Inspection Reports for Professional and Quality Home Care
1180 McKendree Church Rd, Lawrenceville, GA 30043, GA, 30043
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Inspection Report
Routine
Deficiencies: 4
Aug 13, 2024
Visit Reason
The purpose of this visit was to conduct a periodic compliance survey on 8/13/2024.
Findings
Rule violations were cited related to governance, personnel records, supervisory visits, and service plan reviews. Deficiencies included missing policies, incomplete employee records, lack of vital signs documentation during supervisory visits, and failure to timely review and update service plans.
Severity Breakdown
D: 3
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Governing body failed to ensure agency developed and implemented policies and procedures in accordance with rules; missing documentation of policies for Service Plan Content. | D |
| Provider failed to maintain complete personnel records for 4 of 4 employees sampled, including missing emergency contact, TB tests, signed abuse statements, orientation dates, CPR certification, and other required documents. | D |
| Client supervisory visits failed to include all required elements for 1 of 3 sampled clients; vital signs documentation was missing. | D |
| Service plans were not reviewed and updated at the time of each supervisory visit or whenever there were changes for 3 of 3 sampled clients. | E |
Report Facts
Employees with incomplete personnel records: 4
Sampled clients with supervisory visit deficiencies: 1
Sampled clients with service plan review deficiencies: 3
Inspection Report
Follow-Up
Deficiencies: 0
Aug 8, 2023
Visit Reason
The purpose of this visit was to conduct the follow-up to the 4/26/2023 compliance inspection.
Findings
No rule violation was cited as a result of this inspection.
Inspection Report
Routine
Deficiencies: 7
Apr 26, 2023
Visit Reason
The purpose of this visit was to conduct a periodic compliance survey on 4/26/2023.
Findings
The inspection identified multiple deficiencies including failure to conduct required criminal background checks for staff, lack of policies to determine medically frail or medically compromised clients, incomplete or missing service agreements and service plans for clients, failure to document supervisory home visits, and lack of documentation of personal care tasks performed for clients.
Severity Breakdown
F: 2
D: 5
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure staff hired after October 1, 2019 had required criminal background checks after 30 days of employment for 1 of 6 sampled staff. | F |
| Failure to establish policy and procedure to determine whether clients may be medically frail and/or medically compromised for 4 of 4 sampled clients. | F |
| Failure to ensure the service agreement documented a start of care date for 1 of 4 sampled clients. | D |
| Failure to ensure a service agreement was included in the record for 4 of 4 clients sampled. | D |
| Failure to ensure a service plan was included in the record for 4 of 4 clients sampled. | D |
| Failure to document routine quarterly supervisory visits for 1 of 4 sampled clients. | D |
| Failure to ensure documentation of personal care tasks and/or companion sitter tasks performed were incorporated in the client files for 4 of 4 sampled clients. | D |
Report Facts
Sampled staff: 6
Sampled clients: 4
Supervisory visit interval: 92
Personal care service frequency: 7
Personal care service hours: 8
Personal care service frequency: 2
Personal care service hours: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding deficiencies and exit conference | |
| Staff D | Sampled staff lacking required criminal background check |
Inspection Report
Follow-Up
Deficiencies: 0
Feb 28, 2022
Visit Reason
The purpose of this visit was to conduct the follow-up to the 11-2-2021 compliance inspection.
Findings
No rule violation was cited as a result of this inspection.
Inspection Report
Follow-Up
Deficiencies: 19
Nov 2, 2021
Visit Reason
The purpose of this visit was to conduct the follow-up to the 6-16-2021 compliance inspection.
Findings
The inspection found multiple deficiencies related to personnel files, service agreements, service plans, employee qualifications, supervision, and documentation. The provider failed to ensure required criminal background checks, employment history, orientation and training documentation, and proper service plan completion. Service agreements lacked required elements such as referral dates, service descriptions, charges, and client rights acknowledgments. Staff did not provide personal care services according to client service plans, and supervisory reviews were not documented.
Severity Breakdown
E: 16
D: 1
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to ensure staff hired after October 1, 2019 had required criminal background checks after 30 days of employment for 2 of 4 staff. | E |
| Failed to maintain documentation as an employee for unlicensed professionals for 1 of 4 staff. | E |
| Failed to submit an acceptable plan of correction within ten days of receipt of the written report. | D |
| Failed to establish policy and procedure to determine whether clients may be medically frail and/or medically compromised for 3 of 3 clients. | E |
| Failed to document referral date for services on service agreements for 3 of 3 clients. | E |
| Failed to provide description of services needed as stated by client or responsible party for 3 of 3 clients. | E |
| Failed to provide description of services to be provided, expected frequency, and duration for 3 of 3 clients. | E |
| Failed to provide charges for services and mechanisms for billing and payment for 3 of 3 clients. | E |
| Failed to ensure service agreements included acknowledgment of receipt of client's rights for 3 of 3 clients. | E |
| Failed to ensure service agreements included authorization for access to client's funds or vehicle for 3 of 3 clients. | E |
| Failed to document revisions to initial service agreement noting specific changes for 3 of 3 clients. | E |
| Failed to document referral source for 3 of 3 clients. | E |
| Failed to provide five-year employment history for 2 of 4 staff. | E |
| Failed to include documentation of orientation and training for 1 of 4 staff. | E |
| Failed to ensure employees providing personal care were qualified as CNA or completed required competency tests for 2 of 4 staff. | E |
| Failed to ensure staff provided personal care services in accordance with client service plans for 3 of 3 clients. | E |
| Failed to ensure documentation of supervisory review of services provided by staff for 3 of 3 clients. | E |
| Failed to ensure service plans were completed by an appropriate supervisor for 3 of 3 clients. | E |
| Failed to utilize complete and comprehensive service plans documenting all required elements for 3 of 3 clients. | E |
Report Facts
Staff without criminal background checks: 2
Clients with incomplete service agreements: 3
Clients with incomplete service plans: 3
Staff lacking five-year employment history: 2
Staff lacking orientation documentation: 1
Staff not qualified as CNA or completed competency tests: 2
Clients without documented supervisory review: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Personal Care Assistant | Failed to have required criminal background check, five-year employment history, and CNA qualification. |
| Staff C | Personal Care Assistant | Failed to have required criminal background check, five-year employment history, orientation documentation, and CNA qualification. |
| Staff D | Interviewed multiple times; stated lack of understanding of follow-up survey and acknowledged missing client files. | |
| Staff G | Interviewed regarding employee records and orientation documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 2, 2021
Visit Reason
The purpose of this visit was to investigate complaint #GA00217544.
Findings
Rule violations were cited due to failure to ensure documentation of personal care tasks actually performed for 1 of 4 sampled clients. Specifically, no task sheets were provided for Client #1 for July 21-31, August, and September 2021.
Complaint Details
Complaint #GA00217544 was investigated and substantiated with rule violations cited.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure documentation of personal care tasks actually performed for Client #1. | SS= D |
Report Facts
Clients sampled: 4
Days per week: 4
Hours per day: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff AA | Interviewed regarding missing task sheets for Client #1 |
Inspection Report
Original Licensing
Deficiencies: 15
Jun 16, 2021
Visit Reason
An initial onsite licensure survey was conducted to assess compliance with state regulations for private home care providers.
Findings
The inspection identified multiple deficiencies related to personnel files, service agreements, employee qualifications, supervision, and service plans. The provider failed to maintain required documentation for staff background checks, employment history, TB screening, orientation, and training. Service agreements lacked essential elements such as referral dates, service descriptions, charges, client rights acknowledgment, and authorization for access to client funds or vehicles. Service plans were incomplete and not signed off by qualified supervisors. Staff provided personal care services not aligned with client service plans.
Severity Breakdown
SS= D: 15
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure staff hired after October 1, 2019 had required criminal background checks after 30 days of employment for 2 of 4 staff. | SS= D |
| Failed to maintain documentation of unlicensed professionals as employees, including missing signed W-4 form for 1 of 4 staff. | SS= D |
| Governing body failed to develop and implement required policies and procedures, including service agreements and nursing/companion services policies. | SS= D |
| Failed to establish policy to determine medically frail/compromised status for clients. | SS= D |
| Service agreements lacked documentation of referral date, description of services needed, description of services to be provided with frequency and duration, charges and billing mechanisms, acknowledgment of client rights, and authorization for access to client funds or vehicles. | SS= D |
| Failed to document revisions to initial service agreements noting specific changes in services for clients. | SS= D |
| Failed to document referral source for clients. | SS= D |
| Failed to provide five-year employment history for 2 of 4 staff. | SS= D |
| Employee records lacked documentation of satisfactory tuberculosis screening tests for 3 of 4 staff. | SS= D |
| Employee files lacked documentation of orientation and training for 2 of 4 staff. | SS= D |
| Failed to ensure employees providing personal care were qualified as certified nursing assistants or completed required competency tests for 2 of 4 staff. | SS= D |
| Staff provided personal care services not in accordance with clients' service plans for 3 clients. | SS= D |
| Failed to ensure documentation of supervisory review of services provided by staff for 3 clients. | SS= D |
| Service plans were completed by an unqualified supervisor for 3 clients. | SS= D |
| Service plans were incomplete, lacking documentation of duration of hours, goals/objectives, discharge plans, diagnoses, medications, treatments, equipment needs, and diet/nutritional needs for 3 clients. | SS= D |
Report Facts
Staff without criminal background checks: 2
Clients with incomplete service agreements: 3
Staff lacking five-year employment history: 2
Staff lacking TB screening documentation: 3
Staff lacking orientation and training documentation: 2
Clients with incomplete service plans: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Personal Care Assistant | Failed to have required criminal background check, five-year employment history, TB screening, orientation, training, and competency test documentation. |
| Staff C | Personal Care Assistant | Failed to have required criminal background check, five-year employment history, orientation, training, and competency test documentation. |
| Staff D | Owner | Interviewed and acknowledged deficiencies; completed service plans but not qualified as supervisor. |
| Staff A | Registered Nurse | Lacked documentation of TB screening and orientation. |
| Staff G | Interviewed regarding orientation and training documentation deficiencies. |
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