Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on May 28, 2026, Brightstar Care of Greater Chester County, 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 unannounced home care agency state re-licensure survey conducted on May 28, 2026, Brightstar Care of Greater Chester County, 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 upon personnel file (PF) review and interview with the agency's Administrator, it was determined that the agency failed to ensure documentation of verification of two satisfactory references prior to hire for six (6) out of seven (7) PF's reviewed (PF#1-PF#3 and PF#5-PF#7) and failed to ensure documentation of a face to face interview for six (6) out of seven (7) personnel files reviewed (PF#1, PF#3-PF#7) .
Findings include:
Personnel files were reviewed on 5/28/26 from approximately 12:00 PM-12:45 PM, revealing the following:
PF#1, Date of hire (DOH): 9/12/2025: No documentation of verification of two satisfactory references and no documentation of a face to face interview.
PF#2, DOH: 11/17/2025: No documentation of a face to face interview.
PF#3, DOH: 11/24/2025: No documentation of verification of two satisfactory references and no documentation of a face to face interview.
PF#4, DOH: 12/10/2025: No documentation of verification of two satisfactory references.
PF#5, DOH: 7/25/2025: No documentation of verification of two satisfactory references and no documentation of a face to face interview.
PF#6, DOH: 8/26/2025: No documentation of verification of two satisfactory references and no documentation of a face to face interview.
PF#7, DOH: 12/24/2025: No documentation of verification of two satisfactory references and no documentation of a face to face interview.
An interview with the agency Administrator on 5/28/26 at approximately 12:45 PM confirmed the above findings.
Plan of Correction:Face to face interviews and 2 verified references will be obtained for all employees and documentation of the face-to-face interview and reference verifications will be maintained in the employee personnel record. A standardized onboarding checklist has been implemented to ensure all required hiring documentation is completed, verified, and filed before an employee is eligible for assignment. The Administrator and hiring personnel will review all new employee records for compliance prior to activation. PF identified during the in-person survey will be corrected by 6/30/2026
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 upon personnel file (PF) reviews and interview with the agency's Administrator, it was determined that the agency failed to ensure documentation the direct care worker, prior to consumer contact, was screened for mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for one (1) out of seven (7) personnel files reviewed ( PF#1) .
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).
Personnel files were reviewed on 5/28/26 from approximately 12:00 PM-12:45 PM, revealing the following:
PF#1, Date of hire (DOH): 9/12/2025: No documentation of completed baseline testing.
An interview with the agency Administrator on 5/28/26 at approximately 12:45 PM confirmed the above findings.
Plan of Correction:Negative TB test results will be obtained for every employee prior to hire. Results will be reviewed and filed in the employee record. PF#1 submitted a negative QF Gold test on 6/5/2026
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on May 28, 2026, Brightstar Care of Greater Chester County, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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