Initial Comments:
Based on the findings of an onsite State Re-Licensure Survey conducted on April 28, 2026, T & T Home Care, LLC 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 28, 2026, T & T Home Care, LLC 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 personnel files (PF) and an interview with the administrator, the home care agency (HCA) failed to provide evidence that prior to hiring the individual, 1) a face to face interview was conducted for three (3) of seven (7) PF's reviewed: PF#1, PF#2, and PF#4, 2) two (2) satisfactory non-family member references were obtained for seven (7) of seven (7) PF's reviewed: PF#1, PF#2, PF#3, PF#4, PF#5, PF#6, and PF#7, and 3) a criminal history report was obtained for the applicant at the time of application or within one (1) year immediately preceding the date of application for seven (7) of seven (7) PF's reviewed: PF#1, PF#2, PF#3, PF#4, PF#5, PF#6, and PF#7,
Findings include:
A review of PF's was conducted on April 28, 2026 starting at 10:00 AM. The start date of service (DOS) is indicated below.
PF#1 DOS 06/04/2024 contained no evidence that a criminal history report was obtained at the time of hire or within one (1) year immediately preceding the date of hire. There was no evidence that a face to face interview was conducted nor that references were checked prior to hiring the individual.
PF#2 DOS 02/25/2026 contained no evidence that a criminal history report was obtained at the time of hire or within one (1) year immediately preceding the date of hire. There was no evidence that a face to face interview was conducted nor that references were checked prior to hiring the individual.
PF#3 DOS 03/25/2026 contained no evidence that a criminal history report was obtained at the time of hire or within one (1) year immediately preceding the date of hire. The Pennsylvania Access to Criminal History (PATCH) report contained in the file was dated 04/13/2026, nineteen (19) days after the start of service. There was no evidence that references were checked prior to hiring the individual.
PF#4 DOS 10/18/2024 contained no evidence that a criminal history report was obtained at the time of hire or within one (1) year immediately preceding the date of hire. There was no evidence that a face to face interview was conducted nor that references were checked prior to hiring the individual.
PF#5 DOS 01/11/2026 contained no evidence that a criminal history report was obtained at the time of hire or within one (1) year immediately preceding the date of hire. The PATCH report contained in the file was dated 04/13/2026, three (3) months after the start of service. There was no evidence that references were checked prior to hiring the individual.
PF#6 DOS 09/23/2025 contained no evidence that a criminal history report was obtained at the time of hire or within one (1) year immediately preceding the date of hire. The PATCH report contained in the file was dated 10/01/2025, eight (8) days after the start of service. There was no evidence that references were checked prior to hiring the individual.
PF#7 DOS 09/25/2024 contained no evidence that a criminal history report was obtained at the time of hire or within one (1) year immediately preceding the date of hire. The PATCH report contained in the file was dated 06/09/2025, nine (9) months after the start of service. There was no evidence that references were checked prior to hiring the individual.
An interview conducted with the administrator on April 28, 2026 starting at 11:10 AM confirmed the above findings.
Plan of Correction:To ensure this agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files including and Personnel file #'s (1,2,3,4,5,6, and 7), as directed by Citation 0200.
The review showed the Agency did and does perform face to face interviews and reference checks for employees, but the did not conduct for employees' personnel #'s (1,2,3,4,5,6, and 7) as required by 611.51(a)
To correct this error on the Admin conducted face to face interviews along with contacting the references for employees' personnel #'s (1,2,3,4,5,6, and 7)
To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP"). This policy will ensure all new hiring requirements of 11.51(a), have been net before a new employee can provide service consumers.
EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation
As of may 15 2026; with the EPIP implementation, all employee Personal file's including file #'s (1,2,3,4,5,6, and 7), have all required documents as directed by 611.51(a). all deficiencies under citation 0200 have been addressed.
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 administrator, the home care agency (HCA) failed to ensure that an individual required to obtain a criminal history record furnished proof of Pennsylvania (PA) residency for two (2) consecutive years immediately 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 three (3) of seven (7) PF's reviewed: PF#2, PF#3, and PF#5.
Findings include:
A review of PF's was conducted on April 28, 2026 starting at 10:00 AM. The start date of service (DOS) is indicated below.
PF#2 DOS 02/25/2026 contained a Pennsylvania (PA) Driver's License (DL) issued 04/04/2025. There was no verifiable documentation contained in the PF of PA residency for the two (2) consecutive years immediately preceding the DOH from 02/25/2024 to 04/04/2025.
PF#3 DOS 03/25/2026 contained a Pennsylvania (PA) Driver's License (DL) issued 09/19/2025. There was no verifiable documentation contained in the PF of PA residency for the two (2) consecutive years immediately preceding the DOH from 03/25/2024 to 09/19/2025.
PF#5 DOS 01/11/2025 contained a Pennsylvania (PA) Driver's License (DL) issued 12/31/2024. There was no verifiable documentation contained in the PF of PA residency for the two (2) consecutive years immediately preceding the DOH from 01/11/2023 to 12/31/2024.
An interview conducted with the administrator on April 28, 2026 starting at 11:10 AM confirmed the above findings.
Plan of Correction:To ensure the Agency remains in full compliance with all applicable hiring and personnel record requirements, the Administrator conducted a comprehensive review of all employee personnel files.
The review determined that the Agency failed to maintain sufficient documentation verifying that certain employees had resided in Pennsylvania for two consecutive years immediately preceding their dates of hire. Acceptable documentation includes, but is not limited to, a valid Pennsylvania driver's license or state- issued identification card, housing records, utility bills, tax records, signed tax returns, or employment records, including unemployment compensation records.
To correct This deficiency, the Agency obtained and placed acceptable proof of two consecutive years of Pennsylvania residency in the personnel files of all affected employees and reviewed all remaining personnel files to ensure that the required documentation is present and current.
In addition, the agency revised its hiring procedures and implemented a standardized Personnel File Checklist requiring verification of Pennsylvania residency before an employee is permitted to provide services. The Administrator or designee will review each new hire file prior to the employee's start date to confirm that all required residency documents are obtained and filed.
To prevent recurrence, quarterly audits of all personnel files will be conducted by the Administrator or designee to verify continued compliance background checks and employee documentation requirements.
All deficiencies related to this citation have been corrected, and ongoing monitoring procedures have been established to maintain full compliance.
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 a review of personnel files (PF) and an interview with the administrator, the home care agency (HCA) failed to ensure that prior to assigning a direct care worker (DCW) to provide services to a consumer, the DCW had completed one of the following: 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 met the requirements of subsection (b) and (c). (3) Had successfully completed one of the following: (i) A training program developed by the HCA or other entity which met the requirements of subsection (b) and (c). (ii) A home health aide training program that met 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 ww.pde.state.pa.us. (iv) A training program that met the training standards imposed on the HCA by virtue of the HCA'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. Seven (7) of seven (7) PF's did not meet the requirement: PF#1, PF#2, PF#3, PF#4, PF#5, PF#6, and PF#7.
Findings include:
In an interview conducted with the administrator on April 28, 2025 at 11:10 AM, the administrator stated that all direct care workers (DCW) complete a competency exam, prior to providing services to a consumer and that the results should be in PF. The administrator also stated that 80% was considered the passing grade for the exam.
A review of PF's was conducted on April 28, 2026 starting at 10:00 AM. The start date of service (DOS) is indicated below.
PF#1 DOS 06/04/2024 did not contain any evidence that the DCW completed any of the training/competency requirements prior to providing services to a consumer.
PF#2 DOS 02/25/2026 did not contain any evidence that the DCW completed any of the training/competency requirements prior to providing services to a consumer.
PF#3 DOS 03/25/2026 did not contain any evidence that the DCW completed any of the training/competency requirements prior to providing services to a consumer.
PF#4 DOS 10/18/2024 did not contain any evidence that the DCW completed any of the training/competency requirements prior to providing services to a consumer.
PF#5 DOS 01/11/2026 contained a "Written/Oral Exam Answer Sheet," dated 01/13/2026, with 50 questions answered, but there was no score on the examination to denote whether the DCW passed or failed the competency examination.
PF#6 DOS 09/03/2025 did not contain any evidence that the DCW completed any of the training/competency requirements prior to providing services to a consumer.
PF#7 DOS 09/25/2024 did not contain any evidence that the DCW completed any of the training/competency requirements prior to providing services to a consumer.
An interview conducted with the administrator on April 28, 2026 starting at approximately 11:10 AM confirmed the above findings.
Plan of Correction:To ensure this agency is in the future compliance, the Admin has reviewed the entire Agency's employee personnel files including and Personnel file # (1.2,3,4.5,6 and 7) as directed by citation 0600.
The review showed the agency does provide employees with competency training and test prior to employees services to customer, but did not provide said testing and related documentation for employees personnel # (1 ,2,3,4,5,6 and 7 ) as required by 611.51(a).
To correct this error . the admin has provided and ensured all employees with the required Competency Training and Test including maintaining the required documentation for said test employees personnel # (1,2,3,4,5,6,and 7)
To prevent this from reoccurring the agency created a new Employee Personnel In- Take Policy ("EPIP"). This Policy will ensure all new hiring requirements of 11.51(a), have been met before a new employee can provide service consumers.
EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation.
; with the EPIP implementation, all employees including file # (1 2,3,4,5,6,and 7), have all completed the required Competency Training and relating testing as directed by 611.51(a). All deficiencies under Citation 0600 have been addressed.
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 administrator, the home care agency (HCA) failed to provide evidence that a competency review occurred at least once per year for three (3) of seven (7) PF's reviewed: PF#1, PF#4, and PF#7.
Findings include:
A review of PF's was conducted on April 28, 2026 starting at 10:00 AM. The start date of service (DOS) is indicated below:.
PF#1 DOS 06/04/2024 did not contain evidence that an annual competency review occurred in 2025.
PF#4 DOS 10/18/2024 did not contain evidence that an annual competency review occurred in 2025.
PF#7 DOS 09/25/2024 did not contain evidence that an annual competency review occurred in 2025.
An interview conducted with the administrator on April 28, 2026 starting at 11:10 AM confirmed the above findings.
Plan of Correction:To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files including and Personnel files # (1,4,7) as directed by Citation 0621.
The review showed the Agency does provide employees with a competency training and test, but did not provide documentation for employee's personal # (1,4,7) as required by 611.51(a).
To correct this error the Admin has obtained the required documentation for employees' personnel # (1,4, and 7).
To prevent this form reoccurring the Agency created a new Employee personnel In- Take Policy ("EPIP"). This Policy will ensure all new hiring requirements of 11.51(a), have been met before a new employee can provide service consumers.
EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation.
With the EPIP implementation, all employee Personnel file's documents as directed by 611.51(a). All deficiencies under Citation 0621 have been addressed.
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 a review of personnel files (PF), the Centers for Disease Control and Prevention (CDC) Guidelines, and an interview with the administrator, the home care agency (HCA) did not provide evidence that a direct care worker (DCW), upon hire, completed a TB test (e.g., a TB single blood assay test or a two-step tuberculin skin test (TST) for five (5) of seven (7) PF's reviewed: PF#1, PF#2, PF#4, PF#6, and PF#7, that the DCW completed a baseline individual TB risk assessment for six (6) of seven (7) PF's reviewed: PF#1, PF#3, PF#4, PF#5, PF#6, and PF#7, a TB symptom evaluation upon hire for seven (7) of seven (7) PF's reviewed: PF#1, PF#2, PF#3, PF#4, PF#5, PF#6, and PF#7, and completed annual TB education for two (2) of seven (7) PF's reviewed: PF#4 and PF#7.
Findings include:
The Centers for Disease Control and Prevention (CDC) and the National TB Controllers Association released updated recommendations for Tuberculosis (TB) screening, testing, and treatment of health care personnel on May 17, 2019. These recommendations update the health care personnel screening and testing section of the 2005 CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings. All health care personnel should be screened for TB upon hire (i.e., preplacement). TB screening is a process that includes: a baseline individual TB risk assessment, a TB symptom evaluation, and a TB test (e.g., a TB single blood assay test or a two-step tuberculin skin test (TST), and additional evaluation for TB disease as needed. Health care personnel with a positive TB test result should receive a symptom evaluation and a chest x-ray to rule out TB disease. Additional workup may be needed based on those results. All health care personnel should receive TB education annually. TB education should include information on TB risk factors, the signs and symptoms of TB disease, and TB infection control policies and procedures. (CDC/MMWR/May 17, 2019/Vol.68/No.19).
In an interview conducted with the administrator on April 28, 2026 at approximately 11:10 AM, the administrator stated that s/he believed s/he had been informed by a Department of Health representative to remove TB test results from the PF and to only maintain the TB questionnaires in the file. The administrator stated that all DCW's are tested for TB.
A review of PF's was conducted on October 14, 2025 starting at 10:30 AM. The date of hire (DOH) is indicated below.
PF#1 DOS 06/04/2024 did not contain evidence that a TST or a single blood assay test was completed upon hire. There was no evidence that a baseline individual TB risk assessment or TB symptom evaluation was completed upon hire.
PF#2 DOS 02/25/2026 did not contain evidence that a two-step TST or a single blood assay test was completed upon hire. There was no evidence that a TB symptom evaluation was completed upon hire.
PF#3 DOS 02/12/2024 did not contain evidence that a baseline individual TB risk assessment or TB symptom evaluation was completed upon hire.
PF#4 DOS 10/18/2024 did not contain evidence that a TST or a single blood assay test was completed upon hire. There was no evidence that a baseline individual TB risk assessment or TB symptom evaluation was completed upon hire, and no evidence that annual TB education was conducted in 2025.
PF#5 DOS 01/11/2026 did not contain evidence that a baseline individual TB risk assessment or TB symptom evaluation was completed upon hire.
PF#6 DOS 09/23/2025 did not contain evidence that a TST or a single blood assay test was completed upon hire. There was no evidence that a baseline individual TB risk assessment or TB symptom evaluation was completed upon hire.
PF#7 DOS 09/25/2024 did not contain evidence that a TST or a single blood assay test was completed upon hire. There was no evidence that a baseline individual TB risk assessment or TB symptom evaluation was completed upon hire, and no evidence that annual TB education was conducted in 2025.
An interview conducted with the administrator on April 28 2026 starting at 11:10 AM confirmed the above findings.
Plan of Correction:To ensure the Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files including and Personnel file #'s (PF# 1, 2,3,4,5.6 and 7) as directed by Citation 0700.
The review showed the Agency does require employees to provide test results for mycobacterium tuberculosis according the Center for Disease Control (CDC) guidelines, but did not provide the required symptom screen questionnaire and an individual TB risk assessment.
To prevent this from reoccurring the Agency created a new Employee Personnel In- Take Policy ("EPIP"). This Policy will ensure all new hiring requirements of 11.51(a), have been met before a new employee can provide service consumers. EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee filles files have missing documentation.
With the EPIP implementation, all employee Personnel file's including file employees' and (PF# 1,2,3,4,5,6 and 7) by 611.51(a). All deficiencies under Citation 0700 have been addressed.
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), the home care agency's (HCA) consumer welcome packet, and an interview with the administrator, the HCA failed to provide evidence that the consumer received information regarding the prohibitions that no individual as a result of the individual's affiliation with a HCA may assume power of attorney or guardianship over a consumer utilizing the services of that HCA. The HCA may not require a consumer to endorse checks over to the HCA. Five (5) of five (5) CF's reviewed did not meet the requirement: CF#1, CF#2, CF#3, CF#4, and CF#6.
Findings include:
The HCA's Welcome Package for Consumers, reviewed on April 28, 2026 at 9:15 AM contained a Patient Bill of Rights & Responsibilities Section on page 36 which stated, "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." Page 43 of the same document, titled Patient Admission Checklist read in part, "The following information has been provided to and/or discussed with the Patient: Rights and Responsibilities..."
The HCA's "Agency Copy (Service) Agreement for Non Medical In Home Living Assistance" reviewed on April 28, 2026 at 9:20 AM read in part, "Pennsylvania Laws requires certain consumer notices regarding services and direct care workers prior to home care agencies providing services to consumers. Please make sure to review providers' new welcome package for such consumer notices;" and "The following information (intended to be checked off) has been provided to and/or discussed with the patient...Rights & Responsibilities (page 48.)" Page 49 of the Service Agreement contained signature lines for the HCA and the consumer intended to denote that the information was provided to and received by the consumer.
In an interview with the administrator on April 28, 2026 at approximately 11:10 AM, the administrator stated that the Welcome Package is provided to the consumer.
A review of CF's was started on April 28, 2026 at approximately 9:20 AM. The start of care (SOC) is indicated below.
CF#1 SOC 02/01/2025 did not contain evidence that the consumer received information contained in the Welcome Package. The Service Agreement (AS) contained in the CF was incomplete. Page 48 (intended to show the list of items/information provided to the consumer, including the Rights and Responsibilities) and Page 49 (containing the signature lines of HCA personnel and the consumer) of the AS were missing.
CF#2 SOC 03/18/2026 did not contain evidence that the consumer received information contained in the Welcome Package. The AS contained in the CF was incomplete. Page 48 (intended to show the list of items/information provided to the consumer, including the Rights and Responsibilities) and Page 49 (containing the signature lines of HCA personnel and the consumer) of the AS were missing.
CF#3 SOC 02/01/2025 did not contain evidence that the consumer received information contained in the Welcome Package. The AS contained in the CF was incomplete. While page 49 of the AS was signed by HCA personnel and the consumer, page 48 (intended to show the list of items/information provided to the consumer, including the Rights and Responsibilities) of the AS was missing.
CF#4 SOC 02/01/2025 did not contain evidence that the consumer received information contained in the Welcome Package. The AS contained in the CF was incomplete. While page 49 of the AS was signed by HCA personnel and the consumer, page 48 (intended to show the list of items/information provided to the consumer, including the Rights and Responsibilities) of the AS was missing.
CF#5 SOC 03/31/2025 did not contain evidence that the consumer received information contained in the Welcome Package. The AS contained in the CF was incomplete. Page 48 (intended to show the list of items/information provided to the consumer, including the Rights and Responsibilities) and Page 49 (containing the signature lines of HCA personnel and the consumer) of the AS were missing.
An interview conducted with the administrator on April 28, 2026 starting at 11:10 AM confirmed the above findings.
Plan of Correction:
To correct this deficiency. The agency has revised the consumer Welcome Packet service Agreement to include a separate acknowledgment form titled Consumer rights and prohibitions acknowledgment. Signed acknowledgments have been obtained for all active consumers and placed in respective consumer files.
To prevent recurrence, the Administrator or designee will review each new admission packet to ensure the acknowledgment form is signed before services begin. in addition, quarterly audits of all consumer records will be conducted to verify that required disclosures and signed acknowledgments are present and complete.
All deficiencies related to this citation have been corrected, and monitoring procedures have been implemented to maintain ongoing compliance.
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), the home care agency's (HCA) consumer welcome packet, and an interview with the administrator, the HCA failed to provide evidence that prior to the start of services, the consumer received information regarding the listing of services to be provided, and/or the identity of the direct care worker (DCW) who would be providing services, and/or the hours when the services were to be provided, and/or contact information at the Department concerning the HCA's licensure and compliance, and/or the Department's complaint hotline, and/or contact information for the local area agency on aging, and/or the hiring and competency requirements applicable to DCW, and/or a disclosure addressing the employee or independent contractor status of the DCW providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the HCA. Five (5) of five (5) CF's did not meet the requirement: CF#1, CF#2, CF#3, CF#4, and CF#5.
Findings include:
The HCA's Welcome Package for Consumers, reviewed on April 28, 2026 at 9:15 AM contained a Patient Bill of Rights & Responsibilities Section on page 36 which listed the information to be provided to the consumer prior to the start of services as outlined above. Page 43 of the same document, titled Patient Admission Checklist read in part, "The following information has been provided to and/or discussed with the Patient: Rights and Responsibilities..."
The HCA's "Agency Copy (Service) Agreement for Non Medical In Home Living Assistance" reviewed on April 28, 2026 at 9:20 AM read in part, "Pennsylvania Laws requires certain consumer notices regarding services and direct care workers prior to home care agencies providing services to consumers. Please make sure to review providers' new welcome package for such consumer notices;" and "The following information (intended to be checked off) has been provided to and/or discussed with the patient...Rights & Responsibilities (page 48.)" Page 49 of the Service Agreement contained signature lines for the HCA and the consumer intended to denote that the information was provided to and received by the consumer.
In an interview with the administrator on April 28, 2026 at approximately 11:10 AM, the administrator stated that the Welcome Package is provided to consumers.
A review of CF's was started on April 28, 2026 at approximately 9:20 AM. The start of care (SOC) is indicated below.
CF#1 SOC 02/01/2025 did not contain evidence that the consumer received the following information contained in the Welcome Package prior to the start of services: contact information at the Department concerning the HCA's licensure and compliance, the Department's complaint hotline, contact information for the local area agency on aging, and the hiring and competency requirements applicable to DCW. The disclosure form contained in the CF did not denote whether the DCW was an employee of the HCA or an independent contractor (both sections of the form were checked), and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the HCA, intended to indicate whether the HCA maintained or did not maintain professional and general liability insurance was blank. The Service Agreement (SA) contained in the CF was incomplete. The SA did not contain the listing of services to be provided, the identity of the DCW who was to provide services, and the hours when the services were to be provided. Page 48 (intended to show the information that was provided to the consumer, including the Rights and Responsibilities) and Page 49 (containing the signature lines of HCA personnel and the consumer) of the SA were missing.
CF#2 SOC 03/18/2026 did not contain evidence that the consumer received the following information contained in the Welcome Package prior to the start of service: contact information at the Department concerning the HCA's licensure and compliance, the Department's complaint hotline, contact information for the local area agency on aging, and the hiring and competency requirements applicable to DCW. The disclosure form contained in the CF did not denote whether the DCW was an employee of the HCA or an independent contractor (both sections of the form were checked), and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the HCA, intended to indicate whether the HCA maintained or did not maintain professional and general liability insurance was blank. The Service Agreement (SA) contained in the CF was incomplete. The SA did not contain the listing of services to be provided, the identity of the DCW who was to provide services, and the hours when the services were to be provided. Page 48 (intended to show the information that was provided to the consumer, including the Rights and Responsibilities) and Page 49 (containing the signature lines of HCA personnel and the consumer) of the SA were missing.
CF#3 SOC 02/01/2025 did not contain evidence that the consumer received the following information contained in the Welcome Package prior to the start of services: contact information at the Department concerning the HCA's licensure and compliance, the Department's complaint hotline, contact information for the local area agency on aging, and the hiring and competency requirements applicable to DCW. The disclosure form contained in the CF did not denote whether the DCW was an employee of the HCA or an independent contractor (both sections of the form were checked), and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the HCA, intended to indicate whether the HCA maintained or did not maintain professional and general liability insurance was blank. The SA contained in the CF was incomplete. The SA did not contain the identity of the DCW who was to provide services, While page 49 of the SA was signed by HCA personnel and the consumer, page 48 (intended to show the list of items/information provided to the consumer, including the Rights and Responsibilities) of the SA was missing.
CF#4 SOC 02/01/2025 did not contain evidence that the consumer received the following information contained in the Welcome Package prior to the start of service: contact information at the Department concerning the HCA's licensure and compliance, the Department's complaint hotline, contact information for the local area agency on aging, and the hiring and competency requirements applicable to DCW. The disclosure form contained in the CF did not denote whether the DCW was an employee of the HCA or an independent contractor (both sections of the form were checked). The SA contained in the CF was incomplete. The SA did not contain the listing of services to be provided, the identity of the DCW who was to provide services, and the hours when the services were to be provided. While page 49 of the SA was signed by HCA personnel and the consumer, page 48 (intended to show the list of items/information provided to the consumer, including the Rights and Responsibilities) of the SA was missing.
CF#5 SOC 03/31/2025 did not contain evidence that the consumer received the following information contained in the Welcome Package prior to the start of service: contact information at the Department concerning the HCA's licensure and compliance, the Department's complaint hotline, contact information for the local area agency on aging, and the hiring and competency requirements applicable to DCW. Two disclosure forms present in the CF contained the signature of HCA personnel and the consumer, but neither form indicated whether the DCW was an employee of the HCA or an independent contractor (both sections of the form were blank), and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the HCA, intended to indicate whether the HCA maintained or did not maintain professional and general liability insurance was blank. The disclosure form was signed on 04/27/2026, almost one month after the start of care. The Service Agreement (SA) contained in the CF was incomplete. The SA did not contain the listing of services to be provided, the identity of the DCW who was to provide services, and the hours when the services were to be provided. Page 48 (intended to show the information that was provided to the consumer, including the Rights and Responsibilities) and Page 49 (containing the signature lines of HCA personnel and the consumer) of the SA were missing.
An interview conducted with the administrator on April 28, 2026 starting at 11:10 AM confirmed the above findings.
Plan of Correction:T&T HomeCare Registry immediately reviewed its admission and intake procedures to ensure that all required consumer information is provided and documented before the initiation of services. A standardized Welcome Packet was created and is now given to every consumer, legal representative, or responsible family member prior to the first day of service
All current client files were audited to confirm that signed acknowledgments forms are present. Any missing acknowledgements were obtained and added to consumer records.
The agency has implemented a mandatory Pre-Service admission Checklist that must be completed before any caregiver is assigned.
The Administrator will review 100% of all new admissions weekly for three months to ensure compliance with pre-service disclosure requirements.
T7t Homecare Registry is committed to ensuring that all consumers, legal representatives, responsible family members receive complete and accurate information before services begin. Policies, staff training, and ongoing monitoring have been implemented to maintain full compliance.
Initial Comments:
Based on the findings of an onsite State Re-Licensure Survey conducted on April 28, 2026, T & T Home Care, LLC was found not to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
35 P. S. § 448.809b LICENSURE
Photo Id Reg
Name - Component - 00
Law amended July 11, 2022 Act 79 2022 HB 2604
(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.
(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.
(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.
(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.
Observations:
Based on observation and an interview with the administrator, the home care agency (HCA) failed to provide photo identification tags for HCA's employees that would include the employee's name, title, picture and the name of the agency.
Findings include:
In an interview conducted with the administrator on April 28, 2026 at approximately 10:55 AM, the administrator was asked by the surveyor if the Agency is using photo identification tags for its employees. The Administrator stated that the HCA is not using photo identification tags at this time.
Plan of Correction:To ensure T&T HomeCare future compliance. conducted an immediate review of all active employees.identifications badges were created and issued to all staff who proovide services or represent the agency .Employees were instructed that agency issued id.badges must be worn and displayed at all times while providing services in consumers homes and while conducting agency business.
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