Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on May 22, 2025, Daffodil Home Care, 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 state re-licensure survey conducted on May 22, 2025, Daffodil 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(c) LICENSURE
Information to be Provided
Name - Component - 00
(c) Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.
Observations:
Based on review of consumer records (CR) and an interview with the administrator, the agency failed to provide the following information to the consumer, the consumer's legal representative, or a responsible family member prior to the start of services: the hours when those services will be provided for eight (8) of nine (9) CR's reviewed: CR# 1, 2, 3, 4, 5, 7, 8 & 9.
Findings include:
A review of CR's was conducted on 5/22/25 starting at 11:00 AM and revealed the following:
CR#1 Start of Care: 3/27/25. File did not have documentation of the consumer's hours when services were to be provided.
CR#2 Start of Care: 9/9/24. File did not have documentation of the consumer's hours when services were to be provided.
CR#3 Start of Care: 2/14/25. File did not have documentation of the consumer's hours when services were to be provided.
CR#4 Start of Care: 6/16/25. File did not have documentation of the consumer's hours when services were to be provided.
CR#5 Start of Care: 8/22/24. File did not have documentation of the consumer's hours when services were to be provided.
CR#7 Start of Care: 11/22/24. File did not have documentation of the consumer's hours when services were to be provided.
CR#8 Start of Care: 1/3/23. File did not have documentation of the consumer's hours when services were to be provided.
CR#9 Start of Care: 6/27/24. File did not have documentation of the consumer's hours when services were to be provided.
An interview conducted with the administrator on 5/22/25 starting at 1:00 PM confirmed the above findings.
Plan of Correction:Daffodil Home Care LLC
Plan of Correction
Deficiency: Failure to Provide Service Hours to Consumer or Representative Prior to Start of Care
Audit Date: May 22, 2025
Citation: Consumer Records CR#1–5, 7–9 Missing Documentation of Scheduled Service Hours
Effective Date of Full Implementation: June 15, 2025
Corrective Action Plan:
1. Immediate Corrective Measures (To Be Completed by June 14, 2025):
a. Record Audit and Remediation:
By June 5, 2025, all existing consumer records (including CR#1–5, 7–9) will be reviewed and updated to include written documentation of scheduled service hours. This documentation will be clearly indicated on the Consumer Service Agreement and/or the Acknowledgment of Care Plan, and signed by the consumer or legal representative prior to the next scheduled service.
b. Form Revision:
A revised Service Initiation and Schedule Agreement Form will be finalized and approved by May 31, 2025. This form will explicitly include:
Specific days of the week services will be provided
Start and end times for each scheduled service
A section for both the caregiver and consumer (or legal representative) signatures
c. Staff Training:
All office staff, including intake coordinators and care managers, will be trained on the new documentation protocol by June 7, 2025. A mandatory in-service session will be held, and staff will be required to sign a training acknowledgment form confirming understanding of the new requirements.
d. Policy Update:
Agency intake and care plan documentation policies and procedures will be revised to reflect the requirement of documented service hours prior to initiation of services. The updated policy will be distributed to all staff by June 10, 2025.
2. Ongoing and Preventative Measures (Effective June 15, 2025):
a. Standard Intake Protocol Implementation:
Beginning June 15, 2025, no services will commence without a completed and signed Service Initiation and Schedule Agreement Form. Intake staff will be held accountable for compliance via routine file audits.
b. Quarterly Compliance Audits:
Starting June 30, 2025, the Administrator will conduct quarterly audits of a random sample of consumer records (minimum of 10%) to ensure service hours are properly documented and acknowledged. Non-compliance will be addressed with immediate retraining and corrective action.
c. Ongoing Staff Refresher Training:
Bi-annual refresher training sessions will be held to reinforce documentation protocols and any updates to Department of Health regulations.
Responsible Party:
The President will be responsible for overseeing implementation, staff compliance, and ongoing quality assurance regarding documentation of service hours.
If any additional information or documentation is required to support this Plan of Correction, please contact our office directly.
Sincerely,
President
Daffodil Home Care LLC
Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on May 22, 2025, Daffodil Home Care, LLC., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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