QA Investigation Results

Pennsylvania Department of Health
ABUNDANT LIFE HOME HEALTH SERVICES
Health Inspection Results
ABUNDANT LIFE HOME HEALTH SERVICES
Health Inspection Results For:

This is the only survey for this facility

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 unannounced on-site state licensure survey conducted August 8, 2016, Abundant Life Home Health Service was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.







Plan of Correction:




Initial Comments:

Based on the findings of an unannounced state licensure survey conducted on August 8, 2016, Abundant Life Home Health Services, was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries.









Plan of Correction:




611.51(a) LICENSURE
Hiring or Rostering Prerequisites

Name - Component - 00
Prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. (3) Require the individual to submit a criminal history report, in accordance with the requirements of 611.52 (relating to criminal background checks), and a ChildLine verification, if applicable, in accordance with the requirements of 611.53 (relating to child abuse clearance).

Observations:


Based on a review of the Employee Files (EFs) and an interview with the agency administrator, the agency failed to ensure that the direct care workers had two (2) references prior to employment. Four (4) of the thirteen (13) EFs for direct care workers did not meet these requirements. (EF #1, EF #6, EF# 11, EF #12).

Findings Include:

A review of the PFs was conducted on August 8, 2016 between approximately 1130 and 1330. Date of hire (DOH) was noted for the employee.

EF #1 DOH 04/05/16: No evidence of two (2) satisfactory references prior to employment.

EF #6 DOH 03/04/16: No evidence of two (2) satisfactory references prior to employment.

EF #11 DOH 03/04/16: No evidence of two (2) satisfactory references prior to employment. One satisfactory reference in EF.

EF #12 DOH 04/07/16: No evidence of two (2) satisfactory references prior to employment.

An interview with the administrator and agency office personnel on August 8, 2016 at approximately 1530 confirmed the above findings.










Plan of Correction:

CEO will create policy so that all new employee references are in place two weeks after the starting date of the new employee.

The direct will be responsible to validate all forms and paper work are signed and turned in three weeks after employment.

Administrator will audit employee files to ensure that all paper work are in place according to the policy. Employee has thirty days after date of employment to submit all paper work. If the paper work are not submitted within thirty days, employee will be terminated.

The Director will be responsible for an internal audit and monitoring all employees and clients paper work every six months to ensure ALHHS compliance.


611.52(a) LICENSURE
Criminal Background Checks

Name - Component - 00
The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.

Observations:

Based on a review of the Employee Files (EF), and an interview with the agency administrator, the agency failed to ensure that all employees had criminal background checks. nine (9) of the thirteen (13) EFs reviewed did not have criminal background checks in their files (EF #1, EF #2, EF #4, EF #5, EF#7, EF #8, EF #9, EF #11, EF #13).

According to the Act 169 of 1996 as amended by Act 13 of 1997,"If the applicant/employee has been a resident of the Commonwealth of Pennsylvania for 2 or more years prior to application for employment, the applicant will need to obtain a clearance from the Pennsylvania State Police. This clearance is obtained by doing the following: Request for Criminal Record Check Form (SP4-164)." "When the applicant/employee has not been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application for employment or currently lives out of state, in addition to the Pennsylvania State Police Criminal History Check, the applicant/employee will also need to obtain an FBI Criminal History Check. Facilities are defined by the act to include: Domiciliary Care Homes, Home Health Care Agency, Nursing Facility (licensed by the Department of Aging), and Personal Care Home (licensed by the Department of Public Welfare). A home Health Care Agency is further defined to include those agencies licensed by the Department of Health and any public or private organization which provides care to a care-dependent individual in their place of residence." "If entities run into special circumstances where they need to hire an employee before the results of their record checks are returned, there is a provision in CPSL that allows for a provisional hiring period. The period is to not exceed 30 days for in state residents and 90 for out of state residents."


Findings Include:

A review of the EFs was conducted on August 8, 2016 between 1130 and 1330. The date of hire (DOH) was noted for each employee.

EF #1 DOH 04/05/16: No evidence of the Pennsylvania Access to Criminal History (PATCH) criminal background check.

EF #2 DOH 04/12/16: No evidence of the Pennsylvania Access to Criminal History (PATCH) criminal background check.

EF #4 DOH 07/19/16: No evidence of the Pennsylvania Access to Criminal History (PATCH) criminal background check

EF #5 DOH 03/07/16: No evidence of the Pennsylvania Access to Criminal History (PATCH) criminal background check

EF #7 DOH 06/06/16: No evidence of the Pennsylvania Access to Criminal History (PATCH) criminal background check

EF #8 DOH 05/19/16: No evidence of the Pennsylvania Access to Criminal History (PATCH) criminal background check

EF #9 DOH 03/03/16: No evidence of the Pennsylvania Access to Criminal History (PATCH) criminal background check

EF #11 DOH 03/04/16: No evidence of the Pennsylvania Access to Criminal History (PATCH) criminal background check

EF #13 DOH 05/04/16: No evidence of the Pennsylvania Access to Criminal History (PATCH) criminal background check

An interview with the agency administrator on August 8, 2016 at approximately 1500 confirmed the above findings.













Plan of Correction:

CEO will create policy so that all new employee background check is submitted the same or next day after application has been completed.

The direct will be responsible to validate that the background check has been done on the epatch.state.pa.us site only.If an employee has an out of state licenses or has not been a PA resident for more than two years, an FBI check will be required. Employment status will be pending after background check has been completed.
No employee will be able to start working until background check has been completed.

Administrator will ensure that employee background check is in and the results are satisfying for employment. Employee result should be attached with all employee files.

The Director will be responsible for an internal audit and monitoring all employees and clients paper work every six months to ensure ALHHS compliance.


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 a review of the Employee Files (EFs) and an interview with the agency administrator, the agency failed to ensure that the direct care workers have an initial competency review such as passing a competency examination developed by the home care agency, have a valid nurse's license, nurse aid certification, or has successfully completed a training program. Twelve (12) of the Thirteen (13) PFs for direct care workers did not meet this requirement (EF #1, EF #2, EF #3, EF #4, EF #5, EF #6, EF #7, EF #8, EF #9, EF# 11, EF #12, and EF #13).

Findings Include:

A review of the EFs was conducted on August 8, 2016 between approximately 1130 and 1330. The date of hire (DOH) was noted for each employee.

EF #1 DOH 04/15/16: No evidence of an initial competencies

EF #2 DOH 04/12/16: No evidence of an initial competencies

EF #3 DOH 03/03/16: No evidence of an initial competencies

EF #4 DOH 07/19/16: No evidence of an initial competencies

EF #5 DOH 03/07/16: No evidence of an initial competencies

EF #6 DOH 03/04/16: No evidence of an initial competencies

EF #7 DOH 06/06/16: No evidence of an initial competencies

EF #8 DOH 05/19/16: No evidence of an initial competencies

EF #9 DOH 03/03/16: No evidence of an initial competencies

EF #11 DOH 03/04/16: No evidence of an initial competencies

EF #12 DOH 04/07/16: No evidence of an initial competencies

EF #13 DOH 05/04/16: No evidence of an initial competencies


An interview with the administrator and agency office personnel on August 8, 2016 at approximately 1530 confirmed the above findings.













Plan of Correction:

CEO will create the training policy so that all new employee are training accordingly.

The CEO/direct will be responsible to train all employees.

Administrator will audit employee files to ensure that all training and any competency exam are completed according to the policy. Employee has thirty days after date of employment to complete all training and competency exam. If training is not completed after that, employee working status will be on hold until employee has completed all training.

The Director will be responsible for an internal audit and monitoring all employees and clients paper work every six months to ensure ALHHS compliance.


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 Employee Files (EF) and an interview with the agency administrator, it was determined that the agency failed to ensure direct care workers were screened for and were free from active mycobacterium tuberculosis per CDC guidelines prior to assignment with clients. Twelve (12) of the Thirteen (13) EFs for direct care workers did not meet this requirement (EF #1, EF #2, EF #3, EF #4, EF #5, EF #6, EF #7, EF #8, EF #9, EF #11, EF #12 and PF #13

The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease.
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.


Findings Include:

A review of the EFs was conducted on August 8, 2016 between approximately 1000 and 1200 the date of hire (DOH) was noted for each employee.

EF #1 DOH 04/15/16: No evidence of TB screening prior to providing services to a consumer.

EF #2 DOH 04/12/16: No evidence of TB screening prior to providing services to a consumer.

EF #3 DOH 03/03/16: No evidence of TB screening prior to providing services to a consumer.

EF #4 DOH 07/19/16: No evidence of TB screening prior to providing services to a consumer.

EF #5 DOH 03/07/16: No evidence of TB screening prior to providing services to a consumer.

EF #6 DOH 03/04/16: No evidence of TB screening prior to providing services to a consumer.

EF #7 DOH 06/06/16: No evidence of TB screening prior to providing services to a consumer.

EF #8 DOH 05/19/16: No evidence of TB screening prior to providing services to a consumer.

EF #9 DOH 03/03/16: No evidence of TB screening prior to providing services to a consumer.

EF #11 DOH 03/04/16: No evidence of TB screening prior to providing services to a consumer.

EF #12 DOH 04/07/16: No evidence of TB screening prior to providing services to a consumer.

EF #13 DOH 05/04/16: No evidence of TB screening prior to providing services to a consumer.


An interview with the agency administrator on August 8, 2016 at approximately 1530 confirmed the above findings.








Plan of Correction:

CEO will create policy so that all new employee receive baseline tuberculosis screening upon hiring.

The direct will be responsible to validate employees are using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis.
Employees have 72 hours to submit the results of the 1st step PPD from the signing for job application. The 2 step PPD should be administered 3 weeks after the 1st step PPD was sumitted. If an employee already completed a PPD test within the 12 months, that test can be used as the 1st step PPD. Employee are not permitted to work or in contact with the client before the results have been reviewed.

Administrator will audit employee files to ensure that PPD results are in place according to the policy. If the results are not submitted within 3 weeks after filling out job application, employee will not be hired from ALHHS.

The Director will be responsible for an internal audit and monitoring all employees and clients paper work every six months to ensure ALHHS compliance.


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 review of Consumer Files (CF), review of admission packet, and interview with the administrator, it was determined the agency failed to ensure that the consumers received all required information prior to the initiation of services for eleven (11) of twelve (12) Consumer Files (CF). (CF), #'s 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, and 12) that were reviewed.


Findings include:
A review of the CFs was conducted August 8, 2016 between approximately 1000 and 1100. The start of service (SOS) was noted for each consumer.
CF #1 SOS 04/05/16: No evidence in the file the consumer had been advised on 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.
CF #2 SOS 03/04/16: No evidence in the file the consumer had been advised on 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.
CF #3 SOS 04/12/16: No evidence in the file the consumer had been advised on 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.
CF #5 SOS 03/16/16: No evidence in the file the consumer had been advised on 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.
CF #6 SOS 03/03/16: No evidence in the file the consumer had been advised on 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.
CF #7 SOS 06/06/16. No evidence in the file the consumer had been advised on 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.
CF #8 SOS 04/07/16: No evidence in the file the consumer had been advised on 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.
CF #9 SOS 03/28/16: No evidence in the file the consumer had been advised on 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.
CF #10 SOS 07/03/16: No evidence in the file the consumer had been advised on 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.
CF #11 04/10/16: No evidence in the file the consumer had been advised on the right to 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.
CF #12 05/19/16: No evidence in the file the consumer had been advised on the right to 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.

An interview with the administrator on August, 2016 at approximately 1530 confirmed the above findings.













Plan of Correction:

CEO will create policy to advised on 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.

Administrator will ensure that employee have read and signed its 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.

The Director will be responsible for an internal audit and monitoring all employees and clients paper work every six months to ensure ALHHS compliance.


611.57(b) LICENSURE
Prohibitions

Name - Component - 00
(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

Observations:

Based on a review of Consumer Files (CF) and interview with the agency administrator, the agency failed to provide consumer information regarding the prohibition of assuming power of attorney or guardianship over a consumer utilizing the services of that home care agency or not requiring a consumer to endorse checks over to the home care agency for twelve (12) of thirteen (13) CFs reviewed (CFs #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12).

Findings include:

Review of consumer records on August 8, 2016, between approximately 1000 and 1130 revealed the following. The start of service (SOS) date is noted for each consumer.

CF #1 04/05/16: No evidence in the CF that the consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks.

CF #2 03/04/16: No evidence in the CF that the consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks.

CF #3 SOS 04/12/16: No evidence in the CF that the consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks..
CF #5 SOS 03/16/16: No evidence in the CF that the consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks..
CF #6 SOS 03/03/16: No evidence in the CF that the consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks..
CF #7 SOS 06/06/16. No evidence in the CF that the consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks..
CF #8 SOS 04/07/16: No evidence in the CF that the consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks..
CF #9 SOS 03/28/16:No evidence in the CF that the consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks.
CF #10 SOS 07/03/16: No evidence in the CF that the consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks.
CF #11 04/10/16: No evidence in the CF that the consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks.
CF #12 05/19/16: No evidence in the CF that the consumer was made aware of the prohibition regarding assuming power of attorney or guardianship over a consumer or the endorsement of checks.

Interview with the director on August 8, 2016 at approximately 1530 confirmed the above mentioned information.








Plan of Correction:

CEO will create policy in regard the prohibition of assuming power of attorney or guardianship over consumer to endorse check over the home care agency.

The director will be responsible to validate all forms and power of attorney or guardianship to not requiring a consumer to endorse check checks. Customer must read and signed form the day of enrollment.

Administrator will audit employee files to ensure that all paper work are in place according to the policy.

The Director will be responsible for an internal audit and monitoring all employees and clients paper work every six months to ensure ALHHS compliance.



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 Consumer Files (CF), review of admission packet, and interview with the administrator, it was determined the agency failed to ensure that the consumers received all the required information prior to the initiation of services for eleven (11) of twelve (12) Consumer Files (CF). (CF) #'s 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, and 12) reviewed.

Review of CF #1 SOS 04/05/16, revealed that the consumer had not received the correct telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA), the correct Department of Health complaint Hot Line (1-800-254-5164 ) telephone number, and had not received contact information to 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.
Review of CF #2 SOS 03/04/16, revealed that the consumer had not received the correct telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA), the correct Department of Health complaint Hot Line (1-800-254-5164 ) telephone number, and had not received contact information to 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.
Review of CF #3 SOS 04/12/16, revealed that the consumer had not received the correct telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA), the correct Department of Health complaint Hot Line (1-800-254-5164 ) telephone number, and had not received contact information to 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.
Review of CF #5 SOS 03/16/16, revealed that the consumer had not received the correct telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA), the correct Department of Health complaint Hot Line (1-800-254-5164 ) telephone number, and had not received contact information to 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.
Review of CF #6 SOS 03/03/16, revealed that the consumer had not received the correct telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA), the correct Department of Health complaint Hot Line (1-800-254-5164 ) telephone number, and had not received contact information to 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.
Review of CF #7 SOS 06/06/16, revealed that the consumer had not received the correct telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA), the correct Department of Health complaint Hot Line (1-800-254-5164 ) telephone number, and had not received contact information to 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.
Review of CF #8 SOS 04/07/16, revealed that the consumer had not received the correct telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA), the correct Department of Health complaint Hot Line (1-800-254-5164 ) telephone number, and had not received contact information to 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.
Review CF #9 SOS 03/28/16, revealed that the consumer had not received the correct telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA), the correct Department of Health complaint Hot Line (1-800-254-5164 ) telephone number, and had not received contact information to 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.
Review of CF #10 SOS 07/03/16, revealed that the consumer had not received the correct telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA), the correct Department of Health complaint Hot Line (1-800-254-5164 ) telephone number, and had not received contact information to 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.
Review of CF #11 04/10/16, revealed that the consumer had not received the correct telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA), the correct Department of Health complaint Hot Line (1-800-254-5164 ) telephone number, and had not received contact information to 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.
Review of CF #12 05/19/16 revealed that the consumer had not received the correct telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA), the correct Department of Health complaint Hot Line (1-800-254-5164 ) telephone number, and had not received contact information to 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.
Interview with the director on August 8, 2016 at approximately 1530 confirmed the above mentioned information.






Plan of Correction:

CEO will create policy to continuously updating all third-party information.

Administrator will ensure that the Ombudsman program located with the local area agency numbers are updated.
All the updated information will be sent by email, mail to clients. All current client will sign a form stated that they received the updated Ombudsman form. All new client will be given the correct form.

All the third-party information will be validated and updated every six months by administrator to ensure accurate information are giving the the customers.

The Director will be responsible for an internal audit and monitoring all employees and clients paper work every six months to ensure ALHHS compliance.


Initial Comments:

Based on the findings of an unannounced onsite state licensure survey conducted August 8, 2016, Abundant Life Home Health Services was found to be in compliance with the requirements of 35 P.S. 448.809 (b).









Plan of Correction: