Initial Comments:
Based on the findings of an onsite unannounced state licensure complaint survey conducted on April 20, 2026, Savvy Home Care, Llc was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
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 a review of Pennsylvania Department of Health (DOH) Event Reporting System (ERS), agency ' s client record (CR), Personnel Files (PF), policies and interviews with agency ' s office administrator, business partner (BP) #1 and #2, the agency failed to notify Department of Health for following event: situation or the occurrence of an event at the facility which could seriously compromise quality assurance or patient safety for one (1) of one (1) incident (incident #1).
Findings include:
Interview with BP#2 on 4/20/2026 at 11:20 am revealed the following: one of agency's clients previously forced a DCW (direct care worker) to drive against agency ' s policy which ended in a car accident (incident #1).
An email from agency on 4/23/2026 at 1:27 pm found that the accident happened in late February or early March of 2026.
Pennsylvania Department of Health (DOH) Event Reporting System (ERS) was reviewed on 4/20/2026 at 3 pm. Review range was set from 10/1/2025 to 4/20/2026. There was no ERS report regarding CR#2 and agency ' s DCW car accident.
An email from agency on 4/24/2026 at 11:12 am confirmed that above findings.
Plan of Correction:Savvy Home Care Plan of Correction
Exit Date: 04/20/2026 (Prefix Tag H 0008)
Regulation 51.3(f) – Notification of Reportable Events
I. Corrective Action for Individuals/Practices Identified
Client Record #2 (CR#2) Correction: The Office Manager reviewed the specific incident (Incident #1) involving CR#2 and the Direct Care Worker (DCW) motor vehicle accident. A retrospective written report detailing the late February/early March 2026 accident, including root causes and immediate safety measures implemented, was submitted retroactively to the Pennsylvania Department of Health (DOH) Event Reporting System (ERS).
Staff Action: The DCW involved was retrained on the agency's strict policy prohibiting clients from operating or directing agency-reimbursed transport outside of authorized care plan bounds.
II. Identification of Others with Potential to Be Affected
Audit of Past Events: The Office Manager conducted a 100% audit of all internal incident reports, communication logs, and client complaints dating back to October 1, 2025.
Verification: The audit compared internal logs against the DOH ERS portal to ensure no other reportable quality assurance or patient safety events were missed. No other unreported incidents were found.
III. Measures to Ensure Deficient Practice Does Not Recur
Systemic Alterations: The agency will update its Incident Management Policy to explicitly list motor vehicle accidents involving staff and clients as mandatory reportable events under § 51.3(f).
Mandatory Staff Training: All administrative staff, including Business Partner #1 and Business Partner #2, will complete mandatory training on the DOH ERS portal guidelines, emphasizing the "immediate notification" standard (within 24 hours of agency knowledge).
Onboarding Updates: The ERS reporting protocol will be integrated into the standard orientation packet for all new administrative hires.
IV. Monitoring Practices
Quality Assurance (QA): The Office Manager will conduct a monthly audit of all internal incident logs, client files, and employee accident reports.
Oversight Log: The Office Manager will cross-reference these internal files with the DOH ERS submission receipts to guarantee compliance.
Reporting: Audit findings will be documented and reviewed quarterly for continuous quality improvement.
V. Date of Completion
June 15, 2026
Agency Responsible Person: Office Manager
Initial Comments:
Based on the findings of an onsite unannounced home care agency state licensure complaint survey conducted on April 20, 2026, Savvy Home Care, Llc 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:
611.57(a) LICENSURE
Consumer Rights
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(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 agency's client record (CR), Personnel Files (PF), policies and interviews with agency's office administrator, business partner #1 and #2, the agency failed to ensure following consumer 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 for one (1) of three (3) CRs reviewed (CR#2).
Findings include:
A review of Client Records (CR) was conducted on 4/20/2026 from 11 am.
CR#2, SOC: 10/14/2025, file contains, " Authorized Caregiver Services What tasks might a Caregiver perform? " which reads, " The following tasks are authorized for Self-Direct Personal Assistance Services program ... medical escort - ... where a caregiver can be reimbursed for proving hands-on personal care of mobility, transfer, dressing, undressing, or toileting en-route to, or while at, medical appointments ... Medical escort is only authorized when a family member or live-in caregiver is not available to assist..." this was signed by CR#2 on 8/14/2025.
An interview with BP#2 and office administrator on 2/20/2026 at approximately 11 am confirmed that CR#2 has dementia and blindness.
An email sent on 4/8/2026 2:22 pm by agency revealed that a direct care worker staff who provided service for CR#2 left a medical facility without CR#2 while CR#2 was attending a medical appointment on 4/8/2026.
An email from agency's administrative staff on 4/23/2026 at 1:27 pm confirmed above findings.
Plan of Correction:Exit Date: 04/20/2026 (Prefix Tag H 0008)
Regulation 611.57(a) – Consumer Rights (Involvement in Care & Accommodations)
I. Corrective Action for Individuals/Practices Identified
Client Record #2 (CR#2) Correction: The Office Manager and administrative staff contacted CR#2 and their designated legal representative to review and update the service planning process.
Accommodation Plan: The agency established a verified, safe medical escort protocol tailored to the client's dementia and blindness. This ensures clear hand-off procedures at medical facilities, so the client is never left unattended.
Disciplinary/Corrective Action: The DCW who abandoned CR#2 at the medical facility on April 8, 2026, was disciplined according to agency policy and has been terminated.
II. Identification of Others with Potential to Be Affected
Care Plan Audit: The Office Manager conducted a full audit of all active client records utilizing "Medical Escort" or "Self-Directed Personal Assistance Services" to ensure clear, task sheets are present.
Risk Screening: All clients with cognitive impairments (e.g., dementia) or sensory impairments (e.g., blindness) were flagged to ensure their specific accommodation plans and emergency contact protocols are actively detailed in their care plans.
III. Measures to Ensure Deficient Practice Does Not Recur
Systemic Policy Implementation: The agency will implement a "Medical Escort and Hand-Off Protocol." DCWs will be strictly prohibited from leaving a medical appointment site until the client is safely handed over to facility staff or the appointment is concluded and return transport is initiated.
Field Training: All current active DCWs will be issued a competency training module on Consumer Rights (§ 611.57), focusing on reasonable accommodation and the prevention of client abandonment.
IV. Monitoring Practices
Compliance Audits: The Office Manager will randomly audit 10% of active client records monthly to ensure service plans accurately reflect individual needs and preferences.
Supervisory Phone Calls: The Office Manager will conduct monthly random check-in phone calls to 5 active clients utilizing escort services to verify that DCWs remain present and accommodate individual preferences.
Documentation: All audit logs and phone logs will be maintained by the Office Manager.
V. Date of Completion
June 15, 2026
Agency Responsible Person: Office Manager
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