Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on April 14, 2026, Lifetime Skills Home Healthcare Services Company was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on April 14, 2026, Lifetime Skills Home Healthcare Services Company 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:
611.55(e) LICENSURE
Competency Requirements
Name - Component - 00
The competency review must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction.
Observations:
Based on review of personnel files (PF), and interview with the administrator, it was determined that the agency failed to ensure personnel files included documentation that the home care agency or home care registry reviewed the direct care worker ' s competency on hire and annually, for five (5) of five (5) personnel files reviewed. (PF1, PF2, PF3, PF4, and PF5)
Findings Include:
Review of personnel files (PF) on 4/14/2026 from approximately 10:58AM until approximately 11:42AM revealed:
PF1 - Date of Hire (3/20/2024): File did not contain documentation for initial competency evaluation on hire or annual competency evaluation for 2025.
PF2 - Date of Hire (10/15/2019): File did not contain annual competency evaluation documentation for 2021, 2022, and 2023.
PF3 - Date of Hire (8/25/2024): File did not contain annual competency evaluation documentation for 2025.
PF4 - Date of Hire (7/27/2020): File did not contain annual competency evaluation documentation for 2021, 2022, 2023, 2024, and 2025.
PF5 - Date of Hire (10/16/2019): File did not contain annual competency evaluation documentation for 2022, 2023, 2024, and 2025.
An interview with the administrator on 4/14/2026 at approximately 12:15PM confirmed the above findings.
Plan of Correction:Administrator will take corrective action to ensure personnel files include documentation that home care agency or home registry test the direct care worker's competency on hire and thereafter annually for five (5) of five (5) personnel files reviewed during survey on 04/14/2026. (PF1, PF2, PF3, PF4 and PF5) and results of tests will be filed in direct care workers' files. In addition, all future direct care worker competency must be tested upon hire This measure will take effect as of 06/26/26.
Administrator will have PF1-test for 2025, PF2 -test for 2021,2022 and 2023, PF3 - test for 2025, PF4 -test for 2021, 2022,2023,2024 and 2025 and PF5 take the competency test for 2022,2023,2024 and 2025. These tests shall be taken to comply with requirements of the home care agency or home care registry review of direct care worker competency test on hiring per department regulations. In addition, a data spreadsheet shall be set up with names of direct care workers and dates of completion of competency test requirements to ensure that there are no reoccurrences of such deficiencies at future reviews of personnel files.
611.56(a) LICENSURE
Health Screening
Name - Component - 00
The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.
Observations:
Based on review of personnel files (PF), and interview with the administrator, it was determined that personnel files did not include documentation conducted in accordance with CDC guidelines, for five (5) of five (5) personnel files reviewed. (PF1, PF2, PF3, PF4, and PF5)
Findings Include:
"Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019 - Historically, U.S. health care personnel were at increased risk for latent TB infection (LTBI) and TB disease from occupational exposures, but recent data suggest that this is no longer the case. CDC and the National Tuberculosis Controllers Association have updated the 2005 CDC recommendations for testing health care personnel. The update includes 1) TB risk assessment, symptom screening, and TB testing upon hire with a TB blood test (e.g., interferon-gamma release assay) or tuberculin skin test for those without documented prior TB or LTBI; 2) no annual TB testing for most health care personnel without a known exposure or ongoing transmission; 3) for health care personnel with LTBI treatment is strongly encouraged; 4) annual symptom screening for health care personnel with untreated LTBI; and 5) annual TB education for all health care personnel. These recommendations apply to health care personnel and volunteers in all health care settings. However, state and local TB screening and testing regulations may have different requirements."
Findings Include:
Review of personnel files (PF) on 4/14/2026 from approximately 10:58AM until approximately 11:42AM revealed:
PF1 - Date of Hire (3/20/2024): File did not contain documentation for any form of TB testing (i.e., 2-Step PPD skin test, QuantiFERON blood test). File did not contain documentation for a TB symptom screen and TB risk assessment on hire, or annual TB education for 2025.
PF2 - Date of Hire (10/15/2019): File did not contain documentation for a TB symptom screen and TB risk assessment on hire, or annual TB education for 2020, 2021, 2022, 2023, 2024, and 2025.
PF3 - Date of Hire (8/25/2024): File did not contain documentation for a TB symptom screen and TB risk assessment on hire, or annual TB education for 2025.
PF4 - Date of Hire (7/27/2020): File did not contain documentation for a TB symptom screen and TB risk assessment on hire, or annual TB education for 2021, 2022, 2023, 2024, and 2025.
PF2 - Date of Hire (10/15/2019): File did not contain documentation for annual TB education for 2021, 2022, 2023, 2024, and 2025.
An interview with the administrator on 4/14/2026 at approximately 12:15PM confirmed the above findings.
Plan of Correction:Administrator will ensure that all direct care worker upon hire have their TB Test and or annual PPD test done prior to hire or working with participants in accordance with CDC guidelines. Administrator will ensure that the five (5) personnel files that were reviewed, (PF1 - for year 2025, PF2 for years 2020,2021,2022,2023,2024,2025, PF3 for year 2025, PF4 - for years 2021,2022,2023,2024 and 2025 and PF5 -for years 2020,2021,2022,2023,2024,2025) The direct care workers shall have their PPD and or TB test done and completed to be in compliance with CDC guidelines. Administrator will ensure that no new hire works with participants until all physical and PPD tests are done and results completed and finalized prior to the direct care worker commencing work with a participant. Administrator will have PF1-test for 2025, PF2 -test for 2021,2022 and 2023, PF3 - test for 2025, PF4 -test for 2021, 2022,2023,2024 and 2025 and PF5 take the competency test for 2022,2023,2024 and 2025. These PPD (2-step PPD tests) tests or screenings shall be done and completed shall be taken to comply with requirements of the home care agency or home care registry review of direct care worker 2-steps PPD tests prior to hiring per department regulation requirements. In addition, a data spreadsheet shall be set up with names of direct care workers and dates of completion of PPD screenings (2-step PPD tests) requirements to serve as a reminder to office staff, to ensure that there are no reoccurrences of such deficiencies at future reviews of personnel files.
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.
Observations:
Based on review of consumer records (CR), and interview with the administrator, it was determined that the agency failed to ensure that consumer rights were protected by providing services per service agreement, for one (1) of five (5) consumer records (CR) reviewed. (CR5)
Findings Include:
Review of consumer records (CR) was conducted on 4/14/2026 from approximately 9:47AM until approximately 10:52AM revealed:
CR5 - (Start of Care): 4/8/2022 - Consumer receives personal assistive services for six (6) hours per day (Monday through Saturday); and seven (7) hours per day (Sunday).
Reviewed visit calendars on 4/14/2026 from approximately 11:43AM until approximately 11:58AM. Services were provided for six (6) hours per day (Monday through Saturday); and seven (7) hours per day (Sunday) per service agreement for the timeframe of 3/1/2026 through 4/12/2026, with the following exceptions:
3/19/2026: The agency did not have documentation to confirm that services were provided for the entire shift of six (6) hours.
4/1/2026: The agency did not have documentation to confirm that services were provided for the entire shift of six (6) hours.
4/2/2026: The agency did not have documentation to confirm that services were provided for the entire shift of six (6) hours.
4/3/2026: The agency did not have documentation to confirm that services were provided for the entire shift of six (6) hours.
4/8/2026: The agency did not have documentation to confirm that services were provided for the entire shift of six (6) hours.
An interview with the administrator on 4/14/2026 at approximately 12:15PM confirmed the above findings.
Plan of Correction:Administrator shall ensure that (CR5) consumer personal assistive services be fully utilized for the 6 hours per day from Monday thru Saturday and 7 hours per day on Sundays per the participants service agreement. If for some reason, the participant goes for a doctor's visit for the day, Administrator will have the visit noted in HHaexchange so that the participant does not lose the hours and the hours can be used another day in the future if allowed by the MCO. The dates reviewed by the surveyor from 3/1/2026 thru 4/12/2026 with exceptions on 3/19/2026, 4/1/2026,4/2/2026,4/3/2026 and 4/8/2026 that services were not provided to the participant in HHaexchange shall upon review and verified be deleted in HHaexchange and subsequently added back to CR5 in HHaexchange as additional service hours that were not used by the participant to be used at a future time. To avoid future reoccurrences, Administrator shall check weekly to ensure that service hours are used and if not used, deleted and added back to participants hours to be use at later dates in the future and in addition a database shall be created to have same done to every participant to avoid any future reoccurrences of participants not be able to utilize service hours that were not use as a result of hospital or other medical visits and or hours not utilized at all be participants.
611.57(c) LICENSURE
Information to be Provided
Name - Component - 00
(c) Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.
Observations:
Based on review of consumer records, and interview with the administrator, it was determined that the agency failed to ensure consumer service agreements included a listing of the available home care services that will be provided to the consumer by the Direct Care Worker, and a disclosure that addressed the employee or independent contractor status of the Direct Care worker providing services for the consumer, for five (5) of five (5) consumer records (CR) reviewed. (CR1, CR2, CR3, CR4, and CR5)
Findings Include:
Review of consumer records (CR) was conducted on 4/14/2026 from approximately 9:47AM until approximately 10:52AM revealed:
CR1 - (Start of Care): 10/26/2021 - The consumer record did not contain a listing of available home care services that will be provided to the consumer by the Direct Care Worker.
CR2 - (Start of Care): 10/26/2020 - The consumer record did not contain a listing of available home care services that will be provided to the consumer by the Direct Care Worker.
CR3 - (Start of Care): 4/13/2016 - The consumer record did not contain a Direct Care Worker status form.
CR4 - (Start of Care): 3/21/2024 - The consumer record did not contain a listing of available home care services that will be provided to the consumer by the Direct Care Worker.
CR5 - (Start of Care): 4/8/2022 - The consumer record did not contain a listing of available home care services that will be provided to the consumer by the Direct Care Worker.
An interview with the administrator on 4/14/2026 at approximately 12:15PM confirmed the above findings.
Plan of Correction:Administrator shall ensure that consumer services agreements include a listing of the available home care services that shall be provided to the consumer by the direct care worker, and a disclosure that addressees the employee or independent contractor status of the Direct Care Worker providing services for the consumer, for all five (5) consumer records (CR) reviewed (CR1,CR2,CR3,CR4 and CR5). These documents shall be placed in the Consumer Record files on or before 06/13/2026 to correct this deficiency. In addition, Administrator shall create a database with names of all consumers stating those with consumer service agreements related to listing of the available home care services that will be provided to consumer by the Direct Care Worker, and a disclosure that addresses the employee or independent contractor status of the Direct Care Worker providing services for the Consumer, for all consumers to avoid any future reoccurrences of this deficiency by the agency during surveys by the department.
Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on April 14, 2026, Lifetime Skills Home Healthcare Services Company was found to be in compliance with the requirements of 35 P.S. 448.809(b).
Plan of Correction:
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