QA Investigation Results

Pennsylvania Department of Health
ANGEL HEARTS HOME CARE
Health Inspection Results
ANGEL HEARTS HOME CARE
Health Inspection Results For:


There are  3 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 onsite unannounced complaint investigation survey initiated on February 27, 2020, and completed on March 10, 2020, Angel Hearts Home Care 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 (a) LICENSURE
NOTIFICATION

Name - Component - 00
51.3 Notification

(a) A health care facility shall
notify the Department in writing at
least 60 days prior to the intended
commencement of a health care service
which has not been previously provided
at that facility.

Observations:

Per 35 P.S. 448.813, "Authorization.--For the purpose of determining the suitability of the applicants and of the premises or for determining the adequacy of the care and treatment provided or the continuing conformity of the licensees to this act and to applicable local, State and Federal regulations, any authorized agent of the department may enter, visit and inspect the building, grounds, equipment and supplies of any health care facility licensed or requiring a license under this act and shall have full and free access to the records of the facility and to the patients and employees therein and their records, and shall have full opportunity to interview, inspect, and examine such patients and employees."

Based on review of agency correspondence, observation, and staff (EMP) interview, the agency failed to maintain standards required by the Commonwealth. The agency failed to be subject to an unannounced inspection by authorized representatives of the Department.

Findings included:

On February 27, 2020, at 9:15 a.m., the agency was subject to the provisions of an onsite inspection (survey). Observations from 9:18 a.m. to 9:30 a.m. revealed no one present at agency office.

Phone interview with EMP1 (administrator) on February 27, 2020, at 9:30 a.m. confirmed he/she would not be available at agency office location until 4:30 p.m., and no other personnel were available for this purpose either. Surveyor unable to gain access to agency to conduct Department inspection.

Review of Department's file for this agency on February 27, 2020, at 1:38 p.m., showed correspondence sent to the Department from EMP1, "4/30/2018 ... To Whom it May Concern. I am writing to request a change in my agencies [sic] office hours during the week. Request for change to reflect the following: DAYS OF OFFICE HOURS: TUESDAY AND THURSDAY OFFICE HOURS: 9:30am to 1:30 pm." There was no notification from agency concerning its unavailability on 2/27/2020.







Plan of Correction:

As per the survey conducted on 03/10/2020, Angel Hearts Home Care, LLC will meet the requirement of provision 51.3(a) by having an office administrator present at the agency physical location during all office hours as listed to the PA Department of Health for all Tuesdays and Thursdays from 9:30 am-1:30 pm, without exception. The management team (President/Director of Human Resources) of the agency will notify the PA Department of Health in writing via email to Acting Director and last known surveyor, via email and to the department fax number (717-772-0232) of any dates that the office will be closed sixty (60) days in advance. Agency management will also request that written notification be sent via email that the notice has been received as a final measure to ensure compliance with the provision.


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 Pennsylvania's (PA) event reporting system (ERS), agency documentation, and staff (EMP) interview, the agency failed to resubmit rejected reports in a timely manner for two (2) of two (2) reports reviewed (Event No. 614676. & Event No. 614972).

Findings included:

Review or PA's ERS during pre-survey preparation on February 26, 2020, at 2 p.m. showed agency had two submissions in rejected status from 1/28/2020 (614676), and 1/29/2020 (614972). Both aforementioned reports were reviewed and rejected by the Department on 2/18/2020.

According to PA's ERS, agencies have to resubmit rejected reports in a timely manner, "Event Reporting System - Facility Login 28 PA Code - 51.3 Notification Confidential Information Welcome to the Department of Health, Division of Home Health site for electronic submission of the Event Reporting Form. The information submitted by your facility, following acceptance by Division of Home Health professional staff, will be used to investigate facility events and become part of an electronic repository of event information. This repository will provide easier access to event information as well as the capability to evaluate event trends by regions, facilities, event categories, date ranges, and other criteria. All information is considered confidential and shall not be released without consent of the facility or by a Court Order as outlined in 28 PA Code ... After facility submission of an event, Department of Health professional staff will review each submitted event and either accept or reject the submission. When a submitted event is rejected, the facilities have three (3) calendar days to either correct and resubmit the event information or to withdraw the original submission. It is expected that only a small number of events will have to be withdrawn. An example of when a facility would withdraw an event would be if they made a duplicate submission of the same event in error." Retrieved from https://sais.health.pa.gov/Incidents/FacilityLogin.asp

Review of agency's incident reports on March 10, 2020, with EMP1 during an onsite complaint investigation, showed agency had submitted the above reports on 1/28/2020, and 1/292020. However, the reports were not resubmitted within 3 days after they were rejected on 2/18/2020. Interview with EMP1 on March 10, 2020, at 10:30 a.m. confirmed he/she did not resubmit the above rejected reports, "I didn't know they were rejected."










Plan of Correction:

As per the survey conducted on 03/10/2020, Angel Hearts Home Care, LLC will meet the requirement of provision of 51.3 by alerting the PA Department of Health in writing any time a situation or an occurrence of any event which would seriously compromise quality assurance or participant safety via the ERS system, which includes full and 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. After the ERS reports have been submitted, agency management of either the President or the Director of Human Resources will then log in daily to check the status of any outstanding ERS reports until they have either been marked as accepted or rejected by the PA Department of Health. In the event of a rejected report, agency management will make the necessary changes within three (3) business days to ensure that the initial report made via the ERS system is therefore accepted by the PA Department of Health and thusly that the agency has met their obligation under the requirement. In summation, any time an ERS report needs entered in, the Director of Human Resources will notify the President via email in order for the President to submit the necessary information via the ERS site. After completion, the Director of Human Resources will check daily until the report is either accepted or rejected and send an email to the President stating the current status. After acceptance (including the necessary corrections to be made to get to accepted status), the need to check daily and send follow up emails will no longer apply.


Initial Comments:

Based on the findings of an onsite unannounced complaint investigation survey initiated on February 27, 2020, and completed on March 10, 2020, Angel Hearts Home Care was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.




Plan of Correction:




611.4(c) LICENSURE
Requirements for HCA and HCR

Name - Component - 00
Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.

Observations:


Per 35 P.S. 448.813, "Authorization.--For the purpose of determining the suitability of the applicants and of the premises or for determining the adequacy of the care and treatment provided or the continuing conformity of the licensees to this act and to applicable local, State and Federal regulations, any authorized agent of the department may enter, visit and inspect the building, grounds, equipment and supplies of any health care facility licensed or requiring a license under this act and shall have full and free access to the records of the facility and to the patients and employees therein and their records, and shall have full opportunity to interview, inspect, and examine such patients and employees."

Based on review of agency correspondence, observation, and staff (EMP) interview, the agency failed to maintain standards required by the Commonwealth. The agency failed to be subject to an unannounced inspection by authorized representatives of the Department.

Findings included:

On February 27, 2020, at 9:15 a.m., the agency was subject to the provisions of an onsite inspection (survey). Observations from 9:18 a.m. to 9:30 a.m. revealed no one present at agency office.

Phone interview with EMP1 (administrator) on February 27, 2020, at 9:30 a.m. confirmed he/she would not be available at agency office location until 4:30 p.m., and no other personnel were available for this purpose either. Surveyor unable to gain access to agency to conduct Department inspection.

Review of Department's file for this agency on February 27, 2020, at 1:38 p.m., showed correspondence sent to the Department from EMP1, "4/30/2018 ... To Whom it May Concern. I am writing to request a change in my agencies [sic] office hours during the week. Request for change to reflect the following: DAYS OF OFFICE HOURS: TUESDAY AND THURSDAY OFFICE HOURS: 9:30am to 1:30 pm." There was no notification from agency concerning its unavailability on 2/27/2020.







Plan of Correction:

As per the survey conducted on 03/10/2020, Angel Hearts Home Care, LLC will meet the requirement of provision 611.4(c) by having an office administrator present at the agency physical location during all office hours as listed to the PA Department of Health for all Tuesdays and Thursdays from 9:30 am-1:30 pm, without exception. The management team of the agency will notify the PA Department of Health in writing via email to Acting Director and previous surveyor by email and to the department fax number (717-772-0232) of any dates that the office will be closed sixty (60) days in advance. Agency management will also request that written notification be sent via email that the notice has been received as a final measure to ensure compliance with the provision.