Inspection Report Summary
The most recent inspection on April 16, 2024, identified a deficiency related to staff not providing personal care services according to a client’s service plan. Earlier inspections showed a pattern of deficiencies including incomplete personnel records, missing documentation of supervisory visits, incomplete client service agreements and plans, and lack of an effective quality improvement program. Complaint investigations were substantiated in the most recent visit, with repeated issues around personal care services and staffing challenges. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history indicates ongoing challenges with documentation and service delivery, with no clear improvement trend over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 16, 2024
Visit Reason
The purpose of this visit was to investigate complaint GA00244425.
Complaint Details
Visit was complaint-related for complaint GA00244425. Rule violations were cited. The deficiency was previously cited on 12/12/2023.
Findings
The provider failed to ensure staff provided personal care services in accordance with the client's service plan for one of four clients sampled. Specifically, Client #3 did not receive documented personal care services on two occasions in March 2024 due to caregiver call-outs and inability to replace staff.
Deficiencies (1)
Failure to ensure staff provided personal care services in accordance with client's service plan for Client #3.
Report Facts
Clients sampled: 4
Hours of service: 8
Days per week: 7
Dates with no documented service: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed on April 16, 2024 regarding caregiver call-outs and inability to replace staff |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Feb 26, 2024
Visit Reason
The purpose of this visit was to conduct the follow-up to the December 12, 2023 compliance inspection.
Findings
Rule violations were cited including incomplete personnel records for three of four sampled employees, inadequate documentation of supervisory visits for one of three sampled clients, and failure to implement a quality improvement program as required.
Deficiencies (3)
Failed to maintain complete personnel records for three of four sampled employees, missing five-year employment history and CPR/First Aid documentation.
Client supervisory visits failed to include all required elements such as review of progress, client satisfaction, and appropriateness of services for one of three sampled clients.
Failed to provide documentation reflecting an effective quality improvement program that continuously monitors program performance and client outcomes.
Report Facts
Sampled employees with incomplete records: 3
Sampled clients with supervisory visit deficiencies: 1
Supervisory visit frequency requirement: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed and provided statements during exit conference regarding deficiencies and corrective actions. | |
| Staff B | Employee with incomplete personnel records missing five-year employment history and CPR/First Aid. | |
| Staff C | Employee with incomplete personnel records missing five-year employment history and CPR/First Aid. | |
| Staff E | Employee with incomplete personnel records missing in-person CPR/First Aid. |
Inspection Report
Routine
Deficiencies: 11
Date: Dec 12, 2023
Visit Reason
The purpose of this visit was to conduct a periodic compliance survey on December 12, 2023.
Findings
The inspection identified multiple rule violations including failure to conduct required criminal background checks for staff, incomplete client service agreements and plans, missing documentation of supervisory reviews, incomplete personnel records, and lack of an effective quality improvement program.
Deficiencies (11)
Failed to ensure staff hired had required criminal background checks after 30 days of employment for one of four sampled staff.
Failed to establish a policy and procedure to determine whether clients may be medically frail and/or medically compromised for three sampled clients.
Failed to ensure service agreements included all required elements for three sampled clients.
Failed to ensure service agreements included signatures for the provider's representative and the client or responsible party, and/or the date signed for two sampled clients.
Failed to ensure a complete service plan was included in the record for three sampled clients.
Failed to document the referral source for one sampled client.
Failed to maintain complete personnel records for four sampled employees, missing employment history, TB screening, CPR/First Aid, and qualifications.
Failed to ensure staff provided personal care services in accordance with client's service plans for one sampled client.
Failed to ensure documentation of supervisory review of services provided by staff for three sampled clients.
Failed to ensure supervisory home visits included all required elements for three sampled clients.
Failed to provide documentation reflecting an effective quality improvement program that continuously monitors the performance of the program and client outcomes.
Report Facts
Number of sampled clients with incomplete service agreements: 3
Number of sampled clients with incomplete service plans: 3
Number of sampled employees with incomplete personnel records: 4
Frequency of personal care services per week in service plan: 3
Frequency of personal care services per week actually provided: 5
Duration of personal care services per day in service plan: 4
Duration of personal care services per day actually provided: 5
Supervisory home visit frequency requirement: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed during exit conference; stated agency will make all changes. | |
| Staff B | Employee record reviewed; missing five-year employment history, TB screening, CPR/First Aid. | |
| Staff C | Employee record reviewed; missing five-year employment history, TB screening, CPR/First Aid; no criminal background check after hire. | |
| Staff D | Employee record reviewed; missing qualifications and CPR/First Aid. | |
| Staff E | Employee record reviewed; missing in-person CPR/First Aid. |
Inspection Report
Original Licensing
Deficiencies: 1
Date: Oct 26, 2021
Visit Reason
The purpose of this visit was to conduct the initial on-site compliance inspection of Divine Angels Home Care, LLC.
Findings
The inspection found that the agency had no active clients at the time of the scheduled compliance visit, preventing access to all records relevant to licensure and provider staff. Rule violations were cited.
Deficiencies (1)
Based on an attempt to conduct an announced compliance visit on 10/27/21, the Department was unable to conduct the visit due to lack of clients and inability to access all records relevant to licensure and provider staff.
Report Facts
Inspection date: Oct 26, 2021
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