QA Investigation Results

Pennsylvania Department of Health
BLESSED HANDS HOME HEALTH CARE
Health Inspection Results
BLESSED HANDS HOME HEALTH CARE
Health Inspection Results For:


There are  6 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 results of an unannounced complaint investigation survey, conducted on January 29, 2019, to determine compliance for complaint allegations made on January 15, 2019, for Blessed Hands Home Health Care, the state surveyors were unable to determine compliance with the following requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries.

As a result, the agency is determined to be not in compliance with the following state licensure tags: S0120, S0830.









Plan of Correction:




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 "Title 45 of the Electronic Code of Federal Regulations, Part 164 - SECURITY AND PRIVACY, Subpart E", "OCR HIPAA Privacy December 3, 2002 INCIDENTAL DISCLOSURE", "United States Health & Human Services OCR PRIVACY BRIEF SUMMARY OF THE HIPAA PRIVACY RULE", agency observations (Observation #1), and an interview with a "friend of the owner", it was determined the agency failed to ensure protection of patient medical records from an individual present in the agency who was not an employee or contractor.

Findings include:

According to Title 45 of the Electronic Code of Federal Regulations, Part 164 - SECURITY AND PRIVACY, Subpart E- Privacy of Individually Identifiable Health Information, "164.530 Administrative requirements," "(c)(1) Standard: Safeguards. A covered entity must have in place appropriate administrative, technical, and physical safeguards to protect the privacy of protected health information." Retrieved from https://www.ecfr.gov/cgi-bin/text-idx?SID=d9614eaf433ed3f49041777883125e47&mc=true&node=se45.1.164_1530&rgn=div8

According to "OCR HIPAA Privacy December 3, 2002 INCIDENTAL DISCLOSURE," "How the Rule Works ... Reasonable Safeguards. See 45 CFR 164.530(c). ... Many health care providers and professionals have long made it a practice to ensure reasonable safeguards for individuals' health information - for instance: ... By isolating or locking file cabinets or records rooms." Retrieved from https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/coveredentities/incidentalu%26d.pdf

According to "United States Health & Human Services OCR PRIVACY BRIEF SUMMARY OF THE HIPAA PRIVACY RULE," "HIPPA Compliance Assistance ... Who is Covered by the Privacy Rule ... Last Revised 05/03 ... The Privacy Rule, as well as all the Administrative Simplification rules, apply to ... any health care provider who transmits health information in electronic form in connection with transactions for which the Secretary if HHS has adopted standards under HIPAA ... Health Care Providers. Every health care provider, regardless of size, who electronically transmits health information in connection with certain transactions, is a covered entity. These transactions include claims, benefit eligibility inquiries, referral authorization requests, or other transactions for which HHS has established standards under the HIPAA Transaction Rule." Retrieved from https://www.hhs.gov/sites/default/files/privacysummary.pdf

Observation #1: On 1/29/2019 at approximately 10:00 AM revealed one (1) individual present at the agency, who identified as a "friend of owner", and not an employee or sub contractor. This individual was in possession of keys to a file cabinet containing patient records and access to the fax machine, which could potentially receive an incoming fax with patient medical information. The fax machine was located in the front room of the agency, not in a locked secure room.

An interview with the "friend of the owner" on 1/29/2019 at approximately confirmed that she was not an employee or contractor, and was helping out only to answer phones because the Administrator had personal and staffing issues.







Plan of Correction:

An approved Plan of Correction is not on file.


611.57(d) LICENSURE
Documentation

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(d) The home care agency or home care registry shall maintain documentation on file at the agency or registry of compliance with the requirements of this section which shall be available for Department inspection.

Observations:


Based on observation and interview with a "friend of the owner", it was determined the agency failed to ensure documentation maintained on file of compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries, to be made available for Department Inspection, in order to ensure the health, safety, and welfare of patients (Observation #2).

Findings include:

Observation #2: On 1/29/2019 at approximately 9:05 AM, office hours observed posted, for the public to view, on the front door of the agency, revealed the agency's office hours to be Monday-Friday, 9:00 AM to 5:00 PM. The agency's door was locked with no available entry for the Department surveyors at that time. A phone call was placed to the agency phone number provided to the department, with no answer.

In an interview with the sole individual present at the agency, identified as a "friend of the owner", on 1/29/2019 at approximately 10:05 AM , revealed that there was no Administrator present onsite or available by phone. The "friend of the owner" did not know when the Administrator would be available. The individual identified as the "friend of the owner" stated she was unable to access patient or personnel files to allow for a survey from the Department. The two surveyors present each left their business cards which contained email addresses and office phone numbers. As of 1/30/2019 at 4:00 PM, there was no contact from an agency representative.












Plan of Correction:

An approved Plan of Correction is not on file.