QA Investigation Results

Pennsylvania Department of Health
EFFRAIM HOME CARE AGENCY, LLC
Health Inspection Results
EFFRAIM HOME CARE AGENCY, LLC
Health Inspection Results For:


There are  2 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 findings of an unannounced onsite state re-licensure survey conducted February 21, 2020, Effraim Home Care Agency, LLC., was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health facilities, Subpart G. Chapter 601.



Plan of Correction:




601.21(c) REQUIREMENT
GOVERNING BODY

Name - Component - 00
601.21(c) Governing Body. A governing
body (or designated persons so
functioning) assumes full legal
authority and responsibility for the
operation of the agency. The
governing body appoints: (i) a
qualified administrator, (ii) arranges
for professional service, (iii) adopts
and periodically reviews written
bylaws or an acceptable equivalent,
and (iv) oversees the management and
fiscal affairs of the agency. The
name and address of each officer,
director, and owner are disclosed to
the State agency with changes reported
promptly.



Observations:



Based on a review of agency documentation, policy and procedure and interview with the administrator, it was revealed the agency lacked documentation in their meeting minutes for the fiscal affairs of the agency in regard to approving an annual operating budget and reviewing the annual program evaluation.

Findings include:

Review of policy titled, "Policy #A-3.0 Managing Member, Administration, Supervision, Management, and Oversight." was completed on February 21, 2020 at approximately 10:00 AM. The policy states " The Managing Member assumes full legal authority and responsibility for the management of the agency's overall management and operation, the provision of all home health services, its fiscal operations, review of the agency's budget and its operational plans and its quality assessment and performance improvement program....Activities of the Managing Member include, but are not limited to...D. Reviewing the annual program evaluation."

1. Review of agency documentation on February 21, 2020 at approximately 10:15 AM revealed there was documentation to show the Governing Body had meeting minutes but the last mention of a budget approval was dated 12/30/2018 for 2019. There was no documentation of a budget approval for 2020.

2. Review of agency documentation on Febraury 21, 2020 at approximateley 10:15 AM revealed there was documentation to show the Governing Body had meeting minutes but no documentation of annual program evaluation for 2018, 2019, or 2020.

Interview with the administrator on February 21, 2020 at approximately 1:00 PM confirmed the above findings.

























Plan of Correction:

The administrator will ensure that annual meeting minutes for the full year document reviewing and approving the annual budget and program evaluation.
Administrator Oluwaseyi Adeoye reviewed and documented annual budget and annual program evaluation on 2/24/2020.



Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted on February 21, 2020, Effraim Home Care Agency, LLC., was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.




Plan of Correction:




Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted on February 21, 2020, Effraim Home Care Agency, LLC., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: