Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on May 7, 2025, with the off-site portion of the survey being completed on May 8, 2025, Complete Homecare, Inc. was found not to be in compliance with the following requirement of 28 Pa. Code, Part IV, Health Facilities, Subpart A. Chapter 51.
Plan of Correction:
51.3 (f) LICENSURE
NOTIFICATION
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.
Observations:
Based on review of agency documentation and consumer (agency) files and the Pennsylvania Department of Health Event Reporting System (PA DOH ERS) website, and based on interview with the local administrator (Employee #7), the agency failed to submit a report to the PA DOH ERS website of three (3) of four (4) incidents involving direct care workers (DCW) to the PA DOH ERS website which occurred after June 14, 2022. (Incident #1, #2 and #3)
Findings included:
On May 7, 2025 at approximately 4:15 PM, review of agency Direct Care Worker Annual In-Service Education packet revealed the following:
Neglect: Failure of caregiver to supply client with necessary...healthcare or supervision...
Exploitation: Intimidating or deceiving a victim in way that deprives them of money, assets or property--for the benefit of someone other than the victim...
Medicare/Medicaid Fraud...Need to check if provider billed for what was actually provided...
Role of Administrator...In accordance with state law, the Administrator will immediately submit a...report of suspected abuse or neglect to the proper Pennsylvania Mandatory Reporting Agencies...
On May 7, 2025 at approximately 8:30 AM, review of the PA DOH ERS website revealed the following are reportable events:
-Care or Services;
-Misappropriation of Patient/Resident Property; and
-Patient/Resident Neglect.
Consumer #6: On May 7, 2025 at approximately 11:22 AM, review of the consumer file revealed the following incidents were reported to the agency:
Incident #1: On 02/02/2023, a report was received from a local law enforcement officer that the consumer had been without care for days and that the law enforcement officer wanted the names and telephone numbers of the caregivers (DCW). The agency contacted the consumer's Service Coordinator after the allegations were received.
Incident #2: On 08/08/2023, the consumer notified the agency that the consumer provided a DCW with the consumer's debit card to obtain money in order for the DCW to pay the consumer's rent. The consumer reported that an eviction notice had been received, that the DCW admitted to only paying a portion of the consumer's rent and that the DCW admitted to using a portion of the money to pay personal expenses. The agency terminated the DCW and notified the consumer's Service Coordinator of the allegations. The agency submitted a report of the allegations to Older Adult Protective Services.
Incident #3: Enterprise Incident Management (EIM) report documentation revealed that on 01/31/2024, the agency staff documented that the agency was unable to contact a DCW (Employee #4) for several days. The agency contacted the consumer who reported the DCW had been receiving inpatient treatment since 01/19/2024 and that a different person was assisting the consumer. The consumer reported that the consumer had been "clocking" in the DCW (Electronic Visit Verification (EVV) system) so that the money from the DCW's pay could be utilized to pay the person currently assisting the consumer. EIM report documentation revealed the consumer's Service Coordinator was notified of the above listed incident and that the billing department was notified to "unbill" for all shifts from 01/19/2024 through 01/31/2024.
On May 7, 2025 at approximately 8:30 AM, review of the PA DOH ERS website failed to reveal the agency had submitted a report of the above referenced incidents to the PA DOH ERS website.
During interview conducted on May 7, 2025 at approximately 4:30 PM, the local administrator confirmed the agency had failed to submit a report of the above referenced incidents to the PA DOH ERS website.
Plan of Correction:Agency completed a staff Inservice training and completed refresher training on 5/9/25 to re-educate coordinators that missed visits require a detailed reason notation in HHA on the missed visit shift and any reportable event that compromises the quality assurance and patient safety then it must be documented in the DOH Event Reporting System (ERS) within 24 hours of the occurrence or discover and an EIM created for OLTL review.
Each service location Office Administrator will be responsible for reviewing reportable events such as missed visits, allegations of abuse, neglect, death due to medication error/adverse reaction to medication/injury/suicide/unusual circumstances/malnutrition/dehydration/sepsis, reportable diseases. misappropriation of patient/resident property, service interruption/termination of any service vital fir continued safety to ensure if an EIM and/or ERS needs created.
Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on May 7, 2025, with the off-site portion of the survey being completed on May 8, 2025, Complete Homecare, Inc. was found not to be in compliance with the following requirements of Title 28 Health and Safety Part IV, Health Facilities, Subpart H. Chapter 611 Home Care Agencies.
Plan of Correction:
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 review of agency documentation, consumer (agency) and personnel files and based interview with the local administrator (Employee #7), the agency failed to obtain proof-of-residency documentation which verified Pennsylvania (PA) residency for the previous two (2) year period prior to the first date of assignment for one (1) of five (5) direct care workers (DCW) whose first date of assignment was after June 14, 2022. (Employee #4)
Findings include:
On May 7, 2025 at approximately 10:05 AM, review of the "Client Service Agreement" revealed the following under "Hiring and Competency Requirements for Direct Care Workers":
The direct care worker(s) who will be providing services has met the hiring...requirements in accordance with Pennsylvania's Home Care licensing regulations.
Consumer #6: On May 7, 2025 at approximately 11:22 AM, review of the HHAeXchange (software) and consumer file documentation revealed the DCW (Employee #4) provide home care services in April 2025.
On May 7, 2025 at approximately 3:05 PM and May 8, 2025 at approximately 10:14 AM, review of personnel file documentation revealed the following:
Employee #4: The DCW's first date of assignment was 04/14/2023. Review of proof-of-residency documentation revealed the PA driver's license was issued on 12/30/2021 and that the agency obtained a court document date 04/10/2018. There was no documentation in the personnel file which provided evidence the agency had obtained documentation to verify proof of PA residency for the time period of 04/14/2021 through 12/29/2021.
During interview conducted on May 7, 2025 at approximately 4:30 PM, the local administrator confirmed documentation was not present in the personnel file which provided evidence the agency had obtained documentation which verified PA residency for the two (2) year period prior to the first date of assignment for Employee #4.
Plan of Correction:Agency currently has a policy regarding personnel records contents that states that proof of length of residency in Commonwealth of PA should be included in New Hire documents. Agency will reeducate staff that if employee unable to provide proof resided in PA during the previous 2-year period prior to hire date then FBI Fingerprint criminal background check is required. Office staff responsible for onboarding/hiring process of new employees will complete final review of documents prior to completing orientation to ensure applicable background check(s) completed.
Each service location Office Administrator will be responsible for reviewing completed onboarding/hiring documents to confirm 2-year resident requirement met.
611.57(d) LICENSURE
Documentation
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.
Observations:
Based on review of agency documentation and consumer (agency) files, and based on consumer and staff interview and interview with the local administrator (Employee #7), the agency failed to ensure documentation was maintained in the consumer file which provided evidence completed tasks included on the direct care worker (DCW) duties report were in accordance with the plan of care (POC) for four (4) of seven (7) consumers. (Consumers #4, #5, #6 and #7)
Findings included:
On May 7, 2025 at approximately 10:05 AM, review of the "Client Service Agreement" revealed the following under "Agency Responsibilities":
B. Services...The caregiver will provide home care services requested by, and agreed to by the client, Complete Home Care and the Responsible Party.
Consumer #4: On May 7, 2025 at approximately 10:47 AM, review of the HHAeXchange (software) and consumer file documentation revealed home care services to be provided by DCW's include bathing, meal preparation, transfers, assistance with ambulation, incontinence care, dressing, shampoo and combing hair as documented on the POC.
Review of HHAeXchange DCW duties report documentation revealed the DCW's (Employees #1 and #2) documented that tasks performed in April 2025 included gastric (GT) tube feedings and wound care.
There was no documentation on the POC which provided evidence that DCW tasks included GT feedings nor wound care.
During telephone interview conducted on May 7, 2025 at approximately 2:30 PM, the DCW (Employee #1) reported the consumer does not require GT feeds nor wound care and that those tasks are not performed by the DCW.
Consumer #5: On May 7, 2025 at approximately 10:58 AM, review of the HHAeXchange (software) and consumer file documentation revealed home care services to be provided by DCW's include hygiene, assistance with ambulation, incontinence care and dressing as documented on the POC.
Review of HHAeXchange DCW duties report documentation revealed the DCW (Employee #3) documented that tasks performed in April 2025 included gastric tube feedings and wound care.
There was no documentation on the POC which provided evidence that DCW tasks included GT feedings nor wound care.
Consumer #6: On May 7, 2025 at approximately 11:22 AM, review of the HHAeXchange (software) and consumer file documentation revealed home care services to be provided by DCW's include bathing, mouth care, grooming, dressing, skin care, toileting, meal preparation, transfers, assistance with ambulation, incontinence care, shampoo and combing hair as documented on the POC.
Review of HHAeXchange DCW duties report documentation revealed the DCW (Employee #4) documented that tasks performed in April 2025 included gastric tube feedings and wound care.
There was no documentation on the POC which provided evidence that DCW tasks included GT feedings nor wound care.
Consumer #7: On May 7, 2025 at approximately 1;30 PM, review of the HHAeXchange (software) and consumer file documentation revealed home care services to be provided by DCW's include hygiene and dressing as documented on the POC.
Review of HHAeXchange DCW duties report documentation revealed the DCW (Employee #5) documented that tasks performed in April 2025 included gastric tube feedings and wound care.
There was no documentation on the POC which provided evidence that DCW tasks included GT feedings nor wound care.
During telephone interview conducted on May 7, 2025 at approximately 2:20 PM, the consumer reported the consumer does not require wound care nor GT feedings and that that those tasks are not performed by the DCW.
During interview conducted on May 7, 2025 at approximately 4:30 PM, the local administrator confirmed the agency failed to ensure completed tasks included on the direct care worker (DCW) duties report were in accordance with the POC for the above referenced consumers.
Plan of Correction:Agency completed a staff Inservice training and completed refresher training on 5/9/25- implemented a POC training process that includes a specific notation process to be proof of POC training of type, scope, amount, type & frequency. Compliance agency staff per each office will monthly audit 5 caregivers to review EVV/timesheets against participant approved POC to ensure only authorized services being provided.
Each service location Office Administrator will be responsible for reviewing caregiver audits once completed to confirm services are being provided per POC.
Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on May 7, 2025, with the off-site portion of the survey being completed on May 8, 2025, Complete Homecare, Inc. was found not to be in compliance with the following requirement of 35 P.S. 448.809 (b).
Plan of Correction:
35 P. S. § 448.809b LICENSURE
Photo Id Reg
Name - Component - 00
Law amended July 11, 2022 Act 79 2022 HB 2604
(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.
(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.
(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.
(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.
Observations:
Based on review of agency documentation and personnel files and based on interview with the local administrator (Employee #7), the agency failed to ensure the job title occupied a one-half inch tall strip as close to the bottom edge of the photo ID badge as practicable for five (5) of five (5) active direct care workers (DCW). (Employees #1, #2, #3, #4 and #5)
Findings included:
On May 7, 2025 at approximately 2:49 PM, review of the "Employee Handbook" revealed the following under "Appearance/Attire Guidelines/Dress Code":
All employees...will be provided with a photo ID badge which must be worn in an obvious place at all times while on duty.
On May 7, 2025 at approximately 3:05 PM and May 8, 2025 at approximately 10:14 AM, review of personnel file documentation revealed the agency telephone number was located at the bottom portion of the photo ID badge and that the DCW job title was located above the telephone number for the active DCW's (Employees #1, #2, #3, #4 and #5). The DCW job title did not occupy a one-half inch tall strip as close to the bottom edge of the photo ID badge as practicable for the aforementioned DCW's.
During interview conducted on May 7, 2025 at approximately 4:30 PM, the local administrator confirmed the direct care worker job title did not occupy the one-half inch tall strip as close to the bottom edge of the photo ID badge as practicable for the above referenced DCW's.
Plan of Correction:Agency has updated employee photo ID badge template to be in regulation (Section 809b of the Health Care Facilities Act 35 P.S. § 448.809b). Photo ID badges are being updated for direct care staff to display job title "Direct Care Worker" in large block type on a one-half strip at the bottom edge of the badge.
Each service location Office Administrator will ensure all direct care staff photo ID badges are in regulation.
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