QA Investigation Results

Pennsylvania Department of Health
Health Inspection Results
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Initial Comments:

Based on the findings of an offsite incident investigation completed on May 3, 2022, 5 Caring Hearts, Llc was found not to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51

Plan of Correction:

51.3 (f) LICENSURE

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.


Based on review of an older adult protective services report of need (RON) from Beaver County Area Agency on Aging (AAA), email from agency, the Department's event reporting system (ERS), and staff (EMP) interviews, the agency failed to report and incident that could seriously compromise quality assurance or patient safety. More specifically, the agency failed to submit one (1) of one (1) instance of bed begs-- a Health Department reportable disease, and one (1) of one (1) fall with resultant hospital transfer while agency staff were on duty with a consumer (CR1).

Findings included:

Per the Department's ERS Manual, "PA Department of Health (PA-DOH) Event Notification Internet Site Overview - Facilities ... Purpose: To provide a system to enter events per 28 PA Code - 51.3 that is readily available to all appropriate PA-DOH 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 is the mechanism the Department will use to meet this regulatory requirement. ... The following is a list of all Categories that should be submitted: ... Health Department Reportable Diseases. ... Transfer/admission to Hospital Because of Injury/Accident."

Review of RON from AAA for CR1 showed, "Factual Description: The [older adult (OA)] suffered a fall when AP [alleged perpetrator / agency staff] did not assist [OA] with using the restroom, which resulted in a lip laceration and a broken tooth. [OA] was sent to the hospital. [OA] stated that AP often leaves [OA] residence when AP is on a shift. Allegations correlate with agency or agency staff."

A phone interview with EMP1 and EMP2 on May 3, 2022, at 11:50 a.m. confirmed above findings. EMP1 also confirmed a bed bug incident with CR1.

Review of email sent from EMP1 on May 3, 2022, at 1:30 p.m. showed, "5 Caring Hearts, LLC Incident Report Form Date of Incident 4-20-22 ... Time of Incident ... 9:35 a.m. ... During Shift ... Injuries ... Busted lip ... If Hospitalized ... ER/Outpatient ... She fell when trying to use the toilet."

"5 Caring Hearts, LLC Incident Report Form Date of Incident 2/2/2022 ... Nature of incident ... Bed Bugs ... Caregiver think [sic] she has bed bugs ... Calling service coordinator."

"5 Caring Hearts, LLC Incident Report Form Date of Incident 3/28/22 ... Nature of incident ... Bed Bugs ... Called me and said she [CR1] has bed bugs they are eating my [expletive] up. She also stated she called her service coordinator and her service coordinator said she will send someone out to inspect."

Review of ERS on May 3, 2022, at 1:30 p.m. did not show the above events were reported. The review period was from 4/1/2022 to 5/2/2022.

Phone interview with EMP3 on May 3, 2022, at 2 p.m. confirmed findings, "I did not know we needed to report. What Department do we report to?"

Plan of Correction:

Agency will be in compliance with 28 PA Code 51.3 ERS system reporting for all patients safety within 24 hours of occurrence or discovery. Agency will also continue to have a incident report in the client files and also will implement a copy of the submission to ERS to ensure that this does not recur.

Agency will document audits with a spreadsheet for Department reviews. Spreadsheet will be created with any clients that have incidents with date/time/place and what type of incident occurred

Designated Business Manager and CEO's will Monitor this change. Agency will updated our Policy and procedures to reflect this change Effective 5/9/2022. EVV system will also document any changes to each client's safety