Initial Comments:
Based on the findings of an unannounced, onsite complaint investigation survey conducted on May 12, 2025, Circle of Home Homecare 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 files (CFs) and interview with the agency owner (EMP# 1), it was determined that the agency failed ensure hours and services were provided as agreed upon for three (3) of three (3) CFs reviewed. (CF# 1, CF# 2 and CF# 3)
Findings include:
Review of consumer files (CF) was conducted on May 12, 2025, between approximately 10:00 a.m. and 2:00 p.m. revealed the following:
CF# 1, Start of Service (SOS), 11/18/2024. ' Agency Copy Agreement for Non Medical In Home Living Assistance ' was signed by the consumer on September 16, 2023. The section, ' Services to be performed by provider ' reads, " Bath, Showing, Dressing, Grooming, Feeding. " Hours listed are the following: Monday: 7 am- 3 pm; Tuesday 7 am- 3 pm, Wednesday 7 am- 3 pm; Thursday 7 am- 3 pm; Friday 7 am- 3 pm; Saturday 7 am- 3 pm and Sunday 7 am- 3 pm.
Review of calendar, schedule, and daily tasks was conducted for the date range of January 1, 2025, through March 31, 2025.
On 1/1/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. Also, no documentation provided to show the tasks completed during this shift.
On 1/2/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of a bath/shower and dressing tasks being completed.
On 1/3/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of a bath/shower, dressing and grooming tasks being completed.
On 1/4/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of a bath/shower, dressing and grooming tasks being completed.
On 1/5/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of a bath/shower, dressing and grooming tasks being completed.
On 1/6/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 1/7/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of dressing tasks being completed.
On 1/8/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed.
On 1/9/2025, no documentation provided of any tasks being completed.
On 1/10/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 1/11/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of a bath/shower, dressing and grooming tasks being completed.
On 1/12/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of a bath/shower, dressing and grooming tasks being completed.
On 1/13/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of a bath/shower, dressing and grooming tasks being completed.
On 1/14/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of grooming tasks being completed.
On 1/15/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 1/16/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of dressing tasks being completed.
On 1/17/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of a bath/shower, dressing and grooming tasks being completed.
On 1/18/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of a bath/shower, dressing and grooming tasks being completed.
On 1/19/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of a bath/shower, dressing and grooming tasks being completed.
On 1/20/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 1/21/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of a bath/shower, dressing and grooming tasks being completed.
On 1/22/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of grooming tasks being completed.
On 1/23/2025, shifts hours provided 7am to 3 pm and 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed for 7 am to 3 pm shift. No documentation provided of grooming tasks being completed for 11 pm to 7 am shift.
On 1/24/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 1/25/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of a bath/shower, dressing and grooming tasks being completed.
On 1/26/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of dressing tasks being completed.
On 1/27/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of dressing tasks being completed.
On 1/28/2025, shifts hours provided 7am to 3 pm and 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed during both shifts.
On 1/29/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of dressing tasks being completed.
On 1/30/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, dressing, grooming and feeding tasks being completed.
On 1/31/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of dressing tasks being completed.
On 2/1/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of dressing tasks being completed.
On 2/2/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of dressing tasks being completed.
On 2/3/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of dressing tasks being completed.
On 2/4/2025, shifts hours provided 7 am to 3 pm and 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed for 7 am to 3 pm shift. No documentation provided of bathing/showering, dressing and grooming tasks being completed for 11 pm to 7 am shift.
On 2/5/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of dressing tasks being completed.
On 2/6/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of grooming and dressing tasks being completed.
On 2/7/2025, shifts hours provided 7am to 3 pm and 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of dressing tasks being completed during both shifts.
On 2/8/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 2/9/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 2/10/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 2/11/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 2/10/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 2/11/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 2/12/2025, no documentation provided of any tasks being completed.
On 2/13/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 2/14/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 2/15/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 2/16/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 2/17/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 2/18/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 2/19/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 2/20/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 2/21/2025, no documentation of any service hours provided, and no documentation provided to explain why shifts were not completed.
On 2/22/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 2/23/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 2/24/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 2/25/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 2/26/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 2/27/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 2/28/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 3/1/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 3/2/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 3/3/2025, shifts hours provided 7 pm to 3 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 3/4/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 3/5/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 3/6/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering and dressing tasks being completed.
On 3/7/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 3/8/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 3/9/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 3/10/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 3/11/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering and dressing tasks being completed.
On 3/12/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering and grooming tasks being completed.
On 3/13/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 3/14/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 3/15/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 3/16/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 3/17/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 3/18/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 3/19/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 3/20/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 3/21/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 3/22/2025, no documentation of any service hours provided, and no documentation provided to explain why shifts were not completed.
On 3/23/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 3/24/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, feeding, grooming and dressing tasks being completed.
On 3/25/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, feeding, grooming and dressing tasks being completed.
On 3/26/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, feeding, grooming and dressing tasks being completed.
On 3/27/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, feeding, grooming and dressing tasks being completed.
On 3/28/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 3/29/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 3/30/2025, shifts hours provided 3 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering, grooming and dressing tasks being completed.
On 3/31/2025, shifts hours provided 11 pm to 7 am. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of bathing/showering tasks being completed.
CF# 2, SOS, 1/30/2025: ' Agency Copy Agreement for Non Medical In Home Living Assistance ' was signed by the consumer on January 31, 2025. The section, ' Services to be performed by provider ' reads, " Bath, Showing, Dressing, Grooming, Feeding. " Hours listed are the following: Monday: 7 am- 7 pm; Tuesday 7 am- 7 pm, Wednesday 7 am- 7 pm; Thursday 7 am- 7 pm; Friday 7 am- 7 pm; Saturday 7 am- 7 pm and Sunday 7 am- 7 pm.
Review of calendar, schedule, and daily tasks was conducted for the date range of February 1, 2025, through March 31, 2025.
On 2/1/2025, shifts hours provided 7 am to 12 pm. No documentation provided of an update or change of shift hours from the service agreement that was signed. No documentation provided of any tasks being completed.
On 2/2/2025, no documentation of any service hours provided, and no documentation provided to explain why shifts were not completed.
On 2/3/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/4/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/5/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/6/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/7/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/8/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/9/2025, No documentation provided of any tasks being completed during shift of 7 am to 7 pm.
On 2/10/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/11/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/12/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/13/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/14/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/15/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/16/2025, No documentation provided of any tasks being completed during shift of 7 am to 7 pm.
On 2/17/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/18/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/19/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/20/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/21/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/22/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/23/2025, No documentation provided of any tasks being completed during shift of 7 am to 7 pm.
On 2/24/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/25/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/26/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 2/27/2025, No documentation provided of any tasks being completed during shift of 7 am to 7 pm.
On 2/28/2025, No documentation provided of grooming tasks being completed during shift of 7 am to 7 pm.
On 3/1/2025, shifts hours provided 12 pm to 7 pm. No documentation provided of an update or change of shift hours from the service agreement that was signed.
On 3/2/2025, No documentation provided of any tasks being completed during shift of 7 am to 7 pm.
On 3/3/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 3/4/2025, no documentation provided of any tasks being completed during shift of 7 am to 12 pm.
On 3/5/2025, no documentation provided of any tasks being completed during shift of 7 am to 12 pm.
On 3/9/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 3/10/2025, No documentation provided of any tasks being completed during both shifts of 7 am to 12 pm and 12 pm to 7 pm.
On 3/13/2025, no documentation provided of any tasks being completed during shift of 12 pm to 7 pm.
On 3/14/2025, no documentation provided of feeding tasks being completed during shift of 12 pm to 7 pm.
On 3/15/2025, no documentation provided of any tasks being completed during shift of 7 am to 7 pm.
On 3/16/2025, no documentation provided of any tasks being completed during shift of 7 am to 7 pm.
On 3/17/2025, No documentation provided of any tasks being completed during shift of12 pm and 12 pm to 7 pm.
On 3/18/2025, no documentation provided of feeding tasks being completed during shift of 12 pm to 7 pm.
On 3/19/2025, no documentation provided of feeding tasks being completed during shift of 12 pm to 7 pm.
On 3/20/2025, no documentation provided of feeding tasks being completed during shift of 12 pm to 7 pm.
On 3/21/2025, no documentation provided of feeding tasks being completed during shift of 12 pm to 7 pm.
On 3/24/2025, No documentation provided of any tasks being completed during shift of 7 am to 12 pm.
On 3/25/2025, No documentation provided of any tasks being completed during shift of 12 pm to 7 pm.
CF# 3, SOS, 3/3/2025: ' Agency Copy Agreement for Non Medical In Home Living Assistance ' was signed by the consumer on March 4, 2025. The section, ' Services to be performed by provider ' reads, " Bathing, showering, dressing, grooming, feeding, grocery shopping, lite dusting, cooking, pet care, and pharmacy errands. " Hours listed are the following: Monday: 7 am- 2 pm; Tuesday 7 am- 2 pm, Wednesday 7 am- 2 pm; Thursday 7 am- 2 pm; Friday 7 am- 2 pm.
Review of calendar, schedule, and daily tasks was conducted for the date range of March 8, 2025, through March 31, 2025.
On 3/10/2025, No documentation provided of any tasks being completed.
On 3/11/2025, No documentation provided of any tasks being completed.
On 3/12/2025, No documentation provided of any tasks being completed.
On 3/13/2025, No documentation provided of any tasks being completed.
On 3/14/2025, No documentation provided of any tasks being completed.
On 3/17/2025, No documentation provided of any tasks being completed.
On 3/18/2025, No documentation provided of any tasks being completed.
On 3/19/2025, No documentation provided of any tasks being completed.
On 3/20/2025, No documentation provided of any tasks being completed.
On 3/21/2025, No documentation provided of any tasks being completed.
On 3/24/2025, No documentation provided of any tasks being completed.
On 3/25/2025, No documentation provided of any tasks being completed.
On 3/26/2025, No documentation provided of any tasks being completed.
On 3/27/2025, No documentation provided of any tasks being completed.
On 3/28/2025, No documentation provided of any tasks being completed.
On 3/31/2025, No documentation provided of any tasks being completed.
An interview with agency EMP #1, conducted on May 12, 2025 at approximately 2:00 p.m. confirmed the above findings.
Plan of Correction:
Immediate Corrective Actions:
1. Service Agreement Review:
The administrator will conduct a thorough review of all current service agreements to ensure that all service hours and tasks are clearly documented and followed.
All staff will be retrained on the importance of adhering to the service agreements and documenting any changes or deviations.
2. Documentation Standardization:
The administrator will implement a standardized documentation procedure for logging daily shifts and tasks performed through the timesheet and HHA Exchange. This includes a checklist format that caregivers must complete every shift.
The administrator will ensure that all caregivers use a daily log to record hours worked and tasks completed in the HHA exchange at the end of every shift.
3. Consumer Communication:
The administrator will develop a protocol for notifying consumers in writing of any changes to their service hours or task assignments. Ensure that at least 10 calendar days' written notice is provided for any client that will be discharged.
4. Staff Training:
The administrator will schedule a mandatory training session for all staff focused on consumer rights, documentation requirements, and the importance of compliance with service agreements.
Training will occur every three months to reinforce practices and ensure accountability.
Long-Term Corrective Actions:
1. Quality Assurance Program:
Establish a quality assurance program that includes regular reviews of consumer files and caregiver logs to ensure compliance with service agreements.
The office manager will conduct monthly audits of consumer files for the next six months to identify any discrepancies and address them promptly.
2. Consumer Feedback Mechanism:
The agency will create a consumer feedback form that allows consumers to report any issues related to their care services, including missed services or hours.
The office manager will review feedback bi-weekly to detect trends and identify areas needing improvement.
3. Supervisory Oversight:
Increase supervisory oversight of caregiver assignments to ensure adherence to service agreements. Supervisors will conduct weekly random checks of schedules and consumer logs.
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