The Pennsylvania Department of Health conducts inspections of home care agencies (HCA)/home care registries (HCR) every 12 months based on state regulations. Inspections may be on or off site. If an agency has a history of serious problems, or if complaints are received, they may be inspected more frequently. All home care agencies/home care registries must have a license to operate in Pennsylvania. Inspections of home care agencies/home care registries are called surveys. The Department of Health surveys home care agencies/home care registries to ensure that they are following state licensure regulations.
The Department of Health surveyors review all of the available information about a home care agency/home care registry prior to conducting the survey.
Surveys may cover a period of days. Surveys may or may not be announced in advance.
During the survey, areas of non-compliance with the regulations maybe identified. If identified, the surveyors will write an official report of their observations and record them on a form called the Statement of Deficiencies and Plan of Correction. For every problem that is identified, the surveyor must decide how serious the problem is. The surveyor will write a description of the problems, which is then called a "Statement of Deficiencies". A copy of this report is sent to the home care agency/home care registry, and requires that a plan to fix the problems be submitted. The HCA/HCR must then submit in writing their proposed solutions to the identified problems.This is called a "Plan of Correction". You can ask to see a copy of this report from the HCA/HCR, or you can view this report on the Department of Health web site at www.health.state.pa.us; go to Provider Information, Community Programs Licensure and Certification.
When you select a survey to review you will notice several things. This is a slightly modified version of the Statement of Deficiencies and Plan of Correction form version that identifies sections noting the regulation, observation and findings. The surveyor writes these sections, and each contain information for the agency and the public to understand how their conclusions were reached.
The heading regulation identifies the specific rule from the state regulations with which the agency was not complying.It may also include reference to other regulations that could be used in citing the particular area of non-compliance.
The section observation and findings describe the process by which a surveyor gathers information. Detailed documentation of observations of deficient practice assists the provider in identifying when and where the deficient practice was observed and, as appropriate, the duration of each observation.Essentially, the statement of findings describes the specific results and consequences of the home care agency's/home care registry's deficient practice for the individual cases reported in the findings.
Immediately following the section written by the surveyors, you will find a section entitled "Plan of Correction - To be completed: Date." This section is written by the home care agency/home care registry and tells you what steps they will take to correct the problems noted on the Statement of Deficiencies and Plan of Correction and the date they expect to have the problem corrected.
Depending on the seriousness of the deficiencies, different consequences may be given to the HCA/HCR.If the problems are very severe, the Department may revoke the HCA/HCR license to prevent them from providing care to consumers. The Department may issue what is called a “provisional license” to a HCA/HCR. This provisional license allows the HCA/HCR to continue to operate while the Department monitors areas in which improvements must be made to insure the health and safety of the consumers.
When you look at the Statement of Deficiencies and Plan of Correction, please keep in mind that the report only tells you what was observed on the dates of the survey. It is simply a "snapshot" of the care that is being provided by the agency during the survey time frame. Since that date, conditions at the agency may have changed.