QA Investigation Results

Pennsylvania Department of Health
COMPASSIONATE HEARTS PERSONAL CARE, LLC
Health Inspection Results
COMPASSIONATE HEARTS PERSONAL CARE, LLC
Health Inspection Results For:

This is the only survey for this facility

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an onsite unannounced State relicensure survey completed 12/27/2021, Compassionate Hearts Personal Care Llc, was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.




Plan of Correction:




Initial Comments:


Based on the findings of an onsite unannounced State relicensure survey completed 12/27/2021, Compassionate Hearts Personal Care 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:




611.51(a) LICENSURE
Hiring or Rostering Prerequisites

Name - Component - 00
Prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. (3) Require the individual to submit a criminal history report, in accordance with the requirements of 611.52 (relating to criminal background checks), and a ChildLine verification, if applicable, in accordance with the requirements of 611.53 (relating to child abuse clearance).

Observations:


Based on review of agency documents and personnel files (PF), and staff (EMP) interview, it was determined agency failed to conduct a face-to-face interview with the applicant or obtain verification of two (2) positive references for the applicant for seven (7) of seven (7) PF's reviewed (PF1-PF7).

Findings included:

Review of the agency policy and procedure on 12/9/2021 at approximately 11:00 AM revealed, "EMPLOYEE HANDBOOK...JOB DESCRIPTION...QUALIFICATIONS: Minimum of ninth education; high school diploma or GED preferred. Must demonstrate satisfactory completion of any state mandated training. Applicant must be bondable and meet or exceed minimum qualifications for each of the following background checks: Criminal Background Investigation, Motor Vehicle Driving Record, Credit History, Professional and Personal Reference Checks...Must satisfactorily complete (Agency), training and orientation program(s)..."
A review of the personal files (PF) was conducted on 12/27/2021 from 1:00 PM to 1:45 PM,
PF#1 Date of Hire (DOH) 11/20/2020, The PF did not contain evidence of a face-to-face interview having been completed or evidence of two references having been verified as positive by the agency.

PF#2 DOH 6/7/21, The PF did not contain evidence of a face-to-face interview having been completed or evidence of two references having been verified as positive by the agency.

PF#3 DOH 3/17/2021, The PF did not contain evidence of a face-to-face interview having been completed or evidence of two references having been verified as positive by the agency.

PF#4 DOH 4/2/2021, The PF did not contain evidence of a face-to-face interview having been completed or evidence of two references having been verified as positive by the agency.

PF#5 DOH 2/5/2021, The PF did not contain evidence of a face-to-face interview having been completed or evidence of two references having been verified as positive by the agency.

PF#6 DOH 11/12/2021, The PF did not contain evidence of a face-to-face interview having been completed or evidence of two references having been verified as positive by the agency.

PF#7 DOH 4/12/2021, The PF did not contain evidence of a face-to-face interview having been completed or evidence of two references having been verified as positive by the agency.

An interview was conducted with the administrator on 12/30/2021 at approximately 8:57 AM which confirmed the above findings.









Plan of Correction:

Regarding rule 611.51(a)PF#1. Agency is unable to provide supporting documents due to the employee is no longer employed with the company. Moving forward agency will require documentation that is consistent with verification of interview. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.

Regarding rule 611.51(a)PF#2. Agency is unable to provide supporting documents due PF#1 is no longer employed with the company. Moving forward agency will require documentation that is consistent with verification of interview. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.

Regarding rule 611.51(a)PF#3. Agency is unable to provide supporting documents PF#3 is no longer employed with the company. Moving forward agency will require documentation that is consistent with verification of interview. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met

Regarding rule 611.51(a)PF#4. Agency is unable to provide supporting documents due to PF#4 is no longer employed with the company. Moving forward agency will require documentation that is consistent with verification of interview. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met

Regarding rule 611.51(a)PF#5. Agency is unable to provide supporting documents due to PF#5 is no longer employed with the company. Moving forward agency will require documentation that is consistent with verification of interview. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met

Regarding rule 611.51(a)PF#6. Agency is unable to provide supporting documents due to PF#6 is no longer employed with the company. Moving forward agency will require documentation that is consistent with verification of interview. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.

Regarding rule 611.51(a)PF#7. Agency is unable to provide supporting documents due to PF#7 is no longer employed with the company. Moving forward agency will require documentation that is consistent with verification of interview. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.




611.52(d) LICENSURE
Proof of Residency

Name - Component - 00
The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation

Observations:


Based on a review of policy, personnel files (PFs) and staff interview it was determined the agency failed to show proof of residency in this Commonwealth for the 2 years preceding the date of hire (DOH) for five (5) of seven (7) PFs reviewed (PF1, PF2, PF4, PF5 and PF6).

Findings included:

Review of the agency policy and procedure on 12/9/2021 at approximately 11:00 AM revealed, " EMPLOYEE HANDBOOK ...MANDATORY BACKGROUND/CRIMINAL CHECK: (Agency) requires all employees prior to any offer of employment; all employees must successfully pass a state mandatory criminal background check. (agency is prohibited from hiring and or retaining any individual(s) with a prohibited conviction or Department of Aging ineligibility determination. (Agency) Background Check Investigation guidelines as required under PA Code 611.52(a-j) (b) State Police history record. If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record...(d) Proof of residency. The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents: 1. Motor vehicle records, such as a valid driver's license or a State-issued identification. 2. Housing records, such as mortgage records or rent receipts. 3. Public utility records and receipts, such as electric bills. 4. Local tax records. 5. A completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it. 6. Employment records, including records of unemployment compensation."
A review of the personal files (PF) was conducted on 12/27/2021 from 1:00 PM to 1:45 PM,
PF#1 Date of Hire (DOH) 11/20/2020, There was a Pennsylvania driver's license with an issue date of 10/8/2019. There was no additional documentation in PF to confirm the agency verified proof of residency in this Commonwealth for two (2) years immediately preceding the date of hire.

PF#2 DOH 6/7/21, There was no documentation in PF to confirm the agency verified proof of residency in this Commonwealth for two (2) years immediately preceding the date of hire.

PF#4 DOH 4/2/2021, There was a Pennsylvania driver's license with an issue date of 8/7/2019. There was no additional documentation in PF to confirm the agency verified proof of residency in this Commonwealth for two (2) years immediately preceding the date of hire.

PF#5 DOH 2/5/2021, There was a Pennsylvania driver's license with an issue date of 6/6/2020. There was no additional documentation in PF to confirm the agency verified proof of residency in this Commonwealth for two (2) years immediately preceding the date of hire.

PF#6 DOH 11/12/2021, There was no documentation in PF to confirm the agency verified proof of residency in this Commonwealth for two (2) years immediately preceding the date of hire.

An interview was conducted with the administrator on 12/30/2021 at approximately 8:57 AM which confirmed the above findings.







Plan of Correction:

Agency corrected action relating to rule 611.52(d) for PF#1 was corrected on 01/14/2022. Agency was unable to obtain additional documents due to the employee no longer being employed with the company. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.

Agency corrected action relating to rule 611.52(d) for PF#2 was corrected on 01/14/2022. Moving forward, the agency will ensure all required
documents are obtained before employment through the use of software. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are being met.


Agency corrected action relating to rule 611.52(d) for PF#4 was corrected on 01/14/2022. Agency was unable to obtain additional documents due to the employee no longer being employed with the company. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.

Agency corrected action relating to rule 611.52(d) for PF#5 was corrected on 01/14/2022. Additional documents were obtained to verify proof of residency.
Moving forward, the agency will ensure all required documents are obtained before employment through the use of software for onboarding. Director of Operations will be assigned as Chief of Compliance to ensure regulations are met.


Agency corrected action relating to rule 611.52(d) for PF#6 was corrected on 01/14/2022. Agency was unable to obtain additional documents due to the employee no longer being employed with the company. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.






611.55(a) LICENSURE
Compentency Requirements

Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.

Observations:


Based on review of the agency policy, personnel files (PF) and staff (EMP) interview, the agency failed to ensure direct care worker (DCW) competency/training was completed prior to assigning staff to provide services to consumers for one (1) of seven (7) PF's reviewed. (PF3).

Findings Included:

Review of the agency policy and procedure on 12/9/2021 at approximately 11:00 AM revealed, " EMPLOYEE HANDBOOK ...JOB DESCRIPTION ...QUALIFICATIONS: Minimum of ninth education; high school diploma or GED preferred. Must demonstrate satisfactory completion of any state mandated training. Applicant must be bondable and meet or exceed minimum qualifications for each of the following background checks: Criminal Background Investigation, Motor Vehicle Driving Record, Credit History, Professional and Personal Reference Checks ...Must satisfactorily complete (Agency), training and orientation program(s) ... "
A review of the personal files (PF) was conducted on 12/27/2021 from 1:00 PM to 1:45 PM,
PF#3 DOH 3/17/2021, did not contain evidence to confirm the direct care worker had demonstrated competency at the time of hire. The PF did not contain evidence of competency/evaluation testing being completed.

An interview was conducted with the administrator on 12/30/2021 at approximately 8:57 AM which confirmed the above findings.







Plan of Correction:

Agency corrected action relating to rule 611.55(a) on 01/11/2022 for PF#3. Agency is unable to complete verification of competency due to no longer being employed with the company. Agency will revise new onboard training by utilizing programs to ensure competency and compliance is met. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met



611.55(c) LICENSURE
Competency Requirements

Name - Component - 00
A competency examination or training program developed by an agency or registry for a direct care worker who will provide personal care must address the following additional subject areas: 1. Bathing, shaving, grooming and dressing; 2. Hair, skin and mouth care; 3. Assistance with ambulation and transferring; 4. Meal preparation and feeding; 5. Toileting; 6. Assistance with self-administered medications.

Observations:


Based on review of direct care worker personnel files (PF), interview with the owner, and review of the agency's training program, it was determined the agency failed to ensure their training program included all required subject areas for six (6) of seven (7) PFs reviewed (PF1-PF7).

Findings Include:

Review of the agency policy and procedure on 12/9/2021 at approximately 11:00 AM revealed, " EMPLOYEE HANDBOOK ...JOB DESCRIPTION ...QUALIFICATIONS: Minimum of ninth education; high school diploma or GED preferred. Must demonstrate satisfactory completion of any state mandated training. Applicant must be bondable and meet or exceed minimum qualifications for each of the following background checks: Criminal Background Investigation, Motor Vehicle Driving Record, Credit History, Professional and Personal Reference Checks ...Must satisfactorily complete (Agency), training and orientation program(s) ... "
A review of the personal files (PF) was conducted on 12/27/2021 from 1:00 PM to 1:45 PM,
PF#1 Date of Hire (DOH) 11/20/2020, competency completed 11/25/2020, all required competency subject areas were not covered.

PF#2 DOH 6/7/21, competency completed 7/8/2021, all required competency subject areas were not covered.

PF#4 DOH 4/2/2021, competency completed 4/2/20201, all required competency subject areas were not covered.

PF#5 DOH 2/5/2021, competency completed 3/2/2021, all required competency subject areas were not covered.

PF#6 DOH 11/12/2021, competency completed 1/13/2021, all required competency subject areas were not covered.

PF#7 DOH 4/12/2021, competency completed 4/14/2021, all required competency subject areas were not covered.

An interview was conducted with the administrator on 12/30/2021 at approximately 8:57 AM which confirmed the above findings.






Plan of Correction:

Agency corrected action relating to rule 611.55(c) on 01/11/2022 for PF#1. Agency is unable to complete verification of competency due to the employee no longer being employed with the company. Agency will revise onboard training by utilizing programs to ensure competency and compliance is met. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.

Agency corrected action relating to rule 611.55(c) on 01/11/2022 for PF#2. Agency is unable to complete verification of competency due the employee no longer being employed with the company. Agency will revise new onboard training by utilizing programs to ensure competency and compliance is met. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.

Agency corrected action relating to rule 611.55(c) on 01/11/2022 for PF#4. Agency is unable to complete verification of competency due to the employee no longer being employed with the company. Agency will revise new onboard training by utilizing programs to ensure competency and compliance is met. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.

Agency corrected action relating to rule 611.55(c) on 01/11/2022 for PF#5. Agency is unable to complete verification of competency due the employee is no longer employed with the company. Agency will revise new onboard training by utilizing programs to ensure competency and compliance is met. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.

Agency corrected action relating to rule 611.55(c) on 01/11/2022 for PF#6. Agency is unable to complete verification of competency due the employee is no longer employed with the company. Agency will revise new onboard training by utilizing programs to ensure competency and compliance is met. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.




Agency corrected action relating to rule 611.55(c) on 01/11/2022 for PF#7. Agency is unable to complete verification of competency due to the employee is no longer employed with the company. Agency will revise new onboard training by utilizing programs to ensure competency and compliance is met. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.



611.56(a) LICENSURE
Health Screening

Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.

Observations:


Based on a review of agency policy, Centers for Disease Control (CDC) guidelines, agency personnel files (PF) and staff (EMP) interview it was determined the agency failed to ensure direct care workers, prior to consumer contact had been screened for and was free from active mycobacterium tuberculosis (TB) for one (1) of seven (7) PF's reviewed. (PF3).

Findings Included:

Review of the agency policy and procedure on 12/9/2021 at approximately 11:00 AM revealed, "EMPLOYEE HANDBOOK...TUBERCULOSIS SCREENING POLICY...In order to comply with the Pennsylvania regulation and Home care Agency/Home Care Registry licensing standards, (Agency) and its employees proving home care and home care services who are in direct contact with the public (residential and non-residential) shall adhere to the following: Establish and maintain personnel policies that address TB test results for staff, interns and volunteers. Require all staff, interns and volunteers whose functions require or necessitate contact with participants or food preparation be tested for TB prior to Patient contact and screened annually thereafter."
"PA Department of Health...Guidance for Home Care Agencies, Home Health Care Agencies and Hospices During COVID-19 Pandemic...May 20, 2020...Pre-employment Health Screening...The requirement for an initial baseline 2 step Mantoux skin test for tuberculin skin testing is temporarily suspended. All applicants must complete an individual risk assessment and symptom evaluation prior to hire...Any new employee who does not provide evidence of a Mantoux skin test within the previous 12 months must, as a condition of employment, receive the tuberculin skin test as soon as possible following termination of the Governor's COVID-19 Disaster Declaration...."

A review of the personal files (PF) was conducted on 12/27/2021 from 1:00 PM to 1:45 PM,
PF#3 DOH 3/17/2021, did not contain an individual TB risk assessment and a symptom screen questionnaire.

An interview was conducted with the administrator on 12/30/2021 at approximately 8:57 AM which confirmed the above findings.







Plan of Correction:

Agency corrected action relating to rule 611.56(a) on 01/11/2022 for PF#3. Agency is unable to complete Health Screening due to PF#3 is no longer employed with the company. Agency will ensure all pre-screen requirements are met prior to employment by implementing documentation on steps through on boarding. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.


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 the agency policy, consumer records (CR) and staff (EMP) interview, the agency failed to involve the consumer in the service planning process and to receive services with reasonable accommodation of individual needs and preferences for three (3) of five (5) CR's reviewed (CR2, CR3 and CR5).

Findings included:

Review of the agency policy and procedure on 12/9/2021 at approximately 12:30 PM revealed, " CONSUMER PROTECTION AND PATIENTS BILL OF RIGHTS & RESPONSIBILITIES, (a) Consumer rights. 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.
Review of the agency policy and procedure on 12/9/2021 at approximately 12:30 PM revealed, " PATIENT ' S PLAN OF CARE HOME CARE SERVICES PATIENT NEEDS: PERSONAL CARE SERVICES ...LONG TERM CARE ...ELDERLY COMPANION CARE SERVICE ... PLEASE SELECT THE HOURS THE PATIENT NEEDS SERVICES: Monday From:_______ to:_____, Tuesday From:_______ to:_____, Wednesday From:_______ to:_____, Thursday From:_______ to:_____, Friday From:_______ to:_____, Saturday From:_______ to:_____, Sunday From:_______ to:_____... "
A review of consumer records was conducted on 12/27/2021 at approximately 9:25 AM to 11:15 AM.

CR2 revealed start of services 2/1/2021. The agency documentation within the CR listed all seven days for services to be provided, but only Monday, Tuesday and Wednesday were times given for services to be provided. No additional times were documented to confirm the hours to be scheduled on the plan of care for Thursday through Sunday.

CR3 revealed start of services 1/28/2021. The agency documentation within the CR listed all seven days for services to be provided, but only Monday were the times 8:00 AM to 12:00PM and 3:00 PM to 7:00 PM given. No additional times were documented to confirm the hours to be scheduled on the plan of care for Tuesday through Sunday.

CR5 revealed start of services 12/9/2020. The agency documentation within the CR did not list the initial days and times that confirmed the agency had meant consumer/consumer representative to discuss the individual service planning needs and preferences.

An interview was conducted with the administrator on 12/30/2021 at approximately 8:57 AM which confirmed the above findings.








Plan of Correction:

Agency corrected action relating to rule 611.57(a) on 01/11/2022 for CR#2.
Agency added required specifics on Plan of Care. Agency will continue to ensure that Plan of Care is properly completed and specify all of the consumers goals, preferences, schedule, and needs. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.


Agency corrected action relating to rule 611.57(a) on 01/11/2022 for CR#3.
Agency added required specifics on Plan of Care. Agency will continue to ensure that Plan of Care is properly completed and specify all of the consumers goals, preferences, schedule, and needs. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.


Agency corrected action relating to rule 611.57(a) on 01/11/2022 for CR#5.
Agency added required specifics on Plan of Care. Agency will continue to ensure that Plan of Care is properly completed and specify all of the consumers goals, preferences, schedule, and needs. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.




611.57(c) LICENSURE
Information to be Provided

Name - Component - 00
(c) Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.

Observations:


Based on a review of agency policy, consumer records (CR) and staff (EMP) interview, the agency failed to provide required information in writing to consumers/consumer representatives prior to the commencement of services for five (5) of five (5) CRs reviewed (CR1-CR5)

Findings included:

Review of the agency policy and procedure on 12/9/2021 at approximately 12:30 PM revealed, " c) Information to be provided. Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer ' s representative, or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) the hours when those services will be provided ... "
Review of the agency policy and procedure on 12/9/2021 at approximately 12:30 PM revealed, " PATIENT ' S PLAN OF CARE HOME CARE SERVICES PATIENT NEEDS: PERSONAL CARE SERVICES ...LONG TERM CARE ...ELDERLY COMPANION CARE SERVICE ... PLEASE SELECT THE HOURS THE PATIENT NEEDS SERVICES: Monday From:_______ to:_____, Tuesday From:_______ to:_____, Wednesday From:_______ to:_____, Thursday From:_______ to:_____, Friday From:_______ to:_____, Saturday From:_______ to:_____, Sunday From:_______ to:_____... "
A review of consumer records was conducted on 12/27/2021 at approximately 9:25 AM to 11:15 AM.

CR1 revealed a start of services on 6/10/2021, No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The identity of the direct care worker who would provide services.

CR2 revealed start of services 2/1/2021. No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The identity of the direct care worker who would provide services.
2. The hours when services would be provided.


CR3 revealed start of services 1/28/2021. No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The identity of the direct care worker who would provide services.
2. The hours when services would be provided.

CR4 revealed a start of services on 5/17/2021, No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The identity of the direct care worker who would provide services.

CR5 revealed start of services 12/9/2020. No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The identity of the direct care worker who would provide services.
2. The hours when services would be provided.

An interview was conducted with the administrator on 12/30/2021 at approximately 8:57 AM which confirmed the above findings.






Plan of Correction:

Agency corrected action relating to rule 611.57(c) on 01/11/2022 for CR#1.
Agency added required specifics on Plan of Care. Agency will continue to ensure that Plan of Care is properly completed and specify all of the consumers goals, preferences, schedule, and needs. Agency will also ensure that all consumers are notified of Direct Care Worker assigned and acknowledgement documented. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.


Agency corrected action relating to rule 611.57(c) on 01/11/2022 for CR#2.
Agency added required specifics on Plan of Care. Agency will continue to ensure that Plan of Care is properly completed and specify all of the consumers goals, preferences, schedule, and needs. Agency will also ensure that all consumers are notified of Direct Care Worker assigned and acknowledgement documented. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.


Agency corrected action relating to rule 611.57(c) on 01/11/2022 for CR#3.
Agency added required specifics on Plan of Care. Agency will continue to ensure that Plan of Care is properly completed and specify all of the consumers goals, preferences, schedule, and needs. Agency will also ensure that all consumers are notified of Direct Care Worker assigned and acknowledgement documented. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.


Agency corrected action relating to rule 611.57(c) on 01/11/2022 for CR#4.
Agency added required specifics on Plan of Care. Agency will continue to ensure that Plan of Care is properly completed and specify all of the consumers goals, preferences, schedule, and needs. Agency will also ensure that all consumers are notified of Direct Care Worker assigned and acknowledgement documented. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.


Agency corrected action relating to rule 611.57(c) on 01/11/2022 for CR#5.
Agency added required specifics on Plan of Care. Agency will continue to ensure that Plan of Care is properly completed and specify all of the consumers goals, preferences, schedule, and needs. Agency will also ensure that all consumers are notified of Direct Care Worker assigned and acknowledgement documented. Director of Operations will be assigned as Chief of Compliance to ensure that all regulations are met.





Initial Comments:


Based on the findings of an onsite unannounced State relicensure survey completed 12/27/2021, Compassionate Hearts Personal Care Llc was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: