordance with requirements contained in this section.

Observations:


Based on review of personnel files (PF), and interview with agency administrator, the agency failed to obtain a criminal history report at the time of application or within 1 year immediately preceding the date of application for one (1) of one (10) agency office staff personnel file reviewed (PF7).

Findings included:

Personnel file (PF) reviews conducted on 1/9/19 between approximately 1:40 PM to 3:40 PM revealed:

PF7, Date of hire 9/4/18. There was no documented evidence of a Pennsylvania criminal history report completed.

During an interview conducted on 1/9/19 at approximately 4:00 PM, the agency administrator (EMP1) confirmed the above findings.















Plan of Correction:

1 Person At A Time Administrator will conduct an In-Service training January 28th regarding the requirement to obtain a criminal history report at the time of application or within 1 year immediately preceding the date of application for each new hire. Human Resources & Administrative Assistant will be trained on this policy.
1 Person At A Time Administrative Assistant and Human Resources will review all employee files by February 22nd to identify any instances of non-compliance regarding criminal history background checks.
Human Resources & Administrative Assistant will contact all non-compliant employees February 25th. Administrator will supply the necessary funds required to process any missing background checks to bring the company into conformity with Code 611.52(a) Licensure. All missing background checks will be completed and filed February 26th.
PF 7 employee FBI background was completed on date September 05, 2018 but not properly filed. Upon being made aware the proper documents for PF 7 and all other caregivers have been properly filed.
In the future employees must have a criminal background verified by PA state police before they will be eligible to work in the field. 1 Person At A Time will follow PA Code 611.52 (a) General Rule, (b) State Police Criminal history record, (c) Federal criminal history record, and (d) proof of residency. An employee will receive FBI background check if the employee hasn't lived in PA for at least 2 years.
Administrator will review all employee files at time of hire and utilize the "Personnel checklist" and "Application Cover Sheet". Both the "Personnel checklist" and "Application Cover Sheet" will have all the following information: (a) Criminal Background, (b) Child abuse clearance, (c) Physician Physical Status, and (d) TB status. Both of the latter mentioned documents regarding required background information will be examined by the administrator prior to administering care to the consumer. Administrator will also conduct quarterly reviews thereafter for compliance with policies and procedures.



611.52(d) LICENSURE
Proof of Residency

Name - Component - 00
The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation

Observations:


Based on review of agency submitted plan of correction, personnel files (PF), and interview with agency administrator, the agency failed to verify proof of residency in Pennsylvania for 2 years prior to date of hire for four (4) of ten (10) personnel files reviewed (PF1, PF5, PF8, PF9).

Findings included:

Agency submitted plan of correction (POC) for relicensure survey completed 7/5/18, read "Tag S330...Proof of Residency....Completion Date: 8/17/18 [agency's date of alleged compliance]...will review all current employee files...to identify any instances of non-compliance...will communicate with non-compliant employees...and will require...documentation showing proof of residency...will require each new applicant's file to provide proof of residency at time of hire..."

Personnel file (PF) reviews conducted on 1/9/19 between approximately 1:40 PM to 3:40 PM revealed:

PF1, Date of hire 3/27/17. There was no documented evidence to verify proof of PA residency for the two years immediately preceding the date of hire. There was a copy of employee (PF1) Pennsylvania driver's license with an issue date of 6/10/15 (less than 2 years preceding date of hire). This file was not corrected as stated in the Plan of correction.

PF5, Date of hire 3/1/18. There was no documented evidence to verify proof of PA residency for the two years immediately preceding the date of hire. There was a copy of employee (PF5) Pennsylvania driver's license with an issue date of 5/16/16 (less than 2 years preceding date of hire). This file was not corrected as stated in the Plan of correction.

PF8, Date of hire 7/31/17. There was no documented evidence to verify proof of PA residency for the two years immediately preceding the date of hire. There was a copy of employee (PF8) Pennsylvania driver's license with an issue date of 3/16/16 (less than 2 years preceding date of hire). This file was not corrected as stated in the Plan of correction.

PF9, Date of hire 9/24/18. There was no documented evidence to verify proof of PA residency for the two years immediately preceding the date of hire. There was a copy of employee (PF9) Pennsylvania driver's license with an issue date of 10/11/17 (less than 2 years preceding date of hire).

During an interview conducted on 1/9/19 at approximately 4:00 PM, the agency administrator (EMP1) confirmed the above findings.

Repeat deficiency 7/5/2018



















Plan of Correction:

1 Person At A Time Administrator will hold an In-Service training January 28th regarding proof of residency requirements. Human Resources & Administrative Assistant will be trained on this policy.
1 Person At A Time Administrative Assistant and Human Resources will review all current employee files by February 8th to identify any instances of non-compliance regarding proof of residency.
Human Resources and Administrative Assistant will communicate with any non-compliant employees by February 15th and will require that they comply within a (7) day period by either submitting documentation showing proof of residency or applying for a FBI background check by February 22nd.
Human Resources will require each new applicant's file to provide proof of residency at time of hire by one of the following documents: (1) Motor vehicle records (2) Housing records. (3) Public Utility. (4) Local tax record. (5) Tax returns or apply for a FBI background check, etc.
Human Resources and Administrative Assistant will have employee compliance completed by March 1st. Administrator will then perform quarterly reviews for compliance of employee files with policies and procedures.



611.55(a) LICENSURE
Compentency Requirements

Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.

Observations:


Based on review of agency submitted plan of correction, personnel files (PF), and interview with agency administrator, the agency failed to ensure, prior to assigning or referring a direct care worker to provide services to a consumer, the direct care worker had demonstrated competency, for one (1) of nine (9) direct care worker personnel files reviewed (PF1).

Findings included:

Agency submitted plan of correction (POC) for relicensure survey completed 7/5/18, read "Tag S600...Competency Requirements....Completion Date: 8/17/18 [agency's date of alleged compliance]...will review all current employee files...to identify any instances of non-compliance...will communicate with any non-compliant employees...and require they comply immediately...will start to progressively schedule any employee who hasn't done our initial competency to complete...August 17th..."

Personnel file (PF) reviews conducted on 1/9/19 between approximately 1:40 PM to 3:40 PM revealed:

PF1, Date of hire 3/27/17. There was no documented evidence of demonstrating competency. This file was not corrected as stated in the Plan of correction.

During an interview conducted on 1/9/19 at approximately 4:00 PM, the agency administrator (EMP1) confirmed the above findings.

Repeat deficiency 7/5/2018


















Plan of Correction:

1 Person At A Time Administrator will hold an In-Service training January 28th regarding competency requirements. Human Resources will have extensive training on this policy.
1 Person At A Time Human Resources will review all current employee files by February 8th to identify any instances of non-compliance regarding competency requirements.
Human Resources will communicate with any non-compliant employees February 11th and will require that they comply immediately. Starting February 22nd Human Resource will start to progressively schedule any employee who hasn't done our initial competency training to be completed with a (21) day period March 14th. They will have the option to complete this training in the office using agency computers or any computer available to them to access http://learningcenter.pahomecare.org or IPED.
Human Resources will require each new applicant to complete the direct care online training file for initial competency requirements. Proof of competency will be completed through Direct Care Online Training through this link http://learningcenter.pahomecare.org prior to being eligible to provide care to a consumer.
Human Resources will review files by February 8th. Competency requirements will be in compliance and completed March 1st and completed competency will be placed in employees file. In the future the Administrator will conduct quarterly reviews to ensure compliance with polices and procedure.



611.55(e) LICENSURE
Competency Requirements

Name - Component - 00
The competency review must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction.

Observations:


Based on review of agency submitted plan of correction, personnel files (PF), and interview with agency administrator, the agency failed to review competency at least once per year after initial competency was established for three (3) of ten (10) direct care worker personnel files reviewed (PF1, PF2, PF10).

Findings included:

Agency submitted plan of correction (POC) for relicensure survey completed 7/5/18, read "Tag S621...Competency Requirements....Completion Date: 8/7/18 [agency's date of alleged compliance]...will review all current employee files...to identify any instances of non-compliance...will communicate with any non-compliant employees and will require they comply immediately...will start to schedule employees...to come into office and complete annual training..."

Personnel file (PF) reviews conducted on 1/9/19 between approximately 1:40 PM to 3:40 PM revealed:

PF1, Date of hire 3/27/17. There was no documented evidence of initial competencies completed and/or no documented evidence of annual competencies completed for 2018. This file was not corrected as stated in the Plan of correction.

PF2, Date of hire 12/18/16. Initial competencies documented completed 2/2017; There was no documented evidence of annual competencies completed for 2018. This file was not corrected as stated in the Plan of correction.

PF10, Date of hire 1/12/16. Initial competencies documented completed 1/2016; There was no documented evidence of annual competencies completed for 2017. This file was not corrected as stated in the Plan of correction.

During an interview conducted on 1/9/19 at approximately 4:00 PM, the agency administrator (EMP1) confirmed the above findings.

Repeat deficiency 7/5/2018














Plan of Correction:

1 Person At A Time Administrator will conduct an In-Service training January 28th regarding annual competency requirements. Human Resources will have extensive training on this policy.
1 Person At A Time Human Resources will review all current employee files by February 8th to identify any instances of non-compliance regarding annual competency requirements.
Human Resources will communicate with any non-compliant employee and will require that they comply immediately. Human resource will start to schedule employees February 8th to come into the office and complete annual training on https://learningcenter.pahomecare.org or IPCED.
Human Resources will review files by February 8th, and in the future the administrator will perform quarterly reviews for compliance with policies and procedures. Employee annual trainings will be completed March 1st. Annual completed competencies requirements will printed and put in employees file under skills tab. Competency will be including in the required checklist for eligibility to work in the field.



611.56(a) LICENSURE
Health Screening

Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.

Observations:


Based on review of agency submitted plan of correction, personnel files (PF), and interview with agency administrator, the agency failed to ensure each direct care worker and other office staff, prior to consumer contact, was screened for and free from active mycobacterium tuberculosis for two (2) of ten (10) personnel files reviewed (PF1, PF7).

Findings included:

Agency submitted plan of correction (POC) for relicensure survey completed 7/5/18, read "Tag S700...Health Screening....Completion Date: 8/24/18 [agency's date of alleged compliance]...will review all employee files...to identify any instances of non-compliance...will communicate with any non-compliant employees August 7 and will require that they adhere within a (14) day period...will review all current employee files...for health screening requirements prior to administering care to a consumer..."

Personnel file (PF) reviews conducted on 1/9/19 between approximately 1:40 PM to 3:40 PM revealed:

PF1, Date of hire 3/27/17. There was no documented evidence of a completed tuberculosis screening. This file was not corrected as stated in the Plan of correction.

PF7, Date of hire 9/4/18. There was no documented evidence of a completed tuberculosis screening.

During an interview conducted on 1/9/19 at approximately 4:00 PM, the agency administrator (EMP1) confirmed the above findings.

Repeat deficiency 7/5/2018
















Plan of Correction:

1 Person At A Time Administrator will conduct an In-Service training January 28th regarding the health screening for tuberculosis in accordance with the CDC guidelines prior to consumer contact. Human Resources manager will have extensive training on this policy.
1 Person At A Time Human Resources will review all current employee files by February 15th to identify any instances of non-compliance regarding health screening prior to consumer contact requirements.
Human Resource manager and Administrative assistant will communicate with any non-compliant employees February 15th and will require that they adhere within a (14) day period starting February 15th. Employee's that fail to comply within those (14) days will be removed from the active employee listing and removed from any work sites February 28th.
Human Resources will review all current employee files by February 15th for health screening requirements prior to administering care to a consumer and quarterly thereafter documentation will be filed in a separate file for medical.



611.56(a) LICENSURE
Health Screening

Name - Component - 00
The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.

Observations:


Based on review of agency submitted plan of correction, CDC guidelines, personnel files (PF), and interview with agency administrator, the agency failed to ensure that each employee with direct consumer contact was screened for mycobacterium tuberculosis (TB) in accordance with CDC guidelines for one (1) of ten (10) personnel files reviewed (PF2).

Findings included:

Agency submitted plan of correction (POC) for relicensure survey completed 7/5/18, read "Tag S701...Health Screening....Completion Date: 8/17/18 [agency's date of alleged compliance]...will review all current employee files...for any out of compliance...will contact any employee that is out of compliance August 7th and require their presence in the office within (10) days...to do their TB screening form...will sign off on the employee checklist form to ensure that each new employee has the proper documented negative TST...along with the 2nd TB step..."

The CDC guidelines state that all Health Care Workers (HCW) should received baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis...HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease....If a newly employed HCW has had a documented negative TST within the previous 12 months, a single TST can be administered in the new setting. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(RR-17) http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.

Personnel file (PF) reviews conducted on 1/9/19 between approximately 1:40 PM to 3:40 PM revealed:

PF2, Date of hire 12/18/16. There was a documented negative result TST completed on 2/3/17, forty seven days after date of hire. There was no documented evidence of a 2nd step TST completed. This file was not corrected as stated in the Plan of correction.

During an interview conducted on 1/9/19 at approximately 4:00 PM, the agency administrator (EMP1) confirmed the above findings.

Repeat deficiency 7/5/2018, 7/18/2012






















Plan of Correction:

1 Person At A Time Administrator will conduct an In-Service training January 28th regarding CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings.

Human Resource Manager will review all current employee files by February 8th for any out of compliance direct care workers. Human Resource Manager and Administrative Assistant will contact any employee that is out of compliance by February 15th and require their presence in the office within (14) days March 1st to do their TB Screening form or X-Ray. Any direct care worker who is unable to make it in the office with a valid excuse will have it sent via mail or email and must be returned within (10) days March 1st. The documentation must indicate the date of the screening, which may not be more than 1 year prior to the individual's start date.
Any direct care worker who is currently having direct contact with consumers who does not complete the TB screening form within that (10) business day time frame March 1st will be removed from all work sites and labeled inactive until their TB status is realized.
Human Resources will review all current employee files by February 8th for health screening requirements prior to administering care to preventing the transmission of mycobacterium tuberculosis in health care settings. Administrator will perform quarterly reviews for compliance with policies and procedures.


Administrator going forward will sign off on the employee "personal checklist" to ensure that each new employee has the proper documented negative TST within the 12 months along with the 2nd TB step. The caregiver will not be allowed to moved forward with employment until the CDC Guideline for two-step TB screening has been completed.



611.56(b) LICENSURE
Health Screening

Name - Component - 00
(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.

Observations:


Based on review of agency submitted plan of correction, CDC guidelines, personnel files (PF), and interview with agency administrator, it was determined the agency failed to ensure all workers with direct consumer contact had an updated screening for tuberculosis completed at least every 12 months for two (2) of ten (10) personnel files reviewed (PF1, PF2).

Findings included:

Agency submitted plan of correction (POC) for relicensure survey completed 7/5/18, read "Tag S710...Health Screening....Completion Date: 8/17/18 [agency's date of alleged compliance]...will enforce that the agency utilizes the TB screening form for any direct care worker who has direct consumer contact at least every 12 months...will contact any employee that is out of compliance August 7th and require their presence in the office within (10) days...to do their TB screening form...will review all current employee files by August 7th for health screening requirements prior to administering care to a consumer..."

The CDC guidelines state.... After baseline testing for infection with tuberculosis, HCWs should receive TB screen annually. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(RR-17) http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.

Personnel file (PF) reviews conducted on 7/5/18 between approximately 2:30 PM to 4:45 PM revealed:

PF1, Date of hire, 3/27/17. There was no documented evidence of a baseline TB screening completed upon hire and/or no documented evidence of an annual TB screening completed in March, 2018. This file was not corrected as stated in the Plan of correction.

PF2, Date of hire, 12/18/16. There was a documented negative result TST completed on 2/3/17. There was no documented evidence of a TB screening completed in February, 2018. This file was not corrected as stated in the Plan of correction.

During an interview conducted on 1/9/19 at approximately 4:00 PM, the agency administrator (EMP1) confirmed the above findings.

Repeat deficiency 7/5/2018














Plan of Correction:

1 Person At A Time Administrator will conduct an In-Service training January 28th regarding annual health screening for tuberculosis in accordance with the CDC guidelines.
1 Person At A Time Administrator will enforce that the agency utilizes the TB screening form for any direct care worker who has direct consumer contact at least every 12 months.
Human Resource Manager will review all current employee files by February 8th for any out of compliance direct care workers. Human Resource Manager and Administrative Assistant will contact any employee that is out of compliance February 15th and require their presence in the office within (14) days, which is March 1st to do their TB Screening form. Any direct care worker who is unable to make it in the office with a valid excuse will have it sent via mail or email and must be returned within (14) days March 1st.
Any direct care worker who is currently having direct contact with consumers who does not complete the TB screening form within March 1st times frame will be removed from all work sites and labeled inactive until the form is finalized.
Human Resources will review all current employee files by February 8th for health screening requirements prior to administering care to a consumer. Administrator will perform quarterly reviews for compliance with policies and procedures. Health screening records will be kept in a separate file for employees medical records.



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 reviews of consumer records (CR), agency consumer information packet and interviews with the agency staff, the agency failed to provide and/or inform the consumer/consumer representative of home care services the right 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 for ten (10) of ten (10) consumer records reviewed (CR1 - CR10).
.
Findings included:

A review of the agency "Patient Information Booklet" on 1/9/19 at approximately 10:35 AM revealed no documented evidence of the consumer right to receive at least 10 calendar days advance written notice of the intent of the home care agency 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 the agency consumer service agreement and/or consumer information packet.

A review of consumer records CR1 - CR10 on 1/9/19 between approximately 11:15 AM and 1:25 PM revealed no documented evidence the consumers/consumer representatives were provided and/or informed of the consumer right to receive at least 10 calendar days advance written notice of the intent of the home care agency 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 in the following ten CR's reviewed:
CR1, Start of Services 10/30/16.
CR2, Start of Services 4/20/17.
CR3, Start of Services 3/3/17.
CR4, Start of Services 11/11/18.
CR5, Start of Services 12/22/17.
CR6, Start of Services 9/25/18.
CR7, Start of Services 10/6/18.
CR8, Start of Services 8/3/17.
CR9, Start of Services 8/1/17.
CR10, Start of Services 3/12/18.

During an interview conducted on 1/9/19 at approximately 4:00 PM, the agency administrator (EMP1) confirmed the above findings.

Repeat deficiency 4/20/2010
























Plan of Correction:

1 Person at A Time Administrator will conduct an In-Service training January 28th regarding Consumer Rights information to be provided to the consumer, the consumer's legal representative, or responsible family member.
The patient information booklet, updated February 1, 2019, now shows that all clients will have a 10-calendar day advance written notice of termination. Administrator and Administrative assistant will ensure that a written documentation is issued to any consumer who services must be ceased. A copy of the former mentioned documentation will also be filed into the terminated consumer file.
A letter regarding these changes has been sent out to all clients along with a form to sign acknowledging that they understand and have been informed.
1 Person At A time Administrator will ensure that the patient information booklet reflects all the information required to be giving to the consumer before services are rendered. Administrator will perform quarterly reviews for compliance with policies and procedures.



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 review of agency submitted plan of correction, consumer record (CR) reviews, agency consumer information packet review, and interview with the agency staff, the agency failed to provide, prior to the commencement of services, the following information in a form that was easily read and understood in the consumer information packet: (1) 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. (2) The telephone number/s of the Ombudsman Program located with the local Area Agency on Aging/s (AAA). (3) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry for ten (10) of ten (10) consumer records reviewed (CR1 - CR10).

Findings included:

Agency submitted plan of correction (POC) for relicensure survey completed 7/5/18, read "Tag S820...Information to be Provided....Completion Date: 8/7/18 [agency's date of alleged compliance]...A list of services...is provided in the Patient Admissions packet by means of the Skills needs list and availability form...availability form has been altered to identify the direct care worker and the initial training...direct care worker has undergone. Patient Information booklet includes...contact information for the Department of Health...hiring competency for workers employed by the agency...Administrator will ensure that the patient admissions packet reflects all the information required to be giving (sic) to the consumer before services are rendered..."

A review of the agency "Patient Information Booklet" on 1/9/19 at approximately 10:35 AM revealed no documented evidence of (1) 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. (2) The telephone number/s of the Ombudsman Program located with the local Area Agency on Aging/s (AAA). (3) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. The agency "Patient Information Booklet" was not corrected as stated in the Plan of correction.

A review of consumer records CR1 - CR10 on 1/9/19 between approximately 11:15 AM and 1:25 PM revealed:
CR1, Start of Services 10/30/16.
CR2, Start of Services 4/20/17.
CR3, Start of Services 3/3/17.
CR4, Start of Services 11/11/18.
CR5, Start of Services 12/22/17.
CR6, Start of Services 9/25/18.
CR7, Start of Services 10/6/18.
CR8, Start of Services 8/3/17.
CR9, Start of Services 8/1/17.
CR10, Start of Services 3/12/18.
Aforementioned record reviews revealed no documented evidence the agency provided CR1 - CR10, (1) 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. (2) The telephone number/s of the Ombudsman Program located with the local Area Agency on Aging/s (AAA). (3) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.

An exit interview was conducted on 7/5/18 at approximately 5:00 PM with the agency Clinical Manager (EMP1), Intake Coordinator (EMP2), Human Resources Representative (EMP3), and Scheduler (EMP4). EMP1 confirmed the above findings.

Repeat deficiency 7/5/2018, 6/26/2015, 7/18/2012












Plan of Correction:

1 Person At A Time Administrator will conduct an In-Service training January 28th regarding information to be provided to the consumer, the consumer's legal representative, or responsible family member.
1 Person At A Time Administrator will instruct agency's Intake Coordinator to utilize an employee acknowledgement form that will indicate that the Direct Care Worker is aware of services the consumer will receive and an acknowledgment to sign off that they were trained on the consumers care plan.
A list of services to be administered to consumer is provided in the "Patient Admissions Packet" by means of "Skills needs list and availability" form and "Welcome letter". The "skills need and availability" form has been altered to identify the direct care worker and the initial training that the direct care worker has undergone. "Patient Information booklet" and "Welcome Letter" includes the information of consumer services, Fees/total cost for services, contact information for the Department of Health, the Department of Health's complaint hotline number, and hiring competency for workers employed by the agency. The "Patient information booklet", all forms signed by consumer during intake processes, and Consumer Notice of Direct Care Worker Status are giving to consumer in 1 Person At A Time "Patient Admissions Packet". Agency uses the "Patient education" form for the consumer to acknowledge they have received the Patient admissions packet. We've also altered our "Welcome Letter" with a signature line for the consumer to acknowledge they've received all the required documentation.
Administrator has updated the "Skills need and availability" form to identify the Direct Care Worker that will provide the services and the initial competency training the Direct Care Worker has completed before being able to administer services.
1 Person At A time's "Patient Information Booklet" has reflected 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 on Page 7 under "Problem Solving Procedure". Also we've provided the telephone number/s of the Ombudsman Program located with the local Area Agency on Aging/s (AAA) on Page 7 under "Problem Solving Procedure".
1 Person At A Time Administrator will ensure that the Patient admissions packet reflects all the information required to be giving to the consumer before services are rendered.
These corrections will be implemented immediately into the intake process and included in the 1 Person At A Time Admissions Packet. 1 Person At A Time Administrator and Intake Coordinator will review all current consumer files February 8th to ensure they have "skills needs and availability" form and "Patient education" form. Corrections will be completed March 1st to be in compliance with consumer protection regulations. To ensure this information has been provided to all consumers Administrator will conduct quarterly reviews of consumer files.






Initial Comments:


Based on the findings of an onsite unannounced followup and state relicensure survey completed January 9, 2019, 1 Person At A Time was found to be in compliance with the requirements of 35 P.S. 448.809 (b).







Plan of Correction: