Health Regulation & Licensing Administration - Statement of Deficiencies and Plan of Correction - 04/11/2014

Aug 30, 2026

Survey documentation detailing findings following an onsite investigation by the Department of Health/Health Regulation and Licensing Administration regarding alleged noncompliance involving Premium Select Home Care, Inc. The report summarizes record reviews and interviews connected to PCA services, including authorization details, patient admission and discharge timelines, and references to related Medicaid prior authorization notices. It records the case context involving a patient who died while awaiting PCA services and provides structured deficiency statements with a corresponding plan of correction framework.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages8

Reading Time20 min

AccessFree to download

Initial Comments

Investigation basis and timeline

Record review findings

Interviews and confirmation

# Health Requlation &Licensing Administration | STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION | | (X1)PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
HCA-0009 | (X2)MULTIPLE CONSTRUCTION
A.BUILDING
B.WING_ | | (X3)DATE SURVEY
COMPLETED
C
04/11/2014 | | | --- | --- | --- | --- | --- | --- | --- | | STREETADDRESS,CITY,STATE,ZIP CODE
NAME OF PROVIDER OR SUPPLIER
5513 ILLINOIS AVENUE,NE
PREMIUM SELECT HOME CARE,INC
WASHINGTON,DC 20011 | | | | | | | | (X4)ID
PREFIX
TAG | SUMMARY STATEMENT OF DEFICLENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION) | | ID
PREFIX
TAG | PROVIDER'S PLAN OF CORRECTICN
(EACH CORRECTIVEACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY) | | (X5)
COMPLETE
DATE | | H 000 | |INITIAL COMMENTS
On April 2,2014,the Department of Health/Health
Regulation and Licensing Administration
(DOH/HRLA)received information alleging that a
patient died awaiting PCA services from Premium
Select Home Care,Inc.Due to the nature of the
information presented,on April 3,2014,
DOH/HRLA initiated an onsite investigation,to
verify compliance with the basic standards of
practice and Title 22,Chapter 39(Home Care
Agencies Regulations).The findings of the
investigation were based on record reviews and
interviews.
Please Note:Listed below are abbreviations used
in this report.
Cardiopulmonary Resuscitation(CPR)
Department of Health (DOH)
Department of Health Care Finance(DHCF)
Health Regulation and Licensing Administration
(HRLA)
Home Care Agency(HCA)
Home Health Aide(HHA)
Human Resources(HR)
Personal Care Aide(PCA)
Plan of Care(POC)
She/He(S/he)
Purified Protein Derivative(PPD)
Allegation\#1-Patient\#1 died while awaiting PCA
services from Premium Select Home Care,Inc.
Findings-Record reviews and interviews starting
at approximately 9:00 am,on April 3,2014
through April 11,2014 revealed the following:
-Review of "Notification of Approved Personal
Care Aide(PCA)Services Initial Assessment", | | H 000 | | | | Health Regulation &Licensing Administration 14 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVES SIGNATURETITLESTATE FORMunlala十a儿 698 SDKB11 Health Requlation &Licensing Administration | STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION | | (X1)PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER;
HCA-0009 | (X2)MULTIPLE CONSTRUCTION
A.BUILDING.
BWING. | | (X3)DATE SURVEY
COMPLETED
C
04/11/2014 | | | --- | --- | --- | --- | --- | --- | --- | | STREETADDRESS,CITY,STATE,ZIP CODE
NAME OF PROVIDER OR SUPPLIER
5513ILLINOIS AVENUE,NE
PREMIUM SELECT HOME CARE,INC
WASHINGTON,DC 20011 | | | | | | | | (X4)ID
PREFIX
TAG | SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION) | | ID
PREFIX
TAG | PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVEACTION SHOULD BE
CROSS-REFERENCED TO THEAPPROPRIATE
DEFICIENCY) | | (X5)
COMPLETE
DATE | | H 000 | |Continued From page 1
dated March 12,2014,revealed Patient\#1's
physician requested PCA service on March 5,
2014;
-Review of hospital discharge records from
Medstar Health,dated March 10,2014,revealed
that Patient\#1 was admitted to the Georgetown
hospital on March 6,2014,from a licensed "long
term care facility";
-Review of "Notification of Approval Personal
Care Aide(PCA)Services Initial Assessment",
dated March 12,2014,revealed that Patient\#1
was assessed on March 8,2014,by Delmarva
for PCA services while at Georgetown hospital.
According t

FAQs

What triggered the investigation by the Department of Health/Health Regulation and Licensing Administration?

The investigation was initiated after receiving information alleging a patient died while awaiting PCA services provided by Premium Select Home Care, Inc.

What sources were used to determine the findings?

Findings were based on record reviews and interviews conducted from approximately 9:00 am on April 3, 2014 through April 11, 2014.

What timeframe was included in the PCA service authorization information?

The documentation states PCA services were authorized for eight hours a day, seven days a week, with service dates spanning from March 8, 2014 through September 6, 2014, and also includes Medicaid approval information from March 5, 2014 through August 31, 2014.

Aug 30, 2026

Upload by Chloe Bennett