Initial Comments:
Based on the findings of an onsite state re-licensure survey completed on June 9, 2026, Mahone In-Home Health 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 completed on June 9, 2026, Mahone In-Home Health Care, LLC was found to not be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.
Plan of Correction:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
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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 employee (EMP) interview, the agency failed to conduct a virtual or face-to-face interview for three (3) of five (5) PF reviewed (PF1-3). The agency also failed to obtain two satisfactory references for four (4) of five (5) PF reviewed (PF1-4).
Findings included:
Review of PF conducted on June 9, 2026, at approximately 10:00am revealed:
PF1, date of hire (DOH) 4/2/26, start of services (SOS) 4/2/26, failed to include documentation of a virtual or face-to-face interview and two satisfactory references.
PF2, DOH 10/13/25, SOS 10/13/25, failed to include documentation of a virtual or face-to-face interview and two satisfactory references.
PF3, DOH 12/31/25, SOS 12/31/25, failed to include documentation of a virtual or face-to-face interview and two satisfactory references.
PF4, DOH 9/14/23, SOS 9/14/23, failed to include documentation of two satisfactory references.
Findings confirmed at exit interview with Chief Operating Officer (CEO) and Director of Operations on June 6, 2026, at approximately 3:30pm.
Plan of Correction:Effective 6/9/2026 all employee's file will contain a face sheet that will show the date of face-to-face interview. Also, employee file will contain a reference sheet with the name of reference, date called, and if satisfactory.
I Director of operations will do an internal audit every 30 days to insure Mahone in Home is in compliance.
611.52(c) LICENSURE
Federal Criminal History Record
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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 review of personnel files (PF) and employee (EMP) interview the agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for one (1) of one (1) PF reviewed (PF6) that did not include proof of residency in the state of Pennsylvania within 2 years prior to date of hire.
Findings included:
Review of PF conducted on June 9, 2026, at approximately 10:00am revealed:
PF6, date of hire (DOH) 10/2/23, start of services (SOS) 10/2/23, PF, void of proof of residency in the state of pennsylvania for 2 years prior to hire, failed to contain evidence of a federal criminal history record and a letter of determination from the Department of Aging.
Findings confirmed at exit interview with Chief Operating Officer (CEO) and Director of Operations on June 6, 2026, at approximately 3:30pm.
Plan of Correction:Effective 6/9/2026 all employee's proof of residency will be included in employee file showing residency prior to employee start date. I Director of operations will do an internal audit every 30 days to insure Mahone in Home is in compliance. Pf6 is still a current employee i was able to obtain proof of residency to complete the file. Mahone in Home will do an internal audit of all current employee files to make sure all files are compliant
611.55(e) LICENSURE
Competency Requirements
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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 review of personnel files (PF) and employee (EMP) interview the agency failed to ensure employees demonstrated competency annually after establishing initial competency for three (3) of three (3) PF reviewed (PF4-6).
Findings included:
Review of PF conducted on June 9, 2026, at approximately 10:00am revealed:
PF4, date of hire (DOH) 9/14/23 , start of services (SOS) 9/14/23, PF failed to contain an annual competency review for 2024 and 2025.
PF5, DOH 5/7/22, SOS 5/7/22, PF failed to contain an annual competency review for 2022, 2023, 2024, and 2025.
PF6, DOH 10/2/23, SOS 10/2/23, PF failed to contain an annual competency review for 2024, 2025, and 2026.
Findings confirmed at exit interview with Chief Operating Officer (CEO) and Director of Operations on June 6, 2026, at approximately 3:30pm.
Plan of Correction:Effective 6/9/2026 all employee's who have been employed with Mahone in Home for a Year will receive an annual competency test. I Director of operations will review each employee's start date and have those employees files updated who are due for an annual, An internal quality control audit will be conducted every 30 days to insure compliance. Due to very high turn over rate not many make it a year Moving forward I director of operations will track all employees anniversary date using alerts from payroll app and issue all annuals.
611.56(a) LICENSURE
Health Screening
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(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), CDC (Centers for Disease Control) guidance, and employee (EMP) interview, the agency failed to ensure that each direct care worker, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis for two (2) of five (5) PF reviewed (PF2 & 3).
Findings included:
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...HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease....A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST within the previous 12 months, a single TST can be administered in the new setting. 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.
Review of PF conducted on June 9, 2026, at approximately 10:00am revealed:
PF2, date of hire (DOH) 10/13/25, start of services (SOS) 10/13/25, failed to include evidence of a TB screening upon, or within 1 year preceeding hire. Documentation retained in file of negative TB screening dated 9/24/24, 464 days prior to hire.
PF3, DOH 12/31/25, SOS 12/31/25, failed to include evidence of tuberculosis screening.
Findings confirmed at exit interview with Chief Operating Officer (CEO) and Director of Operations on June 6, 2026, at approximately 3:30pm.
Plan of Correction:Effective 6/9/2026 all employee's will be required to have a 2 step tb test and results listed in file showing completed within a 1 year period prior to hire date. I Director of operations will review each new hire file prior to adding to schedule to insure Mahone in Home is in compliance. In addition Mahone in Home will do an internal audit of all current employee files to insure all are in compliance
611.56(b) LICENSURE
Health Screening
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(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 (PF), CDC (Centers for Disease Control and Prevention) Guidelines, and employee (EMP) interview the agency failed to failed to complete annual Tuberculosis (TB) screenings and education for three (3) of three (3) PF reviewed (PF4-6) with at least 12 months of employment.
Findings included:
The CDC guidelines state that 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).
Review of PF conducted on June 9, 2026, at approximately 10:00am revealed:
PF4, date of hire (DOH) 9/14/23 , start of services (SOS) 9/14/23, PF failed to contain evidence of TB risk screening, symptom screening, and education for 2024 and 2025.
PF5, DOH 5/7/22, SOS 5/7/22, PF failed to contain evidence of TB risk screening, symptom screening, and education for 2024 and 2025.
PF6, DOH 10/2/23, SOS 10/2/23, PF failed to contain evidence of TB risk screening, symptom screening, and education for 2024 and 2025.
Findings confirmed at exit interview with Chief Operating Officer (CEO) and Director of Operations on June 6, 2026, at approximately 3:30pm.
Plan of Correction:Effective 6/9/2026 all employee's who have been employed with Mahone in Home for a Year will receive an annual TB education, TB risk screening, Tb symptom screening. Results will be kept in the employee file. I Director of operations will do an internal audit to have all current employee files updated who has been employed for a year. An internal quality control audit will be conducted every 30 days to insure compliance Due to very high turn over rate not many make it a year Moving forward I director of operations will track all employees anniversary date using alerts from payroll app and issue all annuals.
Initial Comments:
Based on the findings of an onsite state re-licensure survey completed on June 9, 2026, Mahone In-Home Health 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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