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The facility is in the process of reviewing the personnel files for Employees #2, #3, and #5 to identify and resolve missing documentation such as background checks, training verifications, and onboarding materials. Necessary items are currently being collected, verified, and filed to bring each file into full compliance. This corrective action will be fully completed by June 14, 2025.
Protecting Patients in Similar Situations:
-To protect patients from similar risks, the facility is actively conducting a comprehensive audit of all Direct Care Worker (DCW) personnel files for individuals hired after June 2022. This audit is identifying any additional documentation gaps. Direct care workers with incomplete files are being restricted from receiving new assignments or responding to unscheduled visits until their documentation is complete.
Preventing Recurrence – System and Process Enhancements:
-To prevent recurrence, the facility is implementing the following updates:
A revised Pre-Employment Compliance Checklist is being integrated into the hiring process to ensure all regulatory documentation is collected.
An enhanced Onboarding Packet is being rolled out to new hires.
A mandatory HR file review and final approval are required before an employee is added to the active roster.
These improvements are being put in place to ensure consistent compliance from the point of hire forward.
Monitoring Performance – Ensuring Sustainability:
-To sustain improvements, the facility is requiring all personnel documentation to be uploaded into the HR Information System (HRIS) for centralized tracking.
-A designated compliance officer is conducting monthly audits of randomly selected files to verify continued adherence.
-The Administrator is conducting & participating in ongoing training sessions and receiving regular updates on compliance expectations and procedures.
Completion Date:
-All corrective actions will be completed by June 14, 2025.
Responsible Party:
-The staff member responsible for overseeing and ensuring full implementation of this Plan of Correction is the:
Primary Administrator

The agency is addressing the deficiency concerning Employee #6, who was rehired without a current Pennsylvania State Police (PSP) background check or verified documentation of continuous two-year Pennsylvania residency. A new PSP background check is being requested, and Employee #6 is in the process of providing acceptable residency documentation. Both documents will be verified and filed in the personnel record by June 14, 2025. The deadline for Employee #6 to submit required documentation is June 14, 2025, and the employee is not being assigned to clients until compliance is confirmed.
Protecting Clients in Similar Situations:
-To protect other clients, the agency is conducting an internal audit of all current Direct Care Workers (DCWs) to ensure that PSP background checks and residency verifications are present and up to date. Any discrepancies are being flagged and resolved prior to employees being permitted to work independently.
Preventing Recurrence – System Updates:
-To prevent recurrence, the agency is implementing a "New/Rehire Employee Checklist" by June 14, 2025. This checklist requires verification of:
A valid PSP background check dated within 12 months of hire or rehire,
Either proof of two-year Pennsylvania residency, or
FBI fingerprint results if residency cannot be confirmed.
All rehires are being treated as new hires regarding background screening to maintain regulatory compliance.
Monitoring Performance – Sustained Compliance:
-To sustain compliance:
Beginning June 01, 2025, the Administrator is reviewing a monthly report of all new and rehired staff to ensure that onboarding requirements are being fulfilled.
Human Resources is conducting biannual audits of personnel files to verify that background checks and residency documentation remain current.
Staff involved in hiring are receiving annual training on onboarding standards and applicable background check requirements.
Completion Date:
-All corrective actions will be completed by June 14, 2025.
Responsible Party:
-The primary Administrator is overseeing and continuing to monitor this plan of correction.

To correct the deficiency as it relates to the affected individuals, the agency acknowledges that the personnel files of Employees #2, #3, and #5 lacked sufficient documentation verifying Pennsylvania residency for the full two years prior to their hire dates. Each employee will be requested to submit additional supporting documents—such as utility bills, tax returns, or employment records—to verify prior residency, with all available documents to be collected and filed no later than May 19, 2025. To protect other clients in similar situations, a review of all current direct care workers (DCWs) hired after June 2022 is underway to verify the presence of valid two-year PA residency documentation. Any DCW lacking sufficient proof will be required to provide acceptable documents or undergo an FBI fingerprint background check, and no new DCWs will be scheduled for work until complete documentation is obtained and verified. This audit will be completed by May 19, 2025. To ensure the deficiency does not recur, effective May 19, 2025, the Pre-Hire Compliance Checklist will be revised to require either two distinct documents or one verified source covering the whole two-year PA residency period. Where such proof is unavailable, fingerprinting will be initiated in accordance with regulatory guidance. HR staff will also review current and updated residency verification procedures, including acceptable examples and instructions for confirming adequate coverage. To sustain compliance, beginning June 1, 2025, the Administrator will conduct monthly audits of new hire files to ensure residency and background check compliance. In addition, the HR Manager will provide final sign-off on residency verification prior to any new DCW assignment, and compliance results will be reported to agency leadership through a quarterly HR compliance summary.

To correct the deficiency as it relates to the affected individual, the agency acknowledges that Employee #2 was assigned to a client without documented proof of completing a required competency evaluation program. Corrective action will be taken by having Employee #2 complete and sign a post-hire competency evaluation form with supervisory observation and skill validation by May 19, 2025. This completed evaluation will be added to the employee's personnel file and clearly labeled as "Filed post-assignment; not in compliance with initial onboarding standard." To protect other clients in similar situations, an audit of all active direct care workers (DCWs) hired after June 10, 2022, will be completed by May 19, 2025, to ensure each has documented proof of a completed competency evaluation prior to their first assignment. Any employee found lacking such documentation will not be reassigned until competency is evaluated and documented, and no current or future DCWs will be scheduled for client care without verified competency documentation. To ensure the deficiency does not recur, the agency will implement, effective May 19, 2025, a Competency Evaluation Checklist that must be completed, signed by an RN supervisor or designated trainer, and filed before any DCW can be scheduled for client care. A "No Competency, No Assignment" policy will be instituted and incorporated into HR orientation materials.
Additionally, the onboarding tracking system will be updated to include a mandatory "Date of Competency Eval" field that will block scheduling access until completed. To sustain compliance, starting June 1, 2025, the Administrator will conduct monthly audits of new hire files to confirm that competency documentation is present. Supervisory staff will also be required to sign off weekly on new hire readiness checklists. HR and clinical onboarding personnel will attend quarterly training sessions emphasizing the legal and quality assurance importance of verifying competency before assignment.

To correct the deficiency as it relates to the affected individuals, the agency acknowledges that the annual competency evaluations for Employees #1, #4, and #5 were not completed within the required 12-month timeframe. While each employee did complete their most recent evaluation in late 2024, a follow-up review of their files will be conducted and signed by a clinical supervisor by May 19, 2025, to ensure that no further delays occur and future evaluations are scheduled proactively. To protect other clients in similar situations, the agency will review all direct care workers (DCWs) employed for more than 12 months by May 19, 2025, to confirm that annual competency evaluations have been conducted on time. DCWs who are overdue or nearing a 12-month lapse will be prioritized for immediate evaluation, and any employee without a current competency check will be placed on a scheduling freeze until the requirement is met. To prevent recurrence of this deficiency, effective May 19, 2025, the agency will implement a Competency Evaluation Tracking Log within the HR system to monitor due dates and generate alerts 30 days prior to evaluation deadlines. The system will flag overdue evaluations and restrict scheduling for non-compliant staff, and a standing calendar of monthly evaluation sessions will ensure evaluations are conducted regularly and proactively. To sustain compliance, beginning June 1, 2025, the Administrator or a designated staff member will perform monthly audits of DCW competency timelines.

To correct the deficiency as it relates to the affected individuals, the agency acknowledges that Employees #2, #3, #5, and #6 did not have documented TB screening at the time of hire or rehire. To address this, all four employees have been scheduled for baseline TB screening, including a TB symptom evaluation, a risk assessment, and a TB test (via blood test or 2-step skin test) in accordance with CDC guidelines. These screenings will be completed and documented in their personnel files no later than May 19, 2025. To protect other clients in similar situations, a comprehensive audit of all employees hired or rehired since June 1, 2022, is underway to identify any additional staff lacking valid TB documentation. Any employee found with missing or expired TB clearance will be scheduled for immediate screening and temporarily removed from direct consumer contact until clearance is received. This review and follow-up will also be completed by May 19, 2025. To ensure this deficiency does not recur, effective June 1, 2025, the agency will require all prospective hires and rehires to present proof of TB clearance before orientation or assignment. A TB Screening Authorization Form will be incorporated into the pre-hire checklist and must be signed and dated before final employment approval. A standard TB risk assessment tool and symptom review form will also be added to all employee files, and the agency will partner with a mobile testing vendor or designated clinic to ensure easy access to TB testing. To sustain compliance, beginning June 10, 2025, the HR Manager will review TB documentation for all new hires weekly and maintain tracking through the employee health system. An annual TB re-screening calendar will be reviewed monthly, and any lapses will trigger a compliance report and be reviewed with the administrator.

To correct the deficiency as it relates to the affected individuals, the agency acknowledges that annual TB education was not provided or documented in 2022, 2023, or 2024 for Employees #1, #2, #3, #4, #5, and #6. To resolve this, all six staff members will complete a CDC-compliant TB education module covering the basics of TB transmission, symptoms of active TB, infection control practices, and the importance of regular screening. A post-education quiz and signed completion certificate will be obtained and filed in each employee's personnel record by May 19, 2025. To protect other clients in similar situations, the agency is conducting a full TB education compliance review to verify that every employee with direct client contact has received TB education within the past 12 months. Any staff member found non-compliant will be required to complete the training before continuing any client assignments, with full compliance expected by May 19, 2025. To prevent recurrence, the agency will implement, effective June 1, 2025, an Annual TB Education Tracking Log that includes 30-day advance reminders of due dates. TB education will be mandated as part of annual evaluations or recertification sessions, and a new policy requiring yearly TB education will be added to the employee handbook, with documentation kept in personnel files. To sustain compliance, beginning June 1, 2025, the HR department will review and update the TB education log monthly and report any overdue education to supervisors for immediate follow-up. Additionally, a biannual compliance report will be submitted to the Administrator for quality oversight and action.

To correct the deficiency as it relates to the affected individuals, the agency acknowledges that the "Bill of Rights" provided to Consumers #2–#5 did not include the required notification of the right to receive 10 days' advance written notice of discharge. In response, a revised Consumer Bill of Rights has been created that includes the termination notice clause. Updated forms will be issued to all affected consumers along with an explanatory letter, and signed acknowledgments will be obtained and filed in each consumer's chart by May 19, 2025. To protect other clients in similar situations, a full review of all active consumer files will be completed by May 19, 2025, to identify any additional individuals who are missing the updated Bill of Rights. All such consumers will receive the revised document, and confirmation of receipt will be required before the continuation of services. To ensure the deficiency does not recur, effective June 1, 2025, the updated Bill of Rights will be included in all new client onboarding packets, and an onboarding checklist will be implemented to verify that each client has received, reviewed, and signed the document, including the termination clause. Intake staff will also be trained to review this right during onboarding visits or welcome calls, with proper documentation maintained in the client's electronic file. To sustain compliance, beginning June 1, 2025, the Client Services Manager will perform monthly spot audits of newly opened client files to ensure the correct version of the Bill of Rights is included, and quarterly compliance audit results will be presented at agency staff meetings to confirm ongoing adherence.

To correct the deficiency as it relates to the affected individuals, the agency acknowledges that the original "Bill of Rights" provided to Consumers #2–#5 did not include legally required notices regarding prohibitions on power of attorney and check endorsement. To address this, an amended Consumer Bill of Rights has been created to include these specific legal protections. The updated document, along with an explanatory letter, will be issued to all four consumers, and signed acknowledgment forms confirming receipt will be collected and filed in each consumer's chart by May 19, 2025. To protect other clients in similar situations, a review of all active consumer files is underway to identify any additional individuals who did not receive the amended Bill of Rights. All affected clients will be issued the updated version, and signed acknowledgments will be collected by May 19, 2025. To prevent recurrence of this deficiency, effective June 1, 2025, the amended Bill of Rights will be the only version used in all new client onboarding packets. The onboarding checklist will be updated to include confirmation that the revised document was issued and reviewed, and intake staff will be trained to highlight these legal protections specifically during the initial onboarding process. To sustain compliance, beginning June 1, 2025, the Client Services Manager will perform monthly onboarding audits to verify that the correct version of the Bill of Rights is issued and acknowledgment forms are correctly filed. Additionally, quarterly compliance reviews will be conducted to monitor long-term adherence.

To correct the deficiency as it relates to the affected individuals, the agency acknowledges that Consumers #2, #3, #4, and #5 did not receive the complete set of required pre-service disclosures as outlined in §611.57(c). To address this, an amended Information Packet has been developed to include the identity and schedule of the assigned direct care worker, fee and cost structure, PA Department of Health licensing and hotline information, local Ombudsman program contact, direct care worker hiring and competency requirements, and a statement clarifying employee versus independent contractor status. This updated packet will be delivered to the affected consumers along with a cover letter and a signature acknowledgment page by May 19, 2025, and signed forms will be uploaded into each consumer's file. To protect other clients in similar situations, a complete audit of all active client files is underway to identify consumers who may have received incomplete onboarding documentation. All clients found to be missing any of the required disclosures will be provided the updated packet by May 19, 2025, with confirmation of receipt logged. To ensure this deficiency does not recur, effective June 1, 2025, the agency will implement a Pre-Service Consumer Disclosures Checklist for all new clients. The revised packet will be integrated into the electronic onboarding workflow, and no services may begin until the disclosure form is signed and properly filed. All intake staff will undergo mandatory training on the new packet and checklist during a scheduled compliance training session. To sustain compliance, beginning June 1, 2025, the Client Services Manager will conduct monthly audits of newly initiated consumer records to confirm all §611.57(c) documentation is present and signed. Any deviations will be reported to the Administrator and addressed through staff coaching or corrective action, with compliance trends reviewed quarterly during internal quality assurance meetings.

To correct the deficiency as it relates to the affected individual, the agency acknowledges that the photo ID badge for Employee #7 did not meet the legal formatting requirements for job title size and placement. To address this, a new, compliant ID badge will be issued by May 19, 2025, featuring the title "Direct Care Worker" in block type within a one-half inch tall strip located as close to the bottom edge of the badge as practicable, along with all other required elements including a photo, first name, and agency name. To protect other clients in similar situations, an audit of all current employee photo ID badges will be completed by May 19, 2025, to identify any badges that do not meet formatting standards. All noncompliant badges will be reissued with corrected formatting by May 19, 2025, and no staff member will be permitted to engage in fieldwork or direct consumer contact without a compliant badge after that date. To ensure the deficiency does not recur, effective June 1, 2025, a standardized Photo ID Badge Design Template will be adopted for all new employees to ensure legal formatting consistency. The HR onboarding checklist will be updated to include a badge compliance verification step, and the employee handbook will be revised to incorporate a visual ID policy aligned with Act 79 requirements. To sustain compliance, beginning June 1, 2025, the HR Manager will perform quarterly spot checks on 10% of active staff to confirm badge compliance. HR will maintain a badge issuance log that includes a formatting review step prior to distribution.