QA Investigation Results

Pennsylvania Department of Health
Health Inspection Results
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Initial Comments:

Based on the findings of an unannounced complaint investigation survey conducted on April 3, 2024 and offsite on April 19 and 25, 2024, 365 Health Services LLC 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.


Based on a review of consumer record (CR), electronic visit verification (EVV) and an interview with agency's executive director, it was determined that agency failed to provide written notice at least 10 days prior to terminate services for one (1) of four (4) CRs (CR#1).

Findings include:

A review of consumer records was conducted on April 3, 2024. The Start of Care (SOC) and Last day of Service (LDOS) are shown below.

CR#1 SOC 12/22.23, LDOS 2/28/2024 contained" Consumer Service Agreement " and it reads service is to be provided on Sundays through Saturdays 11 PM - 7AM and 9AM - 9PM. A review of EVV revealed that the last day of service was on 3/17/24. CR#1 did not contain a 10 day termination of service notification.

An interview with agency ' s and executive director on April 3, 2024 and vice president of operations on April 12, 2024 revealed that insurance company for CR1 terminated the service authorization and confirmed that the agency did not give 10-day notice to the consumer.

Plan of Correction:

An inservice education will be held by 06/24/2024 with all management staff to make them aware per regulatory guidelines, of the need to provide at least 10 days prior written notice to terminate a consumer from agency services; and if any payer source such as the Medicaid MCO Supports Coordinator communicates that the consumer's services are to be terminated this must be documented in the record for confirmation and then this must be confirmed with the consumer and/or responsible person/party that they are choosing to terminate services with the agency and this must also be documented in the consumer record.

Staff sign-in sheets, agenda and training documentation will be available on site.

The Executive Director is responsible. Completion date 06/24/2024.