Initial Comments:
Based on the findings of an unannounced, on-site state re-licensure survey conducted on April 30, 2026, Pak Homecare 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 unannounced, on-site state re-licensure survey conducted on April 30, 2026, Pak Homecare 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
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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 upon review of employee files (EFs) and interview with agency owner (EMP #1), it was determined agency failed to maintain documentation of verification of two satisfactory references, prior to hiring or rostering direct care workers for two (2) of ten (10) EFs reviewed. (EF# 4 and EF# 8)
Findings include:
Review of EFs conducted on April 30, 2026 at between approximately 9:40 a.m. and 11:00 a.m. revealed the following:
EF# 4, Date of Hire (DOH), 5/12/2025: No documentation of two references being verified prior to hiring or rostering direct care worker. Contained two (2) references dated 5/13/2026, 1 day after initial shift.
EF# 8, DOH, 2/24/2026: No documentation of two references being verified prior to hiring or rostering direct care worker. Contained one (1) reference dated 2/23/2026.
An interview with the agency EMP #1 conducted on April 30, 2026 at approximately 3:00 p.m. confirmed the above findings.
Plan of Correction:1. Corrective Action for Identified Individual/Practice:
PAK HomeCare will maintain the two completed reference checks already obtained for EF #4 in the employee file, noting that they were completed after the employee's initial shift. For EF #8, PAK HomeCare will obtain one additional satisfactory, verifiable reference from a former employer or other non-related person. Once completed, EF #8 will contain documentation of two satisfactory references.
2. Identification of Others Potentially Affected:
PAK HomeCare will review all active direct care worker employee files to determine whether any other employee file is missing documentation of two satisfactory references. Any file found to be missing required reference documentation will be corrected.
3. Measures to Prevent Recurrence:
PAK HomeCare will revise its onboarding checklist to require verification of two satisfactory references before a direct care worker is approved for hire, rostered, or scheduled for the first shift. The administrator/designee will review the checklist and employee file before the employee is activated for work.
4. Monitoring/Quality Assurance:
The administrator/designee will review each new employee file prior to the employee's first shift to confirm that two satisfactory references are documented. Monthly audits of new employee files will be completed for three months, followed by quarterly audits through the agency's Quality Management Program. Audit results and any corrective actions will be documented.
611.52(b) LICENSURE
State Police Criminal History Record
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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 upon review of employee files (EFs) and interview with agency owner (EMP #1), it was determined agency failed to obtain a PA State Police criminal history record within 1 year immediately preceding the date of application for one (1) of ten (10) EFs reviewed. (EF# 2)
Findings include:
Review of EFs conducted on April 30, 2026 at between approximately 9:40 a.m. and 11:00 a.m. revealed the following:
EF# 2, Date of Hire (DOH), 2/20/2024: No documentation provided of PA State Police criminal history record within 1 year immediately preceding the date of application. Contained one PA State Police PATCH dated 2/7/2023.
An interview with the agency EMP #1 conducted on April 30, 2026 at approximately 3:00 p.m. confirmed the above findings.
Plan of Correction:1. Corrective Action for Identified Individual/Practice:
PAK HomeCare will obtain a current PA State Police criminal history record/PATCH for EF #2 and place the completed documentation in the employee file. The agency will review the result and maintain it as part of the employee's personnel record.
2. Identification of Others Potentially Affected:
PAK HomeCare will review all active direct care worker employee files to verify that each file contains a PA State Police criminal history record dated within one year immediately preceding the employee's date of application/hire. Any file found to be missing the required documentation or containing an outdated report will be corrected.
3. Measures to Prevent Recurrence:
PAK HomeCare currently uses a New Hire Checklist during onboarding. The checklist will be updated to include the date the PA State Police criminal history record/PATCH was run. The checklist will also clearly state that the PATCH date cannot be more than one year before the employee's date of hire/application. The administrator/designee will verify this requirement before the employee is approved for hire, rostered, or scheduled.
4. Monitoring/Quality Assurance:
The administrator/designee will review the New Hire Checklist and employee file before each new employee's first shift to confirm the PATCH date is documented and meets the one-year timing requirement. PAK HomeCare will also conduct quarterly employee file audits through the agency's Quality Management Program to ensure continued compliance. Audit results and any corrections will be documented.
611.55(a) LICENSURE
Competency Requirements
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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 upon review of employee files (EFs) and interview with agency owner (EMP #1), it was determined agency failed to demonstrate initial competency, prior to assigning or referring a direct care worker to provide services to a consumer, containing all required topics for one (1) of ten (10) EFs reviewed. (EF# 2)
Findings include:
Review of EFs conducted on April 30, 2026 at between approximately 9:40 a.m. and 11:00 a.m. revealed the following:
EF# 2, Date of Hire (DOH), 2/20/2024: No documentation provided initial competency containing all required topics completed prior to assigning or referring a direct care worker to provide services to a consumer. Contained a competency exam dated 2/24/2024, 4 days after initial shift.
An interview with the agency EMP #1 conducted on April 30, 2026 at approximately 3:00 p.m. confirmed the above findings.
Plan of Correction:1. Corrective Action for Identified Individual/Practice:
PAK HomeCare will keep the completed competency exam for EF #2 in the employee file. The competency exam was completed on 02/24/2024, which was after the employee's first shift. PAK HomeCare reviewed the file and confirmed the competency exam is now completed and in the employee record. No new training is needed for EF #2 because the competency was already completed.
2. Identification of Others Potentially Affected:
PAK HomeCare will review all active employee files to make sure each direct care worker has a completed competency exam in their file. The review will also check if any other employee completed competency after their first shift.
3. Measures to Prevent Recurrence:
PAK HomeCare uses a New Hire Checklist for onboarding. The checklist will be updated to show the date the competency exam was completed. The checklist will also state that competency must be completed before the employee is scheduled or starts working with a consumer.
4. Monitoring/Quality Assurance:
The administrator/designee will review the New Hire Checklist and employee file before each new employee starts working to make sure competency is completed. PAK HomeCare will also complete quarterly employee file audits to check for continued compliance. Any issues found will be corrected and documented.
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 upon review of employee files (EFs) and interview with agency owner (EMP #1), it was determined agency failed to show annual competency review for one (1) of ten (10) EFs reviewed. (EF# 1)
Findings include:
Review of EFs conducted on April 30, 2026 at between approximately 9:40 a.m. and 11:00 a.m. revealed the following:
EF# 1, Date of Hire (DOH), 8/21/2024: No documentation of annual competency for year of 2025.
An interview with the agency EMP #1 conducted on April 30, 2026 at approximately 3:00 p.m. confirmed the above findings.
Plan of Correction:1. Corrective Action for Identified Individual/Practice:
PAK HomeCare will keep the completed initial competency for EF #1 in the employee file. The file was missing the annual competency/retraining for 2025. PAK HomeCare will ensure the employee completes the annual competency/retraining for 2026 and will place the completed documentation in the employee file.
2. Identification of Others Potentially Affected:
PAK HomeCare will review all active employee files to check if any other direct care worker is missing annual competency/retraining documentation.
3. Measures to Prevent Recurrence:
PAK HomeCare will use calendar reminder software to track annual competency/retraining due dates. The reminder system will notify the administrator/designee before each employee's annual competency/retraining is due.
4. Monitoring/Quality Assurance:
The administrator/designee will review employee files and calendar reminders to make sure annual competency/retraining is completed and documented. PAK HomeCare will also complete quarterly employee file audits to check for continued compliance. Any issues found will be corrected and documented.
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 upon review of employee files (EFs) and interview with agency owner (EMP #1), it was determined agency failed to ensure each direct care worker and other staff or contractors with direct consumer contact, prior to consumer contact, were screened for and are free from active mycobacterium tuberculosis using a two-step tuberculin skin test or a single blood assay to test for infection with tuberculosis for two (2) of ten (10) EFs reviewed. (EF# 1 and EF# 2)
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. 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).
Review of EFs conducted on April 30, 2026 at between approximately 9:40 a.m. and 11:00 a.m. revealed the following:
EF# 1, Date of Hire (DOH), 8/21/2024: No documentation of an initial tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB).
EF# 2, DOH, 2/20/2024: No documentation of an initial tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB).
An interview with the agency EMP #1 conducted on April 30, 2026 at approximately 3:00 p.m. confirmed the above findings.
Plan of Correction:1. Corrective Action for Identified Individual/Practice:
PAK HomeCare will obtain current TB screening documentation for EF #1 and EF #2 and place the completed documentation in each employee file. The agency had TB skin test/QuantiFERON documentation, but the issue was that the tests were completed more than one year before the employees' dates of hire. Moving forward, PAK HomeCare will ensure TB screening is current before consumer contact.
2. Identification of Others Potentially Affected:
PAK HomeCare will review all active employee files to check if any other direct care worker or staff with direct consumer contact has missing or outdated TB screening documentation.
3. Measures to Prevent Recurrence:
PAK HomeCare will update the New Hire Checklist to include the TB screening type and completion date. PAK HomeCare will prefer TB chest X-ray screening when appropriate because it can be maintained as long-term documentation. If PAK HomeCare accepts a TB skin test or QuantiFERON test, the agency will verify that the test date is within one year of the employee's date of hire. If the test is older than one year, the employee will be required to obtain a new TB screening before consumer contact, preferably a TB chest X-ray screening when appropriate.
4. Monitoring/Quality Assurance:
The administrator/designee will review the New Hire Checklist and employee file before each new employee starts working to make sure TB screening is completed, current, and documented. PAK HomeCare will also complete quarterly employee file audits to check for continued compliance. Any issues found will be corrected and documented.
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 upon review of employee files (EFs) and interview with agency owner (EMP #1), it was determined agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, were provided with annual mycobacterium tuberculosis education for one (1) of ten (10) EFs reviewed. (EF# 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. 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).
Review of EFs conducted on April 30, 2026 at between approximately 9:40 a.m. and 11:00 a.m. revealed the following:
EF# 1, Date of Hire (DOH), 8/21/2024: No documentation provided of annual 2025 TB education.
An interview with the agency EMP #1 conducted on April 30, 2026 at approximately 3:00 p.m. confirmed the above findings.
Plan of Correction:1. Corrective Action for Identified Individual/Practice:
PAK HomeCare will keep the employee's TB screening documentation in EF #1. The file was missing the annual TB education for 2025. PAK HomeCare will make sure the employee completes the annual TB education for 2026 and will place the completed documentation in the employee file.
2. Identification of Others Potentially Affected:
PAK HomeCare will review all active employee files to check if any other direct care worker or staff with direct consumer contact is missing annual TB education documentation.
3. Measures to Prevent Recurrence:
PAK HomeCare will use calendar reminder software to track all annual trainings and compliance requirements, including annual TB education. The reminder system will notify the administrator/designee before each item is due so it can be completed on time.
4. Monitoring/Quality Assurance:
The administrator/designee will review employee files, training records, and calendar reminders to make sure annual TB education and other annual compliance items are completed and documented. PAK HomeCare will complete quarterly employee file audits to check for continued compliance. Any issues found will be corrected and documented.
611.57(a) LICENSURE
Consumer Rights
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(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.
Observations:
Based upon review of consumer files (CFs) and interview with agency owner (EMP #1), it was determined agency failed to provide documentation of consumer being aware of having at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services for two (2) of five (5) CFs reviewed. (CF# 1 and CF# 4)
Findings include:
Review of CFs conducted on April 30, 2026 at between approximately 11:05 a.m. and 11:50 a.m. revealed the following:
CF# 1, Start of Service (SOS), 9/4/2025: No documentation of consumer being notified of having at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services.
CF# 4, SOS, 3/1/2026: No documentation of consumer being notified of having at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services.
An interview with the agency EMP #1 conducted on April 30, 2026 at approximately 3:00 p.m. confirmed the above findings.
Plan of Correction:1. Corrective Action for Identified Individual/Practice:
PAK HomeCare has a consumer file for each consumer, which includes a consumer rights document. PAK HomeCare will obtain updated/resigned consumer rights documents for CF #1 and CF #4. The documents will include the consumer's right to be involved in the service planning process, to receive services with reasonable accommodation of individual needs and preferences, and to receive at least 10 calendar days advance written notice before the agency terminates services, unless an allowed exception applies. The completed documents will be placed in each consumer file.
2. Identification of Others Potentially Affected:
PAK HomeCare will review all active consumer files to check if any other files are missing the consumer rights document or missing documentation that the consumer was informed of their rights under 611.57(a).
3. Measures to Prevent Recurrence:
PAK HomeCare will update the consumer admission checklist to make sure the consumer rights document is included in each consumer file, reviewed with the consumer, and signed during intake/admission. The checklist will also confirm that the consumer rights document includes service planning rights, reasonable accommodation of individual needs and preferences, and the 10-day termination notice requirement.
4. Monitoring/Quality Assurance:
PAK HomeCare will complete quarterly consumer file audits to make sure consumer rights documents are completed, signed, and maintained in the file. Any missing or incomplete documents will be corrected and documented.
611.57(b) LICENSURE
Prohibitions
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(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 upon review of consumer files (CFs) and interview with agency owner (EMP #1), it was determined agency failed to inform the consumer that 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; and failed to inform the consumer that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer for two (2) of five (5) CFs reviewed. (CF# 1 and CF# 4)
Findings include:
Review of CFs conducted on April 30, 2026 at between approximately 11:05 a.m. and 11:50 a.m. revealed the following:
CF# 1, Start of Service (SOS), 9/4/2025: No documentation of consumer notification that 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 and no documentation of consumer notification that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer.
CF# 4, SOS, 3/1/2026: No documentation of consumer notification that 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 and no documentation of consumer notification that the home care agency or home care registry may not assume power of attorney or guardianship of the consumer.
An interview with the agency EMP #1 conducted on April 30, 2026 at approximately 3:00 p.m. confirmed the above findings.
Plan of Correction:1. Corrective Action for Identified Individual/Practice:
PAK HomeCare has a consumer file for each consumer, which includes a consumer rights/prohibitions document. PAK HomeCare will obtain updated/resigned documents for CF #1 and CF #4. The documents will inform the consumer that PAK HomeCare may not require a consumer to endorse checks over to the agency and may not assume power of attorney or guardianship over the consumer. The completed documents will be placed in each consumer file.
2. Identification of Others Potentially Affected:
PAK HomeCare will review all active consumer files to check if any other files are missing documentation that the consumer was informed of these prohibitions.
3. Measures to Prevent Recurrence:
PAK HomeCare will update the consumer admission checklist to make sure the consumer rights/prohibitions document is included in each consumer file, reviewed with the consumer, and signed during intake/admission. The checklist will confirm that the document includes the prohibition against requiring consumers to endorse checks to the agency and the prohibition against agency staff assuming power of attorney or guardianship.
4. Monitoring/Quality Assurance:
PAK HomeCare will complete quarterly consumer file audits to make sure the required consumer rights/prohibitions documents are completed, signed, and maintained in the file. Any missing or incomplete documents will be corrected and documented.
611.57(c) LICENSURE
Information to be Provided
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(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 upon review of consumer files (CFs) and interview with agency owner (EMP #1), it was determined agency failed to provide, prior to the commencement of services, to the consumer the identity of the direct care worker who will provide the services to two (2) of five (5) CFs reviewed (CF# 1 and CF# 4); failed to provide a listing of the available home care services that will be provided to the consumer by the direct care worker for two (2) of five (5) CFs reviewed (CF# 1 and CF# 4); failed to provide the hours when those services will be provided for two (2) of five (5) CFs reviewed (CF# 1 and CF# 4); failed to provide the fees and total costs for those services on an hourly or weekly basis for two (2) of five (5) CFs reviewed (CF# 1 and CF# 4); failed to provide 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 for two (2) of five (5) CFs reviewed (CF# 1 and CF# 4); failed to provide the Departments complaint Hot Line phone number for two (2) of five (5) CFs reviewed (CF# 1 and CF# 4); failed to provide the telephone number of the Ombudsman Program located with the local Area Agency on Aging for two (2) of five (5) CFs reviewed (CF# 1 and CF# 4); failed to provide the hiring and competency requirements applicable to direct care workers employed by the home care agency for two (2) of five (5) CFs reviewed (CF# 1 and CF# 4); and failed to provide 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 for two (2) of five (5) CFs reviewed (CF# 1 and CF# 4)
Findings include:
Review of CFs conducted on April 30, 2026 at between approximately 11:05 a.m. and 11:50 a.m. revealed the following:
CF# 1, Start of Service (SOS), 9/4/2025: No documentation of the identity of direct care worker being provided to consumer; of providing a listing of the available home care services that will be provided to the consumer by the direct care worker; of providing the hours when those services will be provided; of providing the fees and total costs for those services on an hourly or weekly basis; of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information about a particular home care agency or home care registry; of providing the consumer the Pa. Department of Health complaint Hot Line; of providing the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA); of providing the hiring and competency requirements applicable to direct care workers employed by the home care agency; and of providing 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
CF# 4, SOS, 3/1/2026: No documentation of the identity of direct care worker being provided to consumer; of providing a listing of the available home care services that will be provided to the consumer by the direct care worker; of providing the hours when those services will be provided; of providing the fees and total costs for those services on an hourly or weekly basis; of providing the contact number of the Pa. Department of Health for licensure requirements or compliance information about a particular home care agency or home care registry; of providing the consumer the Pa. Department of Health complaint Hot Line; of providing the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA); of providing the hiring and competency requirements applicable to direct care workers employed by the home care agency; and of providing 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
An interview with the agency EMP #1 conducted on April 30, 2026 at approximately 3:00 p.m. confirmed the above findings.
Plan of Correction:1. Corrective Action for Identified Individual/Practice:
PAK HomeCare has a consumer file for each consumer, which includes the consumer information packet. PAK HomeCare will obtain updated/resigned information packet documents for CF #1 and CF #4. The documents will include the required information, including the direct care worker's identity, services to be provided, hours of service, fees/costs, Department of Health contact information, complaint hotline, local Ombudsman/AAA contact number, hiring and competency requirements, and employee/independent contractor disclosure. The completed documents will be placed in each consumer file.
2. Identification of Others Potentially Affected:
PAK HomeCare will review all active consumer files to check if any other files are missing the required consumer information packet or any required parts of the packet.
3. Measures to Prevent Recurrence:
PAK HomeCare will update the consumer admission checklist to make sure the information packet is completed, reviewed with the consumer/legal representative/responsible family member, signed, and placed in the consumer file before services start. The checklist will include each required item under 611.57(c) so nothing is missed.
4. Monitoring/Quality Assurance:
PAK HomeCare will complete quarterly consumer file audits to make sure the consumer information packet is completed, signed, and maintained in the file. Any missing or incomplete documents will be corrected and documented.
Initial Comments:
Based on the findings of an unannounced, on-site state re-licensure survey conducted on April 30, 2026, Pak Homecare LLC, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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