QA Investigation Results

Pennsylvania Department of Health
FAMILY CARE FOR YOU
Health Inspection Results
FAMILY CARE FOR YOU
Health Inspection Results For:


There are  5 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of a home care agency state licensure survey completed on February 27, 2025, Family Care For You 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 a home care agency state licensure survey completed on February 27, 2025, Family Care For You was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 601, 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 and the Human resources (HR) director, the agency failed to retain documentation of face-to-face interview and/or two satisfactory references prior to hiring or rostering for six (6) of the seven (7) PF's reviewed. (PF#1, PF#3-PF#7)

Findings include:
Personnel file review conducted on February 26, 2025, from approximately 1:00 pm to 2:00 pm and on February 27, 2025, from approximately 4:30 pm to 5:30 pm revealed the following:

PF #1, Date of hire (DOH) 9/14/23: Contained no documentation of two satisfactory, verified references.

PF#3, DOH 8/11/22: Contained no documentation of two satisfactory, verified references.

PF#4, DOH 6/10/24: Contained no documentation of two satisfactory, verified references.

PF#5, DOH 11/28/22: Contained no documentation of two satisfactory, verified references. Contained no documentation of a face to face interview.

PF#6, DOH 4/19/21: Contained no documentation of two satisfactory, verified references. Contained no documentation of a face to face interview.

PF#7, DOH 10/6/20: Contained no documentation of two satisfactory, verified references. Contained no documentation of a face to face interview.


An interview with the administrator and the HR director conducted on February 26, 2025, at approximately 2pm confirmed the above findings.








Plan of Correction:

Family Care For You Home Care Agency will correct this deficiency by doing the following:
1. The Administrator conducted an Inservice for Family Care For You staff to Educate and make aware of the regulatory requirements of Chapter 611.51(a)
2. The Administrator instructed Administrative Assistants #1 and #2 to review all personnel files and that are incomplete so that measures may be made to update the files correctly. The Administrator instructed the Director of Communications to contact the clients associated with the employees that do not have completed files and do a wellness check phone call for safety regarding the care they received.
3. To ensure this issue does not repeat, once yearly the Administrator will conduct a yearly staff training for the office staff that will discuss chapter 611.51(a) and its requirements, and it will be the responsibility of Administrative Assistants #1 and #2 to do a face-to-face interview and reference check that covers the regulation on newly hired personnel. A new hire checklist was created to keep tract of needed documentation for personnel files.
4. As a quality and assurance measure, the Director of Human Resources will audit each personnel file once completed with appropriate documentation. The Administrator will assure that the new hire checklist is completed with each area checked off. Once all required documents are submitted, Administrative Assistants #1 and #2 will check off as complete and submit it to the Director of Human Resources to audit the paperwork. These audits will take place once a personnel file is completed and before being placed on an assignment and quarterly thereafter.
5. This Plan of Correction will be completed by the corrective action date listed.


611.52(b) LICENSURE
State Police Criminal History Record

Name - Component - 00
If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.

Observations:

Based on a review of personnel files (PF), and an interview with the agency administrator and the Human resources (HR) director, the agency failed to provide documentation of a Pennsylvania State Police Criminal Background Check (PATCH) at the time of application or within one (1) year immediately preceding the date of application for six (6) of seven (7) PF's reviewed. (PF #1, PF #2, PF#4, PF#5, PF#6 and PF#7)



Findings include:
Personnel file review conducted on February 26, 2025, from approximately 1:00 pm to 2:00 pm and on February 27, 2025, from approximately 4:30 pm to 5:30 pm revealed the following:

PF #1, Date of hire (DOH) 9/14/23: Contained no documentation of a Pennsylvania State Police Criminal Background Check report on file.

PF#2, DOH 6/5/24: Contained no documentation of a Pennsylvania State Police Criminal Background Check report on file.

PF#4, DOH 6/10/24: Contained no documentation of a Pennsylvania State Police Criminal Background Check report on file.

PF#5, DOH 11/28/22: Contained no documentation of a Pennsylvania State Police Criminal Background Check report on file.

PF#6, DOH 4/19/21: Contained no documentation of a Pennsylvania State Police Criminal Background Check report on file.

PF#7, DOH 10/6/20: Contained no documentation of a Pennsylvania State Police Criminal Background Check report on file.


An interview with the administrator and the HR director conducted on February 26, 2025, at approximately 2pm confirmed the above findings.







Plan of Correction:

Family Care For You Home Care Agency will correct this deficiency by doing the following:
1. The Administrator conducted an Inservice for Family Care For You staff to Educate and make aware of the regulatory requirements of Chapter 611.52(b)
2. The Administrator instructed Administrative Assistants #1 and #2 to review all personnel files that are incomplete and does not contain a Pa. State Police Criminal History Record so that measures may be made to update the files correctly. The Administrator instructed the Director of Communications to contact the clients associated with the employees that do not have those completed files and do a wellness check phone call regarding their safety and the care they received from their worker.
3. To ensure this issue does not repeat, once yearly the Administrator will conduct a yearly staff training for the office staff that will discuss chapter 611.52(b) and its requirements, and it will be the responsibility of Administrative Assistants #1 and #2 to request a Pa Criminal Background Check on each personnel and all newly hired personnel. A new hire checklist was created to keep tract of needed documentation for personnel files.
4. As a quality and assurance measure, the Director of Human Resources will audit each personnel file once completed with appropriate documentation. The Administrator will assure that the new hire checklist is completed with each area checked off. Once all required documents are submitted, Administrative Assistants #1 and #2 will check off as complete and submit it to the Director of Human Resources to audit the paperwork. These audits will take place once a personnel file is completed before they are placed on an assignment and quarterly thereafter.
5. This Plan of Correction will be completed by the corrective action date listed.


611.52(c) LICENSURE
Federal Criminal History Record

Name - Component - 00
If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code § 15.144(b) (relating to procedure).

Observations:

Based on a review of personnel files (PF), and an interview with the administrator and the Human resources (HR) director, the agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging based on the individual's Federal criminal history record for one (1) of seven (7) PFs. PF#7.


Findings include:
Personnel file review conducted on February 26, 2025, from approximately 1:00 pm to 2:00 pm and on February 27, 2025, from approximately 4:30 pm to 5:30 pm revealed the following:

PF #1, Date of hire (DOH) 9/14/23: Contained a Pennsylvania drivers license issued on 6/16/23, which fails to ascertain PA residence of two (2) or more years. Federal criminal history record and a letter of determination from the Department of Aging dated 9/19/23, after the hire date. .

PF#2, DOH 6/5/24: Contained a Pennsylvania drivers license issued on 11/2/23, which fails to ascertain PA residence of two (2) or more years. No other documentation on file to establish proof of residency. The file did not contain a federal criminal history record and a letter of determination from the Department of Aging.


PF#5, DOH 11/28/22: Contained a Pennsylvania drivers license issued on 5/25/21, which fails to ascertain PA residence of two (2) or more years. No other documentation on file to establish proof of residency. The file did not contain a federal criminal history record and a letter of determination from the Department of Aging.


PF#6, DOH 4/19/21: Contained a Maryland drivers license issued 10/9/19. No other documentation on file to establish proof of residency. The file did not contain a federal criminal history record and a letter of determination from the Department of Aging.


PF#7, DOH 10/6/20: Contained a Pennsylvania drivers license issued on 6/14/19, which fails to ascertain PA residence of two (2) or more years. No other documentation on file to establish proof of residency. The file did not contain a federal criminal history record and a letter of determination from the Department of Aging.

An interview with the administrator and the HR director conducted on February 26, 2025, at approximately 2pm confirmed the above findings.











Plan of Correction:

Family Care For You plans to correct this deficiency by doing the following:
1. The Administrator conducted an Inservice for Family Care For You staff to Educate and make aware of the regulatory requirements of Chapter 611.52(c)
2. The Administrator instructed Administrative Assistants #1 and #2 to review all personnel files and that are incomplete and does not contain a federal Criminal History Record and a letter of determination from the Department on Aging based on the individual's Federal Criminal History Record so that measures may be made to update the files correctly. The Administrator instructed the Director of Communications to contact the clients associated with the employees that do not have those completed files and do a wellness check phone call regarding their safety and the care they received from their worker.
3. To ensure this issue does not repeat, once yearly the Administrator will conduct a yearly staff training for the office staff that will discuss chapter 611.52(c) and its requirements, and it will be the responsibility of Administrative Assistants #1 and #2 to request a federal criminal history record and a letter of determination from the Department of Aging based on the individual's Federal criminal history record on each personnel that has not been a resident of the Commonwealth for two years preceding the date of hire and all newly hired personnel that cannot show appropriate documentation that they have been a resident of the Commonwealth for two years preceding the request. A new hire checklist was created to keep tract of needed documentation for personnel files.
4. As a quality and assurance measure, the Director of Human Resources will audit each personnel file once completed with appropriate documentation. The Administrator will assure that the new hire checklist is completed with each area checked off. Once all required documents are submitted, Administrative Assistants #1 and #2 will check off as complete and submit it to the Director of Human Resources to audit the paperwork. These audits will take place once a personnel file is completed before they are placed on an assignment and quarterly thereafter.
5. This Plan of Correction will be completed by the corrective action date listed.


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 a review of personnel files (PF) and an interview with the administrator and the Human resources (HR), the agency failed to obtain proof of residency in order to request/obtain a criminal history record through the 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 five (5) of seven (7) PF's: PF#1, PF#2, PF#5-7)


Findings include:
Personnel file review conducted on February 26, 2025, from approximately 1:00 pm to 2:00 pm and on February 27, 2025, from approximately 4:30 pm to 5:30 pm revealed the following:



PF #1, Date of hire (DOH) 9/14/23: Contained a Pennsylvania drivers license issued on 6/16/23, which fails to ascertain PA residence of two (2) or more years. Federal check dated 9/19/23, after the hire date. No other documentation on file to establish proof of residency.

PF#2, DOH 6/5/24: Contained a Pennsylvania drivers license issued on 11/2/23, which fails to ascertain PA residence of two (2) or more years. No other documentation on file to establish proof of residency.

PF#5, DOH 11/28/22: Contained a Pennsylvania drivers license issued on 5/25/21, which fails to ascertain PA residence of two (2) or more years. No other documentation on file to establish proof of residency.

PF#6, DOH 4/19/21: Contained a Maryland drivers license. No other documentation on file to establish proof of residency.

PF#7, DOH 10/6/20: Contained a Pennsylvania drivers license issued on 6/14/19, which fails to ascertain PA residence of two (2) or more years. No other documentation on file to establish proof of residency.


An interview with the administrator and the HR director conducted on February 26, 2025, at approximately 2pm confirmed the above findings.







Plan of Correction:

Family Care For You Home Care Agency will correct this deficiency by doing the following:
1. The Administrator conducted an Inservice for Family Care For You staff to Educate and make aware of the regulatory requirements of Chapter 611.52(d)
2. The Administrator instructed Administrative Assistants #1 and #2 to review all personnel files and that are incomplete and does not contain adequate proof of residency so that measures may be made to update the files correctly. The Administrator instructed the Director of Communications to contact the clients associated with the employees that do not have those completed files and do a wellness check phone call regarding their safety and the care they received from their worker.
3. To ensure this issue does not repeat, once yearly the Administrator will conduct a yearly staff training for the office staff that will discuss chapter 611.52(d) and its requirements so that staff involved in the hiring process will understand what proper proof of residency entails. It will be the responsibility of Administrative Assistants #1 and #2 to adequate proof of residency on each personnel that does not have adequate documentation in their file and all newly hired personnel thereafter. A new hire checklist was created to keep tract of needed documentation for personnel files.
4. As a quality and assurance measure, the Director of Human Resources will audit each personnel file once completed with appropriate documentation. The Administrator will assure that the new hire checklist is completed with each area checked off. Once all required documents are submitted, Administrative Assistants #1 and #2 will check off as complete and submit it to the Director of Human Resources to audit the paperwork. These audits will take place once a personnel file is completed before they are placed on an assignment and quarterly thereafter.
5. This Plan of Correction will be completed by the corrective action date listed.


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 administrator and the HR director, the agency failed to ensure files contained documentation the employees demonstrated competency prior to assignment for two (2) of seven (7) files reviewed. (PF#1-2).


Findings include:
Personnel file review conducted on February 26, 2025, from approximately 1:00 pm to 2:00 pm and on February 27, 2025, from approximately 4:30 pm to 5:30 pm revealed the following:

PF #1, Date of hire (DOH) 9/14/23: Contained no doucmentation of demonstrated competency prior to assignment.

PF#2, DOH 6/5/24: Contained no doucmentation of demonstrated competency prior to assignment.

An interview with the administrator and the HR director conducted on February 26, 2025, at approximately 2pm confirmed the above findings.






Plan of Correction:

Family Care For You Home Care Agency will correct this deficiency by doing the following:
1. The Administrator conducted an Inservice for Family Care For You staff regarding to Educate and make aware of the regulatory requirements of Chapter 611.55(a)
2.The Administrator instructed Administrative Assistants #1 and #2 to review all personnel files and that are incomplete and does not contain completed competency according to the competency policy that follows chapter 611.55(a) so that measures may be made to update the files correctly. Those workers will be notified and requested to complete the required competencies. The Administrator instructed the Director of Communications to contact the clients associated with the employees that do not have those completed competencies in their files and do a wellness check phone call regarding their safety and the care they received from their worker.
3. To ensure this issue does not repeat, once yearly the Administrator will conduct a yearly staff training for the office staff that will discuss chapter 611.55(a) and its requirements so that staff involved in the hiring process will understand the competency requirement prior to being assigned to a client. It will be the responsibility of Administrative Assistants #1 and #2 to inform newly hired personnel of the competency requirement and make sure each competency is completed prior to the workers being assigned. A new hire checklist was created to keep tract of needed documentation for personnel files.
4. As a quality and assurance measure, the Director of Human Resources will audit each personnel file once completed with appropriate documentation. The Administrator will assure that the new hire checklist is completed with each area checked off. Once all required documents are submitted, Administrative Assistants #1 and #2 will check off as complete and submit it to the Director of Human Resources to audit the paperwork. These audits will take place once a personnel file is completed before they are placed on an assignment and quarterly thereafter. During the quarterly file audits, it is the responsibility of the Director of Human Resources to Administrative Assistants #1 and #2 to reach out to any employee that does not have a yearly competency training completed.
5. This Plan of Correction will be completed by the corrective action date listed.


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 personnel files (PF), the Centers for Disease Control Guidelines, and an interview with the agency administrator and the Human resources (HR) director, it was determined the agency failed to ensure employees were screened for and were free from active mycobacterium tuberculosis prior to assignment with clients for seven (7) out of seven (7) direct personnel files reviewed. (PF #1-PF#7).

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 on February 26, 2025, from approximately 1:00 pm to 2:00 pm and on February 27, 2025, from approximately 4:30 pm to 5:30 pm revealed the following:

PF #1, Date of hire (DOH) 9/14/23: Contained no documentation of any TB testing upon hire or within the year prior to the hire date. Also did not contain a baseline risk and symptom screening questionnaire upon hire.


PF#2, DOH 6/5/24: Contained no documentation of any TB testing upon hire or within the year prior to the hire date. Also did not contain a baseline risk and symptom screening questionnaire upon hire.

PF#3, DOH 8/11/22: Contained no documentation of any TB testing upon hire or within the year prior to the hire date.

PF#4, DOH 6/10/24: Contained no documentation of any TB testing upon hire or within the year prior to the hire date. Also did not contain a baseline risk and symptom screening questionnaire upon hire.

PF#5, DOH 11/28/22: Contained no documentation of any TB testing upon hire or within the year prior to the hire date.

PF#6, DOH 4/19/21: Contained no documentation of any TB testing upon hire or within the year prior to the hire date. Also did not contain a baseline risk and symptom screening questionnaire upon hire.

PF#7, DOH 10/6/20: Contained no documentation of any TB testing upon hire or within the year prior to the hire date. Also did not contain a baseline risk and symptom screening questionnaire upon hire.


An interview with the administrator and the HR director conducted on February 26, 2025, at approximately 2pm confirmed the above findings.













Plan of Correction:

Family Care For You Home Care Agency will correct this deficiency by doing the following:
1. The Administrator conducted an Inservice for Family Care For You staff regarding the survey to Educate and make aware of the regulatory requirements of Chapter 611.56(a)
2. The Administrator instructed Administrative Assistants #1 and #2 to review all personnel files and that are incomplete and does not contain documented clearance of active TB so that measures may be made to update the files correctly. Those workers will be notified and requested to have TB testing completed. The Administrator instructed the Director of Communications to contact the clients associated with the employees that do not have documented tb testing clearance in their files and do a wellness check phone call regarding their safety, any possible symptoms and the care they received from their worker.
3. To ensure this issue does not repeat, once yearly the Administrator will conduct a yearly staff training for the office staff that will discuss chapter 611.56(a) and its requirements so that staff involved in the hiring process will understand the requirement being completed prior to an individual being assigned to a client. It will be the responsibility of Administrative Assistants #1 and #2 to inform newly hired personnel of required TB testing that is needed and make sure it is completed with clearance results filed prior to the workers being assigned. A new hire checklist was created to keep tract of needed documentation for personnel files.
4. As a quality and assurance measure, the Director of Human Resources will audit each personnel file once completed with appropriate documentation. The Administrator will assure that the new hire checklist is completed with each area checked off. Once all required documents are submitted, Administrative Assistants #1 and #2 will check off as complete and submit it to the Director of Human Resources to audit the paperwork. These audits will take place once a personnel file is completed before they are placed on an assignment and quarterly thereafter.
5. This Plan of Correction will be completed by the corrective action date listed.


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 current CDC guidelines, personnel files (PF), and an interview with the administrator and the Human resources (HR) director, the agency failed to ensure documentation showing that its employees were provided with annual TB risk assessments and TB education for seven (7) of seven (7) files reviewed. (PF#1-7).



Findings include:

In May 2019, The National TB Controllers Association (NTCA) and The Centers for Disease Control and Prevention (CDC) issued updated guidelines for TB screening of health care personnel (HCP). "Serial screening and testing for HCP without latent TB infections... recommendations include:... annual TB education for all HCP including information about TB exposure risks for all HCP". MMWR, May 17, 2019; Vol. 98; No. 19.


Personnel file review conducted on February 26, 2025, from approximately 1:00 pm to 2:00 pm and on February 27, 2025, from approximately 4:30 pm to 5:30 pm revealed the following:


PF #1, Date of hire (DOH) 9/14/23: Contained no documentation of an annual risk assessment or education related to TB.

PF#2, DOH 6/5/24: Contained no documentation of an annual risk assessment or education related to TB.

PF#3, DOH 8/11/22: Contained no documentation of an annual risk assessment or education related to TB.

PF#4, DOH 6/10/24: Contained no documentation of an annual risk assessment or education related to TB.

PF#5, DOH 11/28/22: Contained no documentation of an annual risk assessment or education related to TB.

PF#6, DOH 4/19/21: Contained no documentation of an annual risk assessment or education related to TB.

PF#7, DOH 10/6/20: Contained no documentation of an annual risk assessment or education related to TB.

An interview with the administrator and the HR director conducted on February 26, 2025, at approximately 2pm confirmed the above findings.












Plan of Correction:

Family Care For You Home Care Agency will correct this deficiency by doing the following:
1. The Administrator conducted an Inservice for Family Care For You staff to Educate and make staff aware of the regulatory requirements of Chapter 611.56(b)
2. The Administrator instructed Administrative Assistants #1 and #2 to review all personnel files and that are incomplete and does not contain a yearly TB risk assessment so that measures may be made to update the files correctly. Education regarding TB was gathered from CDC website and a TB education packet was created for each employee and for new hires. All current workers will be notified and requested to complete an annual TB risk assessment and will be given TB education packet. The Administrator instructed the Director of Communications to contact the clients associated with the employees that do not have documented tb risk assessments in their files and do a wellness check phone call regarding their safety, any possible symptoms and any issues regarding the care they received from their worker.
3. To ensure this issue does not repeat, once yearly the Administrator will conduct a yearly staff training for the office staff that will discuss chapter 611.56(b) and its requirements. It will be the responsibility of Administrative Assistants #1 and #2 to inform personnel of the yearly TB risk assessment requirement when it is due. Once yearly, Education will be provided by the Administrator during yearly Inservice educating the staff about TB. A new hire checklist was created to keep tract of needed documentation for personnel files and Inservice trainings.
4. As a quality and assurance measure, the Director of Human Resources will audit each personnel file to make sure yearly TB risk assessments are completed for each employee and that they have received the yearly TB education. These audits will take place on a quarterly basis.
5. This Plan of Correction will be completed by the corrective action date listed.


Initial Comments:


Based on the findings of a home care agency state licensure survey completed on February 27, 2025, Family Care For You was found to be in compliance with the following requirements of 35 P.S. 448.809 (b).





Plan of Correction: