Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Routine
Deficiencies: 0
Feb 12, 2020
Visit Reason
The purpose of this visit was to conduct a periodic compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Follow-Up
Deficiencies: 3
Jan 15, 2019
Visit Reason
The purpose of this visit was to conduct a follow up to the 7/31/18 inspection. Rule violations were cited as a result of this inspection.
Findings
The inspection found that service agreements for some clients lacked documentation of frequency, duration, and charges for services. Additionally, personnel records were incomplete, lacking current CPR certification for one employee.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Service agreements failed to include documentation of the frequency and/or duration of services for three of six sampled clients (#1, #4, #6). | D |
| Service agreement lacked documentation of charges for services and mechanism for billing and payment for one of six sampled clients (#1). | D |
| Personnel records lacked documentation of employee qualifications, including current CPR certification for one of seven sampled employees (#5). | D |
Report Facts
Sampled clients: 6
Sampled employees: 7
Clients with deficient service agreements: 3
Clients with deficient charges documentation: 1
Employees lacking current CPR certification: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #8 | Interviewed during inspection; offered no explanation for deficiencies | |
| Employee #5 | Personal Care Assistant | Provided services to a client; lacked current CPR certification |
Inspection Report
Original Licensing
Deficiencies: 5
Jul 31, 2018
Visit Reason
An initial licensure survey was conducted to determine compliance with the Rules and Regulation for Private Home Care Providers.
Findings
The provider was found not in substantial compliance with regulations, with deficiencies including providing services outside licensed counties, failure to provide timely access to client records, failure to document revisions to service agreements, lack of documentation of personal care tasks performed, and incomplete service plans missing required elements.
Severity Breakdown
D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Governing body failed to provide services according to licensed counties; services were provided in unlicensed counties Marion, Macon, and Crisp. | D |
| Agency failed to ensure timely access to clients' records; records for some employees were not provided timely. | D |
| Failed to document revisions to initial service agreements noting specific changes in services for 3 of 6 sampled clients. | D |
| Failed to ensure documentation of personal care tasks actually performed for 2 of 6 sampled clients. | D |
| Failed to utilize complete and comprehensive service plans documenting all required elements for 6 of 6 sampled clients; service plans lacked documentation of functional limitations, equipment, and diet. | D |
Report Facts
Sampled clients: 6
Clients with undocumented service agreement revisions: 3
Clients with missing documentation of personal care tasks: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employees #8 and #9 interviewed regarding governing body and records access; Employee #8 interviewed regarding documentation and service plan deficiencies |
Inspection Report
Original Licensing
Deficiencies: 0
Apr 17, 2018
Visit Reason
A provisional licensure survey was conducted to review policies, procedures, personnel records, and client record forms for compliance with the Rules and Regulations for Private Home Care Providers.
Findings
No deficiencies were cited during the provisional licensure survey. A provisional license was issued valid from April 17, 2018 through March 31, 2019.
Report Facts
License effective period days: 349
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