Initial Comments:
Based on the findings of an unannounced complaint investigation conducted onsite March 31, 2026, offsite April 9, 2026 and onsite April 15, 2026, Villa Home Care, was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
51.3 (g)(1-14) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification
(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.
Observations:
Based on review of agency Complaint/ Incident Log, Department of Health (DOH) Event Reporting system (ERS), and an interview with the Administrator, the agency did not ensure reporting in the ERS system for one (1) of one (1) system reviewed. ERS #1.
Findings include:
Per the Pennsylvania Department of Health Event Reporting System Manual, "...Purpose: To provide a system to enter events per 28 PA Code - 51.3 that is readily available to all appropriate PA-DOH [Pennsylvania Department of Health] facilities, a simple process to insure consistent data entry and submission, and a source for quick and meaningful feedback on event notification submissions...All facilities are required to submit notification of events as defined in 28 Pa Code Chapter 51 to the Department of Health within 24 hours of occurrence or discovery. The Electronic Event Reporting System [ERS] is the mechanism the Department will use to meet this regulatory requirement..."
A review of the ERS#1 conducted on April 9, 2026, at approximately 10:45 am revealed the following:
Agency has not reported any incidents/complaints to the Pennsylvania Department of Health.
Complaint Log Reviewed - Conducted Off-site on April 9, 2026 at approximately 11:00 am
Complaints log included documentation of an incident that was reported on February 6, 2026 regarding patient abuse and neglect allegedly by the Direct Care Worker (DCW) that took place in the consumers home, which was not reported to Pennsylvania Department of Health. Agency contacted Adult Protective Services (APS) regarding allegations of abuse and neglect. Based upon documentation reviewed onsite on April 15, 2026 at approximately 10:15 am, Consumer sister made a report regarding DCW was abused and neglected the consumer. Stated that the patient was not being properly cared for and left in the bed throughout the day and not being bathed. Agency contacted and made a report with APS (adult protective services) regarding allegations. As per an interview with the Office Director conducted on April 15, 2026 at approximately 11:15 am, the consumer would change her story and would admit that it was true and then deny the claims of abuse and neglect. Service coordinator requested that DCW be replaced but consumer refused the change and wanted to keep current DCW. As of 4/10/2026 - the service coordinator indicated that the case with APS was closed as per note in patient electronic chart via HHA eXchange. Office Director stated that they were not aware that the Department of Health should have been notified regarding incidents. Information was provided to agency about Event Report System for the Department of Health.
An interview with the agency Office Director conducted on April 15, 2026 at approximately 11:30 am, the agency understood that all reportable events should be reported to the Department of Health.
Plan of Correction:1. What corrective action will be accomplished for the individual(s) and/or practice identified in the deficiency statement?
We acknowledge that we were previously unaware of the required reporting procedures for abuse and neglect. Following the Department of Health visit, we have now been educated on how to report to the Department of Health in accordance with state requirements. Report will be made to DOH on specific case.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
An Audit of all current and recent clients will be conducted to identify any additional incidents that may meet reporting criteria.
3. What measures will be put in place to ensure that the deficient practice will not recur?
The agency will implement mandatory training for all administrative staff on abuse and neglect identification and reporting requirements. Additionally, a standardized incident reporting protocol will be enforced to ensure all reportable events are escalated appropriately.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur?
The agency will conduct ongoing audits of incident reports binders, and communication records on a regular basis to ensure compliance. The Case Manager will be responsible for reviewing all incidents and confirming that proper reporting procedures are followed.
5. Corrective Action Plan will be corrected by 06/15/26.
Initial Comments:
Based on the findings of an onsite unannounced complaint investigation, conducted onsite March 31, 2026, offsite April 9, 2026 and onsite April 15, 2026, Villa Home Care, 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:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
Name - Component - 00
Prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. (3) Require the individual to submit a criminal history report, in accordance with the requirements of § 611.52 (relating to criminal background checks), and a ChildLine verification, if applicable, in accordance with the requirements of § 611.53 (relating to child abuse clearance).
Observations:
Based on a review of Personal files (PF) and an interview with the Office Director, the agency failed to ensure that prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services for six (6) of the seven (7) PF's, (PF#1, 2, 3, 5, 6 and 7).
Findings Include:
A review of Personnel Files (PF) conducted on March 31, 2026 at approximately 12:35 pm and April 15, 2026 at approximately 11:00 am revealed the following:
PF#1 - Date of Hire: 10/29/2024. PF did not contain evidence that a face to face interview was completed upon hire.
PF#2 - Date of Hire: 2/11/2026. PF did not contain evidence that two (2) reference were obtained upon hire.
PF#3 - Date of Hire: 12/29/2025. PF did not contain evidence that a face to face interview was conducted upon hire and no evidence that two (2) references were obtained upon hire.
PF#5 - Date of Hire: 11/5/2025. PF did not contain evidence that two (2) references were obtained upon hire.
PF#6 - Date of Hire: 2/19/2026. PF did not contain evidence that a face to face interview was conducted and no evidence that two (2) references were obtained upon hire.
PF#7 - Date of Hire: 12/31/2025. PF did not contain evidence that two (2) references were obtained upon hire.
An interview conducted with the Office Director on April 15, 2026 at approximately 11:30 am confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for the individual(s) and/or practice identified in the deficiency statement?
PF#1: The required face-to-face evaluation has been completed.
PF#2: References have been verified.
PF#3: Corrective action includes ensuring both face-to-face evaluations and updated reference forms are completed.
PF#5: References have been obtained.
PF#6: The employee file has been made inactive as of 01/24/2026.
PF#7: References have been obtained.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
The agency will conduct a comprehensive audit of all active employee files to ensure that required face-to-face evaluations and reference verifications are properly completed and documented. Any files found to be non-compliant will be corrected immediately.
3. What measures will be put in place to ensure that the deficient practice will not recur?
Moving forward, Human Resources will ensure that all required documentation, including face-to-face evaluations and reference verification forms, are completed at the time of hire. A standardized hiring checklist will be implemented to confirm that all onboarding requirements are met prior to employee start date approval.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur?
The agency will implement routine internal audits of employee files to verify compliance with hiring requirements. The Human Resources Manager will review all new hire files prior to final approval. Ongoing monitoring will include periodic reviews to ensure that all required documents are on employees files.
5. Corrective Action Plan will be corrected by 06/15/26
611.52(a) LICENSURE
Criminal Background Checks
Name - Component - 00
The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.
Observations:
Based on a review of personnel files (PF) and an interview with the Office Director, the agency failed to obtain final results of a Pennsylvania State Police Criminal Background report at the time of application or within one year immediately preceding the date of application for four (4) of seven (7) files reviewed. (PF #1, 4, 6 and 7).
Findings Include:
A review of Personnel Files (PF) conducted on March 31, 2026 at approximately 12:35 pm and April 15, 2026 at approximately 11:00 am revealed the following:
PF#1 - Date of Hire: 10/29/2024. PF contained evidence that a Pennsylvania Criminal Background Check was conducted on 11/19/2024.
PF#4 - Date of Hire: 10/29/2024. PF contained documentation that a Pennsylvania Criminal Background Check remained under review from 9/13/2024. No evidence that final requests were obtained by the agency.
PF#6 - Date of Hire: 2/19/2026. PF did not contain evidence that a Pennsylvania Criminal Background was obtained upon hire.
PF#7 - Date of Hire: 12/31/2025. PF contained documentation that a Pennsylvania Criminal Background was obtained on 1/7/2026.
An interview conducted with the Office Director on April 15, 2026 at approximately 11:30 am confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for the individual(s) and/or practice identified in the deficiency statement?
PF#4: The employee file is inactive.
PF#6: The employee file is inactive.
PF#7: Corrective action has been addressed to ensure compliance with hiring requirements.
All identified files have been reviewed. For active personnel, required documentation requirements are being enforced.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
The agency will conduct an audit of all active employee files, to identify any missing Pennsylvania Criminal Background Checks.
3. What measures will be put in place to ensure that the deficient practice will not recur?
Moving forward, all Pennsylvania Criminal Background Checks will be completed at the time of hire by Human Resources. A standardized onboarding process and checklist will be implemented to ensure that all required background checks are completed prior to employee activation.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur?
Human Resources Manager will conduct ongoing audits of employee files to ensure compliance with background check requirements. HR will review all new hire files prior to final approval. Continued monitoring will include periodic audits to ensure all Pennsylvania Criminal Background Checks are consistently completed and documented.
5. Corrective Action Plan will be corrected by 06/15/26
611.52(d) LICENSURE
Proof of Residency
Name - Component - 00
The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation
Observations:
Based on review of personnel files (PF) and an interview with the Office Director, determined that the agency failed to document proof of Pennsylvania (PA) residency preceding date of hire through submission of any one of the following documents: (1) Motor vehicle records, such as a valid driver's license or a State-issued identification; (2) Housing records, such as mortgage records or rent receipts; (3) Public utility records and receipts, such as electric bills; (4) Local tax records; (5) A completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it; (6) Employment records, including records of unemployment compensation for four (4) of seven (7) PF's reviewed, (PF#3, 5, 6 and 7.)
Findings Include:
A review of Personnel Files (PF) conducted on March 31, 2026 at approximately 12:35 pm and April 15, 2026 at approximately 11:00 am revealed the following:
PF#3 - Date of Hire: 12/29/2025. PF contained a Pennsylvania Driver's License with an issue date of 5/24/2025. File did not contain any evidence to indicate proof of Pennsylvania residence for the two (2) consecutive years immediately preceding date of hire.
PF#5 - Date of Hire: 11/5/2025. PF contained a Pennsylvania Driver's License with an issue date of 8/3/2024. File did not contain any evidence to indicate proof of Pennsylvania residence for the two (2) consecutive years immediately preceding date of hire.
PF#6 - Date of Hire: 2/19/2026. PF contained a Pennsylvania Driver's License with an issue date of 5/20/2025. File did not contain any evidence to indicate proof of Pennsylvania residence for the two (2) consecutive years immediately preceding date of hire.
PF#7 - Date of Hire: 12/31/2025. PF contained a Pennsylvania Identification Care with an issue date of 2/26/2025. File did not contain any evidence to indicate proof of Pennsylvania residence for the two (2) consecutive years immediately preceding date of hire.
An interview conducted with the Office Director on April 15, 2026 at approximately 11:30 am confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for the individual(s) and/or practice identified in the deficiency statement?
PF#5: Proof of residency has been obtained and placed in the employee file.
PF#6: The employee file is inactive.
PF#7: Proof of residency has been obtained and placed in the employee file.
All identified deficiencies are being addressed, and required documentation is being obtained and maintained in employee files.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
The agency will conduct an audit of all active employee files to verify that proof of residency documentation is present and properly maintained, if not FBI clearance will be obtained.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
The agency will conduct an audit of all active employee files to verify that proof of residency documentation is present and properly maintained, if not FBI clearance will be obtained.
3. What measures will be put in place to ensure that the deficient practice will not recur?
Moving forward, proof of residency will be obtained at the time of hire by Human Resources if unable to provide, an FBI background check will be submitted. A standardized onboarding checklist will be implemented to ensure all required documentation is completed prior to employee activation.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur?
The agency will perform ongoing audits of employee files to ensure compliance. HR Manager will review all new hire documentation prior to final approval. Periodic internal reviews will be conducted to confirm that proof of residency is consistently obtained and documented.
5. Corrective Action Plan will be corrected by 06/15/26
611.54(a) LICENSURE
Provisional Hiring
Name - Component - 00
The home care agency or home care registry may hire an applicant for employment or referral on a provisional basis, pending receipt of a criminal history report or a ChildLine verification, as applicable, if the following conditions are met:
Observations:
Based on a review of personnel files (PF) and an interview with the Office Director, the home care agency failed to ensure that provisional hiring requirements were met for four (4) of seven (7) files reviewed. (PF #1, 4, 6 and 7).
Findings Include:
A review of Personnel Files (PF) conducted on March 31, 2026 at approximately 12:35 pm and April 15, 2026 at approximately 11:00 am revealed the following:
PF#1 - Date of Hire: 10/29/2024. PF contained evidence that a Pennsylvania Criminal Background Check was conducted on 11/19/2024. No evidence in the personnel file that the provisionally hired applicant, while awaiting criminal background check results, was monitored by the HCA through random, direct observation and consumer feedback.
PF#4 - Date of Hire: 10/29/2024. PF contained documentation that a Pennsylvania Criminal Background Check remained under review from 9/13/2024. No evidence that final requests were obtained by the agency. No evidence in the personnel file that the provisionally hired applicant, while awaiting criminal background check results, was monitored by the HCA through random, direct observation and consumer feedback.
PF#6 - Date of Hire: 2/19/2026. PF did not contain evidence that a Pennsylvania Criminal Background was obtained upon hire. No evidence in the personnel file that the provisionally hired applicant, while awaiting criminal background check results, was monitored by the HCA through random, direct observation and consumer feedback.
PF#7 - Date of Hire: 12/31/2025. PF contained documentation that a Pennsylvania Criminal Background was obtained on 1/7/2026. No evidence in the personnel file that the provisionally hired applicant, while awaiting criminal background check results, was monitored by the HCA through random, direct observation and consumer feedback.
A review of Consumer Files (CF) conducted on-site March 31, 2026, at approximately 12:15 pm and April 15, 2026 at approximately 10:15 am revealed the following:
CF#4 - Start of Care: 10/3/2025. Signed waiver in file consumer file about provisional hiring pending criminal investigation and TB testing. Agency has a provisional hiring policy in place for criminal background but provisional hiring regarding TB testing is not included in the agency policy nor included/ permissible in the Chapter 611 home care regualtions.
Review of agency policy regarding Provisional hiring was conducted on April 17, 2026 at approximately 3:45 pm revealed the following:
Criminal Background Check Policy and Procedures
POLICY: 611.52 Criminal Background Checks
Villa Home Care Services requires each applicant for employment or contractor to submit a criminal history report. The home care agency may not hire or roster an individual if the state police criminal history report reveals a prohibited conviction related to facility responsibilities and/or if the Department of Aging Letter of Determination states that the individual is not eligible to be hired or roster.
a. General Rule: all agency staff will be required to submit criminal background report obtained at time of application or within 1 year immediately preceding the date of application.
(Hire will be provisional until criminal background check clears)
The agency has 30 days from the date of employment to obtain a criminal record check from the Pennsylvania State Police. During the 30 day waiting period for the processing of the criminal history check, the employee will be allowed active employment. If at the end of 30 days provisional hire, the person record still appears UNDER REVIEW (When a potential employee has been convicted of a Prohibited Offense contained in Act 168 of 1996 as Amended by Act 13), the person will no longer be allowed to work
Provisional Hiring Policy and Procedures
Policy: 611.54 Provisional Hiring
Villa Home Care may hire an applicant for employment or referral on a provisional basis, pending receipt of a criminal history report, if the following conditions are met:
Procedure:
5. The provisionally hired applicant will be monitored through random, direct observation and consumer feedback. (Results of monitoring must be documented in applicants file)
Termination: If information obtained from the criminal history report reveals that the individual is disqualified from employment or referral under 611.52 (relating to criminal background checks) or if the individual fails to provide criminal history report within the time period permitted for provisional hire, the individual shall be terminated by the agency or removed from the roster immediately.
Agency did not follow the provisional hiring policy as indicated above.
An interview conducted with the Office Director on April 15, 2026 at approximately 11:30 am confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for the individual(s) and/or practice identified in the deficiency statement?
PF#1: Corrective measures have been implemented to ensure compliance with background check requirements.
PF#4: The employee file is inactive.
PF#6: The employee file is inactive.
PF#7: Corrective measures have been implemented to ensure compliance with background check requirements.
All identified files have been reviewed, and appropriate actions have been taken based on employment status.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
The agency will conduct an audit of all active employee files to verify that Pennsylvania background checks have been completed as required.
3. What measures will be put in place to ensure that the deficient practice will not recur?
Moving forward, all Pennsylvania background checks will be obtained at the time of hire by Human Resources. A standardized onboarding checklist will be used to ensure compliance prior to employee activation.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur?
HR will implement routine audits of employee files to ensure compliance with background check requirements. The HR Manager will review all new hire files prior to final approval.
5. Corrective Action Plan will be corrected by 06/15/26
611.55(a) LICENSURE
Competency Requirements
Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.
Observations:
Based on review of personnel files (PF), and an interview with the agency Office Director, it was determined the agency failed to demonstrate, prior to assigning or referring a direct care worker to provide services to a consumer, competency by passing an initial competency examination for seven (7) of seven (7) PF reviewed. (PF#1, 2, 3, 4, 5, 6 and 7).
Findings Include:
A review of Personnel Files (PF) conducted on March 31, 2026 at approximately 12:35 pm and April 15, 2026 at approximately 11:00 am revealed the following:
PF#1 - Date of Hire: 10/29/2024. PF contained a competency exam on file that was incomplete - questions 1-23 completed, whereas questions 24-59 were not completed.
PF#2 - Date of Hire: 2/11/2026. PF contained a competency exam on file that was incomplete - questions 1-23 completed, whereas questions 24-59 were not completed.
PF#3 - Date of Hire: 12/29/2025. PF contained a competency exam on file that was incomplete - questions 1-23 completed, whereas questions 24-59 were not completed.
PF#4 - Date of Hire: 10/29/2024. PF contained a competency exam on file that was incomplete - questions 1-23 completed, whereas questions 24-59 were not completed.
PF#5 - Date of Hire: 11/5/2025. PF contained a competency exam on file that was incomplete - questions 1-23 completed, whereas questions 24-59 were not completed.
PF#6 - Date of Hire: 2/19/2026. PF contained a competency exam on file that was incomplete - questions 1-23 completed, whereas questions 24-59 were not completed.
PF#7 - Date of Hire: 12/31/2025. PF contained a competency exam on file that was incomplete - questions 1-23 completed, whereas questions 24-59 were not completed.
An interview conducted with the Office Director on April 15, 2026 at approximately 11:30 am confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for the individual(s) and/or practice identified in the deficiency statement?
PF#2: The agency is currently in the process of updating the competency exam to include questions 24–59.
PF#3: The agency is currently in the process of updating the competency exam to include questions 24–59.
PF#4: The employee file is inactive.
PF#5: The agency is currently in the process of updating the competency exam to include questions 24–59.
PF#6: The employee file is inactive.
PF#7: The agency is currently in the process of updating the competency exam to include questions 24–59.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
The agency will conduct an audit of all employee files to verify that competency exams are complete and include all required questions.
3. What measures will be put in place to ensure that the deficient practice will not recur?
Moving forward, Human Resources will require completion of the full competency exam, including questions 1–59, at the time of hire. The updated competency exam will be implemented as part of the standardized onboarding process, and all required sections must be completed prior to employee activation.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur?
HR will implement routine audits of employee files to ensure competency exams are fully completed and properly documented.
5. Corrective Action Plan will be corrected by 06/15/26
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 a review of personnel files (PF) and an interview with the Office Director, the agency failed to ensure that an annual competency was performed for one (1) of seven (7) PF's reviewed: (PF# 1).
Findings Include:
A review of Personnel Files (PF) conducted on March 31, 2026 at approximately 12:35 pm and April 15, 2026 at approximately 11:00 am revealed the following:
PF#1 - Date of Hire: 10/29/2024. PF did not contain evidence that annual competency was completed for 2025.
An interview conducted with the Office Director on April 15, 2026 at approximately 11:30 am confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for the individual(s) and/or practice identified in the deficiency statement?
PF#1: Corrective measures have been implemented to ensure compliance with competency evaluation requirements annually.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
The agency will conduct an audit of all employee files to verify that competency exams are fully completed.
3. What measures will be put in place to ensure that the deficient practice will not recur?
Moving forward, Human Resources will require completion of the full competency exam, including questions 1–59, at the time of hire and as part of each employee's annual review. This requirement will be incorporated into the agency's standardized onboarding and annual evaluation processes.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur?
HR will implement routine audits of employee files to ensure competency exams are completed in full.
5. Corrective Action Plan will be corrected by 06/15/26
611.56(a) LICENSURE
Health Screening
Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.
Observations:
Based on a review of personnel files (PF), Centers for Disease Control Guidelines, and an interview with the administrator, the agency failed to provide documentation that the individual has received baseline tuberculosis screening upon hire and symptom screening/risk assessment initially for six (6) of seven the (7) PF's reviewed. (PF#1, 2, 3, 5, 6, and 7)
Findings include:
In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: receive baseline tuberculosis screening upon hire by using: a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB), or a negative chest x-ray to test for infection with tuberculosis. 2. Completion of a tuberculosis symptom questionnaire. And 3. Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCWs should receive TB education annually. HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(5-16-19)
Findings Include:
A review of Personnel Files (PF) conducted on March 31, 2026 at approximately 12:35 pm and April 15, 2026 at approximately 11:00 am revealed the following:
PF#1 - Date of Hire: 10/29/2024. PF contained documentation of a QuantiFERON Gold test dated for 10/10/2023. No documentation of TB symptom screening and Risk assessment was completed upon hire.
PF#2 - Date of Hire: 2/11/2026. PF contained documentation of a QuantiFERON Gold test dated for 5/30/2024 and was completed prior to hire not on hire. No documentation of TB symptom screening was completed upon hire.
PF#3 - Date of Hire: 12/29/2025. PF contained documentation of a QuantiFERON Gold test dated 1/3/2026 resulted as positive. Chest X-Ray conducted on 3/17/2026 resulted in negative for TB. No documentation of TB risk assessment and symptom screening was conducted upon hire.
PF#4 - Date of Hire: 10/29/2024. PF did not contain documentation that a TB symptom screening and Risk assessment was completed upon hire.
PF#5 - Date of Hire: 11/5/2025. PF contained documentation of a QuantiFERON Gold test dated 11/7/2025 resulted as positive. Chest X-Ray conducted on 2/23/2026 resulted in negative for TB. No documentation of TB risk assessment and symptom screening was conducted upon hire.
PF#6 - Date of Hire: 2/19/2026. PF did not contain evidence that TB testing was conducted upon hire. No documentation of TB symptom screening and Risk assessment was completed upon hire.
PF#7 - Date of Hire: 12/31/2025. PF contained documentation of a QuantiFERON Gold test completed on 1/7/2026.
An interview conducted with the Office Director on April 15, 2026 at approximately 11:30 am confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for the individual(s) and/or practice identified in the deficiency statement?
PF#1: A TB symptom screening form has been created and implemented.
PF#2: A TB symptom screening form has been created and implemented.
PF#3: A TB symptom screening form has been created and implemented.
PF#4: The employee file is inactive.
PF#5: A TB symptom screening form has been created and implemented.
PF#6: The employee file is inactive.
PF#7: A TB symptom screening form has been created and implemented.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
HR will conduct an audit of all active employee files to verify that TB test results, TB assessments, and TB symptom screening documentation are present and complete moving forward.
3. What measures will be put in place to ensure that the deficient practice will not recur?
Moving forward, Human Resources will ensure that TB test results, TB assessments, and TB symptom screening forms are completed at the time of hire and during each employee's annual review.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur?
HR will implement routine audits of employee files to ensure compliance with TB documentation requirements.
5. Corrective Action Plan will be corrected by 06/15/26
611.56(b) LICENSURE
Health Screening
Name - Component - 00
(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.
Observations:
Based on review of personnel files (PFs), the Centers for Disease Control guidelines, and interview with the Office Administrator, the agency failed to ensure each direct care worker were provided with annual mycobacterium tuberculosis education for one (1) of seven (7) PF's reviewed, (PF#1).
Findings include:
In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: receive baseline tuberculosis screening upon hire by using: a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB), or a negative chest x-ray to test for infection with tuberculosis. 2. Completion of a tuberculosis symptom questionnaire. And 3. Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCWs should receive TB education annually. HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(5-16-19)
Findings Include:
A review of Personnel Files (PF) conducted on March 31, 2026 at approximately 12:35 pm and April 15, 2026 at approximately 11:00 am revealed the following:
PF#1 - Date of Hire: 10/29/2024. PF did not contain evidence that documentation that annual mycobacterium tuberculosis education was provided for 2025.
An interview conducted with the Office Director on April 15, 2026 at approximately 11:30 am confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for the individual(s) and/or practice identified in the deficiency statement?
The agency has revised the TB symptom questionnaire form to include all required screening elements. Information regarding Mycobacterium tuberculosis has been incorporated into onboarding and annual review documentation.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
HR will conduct an audit of all employee files to verify inclusion of the updated TB symptom questionnaire, TB-related education, and required signatures.
3. What measures will be put in place to ensure that the deficient practice will not recur?
The revised TB symptom questionnaire and TB education materials will be incorporated into the onboarding process and annual review requirements.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur?
Human Resources will be responsible for implementation and oversight. A tracking spreadsheet will be developed and maintained to monitor compliance and ensure all employee files contain the required documentation. Routine audits will be conducted to verify ongoing compliance, and any deficiencies identified will be addressed immediately.
5.Completion Date: June 15, 2026
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 upon an interview with the Owner, the consumer file did not contain proof that the consumer was provided with the following information: (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 for two (2) of five (5) consumer files (CF) reviewed(CF#1, 4 and 5)
Findings Include:
A review of Consumer Files (CF) conducted on-site March 31, 2026, at approximately 12:15 pm and April 15, 2026 at approximately 10:15 am revealed the following:
CF#1 -Start of Care: 12/26/2025. CF did not contain documentation that states the consumer would 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.
CF#4 - Start of Care: 10/3/2025. Approved for 84 hours per week / 7 days per week through UPMC. Care plan includes the following: Light housekeeping, meal preparation, laundry, assist with personal care, assist with dressing/undressing and skin care. Signed waiver in file consumer file about provisional hiring pending criminal investigation and TB testing. Agency has a provisional hiring policy in place for criminal background but provisional hiring regarding TB testing is not included in the agency policy nor included/ permissible in the Chapter 611 home care regualtions.
Does agency have provisional hiring policy for criminal background? CF did not contain documentation that states the consumer would 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.
CF#5 - Start of Care: 12/31/2025. Approved for 24 hours per day, 7 days per week. Care plan includes the following: Light housekeeping, meal preparation, make bed, medication reminder, personal care, errands. Review of HHA eXchange revealed the following:
2/6/2026 - 17.5 hours provided out of 24 hours.
2/10/2026 - 23 hours provided out of 24 hours.
2/11/2026 - 21 hours provided out of 24 hours.
2/12/2026 - 22 hours and 15 minutes provided out of 24 hours.
2/16/2026 - 23.5 hours provided out of 24 hours.
2/18/2026 - 23.5 hours provided out of 24 hours.
2/20/2026 - 23 hours and 45 minutes out of 24 hours provided.
2/21/2026 - 16 hours provided out of 24 hours.
3/1/2026 - 22 hours and 45 minutes provided out of 24 hours.
3/4/2026 - 16 hours out of 24 hours provided out of 24 hours.
3/6/2026 - 22 hours and 45 minutes provided out of 24 hours.
3/8/2026- 21 hours and 45 minutes provided out of 24 hours.
3/11/26 - 17:20-0901 - 15 hours, 45 minutes
3/16/2026 -15.5 hours provided out of 24 hours.
3/30/2026 - 23 hours 45 minutes provided out of 24 hours.
An interview conducted with the Office Director on April 15, 2026 at approximately 11:30 am confirmed the above findings. Surveyor informed Office Director that provisional hiring did not apply to TB testing and awaiting results only to awaiting for criminal background results.
Plan of Correction:1. What corrective action will be accomplished for the individual's and/or practice identified in the deficiency statement?
CF#1: Information regarding termination has been added to page 2 of the agency's service agreement. The updated document will be provided by the Case Manager during the admission process.
CF#4: Pennsylvania Criminal Background Check and TB test results for SF will be obtained by Human Resources upon hire.
CF#5: The President will provide education to the Case Manager regarding monitoring of hours of service provided. The caregiver will also be retrained on proper use of the HHA system.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
The Case Manager will conduct a review of all active consumer to ensure that updated service agreements are properly completed and documented.
3. What measures will be put in place to ensure that the deficient practice will not recur?
Moving forward, all service agreements will include updated termination language and will be signed by consumers prior to the initiation of services. Human Resources will ensure that all required background checks and TB test results are completed upon hire. In addition, Case Manager will be trained to properly monitor service hours, and caregivers will receive retraining on correct use of the HHA system.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur?
The Case Manager will implement routine audits of consumer and employee files to ensure compliance with service agreement requirements.
5.Completion Date: June 15, 2026
611.57(b) LICENSURE
Prohibitions
Name - Component - 00
(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.
Observations:
Based on a review of consumer files (CF) and an interview with the Office Director, there was no evidence that the agency provided the consumer with information regarding the prohibitions that 1) no individual as a result of the individual's affiliation with the home care agency may assume power of attorney or guardianship of a consumer using the services of the agency, and 2) the home care agency may not require a consumer to endorse checks over to the home care agency for two (2) of five (5) CF's reviewed: (CF#4 and 5).
Findings Include:
A review of Consumer Files (CF) conducted on-site March 31, 2026, at approximately 12:15 pm and April 15, 2026 at approximately 10:15 am revealed the following:
CF#4 -Start of Care: 12/26/2025. CF did not contain documentation that the agency provided the consumer with the following information upon admission: Information regarding the prohibitions that 1) no individual as a result of the individual's affiliation with the home care agency may assume power of attorney or guardianship of a consumer using the services of the agency, and 2) the home care agency may not require a consumer to endorse checks over to the home care agency.
CF#5 - Start of Care: 10/3/2025. CF did not contain documentation that the agency provided the consumer with the following information upon admission: Information regarding the prohibitions that 1) no individual as a result of the individual's affiliation with the home care agency may assume power of attorney or guardianship of a consumer using the services of the agency, and 2) the home care agency may not require a consumer to endorse checks over to the home care agency.
An interview conducted with the Office Director on April 15, 2026 at approximately 11:30 am confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for the individual's and/or practice identified in the deficiency statement?
The Case Manager will ensure that the Consumer Rights Policy and Procedures form is printed and maintained in each consumer's paper record at the agency office. This requirement will apply to all new admissions as well as existing consumers, including those records reviewed during the survey.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
The Case Manager will conduct an audit of all active consumer records to verify the presence of the Consumer Rights Policy and Procedures form. Any consumer files found to be missing the required documentation will be updated immediately.
3. What measures will be put in place to ensure that the deficient practice will not recur?
The Case Manager will be responsible for implementing this process and ensuring compliance during the admission process. The Consumer Rights Policy and Procedures form will be included as a required document in the admission packet for all new consumers.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur?
The Case Manager will conduct routine audits of consumer records to ensure compliance with documentation requirements. The audit tool will be used on an ongoing basis to verify that the Consumer Rights Policy and Procedures form is consistently included in all records.
5.Completion Date: June 15, 2026
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 a review of consumer files (CF) and an interview with the Office Director, 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 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 for five (5) of the five (5) CF's reviewed. (CF#1,2,3, 4 and 5)
Findings Include:
A review of Consumer Files (CF) conducted on-site March 31, 2026, at approximately 12:15 pm and April 15, 2026 at approximately 10:15 am revealed the following:
CF#1 -Start of Care: 12/26/2025. File did not contain (1) The identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. 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.
CF#2 - Start of Care: 10/23/2024. File did not contain 1) The identity of the direct care worker who will provide the services.
CF#3 - Start of Care: 5/15/2025. File did not contain (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.
CF#4 - Start of Care: 10/3/2025. File did not contain (1) The identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. 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.
CF#5 - Start of Care: 12/31/2025. File did not contain (1) The identity of the direct care worker who will provide the services. (2) The hours when those services will be provided.
An interview conducted with the Office Director on April 15, 2026 at approximately 11:30 am confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for the individual's and/or practice identified in the deficiency statement?
The Case Manager will ensure that each consumer's signed care plan and service schedule are printed and maintained in the paper file at the agency office. This requirement will apply to all current consumers, including those records reviewed during the survey, as well as all new admissions.
In addition, all consumers will be provided with the appropriate Department contact information, including phone number (717-783-1379), for inquiries regarding licensure requirements and agency compliance status.
The agency will also ensure that the Notice of Direct Care Worker Status form is printed, completed as applicable, and maintained in each consumer record. Any missing documentation identified will be corrected immediately.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
The Case Manager will conduct a comprehensive audit of all active consumer records, including those reviewed during the survey, to verify that signed care plans, service schedules, Department contact information documentation, and Notice of Direct Care Worker Status forms are present and properly maintained.
3. What measures will be put in place to ensure that the deficient practice will not recur?
The Case Manager will be responsible for implementing and maintaining compliance with these requirements during the admission and ongoing service process. All required documents, including signed care plans, service schedules, consumer notification of Department contact information, and Notice of Direct Care Worker Status forms, will be included in the standard admission packet and ongoing documentation procedures.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur?
The Case Manager will conduct routine audits of consumer records to ensure all required documentation is present. An audit tool will be used to verify ongoing compliance. Any missing or incomplete documentation identified during audits will be corrected immediately, and retraining will be provided as necessary.
5.Completion Date: June 15, 2026
|