Initial Comments:
Based on the findings of an onsite unannounced state license survey completed August 18, 2025, Helping Hands Health Network was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.
Plan of Correction:
601.31(a) REQUIREMENT
PATIENT ACCEPTANCE
Name - Component - 00
601.31(a) Patient Acceptance.
Patients are accepted for treatment on
the basis of a reasonable expectation
that the patient's medical, nursing
and social needs can be met adequately
by the agency in the patient's place
of residence. Care follows a written
plan of treatment established and
periodically reviewed by a physician
and care continues under the general
supervision of a physician.
Observations:
Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the agency failed to ensure care was provided in accordance with the physician irdered plan of treatment (care) for four (4) of one 10 clinical records (CR2, CR4, CR6, & CR9).
Finding included:
Review of agency policy on August 13, 2025, at 8:45 a.m., "Policy # C-2.0: Acceptance of Patients, Plan of Care, and Medical Supervision ... 2. Plan of Care ... Care follows a written plan of care established and periodically reviewed by a doctor of medicine," "Policy # C-12.0 ... Helping Hands Home Care Service provides skilled nursing services as ordered by the patient's attending physician ... in accordance with the plan of care."
According to the National Library of Medicine National Center for Biotechnology Information, "Chapter 4 Manage Central Lines ... As the complexity of client conditions continues to evolve within health care settings, the safe use and management of central lines are imperative. A central line is a thin, flexible, large-bore tube inserted into a client ' s large vein, also referred to as a central venous access device (CVAD). ... 4.3. APPLYING THE NURSING PROCESS Ongoing nursing assessments and interventions are essential to provide safe, quality care when a client has a CVAD. These actions are guided by evidence-based practice standards. In acute care and outpatient settings [home health], the overall goals of CVAD infusion therapy are safe administration of medications and the absence of complications. ... Assessment ... Typically, in the acute care setting, site assessment is performed every shift. If the client is in the home care setting, they are educated on how to inspect their site and how frequently this assessment should occur. Home health nurses will assess the site and arm circumference during each visit [EMPHASIS]." Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK594495/
Review of CR2 on August 12, 2025, at 12 p.m. showed a physician ordered plan of care with a recertification period of 6/30/2025 to 8/28/2025. Skilled nursing (SN) was to initially see the patient twice a week for IV (intravenous) medication administration via patient's PICC line (peripherally inserted central catheter - a type of CVAD). Orders also included "SN: Assess central line access device for signs and symptoms of complication/infection : Erythema around insertion site, exudate, warm to touch, increased swelling, increased pain, and fever/chills ... SN: Measure external catheter on PICC to ensure line has no [sic] become dislodged and measure arm circumference." A review of skilled nursing visits showed SN did not measure patient's PICC line's external catheter or patient's arm circumference to assess for signs and symptoms of complications during skilled nurse visits on 7/3 RN (registered nurse), 7/10 (RN) , 7/17 (RN), 7/24 (RN), and 7/28/2025 (RN).
Review of CR4 on August 12, 2025, at 1 p.m. showed a physician ordered plan of care for an initial certification period from 7/7/2025 to 9/4/2025. Skilled nursing (SN) was to see the patient twice a week for care and assessment related to heart failure. Orders included, "SN: Monitor weight daily. Notified [sic] MD for weight gain greater than 2lbs in a 24-hour period" Review of SN start-of-care visit note from 7/7/2025 showed CR3 weighed 134 pounds. A review of subsequent SN visits on 7/10, 7/14, 7/21, 7/24, 7/31, and 8/7/2025, did not show that SN obtained CR4's weight as ordered.
Review of CR6 on August 12, 2025, at 2 p.m. showed a physician ordered plan of care with an initial certification period of 6/30/2025 to 8/28/2025. Skilled nursing (SN) was to initially see the patient twice a week for IV therapy via patient's PICC line related to a post-operative infection. Orders also included "SN: Assess central line access device for signs and symptoms of complication/infection : Erythema around insertion site, exudate, warm to touch, increased swelling, increased pain, and fever/chills ... SN: Measure external catheter on PICC to ensure line has no [sic] become dislodged and measure arm circumference." A review of skilled nursing visits showed SN did not measure patient's PICC line's external catheter or patient's arm circumference to assess for signs and symptoms of complications during skilled nurse visits on 7/16 (RN), 7/17 (RN), 7/21 LPN (licensed practical nurse), 8/7/2025 (RN).
Review of CR9 on August 12, 2025, at 3:15 p.m. showed a physician ordered plan of care for an initial certification period of 7/25/2025 to 9/22/2025. Skilled nurse was to see patient twice a week for care and assessment of a urinary tract infection / sepsis. On 7/30/2025, patient was admitted to hospital for IV antibiotics related to urinary tract infection (UTI), "recurring UTI." The patient was discharged from the hospital with new orders dated 8/2/2025, "PATIENT CARE ORDER ... Assess central line access device for signs and symptoms of complication/infection : Erythema around insertion site, exudate, warm to touch, increased swelling, increased pain, and fever/chills ... Measure external catheter on PICC to ensure line has no [sic] become dislodged and measure arm circumference. Notify MD for any concerns for dislodgement of catheter." A review of skilled nursing visits showed SN did not measure patient's PICC line's external catheter or patient's arm circumference to assess for signs and symptoms of complications during skilled nurse visits on 8/4 (RN), 8/6 (RN), and no circumference only on 8/11/2025 (RN).
A review of the above records and interview with EMP1 (administrator) on August 13, 2025, at 10 a.m. confirmed above findings.
Plan of Correction:The Clinical Manager will provide an in-service to 100% of clinical staff by September 15, 2025 to review Policy # C-2.0 Acceptance of Patients, Plan of Treatment/Care and Medical Supervision and educate staff to the fact that the plan of care is established and authorized in writing by a physician based on an evaluation of the patient's immediate and long-term needs; follows a written plan established and periodically reviewed by a physician and care continues under the general supervision of a physician.
The minutes, supporting documents and completed staff sign-in sheets are available for review on site.
20% of current patient's charts will be audited weekly for 4 weeks by the Clinical Manager to ensure documented evidence exists that reflects each patient served by the agency is cared for under a physician's ordered plan of care with the specific physician orders for skilled services being followed which may include but are not limited to:
-The RN measuring the PICC line's external catheter or patient's arm circumference to assess for signs and symptoms of complications during each RN visit;
-The RN assessing for urinary tract infections/sepsis;
-The RN monitoring the patient's weight each visit and reporting changes based on the physician's patient specific parameters; and
-All clinical staff following any updated needs for the patient based on the plan of care approved, reviewed, updated and supervised by the physician.
Target Threshold = 95-100%.
If consistently met after 4 weeks of audits, will reduce audits to complete as part of clinical record review with 20% or minimum of 10 chart reviews per quarter.
The Clinical Manager is responsible.
Date of accomplishment 09/17/2025
601.31(b) REQUIREMENT
PLAN OF TREATMENT
Name - Component - 00
601.31(b) Plan of Treatment. The
plan of treatment developed in
consultation with the agency staff
covers all pertinent diagnoses,
including:
(i) mental status,
(ii) types of services and equipment
required,
(iii) frequency of visits,
(iv) prognosis,
(v) rehabilitation potential,
(vi) functional limitations,
(vii) activities permitted,
(viii) nutritional requirements,
(ix) medications and treatments,
(x) any safety measures to protect
against injury,
(xi) instructions for timely
discharge or referral, and
(xii) any other appropriate items.
(Examples: Laboratory procedures and
any contra-indications or
precautions to be observed).
If a physician refers a patient under
a plan of treatment which cannot be
completed until after an evaluation
visit, the physician is consulted to
approve additions or modifications to
the original plan.
Orders for therapy services include
the specific procedures and modalities
to be used and the amount, frequency,
and duration.
The therapist and other agency
personnel participate in developing
the plan of treatment.
Observations:
Based on review agency policy, clinical records (CR), and staff (EMP) interview, the agency failed to ensure the plan of treatment (care) included all medications and treatments for two (2) of 10 records (CR1, & CR3).
Findings included:
Review of agency policy on August 13, 2025, at 8:45 a.m., "Policy # A-22.0 Patient Acceptance to Service ... C. Plan of Treatment/Care i. Content of the medical plan of treatment/care: ... Medications and treatments required."
Review of agency policy on August 13, 2025, at 9 a.m., "Policy # N-9.13 Midline Catheter Maintenance and Management of Potential Complications ... General Guidelines: ... 2. Intermittently accessed midline catheters will be flushed with 3ml of heparin solution 100 units/ml every 24 hours after use, or as prescribed by physician. ... 4. When medication is administered and in order to eliminate problems of drug incompatibility, the SASH method of flushing is utilized. Unless otherwise ordered by a physician, 3-5ml of normal saline will be used. S- Saline A- Administer drug/solution S - Saline H - Heparin ... 5. Apply dressing change at least every 5-7 days or PRN when using a transparent permeable adhesive dressing."
Review of CR1 on August 12, 2025, at 12 p.m. showed a physician ordered plan of care with an initial certification period from 4/8/2025 to 6/6/2025. Orders included SN (skilled nursing) for care and assessment of patient's suprapubic catheter (drains urine from bladder) and, "Medication Management." A SN visit note from 4/15/2025 showed, "Patient to begin antibiotic for UTI [urinary tract infection]." A SN visit note from 4/24/2025 showed, "[Patient] reports at [their] last ER [emergency room] visit they found [he/she] had a UTI [urinary tract infection] and [he/she] took the last does of [his/her] antibiotic this am." A review of physician orders and patient's medication profile did not show the above mentioned antibiotic was added to patient's plan of care.
Review of CR3 on August 12, 2025, at 1:30 p.m. showed a physician ordered plan of care with an initial certification period from 8/3/2025 to 10/1/2025. Orders were for SN to initially see the patient twice a week for "IV [intravenous]/PICC [peripherally inserted central catheter] line care." The SN start-of-care visit note from 8/3/2025 showed, "I changed the Midline [IV access was actually a midline type and not a PICC] dressing with today's visit. I left the securement device intact because I was having a hard time removing and did not want to risk midline being pulled out." A SN visit note from 8/4/2025 showed, "NARRATIVE NOTE ... Skills: Midline care and labs every Monday ... Midline dressing was changed during SOC [start of care] yesterday, ... labs collected via Midline today." A SN visit note from 8/11/2025 showed, "NARRATIVE NOTE ... Discontinue PICC line [midline] after final dose [of medication] on 8/13. ... Assessment PICC care and labs drawn. ... Flushes well, good blood return." Further review of CR3 did not show that physician orders were obtained for care and use of patient's midline catheter such as dressing changes and line care to include flushing with heparin or saline to keep patent.
A review of the above records and interview with EMP1 (administrator) on August 13, 2025, at 10 a.m. confirmed above findings and that CR3 was fitted with a midline and not a PICC line without orders for its care/maintenance.
Plan of Correction:The Clinical Manager will educate 100% of clinical staff at an in-service to be held by September 15, 2025 and review Policy # C-2.0 Acceptance of Patients, Plan of Treatment/Care and Medical Supervision and all the required elements that must be included in the patient's plan of treatment which covers all pertinent diagnoses, including: (i) mental status, (ii) types of services and equipment required, (iii) frequency of visits, (iv) prognosis, (v) rehabilitation potential, (vi) functional limitations, (vii) activities permitted, (viii) nutritional requirements, (ix) medications and treatments, (x) any safety measures to protect against injury, (xi) instructions for timely discharge or referral, and (xii) any other appropriate items. (Examples: Laboratory procedures and any contra-indications or precautions to be observed). The minutes, supporting documents and completed staff sign-in sheets are available for review on site.
20% of current patient's charts shall be audited weekly for 4 weeks to ensure there is documentation in the patient record of an individualized plan of care with correlating physician orders per requirements which includes but is not limited to:
-The required elements including such components as: mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, and nutritional requirements, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items.
-All medications and treatments including:
--dressing changes
--line care for IVs and PICC lines, etc.
-Any additional items the home health agency or physician may choose to include.
-The relevant physician(s) has been alerted to any changes in the patient's condition or needs that suggest outcomes are not being achieved on any patient where issues are present
Target Threshold = 95%-100%. If consistently met after 4 weeks of audits, will reduce audits to complete as part of clinical record review with 20% or minimum of 10 chart reviews per quarter.
The Clinical Manager is Responsible
Date of Completion 09/17/2025
601.31(c) REQUIREMENT
PERIODIC REVIEW OF PLAN OF TREATMENT
Name - Component - 00
601.31(c) Periodic Review of Plan of
Treatment. The total plan of
treatment is reviewed by the attending
physician and agency personnel as
often as the severity of the patient's
condition requires, but at least once
every 60 days. Agency professional
staff promptly alert the physician to
any changes that suggest a need to
alter the plan of treatment
Observations:
Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the agency failed to promptly alert the physician to any changes that suggest a need to alter the plan of treatment (care) for one (1) of three (3) patient transferred to the hospital (CR1).
Findings included:
Review of agency policy on August 13, 2025, at 8:435 a.m., "Policy # A-22.0 Patient Acceptance to Service ... C. Plan of Treatment/Care ii. Review of the plan of treatment/care ... All clinical professional staff will promptly notify the physician of any changes in the patient's condition that suggest a need to alter the plan of treatment/care."
Review of CR1 on August 12, 2025, at 12 p.m. showed a physician ordered plan of care with an initial certification period from 4/8/2025 to 6/6/2025. Orders included SN (skilled nursing) for care and assessment of patient's suprapubic catheter (drains urine from bladder) and other problems associated with patient's lower extremity paralysis including, patient's respiratory status, oxygen use, and anticoagulant therapy, "SN: Educate patient on the importance of taking anticoagulant medication as ordered to help prevent blood clots." A SN visit note from Friday 4/11/2025, "Patient reports she was to hold Coumadin (anticoagulation medication) Wednesday and Thursday and recheck Friday but patient forgot to hold Wednesday's dose." At this time, the patient's oxygen saturation (SPO2) was recorded at 95% (more on this later). There was nothing in the record to show the SN called the physician concerning patient's missed Coumadin doses and subsequent INR (time needed for blood to clot) check. A SN visit note from 5/12/2025 showed patient had a non-productive cough and an SPO2 of 96% (above 90% is generally considered normal). Subsequent SN visits on 5/15 showed patient had a productive cough of yellow sputum, an SPO2 of 90% (considered normal but a change/decrease from previously recorded values). A SN visit note from 5/19/2025 showed productive cough with small amount of yellow sputum and an SPO2 of 91%. A SN visit note from 5/21/2025 showed productive cough of small amount of pale yellow sputum and an SPO2 of 92%. A "RN Transfer OASIS-E1 from 5/26/2025," showed patient was admitted to hospital on 5/24/2025 with respiratory failure. There was nothing to show the physician was notified concerning the patient's change in condition related to productive cough with yellow sputum and decreased SPO2.
A review of the above records and interview with EMP1 (administrator) on August 13, 2025, at 10 a.m. confirmed above findings.
Plan of Correction:The Clinical Manager will educate 100% of clinical staff at an in-service to be held by September 15, 2025 and review Policy # C-2.0 Acceptance of Patients, Plan of Treatment/Care and Medical Supervision and the need for the clinical staff to review the plan of treatment with the attending physician as often as the severity of the patient's condition requires, but at least once every 60 days, and to promptly alert the physician to any changes that suggest a need to alter the plan of treatment/care.
The minutes, supporting documents and completed staff sign-in sheets are available for review on site.
20% of current patient's charts shall be audited weekly for 4 weeks to ensure there is documentation in the individualized patient record that the total plan of treatment is reviewed by the attending physician and agency personnel:
-at least once every 60 days
-when agency clinical staff alert the physician to any changes that suggest a need to alter the plan of treatment/care; and
-as often as the severity of the patient's condition requires it.
Target Threshold = 95-100%. If consistently met after 4 weeks of audits, will reduce audits to complete as part of clinical record review with 20% or minimum of 10 chart reviews per quarter.
The Clinical Manager is Responsible
Date of Completion 09/17/2025
601.32(b) REQUIREMENT
DUTIES OF THE REGISTERED NURSE
Name - Component - 00
601.32(b) Duties of the Registered
Nurse. The registered nurse:
(i) makes the initial evaluation
visit,
(ii) regularly reevaluates the
patient's nursing needs,
(iii) initiates the plan of treatment
and necessary revisions,
(iv) provides those services
requiring substantial specialized
nursing skill,
(v) initiates appropriate
preventive and rehabilitative nursing
procedures,
(vi) prepares clinical and progress
notes,
(vii) coordinates services, and
(viii) informs the physician and other
personnel of changes in the patient's
condition and needs, counsels the
patient and family in meeting nursing
and related needs, participates in
inservice programs, and supervises and
teaches other nursing personnel.
Observations:
Based on review of clinical records (CR), job descriptions, standards of practice, and staff (EMP) interview, the agency failed to ensure skilled nursing provided services in accordance with accepted standards of practice for three (3) of three (3) records (CR2, CR6, & CR9) with a PICC (peripherally inserted central catheter).
Findings included:
According to the National Library of Medicine National Center for Biotechnology Information, "Chapter 4 Manage Central Lines ... As the complexity of client conditions continues to evolve within health care settings, the safe use and management of central lines are imperative. A central line is a thin, flexible, large-bore tube inserted into a client ' s large vein, also referred to as a central venous access device (CVAD). ... 4.3. APPLYING THE NURSING PROCESS Ongoing nursing assessments and interventions are essential to provide safe, quality care when a client has a CVAD. These actions are guided by evidence-based practice standards [EMPHASIS]. In acute care and outpatient settings [home health], the overall goals of CVAD infusion therapy are safe administration of medications and the absence of complications. ... Assessment ... Typically, in the acute care setting, site assessment is performed every shift. If the client is in the home care setting, they are educated on how to inspect their site and how frequently this assessment should occur. Home health nurses will assess the site and arm circumference during each visit [EMPHASIS]." Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK594495/
Review of job descriptions on August 13, 2025, at 8:45 a.m., "Job Title Registered Nurse ... A. BASIC PURPOSE The registered nurse (RN) is responsible for planning, coordinating, and documenting skilled professional nursing care provided to meet the patient needs ... The RN utilizes the nursing process which includes the use of technology, therapeutic intervention, [and] evidence based practice ... to achieve positive clinical outcomes with the home health patients."
Review of CR2 on August 12, 2025, at 12 p.m. showed a physician ordered plan of care with a recertification period of 6/30/2025 to 8/28/2025. Skilled nursing (SN) was to initially see the patient twice a week for IV (intravenous) medication administration via patient's PICC line (peripherally inserted central catheter - a type of CVAD). Orders also included "SN: Assess central line access device for signs and symptoms of complication/infection: Erythema around insertion site, exudate, warm to touch, increased swelling, increased pain, and fever/chills ... SN: Measure external catheter on PICC to ensure line has no [sic] become dislodged and measure arm circumference." A review of skilled nursing visits showed the RN did not measure patient's PICC line's external catheter or patient's arm circumference to assess for signs and symptoms of complications during skilled nurse visits on 7/3, 7/10, 7/17, 7/24, and 7/28/2025.
Review of CR6 on August 12, 2025, at 2 p.m. showed a physician ordered plan of care with an initial certification period of 6/30/2025 to 8/28/2025. Skilled nursing (SN) was to initially see the patient twice a week for IV therapy via patient's PICC line related to a post-operative infection. Orders also included "SN: Assess central line access device for signs and symptoms of complication/infection: Erythema around insertion site, exudate, warm to touch, increased swelling, increased pain, and fever/chills ... SN: Measure external catheter on PICC to ensure line has no [sic] become dislodged and measure arm circumference." A review of skilled nursing visits showed the RN did not measure patient's PICC line's external catheter or patient's arm circumference to assess for signs and symptoms of complications during skilled nurse visits on 7/16, 7/17, 8/7/2025.
Review of CR9 on August 12, 2025, at 3:15 p.m. showed a physician ordered plan of care for an initial certification period of 7/25/2025 to 9/22/2025. Skilled nurse was to see patient twice a week for care and assessment of a urinary tract infection / sepsis. On 7/30/2025, patient was admitted to hospital for IV antibiotics related to urinary tract infection (UTI), "recurring UTI." The patient was discharged from the hospital with new orders dated 8/2/2025, "PATIENT CARE ORDER ... Assess central line access device for signs and symptoms of complication/infection: Erythema around insertion site, exudate, warm to touch, increased swelling, increased pain, and fever/chills ... Measure external catheter on PICC to ensure line has no [sic] become dislodged and measure arm circumference. Notify MD for any concerns for dislodgement of catheter." A review of skilled nursing visits showed the RN did not measure patient's PICC line's external catheter or patient's arm circumference to assess for signs and symptoms of complications during skilled nurse visits on 8/4, 8/6, and no circumference only on 8/11/2025.
A review of the above records and interview with EMP1 (administrator) on August 13, 2025, at 10 a.m. confirmed above findings.
Plan of Correction:The Clinical Manager will educate 100% of the nursing at an in-service to be held by September 15, 2025, to follow best practice for PICC line care and to follow Nursing Policy # N-9.14 Peripherally Inserted Central Catheter (PICC) Maintenance and Management of Potential Complications which has been updated to match the evidence-based practice standards outlined at https://www.ncbi.nlm.nih.gov/books/NBK594495/ . This includes that the nurse must measure the patient's PICC line's external catheter or patient's arm circumference to assess for signs and symptoms of complications at every visit.
The minutes, supporting documents and completed staff sign-in sheets are available for review on site.
100% of current patient charts with PICC lines shall be audited weekly for 4 weeks to ensure there is documentation in the patient record that the PICC line's external catheter or the patient's arm circumference was measured and assessed for signs and symptoms of complications every visit.
Target Threshold = 95%--100%. If consistently met after 4 weeks of audits, will reduce audits to complete as part of clinical record review with 20% or minimum of 10 chart reviews per quarter.
The Clinical Manager is Responsible
Date of Completion 09/17/2025
Initial Comments:
Based on the findings of an onsite unannounced state license survey completed August 18, 2025, Helping Hands Health Network was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
51.3 (f) LICENSURE
NOTIFICATION
Name - Component - 00
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.
Observations:
Based on review of a incident reports, the Department's event reporting system (ERS) and its manual, and staff (EMP) interview, the agency failed to report one (1) of four (4) instances of abuse (CR11).
Findings included:
Per the Department's ERS Manual, "PA Department of Health (PA-DOH) Event Notification Internet Site Overview - Facilities ... Purpose: To provide a system to enter events per 28 PA Code - 51.3 that is readily available to all appropriate PA-DOH facilities, a simple process to insure consistent data entry and submission, and a source for quick and meaningful feedback on event notification submissions. All facilities are required to submit notification of events as defined in 28 Pa Code Chapter 51 to the Department of Health within 24 hours of occurrence or discovery. The Electronic Event Reporting System is the mechanism the Department will use to meet this regulatory requirement. ... The following is a list of all Categories that should be submitted: ... Health Department Reportable Diseases."
A review of agency's "Home Health Incident Reports" binder on August 12, 2025, at 10 a.m. showed, "Mandatory Abuse Report" dated 7/1/2025 for self-neglect. Per the report, "[CR11]'s home is in deplorable conditions with clutter, filth an expired food throughout. ... The condition of [his/her] home poses great infection and falls risks."
A review of the Department's ERS website with EMP1 on August 12, 2025, 9:30 a.m., did not show the above incident had been submitted.
Interview with EMP1 on August 12, 2025, at 10 a.m. confirmed he/she did not submit the above incident to ERS.
Plan of Correction:All agency Management Staff will be in-serviced by September 15, 2025, on the list of incidents that are required to be reported to the Department of Health through the ERS system.
The minutes, supporting documents and completed staff sign-in sheets are available for review on site.
100% of the agency incident reports will be audited for the next quarter to verify that any incident that requires reporting through the ERS system is reported to the Department of Health.
Target Threshold = 100%.
If consistently met after 3 months of audits, will add this as part of the agency Quality Management Plan for quarterly review and reporting to the Professional Advisory Committee and Governing Body annually as part of the agency's QAPI Annual Report.
The Administrator is Responsible
Date of Completion 09/17/2025
51.13 (b) LICENSURE
CIVIL RIGHTS COMPLIANCE RECORDS
Name - Component - 00
51.13. Civil rights compliance records
(b) Copies of the health care
facility's nondiscriminatory policy
shall be posted in locations
accessible to the facility's staff and
the general public.
Observations:
Based on observation, and staff (EMP) interview, the agency failed to post its nondiscriminatory policy in an area accessible to staff and the general public.
Findings included:
Observation of agency office space on August 12, 2025, at 9 a.m. did not show that agency's nondiscriminatory policy was posted.
A tour of the agency's office space and interview with EMP1 on August 13, 2025, at 11:15 a.m. confirmed above findings-- nondiscriminatory policy not posted.
Plan of Correction:The agency Non-Discrimination Policy was posted on the agency bulletin board while the surveyor was still present in the office.
All management staff will be in-serviced by September 15, 2025, on the need for this to be hanging in the office, so that it is available to the staff and public at all times.
The minutes, supporting documents and completed staff sign-in sheets are available for review on site.
The need to verify that this is present in the office on the bulletin board will be added to the agency Quality Management Plan for review and reporting to the Professional Advisory Committee and Governing Body annually as part of the agency's QAPI Annual Report.
The Administrator is Responsible
Date of Completion 09/17/2025
Initial Comments:
Based on the findings of an onsite unannounced state license survey completed August 18, 2025, Helping Hands Health Network was found not to be in compliance with the requirement of 35 P.S. 448.809 (b).
Plan of Correction:
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