QA Investigation Results

Pennsylvania Department of Health
Health Inspection Results
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Initial Comments:
Based on the findings of an onsite unannounced complaint investigation completed December 15, 2022, Coordinating Staffing, Llc was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.

Plan of Correction:

611.57(d) LICENSURE

Name - Component - 00
(d) The home care agency or home care registry shall maintain documentation on file at the agency or registry of compliance with the requirements of this section which shall be available for Department inspection.


Based on review of a consumer file (CR), email, and staff (EMP) and consumer interview, the agency failed to maintain documentation to show the requirements of 611.57(a) were met. There was no documentation to show agency notified one (1) of one (1) consumer of changes in their service agreement concerning shifts the agency was unable to staff (CR1).

According to 611.57(a), (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

Findings included:

A review of CR1 on December 15, 2022, at 10:15 a.m. showed consumer was approved for 22 hours per day. She signed her service agreement on 1/23/2022.

Per email reviewed on December 15, 2022, at 10:30 a.m. EMP1 notified CR1's service coordinator on November 3, 2022, concerning a staffing shortfall, "I wanted to reach out to give you an update on the hours and scheduling for [CR1]. Unfortunately, I have run out of caregivers. ... I did speak with [CR1's power of attorney] and made sure she also understood the situation as well. ... Below are the shifts that have currently been scheduled for [CR1] ... 8am-4pm ... 6pm-10pm ... 10 pm-8am ... [CR1] is very adamant that she does not want the shifts to change, as she wants two hours off in-between the daylight and evening shifts."

Further review of CR1 at 10:45 a.m. showed agency failed to provide 22 hours of services in accordance with CR1's wishes. Shortfalls in daily hours are listed below:

11/6/2022 - 15 hours
11/7/2022 - 11 hours
11/8/2022 - 10 hours
11/9/2022 - 10 hours
11/11/2022 - 12 hours
11/12/2022 - 14 hours
11/14/2022 - 11 hours
11/16/2022 - 15 hours
11/17/2022 - 2 hours
11/18/2022 - 15 hours
11/19/2022 - 11 hours
11/20/2022 - 15 hours
11/21/2022 - 15 hours
11/22/2022 - 16 hours
11/23/2022 - 9 hours
11/24/2022 - 15 hours
11/25/2022 - 8 hours
11/26/2022 - 11 hours

Interview with EMP1 on December 15, 2022, at 11:30 a.m. confirmed above findings. He/she had been in regular contact with family concerning staffing but failed to document that he/she notified consumer of these changes.

Plan of Correction:

The agency provides an initial packet of information which contains the client's initial schedule, weekly hours and caregiver information prior to start of service.
The agency will ensure that an updated schedule of service sheet is sent to all client's whenever a change in hours, schedule, or caregiver is made during their time of service.
The agency will monitor each client schedule, hours and caregiver information on a monthly basis for a period of no less than 3-months to ensure that any client who has had a change to their schedule, hours, or caregiver has received the updated schedule of service form.
The agency will document the review of client schedules and files on a spreadsheet which will be maintained and on file with the agency for review, if and when requested.
All current clients will receive an updated information packet, within 45 days from POC date, containing their current schedules, weekly hours, and caregiver information.
The client in question has already been provided the updated service information packet, which provided information regarding her current weekly hours, schedule, and assigned caregivers with the agency. The packet was provided to both the client and the client's authorized representative. The packet was mailed to the client via USPS Mail with tracking, and emailed to the client's authorized representative. The updated hours and schedule information was also provided to the client's UPMC Service Coordinator.
Documentation that the information has been sent to all active clients will be maintained in each client file for review if and when requested.
The agency will also ensure that all conversations with client's, or their authorized representatives, regarding their services, schedules, and/or changes, are documented via written documentation, and saved in the client file.
The Director of the agency, or a designated agency staff member trained by the director, will be responsible for monitoring the schedules, client files, and client correspondence documentation, and ensuring that any needed updated schedule of service forms are sent to clients when needed.