QA Investigation Results

Pennsylvania Department of Health
EXCEL HOME CARE
Health Inspection Results
EXCEL HOME CARE
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 on-site state licensure survey conducted on November 26, 2018, Excel Home Care was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, and Subpart A






Plan of Correction:




51.3 (g)(1-14) LICENSURE
NOTIFICATION

Name - Component - 00
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.


Observations:

Based on review of agency incident and complaints and interview with the office manager and operations manager, agency failed to report or notify the Department in writing of an event that seriously compromised patient safety such as assault by a caregiver, theft of pain pills and client neglect for three (3) of three (3) events.

Finding:

The Health Care Facilities Act 35 P.S. 448.01-448.90b - The Department of
Health of the Commonwealth of Pennsylvania states
51.3 Notification
(f) If a health care facility is aware of a situation or the occurrence of an event at the facility which could seriously compromise quality assurance or patient safety, the facility shall immediately notify the Department in writing. The notification shall include sufficient detail and information to alert the Department as to the reason for its occurrence and the steps which the health care facility shall take to rectify the situation.
(g) For purposes of subsections (e)
and (f), events which seriously compromise quality assurance and patient safety include, but not limited to the following:
(1) Deaths due to injuries, suicide or unusual circumstances.
(2) Deaths due to malnutrition, dehydration or sepsis.
(3) Deaths or serious injuries due to a medication error.
(4) Elopements.
(5) Transfers to a hospital because of injuries or accidents.
(6) Complaints of patient abuse, whether confirmed by the facility.
(7) Rape.
(8) Surgery performed on the wrong patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant discharged to the wrong family.
(11) Significant disruption of services due to disaster such as fire, storm, flood or another occurrence.
(12) Notification of termination of any services vital to continued safe operation of the facility or the health and safety of its patients and personnel, including, but not limited to, the anticipated or actual termination of electric, gas, steam heat, water, sewer and local exchange of telephone service.
(13) Unlicensed practice of a regulated profession.
(14) Receipt of a strike notice.

Review of agency incidents and complaints on November 26, 2018 at 1330 revealed:

Incident # 1 dated October 22, 2018 stated " The service coordinator reported that the client was neglected due to weight loss from not being fed. "

Incident # 2 dated August 3, 2018 stated, " Client called to report that his caregiver took his pain pills. "

Incident # 3 dated February 2, 2018 stated, " Consumer stated that he was assaulted by the caregiver."

Interview with the office manager and operations manager on November 26, 2018 at 1330 confirmed that above events were not reported via the Pennsylvania Department of Health Event Reporting System.






Plan of Correction:

Incident #1 ERS filed on 11-30-2018 Event # 556718.
Incindent #2 ERS filed on 11-30-2018
Event # 556696
Incident #3 ERS filed 11-30-2018
Event # 556678

All staff will be educated by the regional compliance officer on the need to report events in the ERS system using the Dept. of Health internet site overview guidelines to be complaint with 28 Pa. code 51.3. This training will take place December 11-13.
All events are to be monitored by the location manager and the quality management team with oversight by the regional compliance officer. The quality management team will read all electronic progress notes to ensure that any possible reportable events are identified, investigated and reported if it is deemed necessary.
The compliance officer is responsible for the implementation of training and the location manager is responsible for oversight of this process.
All findings will be reported to the quality management team along with the compliance officer for review.



Initial Comments:

Based on the findings of an on-site state licensure survey conducted on November 26, 2018, Excel Home Care was found to be in compliance with the following requirement of Title 28 Health and Safety Part IV, Health Facilities, Subpart H. Chapter 611 Home Care Agencies and Home Care Registries.





Plan of Correction:




Initial Comments:

Based on the findings of an on-site state licensure survey was conducted on November 26, 2018, Excel Home Care was found to be in compliance with the requirements of 35 P.S. 448.809(b)




Plan of Correction: