Initial Comments:
Based on the findings of onsite unannounced state re-licensure survey conducted on December 10, 2025, ADK's 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 onsite unannounced state re-licensure survey conducted on December 10, 2025, ADK's Care, LLC, 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 review of personnel files (PF) and an interview with agency administrator, the agency failed obtain two (2) satisfactory references prior to hiring or rostering for two (2) of the seven (7) PF's reviewed. (PF#1 and PF#4)
Findings include:
Personnel file review conducted December 10, 2025 from approximately 2:00 pm to 3:30 pm revealed the following:
PF #1 Date of hire (DOH), 7/22/25: Did not contain documentation of two (2) satisfactory references prior to the hire date.
PF#4 DOH 5/12/25: Did not contain documentation of two (2) satisfactory references prior to the hire date.
An interview with the administrator on December 10, 2025 at approximately 3:40 pm confirmed the above.
Plan of Correction:For the 2 DCW's references will be rechecked and a paper will be placed in the personnel files. The paper will include the questions asked and the date and time of the call. This will include all the existing personnel files as well as new hires.
The agency will make a checklist to make sure at least two non relative references are checked and placed in personnel files.
All personnel files will be audited by the administrator on a quarterly basis.
The plan of correction will be completed by 2/05/2026.
A checklist will be made with all the steps we need to do in order to hire a DCW. Every time a new DCW is hired, the admin will follow the checklist guidelines.
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 review of CDC guidelines, personnel files (PF) and an interview with the agency's administrator, it was determined the agency failed to ensure that the direct care workers were screened for and were free from active mycobacterium tuberculosis upon hire for five (5) of the seven (7) PF's reviewed. (PF#1, PF#2, PF#4, PF#6, and PF#7)
Findings include:
The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs with a baseline positive or newly 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; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.)
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
Findings include:
Personnel file review conducted December 10, 2025 from approximately 2:00 pm to 3:30 pm revealed the following:
PF #1 Date of hire (DOH), 7/22/25: Contained no documentation that a completed TB test was performed to ensure the staff were free from active Mycobacterium tuberculosis upon hire. Tuberculin skin test (TST) dated 7/17/25. No documentation of a second TST on file.
PF#2 DOH 5/1/24: Contained no documentation that a TB test was performed to ensure the staff were free from active Mycobacterium tuberculosis upon hire. Chest X-ray dated 10/1/25, after the hire date
PF#4 DOH 5/12/25: Contained no documentation that a TB test was performed to ensure the staff were free from active Mycobacterium tuberculosis upon hire. Tuberculin skin test (TST) dated 4/21/25. No documentation of a second TST on file.
PF#6 DOH 5/12/25: Contained no documentation that a TB test was performed to ensure the staff were free from active Mycobacterium tuberculosis upon hire. Tuberculin skin test (TST) dated 5/30/25, after the hire date. No documentation of a second TST on file.
PF#7 DOH 8/28/24: Contained no documentation that a TB test was performed to ensure the staff were free from active Mycobacterium tuberculosis upon hire.
An interview with the administrator on December 10, 2025 at approximately 3:40 pm confirmed the above.
Plan of Correction:For the 5 DCW's administrator will try to find the TB testing that was initially done at the time for hire. If unable to get it then the administrator will have them all get retests for TB.
All other files will be reviewed and all others that had no TB test will be asked to retest for TB. A TB test will be placed in all personnel files.
All personnel files will be audited on a quarterly basis to make sure compliance is achieved. The files will also be audited by the admin.
The plan of correction will be completed by 02/05/2026.
A checklist will be made with all the steps we need to do in order to hire a DCW. Every time a new DCW is hired, the admin will follow the checklist guidelines.
Initial Comments:
Based on the findings of onsite unannounced state re-licensure survey conducted on December 10, 2025, ADK's Care, LLC, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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