There are  11 surveys for this facility. Please select a date to view the survey results.

1.)The agency has corrected their practices and is following the state guidelines under 51.3 (g)(1-14) LICENSURE NOTIFICATION which is outlined in the agency Policy # QM 3.0 Incident Reporting which specifies that the agency management staff will submit notification of events in the Electronic Event Reporting System [ERS] as defined in 28 Pa Code Chapter 51 to the Department of Health within 24 hours of occurrence or discovery any of the following events: (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. Furthermore, it is understood, that the purpose of this per the Pennsylvania Department of Health Event Reporting System Manual, is "...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...and the Electronic Event Reporting System [ERS] is the mechanism the Department will use to meet this regulatory requirement..."

2.) An inservice education will be held by 07/15/2024 with all management staff who need to be aware of the incident reporting process and what must be reported in the ERS system to the Pennsylvania Department of Health per state regulation 51.3 (g)(1-14) LICENSURE NOTIFICATION and agency Policy # QM 3.0 Incident Reporting. Documentation of the inservice including: minutes, attendance and handouts will be maintained onsite and available for review. The Executive Director is responsible.

3.) Incident Reporting will be added to the agency orientation checklist so that it is reviewed with all new employees upon orientation.

The Executive Director is responsible.
Completion date for all elements by 08/01/2024.
The Executive Director is responsible.

1. The agency shall follow the state guidelines to provide the consumer of home care services with 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. This is outlined in the agency Policy # S-5.0 Consumer Rights and Responsibilities.
2.A mandatory inservice for all administrative and management staff is to be held by 07/15/2024 to educate them to the need to follow the state requirement and agency's policies regarding:
a.) All direct care workers and supervisors who coordinate care must complete documentation in the agency computer system—HHAeXchange, that reflects services provided were per the plan of care (hours and days) and service authorization from the MCO including all tasks outlined per the Care Plan.
b.) If the staff member is unable to complete their documentation in the agency computer system—HHAeXchange, a paper-based home visit form is utilized which is signed by the direct care worker and consumer. Lines are available on these forms to add such special tasks as "repositioning" on the forms, prior to their use. The supervisor will verify that these forms have all tasks outlined on the care plan noted on the forms prior to their use by any Direct Care Worker prior to their use if they are using them in lieu of logging tasks outlined in the HHAeXchange EVV system in order to match the plan of care.
Staff attendance sheets, agenda and training documentation will be available on site.
The Executive Director will oversee that 100% of current consumer records will be audited weekly to ensure that the direct care workers assigned in the HHAeXchange computer system are:
a.) Following the plan of care and the MCO service authorizations for each consumer, based on hours and days and services to be provided.
b.) If a direct care worker has missed visit the EVV documentation in HHAeXchange, the paper-based documentation being used, matches services provided per the plan of care for scope (type) and frequency of services and visits provided to the consumer.
This audit will be accomplished by 08/01/2024. Target threshold = 95%.
Ongoing: The Executive Director will oversee that as part of the agency's quality management plan, quarterly record review will include auditing 10% or up to 25 records per quarter to verify that the direct care workers follow the assigned plan of care/MCO service authorizations for each consumer (based on hours, days and services to be provided) and that all missed documentation on paper matches the care plan that has been outlined by the MCO.
The Executive Director is responsible.
Completion Date = 08/01/2024