Initial Comments:
Based on the findings of an unannounced onsite complaint investigation conducted on March 27, 2025, no response at agency. Offsite investigation conducted on April 2, 2025, April 9, 2025, and April 10, 2025. Wellness Homecare Company, 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 (g)(1-14) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification
(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.
Observations:
Based on a review of the Pennsylvania (PA) Department of Health Event Reporting System, and an interview with the administrator, the home care agency failed to document reportable events as per the Pennsylvania (PA) Department of Health's (DOH) Event Reporting System (ERS) for one (1) of three (3) CR's, (CR #1).
Findings include:
Per the Pennsylvania Department of Health Event Reporting System Manual, "...Purpose: To provide a system to enter events per 28 PA Code 51.3 that is readily available to all appropriate PA-DOH [Pennsylvania Department of Health] facilities, a simple process to insure consistent data entry and submission, and a source for quick and meaningful feedback on event notification submissions...All facilities are required to submit notification of events as defined in 28 Pa Code Chapter 51 to the Department of Health within 24 hours of occurrence or discovery. The Electronic Event Reporting System [ERS] is the mechanism the Department will use to meet this regulatory requirement..."
A review into Event Report System was conducted on March 26, 2025, at approximately 3:14 p.m. from time frame of 3/20/2025 to 3/26/2025 found that the HCA had not reported any incidents to the DOH as defined in 28 Pa Code Chapter 51. Alleged perpetrator did not show up for assignment on 3/23/25 and 3/24/25. Consumer was crying for water, unable to move/walk uses a wheelchair. Colostomy bag full, sitting in feces and urine. Consumer asked reporter to contact 911.
An phone interview with the Administrator was conducted on April 9, 2025 at approximately 11:38 a.m., Administrator stated "okay".
An interview with the Administrator was conducted on April 9, 2025, at approximately 11:38 a.m, confirmed the above findings.
Plan of Correction:This plan of correction constitutes a written allegation of substantial compliance with Federal and State requirements. Preparation and/or execution of this correction do not constitute admission or agreement by the provider of the truth of items alleged or conclusions set forth for the alleged deficiencies. The plan of correction demonstrates our good faith and desire to continue to improve the quality of care and services to our consumers.
CHAPTER 28 Pa Code 51.3(g)(1-14) LICENSURE NOTIFICATION:
SYSTEMIC CHANGES TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR
All consumers at Wellness will continue to receive adequate care services ensuring their rights as consumers.
The administrator was retrained on Pa Code 51.3(g) reporting requirements.
The administrator completed Event Reporting Systems (ERS) testing on April 17, 2025.
The administrator will also notify and provide the Support Coordinator, APS, and Surveyor of all ERS event by email within 48 hours.
Appropriate safety measures are now implemented for consumers receiving service care from family/friends.
The administrator will monitor all Family/Friend Caregivers for schedule and care service compliances by conducting unannounced monthly monitoring to ensure start/leave times are accurate.
Monitoring results will be held in consumer records.
All Caregivers will be retrained on consumer rights, health and safety within 30 days.
Acknowledgement of training will be held in employee's records.
Initial Comments:
Based on the findings of an unannounced onsite complaint investigation conducted on March 27, 2025, no response at agency. Offsite investigation conducted on April 2, 2025, April 9, 2025, and April 10, 2025, Wellness HomeCare Company, 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
Name - Component - 00
(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 a review of consumer records (CR), visit calendar, Manual Visit Verification form, and an interview with the Administrator the agency did not provide service 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. (CR # 1).
was conducted.
Findings include:
A review of clinical records (CR) was conducted on 4/2/2025 at approximately 3:34 p.m., and April 10, 2025, at approximatley 8:08 a.m. A total of three (3) CR's were reviewed.
CR # 1 SOC: 4/10/2024 receives services via waiver Keystone First CHC. Unable to verify hours authorized from 3/1/2025 to 3/31/2025. Visit calendar shows two (2) shifts up to 24 hours a day, 7 days a week.
A review of visit calendar for the week of March 17, 2025, through March 23, 2025, missed visit on 3/23/2025 from 07:00-19:00 no manual visit verification provided.
An interview with the Administrator was conducted on April 9, 2025 at approximately 11:25 a.m. confirmed the above findings.
Plan of Correction:CHAPTER 28 Pa Code 611.57(a) LICENSURE CONSUMER RIGHTS:
CONSUMER-1 care was provided by Friend/family member Caregiver. Prior to the incident, the consumer had been satisfied with Friend/family member Caregiver services.
CONSUMER-1 did not notify agency of Caregiver Non-reported March 23, 2025.
CONSUMER-1's Friend/family member Caregiver is no longer employed through agency. Agency cannot terminate the Friend/family member.
SYSTEMIC CHANGES TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR
All Friend/family Caregivers will be required to retake the consumer rights training again within 30 days.
All Friend/family Caregiver will be required to take the consumer reporting incident training within 30 days.
All Friend/family Caregivers will be reeducated on providing care to Friend/family and reporting requirements.
CONSUMERS will be provided with copy of consumer rights and Admin contact for missed services.
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